Keratitis III

Keratitis Keratitis

Complicated Corneal UlcerComplicated Corneal Ulcer

Perforated Corneal Ulcer

Healed Keratocele Healed Keratocele

Hypopyon UlcerHypopyon Ulcer

TypesTypes Corneal Ulcer (Superficial Purulent Keratitis) Corneal Ulcer (Superficial Purulent Keratitis)

with Hypopyon with Hypopyon Ulcer SerpenUlcer Serpen


There is always an associated iritis in all cases There is always an associated iritis in all cases of Corneal Ulcer due to diffusion of toxins of of Corneal Ulcer due to diffusion of toxins of infecting bacteria into the eye.infecting bacteria into the eye.

Sometimes iridocyclitis is so severe that it is Sometimes iridocyclitis is so severe that it is accompanied by outpouring of leucocytes accompanied by outpouring of leucocytes from uveal blood vessels and these cells from uveal blood vessels and these cells gravitate to bottom of the anterior chamber to gravitate to bottom of the anterior chamber to form hypopyon (pus in anterior chamber) form hypopyon (pus in anterior chamber)

IntroductionIntroduction

The hypopyon which forms in bacterial keratitis is The hypopyon which forms in bacterial keratitis is sterile as the leucocyte secretion is due to irritation by sterile as the leucocyte secretion is due to irritation by toxins and not by the bacteria toxins and not by the bacteria

Hypopyon may develop in hours and it may change Hypopyon may develop in hours and it may change in quantity and may also rapidly disappear.in quantity and may also rapidly disappear.

Hypopyon in bacterial keratitis is fluid and changes Hypopyon in bacterial keratitis is fluid and changes its position with change in head postureits position with change in head posture

EtiologyEtiology

Predisposing FactorsPredisposing Factors

1.1. High Virulence of infecting organismHigh Virulence of infecting organism

2.2. Resistance of the tissues, which is low Resistance of the tissues, which is low

3.3. Dacryocystitis Dacryocystitis

4.4. Ocular trauma Ocular trauma

5.5. Old, debilitated or alcoholicOld, debilitated or alcoholic

6.6. Measles or scarlet fever Measles or scarlet fever

OrganismsOrganisms

Pyogenic organisms like Staphylococci, Pyogenic organisms like Staphylococci, Streptococci, Gonococci, Moraxella, Streptococci, Gonococci, Moraxella, Pseudomonas and PneumococciPseudomonas and Pneumococci


Ulcus SerpenUlcus Serpen

Ulcus Serpen is hypopyon ulcer caused by Ulcus Serpen is hypopyon ulcer caused by Pneumococci in adults and has tendency to Pneumococci in adults and has tendency to creep over the cornea in serpiginous fashioncreep over the cornea in serpiginous fashion

Symptoms Symptoms

Sever pain, photophobia, marked diminution Sever pain, photophobia, marked diminution of vision, watering, foreign body sensation of vision, watering, foreign body sensation (grittiness) (grittiness)

SignsSigns

Grayish white or yellowish disc like lesion Grayish white or yellowish disc like lesion near centre of cornea. Opacity is marked at near centre of cornea. Opacity is marked at edges than at the centre and more marked in edges than at the centre and more marked in one direction (where it is progressive). In the one direction (where it is progressive). In the direction of progression there is cloudiness direction of progression there is cloudiness (grey coloured) and fine line ahead of disc (grey coloured) and fine line ahead of disc

Cornea may be lusterless. There is severe iritis Cornea may be lusterless. There is severe iritis and aqueous is hazy or there may be rank and aqueous is hazy or there may be rank hypopyon amount which varies hypopyon amount which varies

SignsSigns

Untreated ulcer increases in depth and spread towards Untreated ulcer increases in depth and spread towards the side of dense infiltration, while on the other side the side of dense infiltration, while on the other side simultaneously healing (cicatrization) takes place.simultaneously healing (cicatrization) takes place.

There is infiltration just anterior to Descemets’ There is infiltration just anterior to Descemets’ membrane underneath the floor of ulcer with normal membrane underneath the floor of ulcer with normal intervening lamellae, due to which there is tendency intervening lamellae, due to which there is tendency for perforation of cornea. Intra-ocular tension is for perforation of cornea. Intra-ocular tension is usually raised in these cases.usually raised in these cases.

ComplicationsComplications

Untreated cases progresses to increase in Untreated cases progresses to increase in hypopyon which becomes fibrinous leading to hypopyon which becomes fibrinous leading to perforation → Iris prolapse through large perforation → Iris prolapse through large opening →whole cornea may slough leaving opening →whole cornea may slough leaving peripheral cornea which is nourished by limbal peripheral cornea which is nourished by limbal vascular loops. Eventually panophthalmitis vascular loops. Eventually panophthalmitis develops which destroys the eye develops which destroys the eye

TreatmentTreatment

Routine treatment of Corneal Ulcer Routine treatment of Corneal Ulcer Tab Acetazolamide Tab Acetazolamide Local Betablocker Local Betablocker Therapeutic keratoplastyTherapeutic keratoplasty

Control of infection results in absorption of Control of infection results in absorption of hypopyonhypopyon

Fungal KeratitisFungal Keratitis


Fungal keratitis is challenging corneal disease and Fungal keratitis is challenging corneal disease and presents as very difficult form bacterial keratitis. presents as very difficult form bacterial keratitis. Difficulty arise in making correct clinical and Difficulty arise in making correct clinical and laboratory diagnosis. The treatment of fungal keratitis laboratory diagnosis. The treatment of fungal keratitis is also difficult due to poor availability of antifungal is also difficult due to poor availability of antifungal drugs and delay in starting treatment. drugs and delay in starting treatment.

Treatment is required on long term basis, intensively Treatment is required on long term basis, intensively and often cases require therapeutic keratoplasty. and often cases require therapeutic keratoplasty.


Fungi enter into corneal stroma through epithelial Fungi enter into corneal stroma through epithelial defect, which may be due to trauma, contact lens defect, which may be due to trauma, contact lens wear, bad ocular surface or previous corneal surgery.wear, bad ocular surface or previous corneal surgery.

In stroma fungi multiply and causes tissue necrosis In stroma fungi multiply and causes tissue necrosis and inflammatory reaction.and inflammatory reaction.

Organisms enter deep into the stroma and through an Organisms enter deep into the stroma and through an intact Descemets membrane into the anterior chamber intact Descemets membrane into the anterior chamber and iris. They can also involve Sclera. and iris. They can also involve Sclera.


The spread is due to the fact that the blood The spread is due to the fact that the blood borne growth inhibiting factors may not reach borne growth inhibiting factors may not reach the avascular tissue like cornea and sclera. the avascular tissue like cornea and sclera.

Risk FactorsRisk Factors

1.1. Trauma outdoor/ or the one which involves Trauma outdoor/ or the one which involves plant matter (including contact lenses)plant matter (including contact lenses)

2.2. Topical medications: corticosteroids, Topical medications: corticosteroids, anaesthetic drug abuse and topical broad anaesthetic drug abuse and topical broad spectrum antibiotics use for long time spectrum antibiotics use for long time (resulting in non-competitive environment (resulting in non-competitive environment for growth)for growth)

Risk FactorsRisk Factors

3. Systemic use of steroids 3. Systemic use of steroids

4. Corneal surgeries (Penetrating keratoplasty, 4. Corneal surgeries (Penetrating keratoplasty, refractive surgery)refractive surgery)

5. Chronic keratitis (herpes simplex, herpes 5. Chronic keratitis (herpes simplex, herpes zoster, Vernal or allergic keratoconjunctivitis, zoster, Vernal or allergic keratoconjunctivitis, and neurotrophic ulcer) and neurotrophic ulcer)

6. Diabetes , Chronically ill / hospitalised 6. Diabetes , Chronically ill / hospitalised patients, AIDS and leprosypatients, AIDS and leprosy

Causative fungi Causative fungi

I.I. Yeast: Candida species (albicans), Yeast: Candida species (albicans), CryptococcusCryptococcus

II.II. Filamentous septated Filamentous septated A. Non-pigmented hyphae: Fusarium A. Non-pigmented hyphae: Fusarium species (solani), Aspergillus species species (solani), Aspergillus species (fumigatus, flavus, niger)(fumigatus, flavus, niger)B. Pigmented hyphae (dematiaceous): B. Pigmented hyphae (dematiaceous): Alternaria, Curularia , Cladosporium Alternaria, Curularia , Cladosporium species species

Causative fungiCausative fungi

III. Filamentous non-septated : Mucor and III. Filamentous non-septated : Mucor and Rhizopus species Rhizopus species

IV. Diphasic forms: Histoplasma, Coccidiodes, IV. Diphasic forms: Histoplasma, Coccidiodes, BlastomycesBlastomyces

Clinical FeaturesClinical Features

SymptomsSymptoms

Onset is slowOnset is slow Symptoms are less compared to signsSymptoms are less compared to signs Diminution of vision, pain, foreign body Diminution of vision, pain, foreign body

sensation sensation

SignsSigns

Diminution of vision, depending on location of Diminution of vision, depending on location of ulcerulcer

Conjunctival and ciliary congestionConjunctival and ciliary congestion Epithelial defectEpithelial defect Stromal infiltratesStromal infiltrates Elevated areas, hypate (branching) ulcers, Elevated areas, hypate (branching) ulcers,

irregular feathery marginsirregular feathery margins Dry and rough texture Dry and rough texture

Fungal Keratitis with HypopyonFungal Keratitis with Hypopyon

SignsSigns

Satellite lesionsSatellite lesions Brown pigmentation due to dematiaceous Brown pigmentation due to dematiaceous

fungus (Curvularia lunata)fungus (Curvularia lunata) Intact epithelium with stromal infiltratesIntact epithelium with stromal infiltrates Anterior chamber reaction Anterior chamber reaction


Fungal Keratitis – Pigmented Lesion

Case of Fungal+ Bacterial KeratitisCase of Fungal+ Bacterial Keratitis

Laboratory DiagnosisLaboratory Diagnosis

The Gram and Giemsa stains are used as initial The Gram and Giemsa stains are used as initial stains stains

Potassium Hydroxide (10-20 %) wet mounts Potassium Hydroxide (10-20 %) wet mounts Culture Media: Sheep blood agar, Chocolate Culture Media: Sheep blood agar, Chocolate

agar, Sabouraud dextrose agar, Thioglycollate agar, Sabouraud dextrose agar, Thioglycollate broth broth

Anterior chamber tap under aseptic conditions Anterior chamber tap under aseptic conditions to aspirate hypopyon and or endothelial plaqueto aspirate hypopyon and or endothelial plaque

TreatmentTreatment

Natamycin 5% suspension: frequency will Natamycin 5% suspension: frequency will depend on severity of conditiondepend on severity of condition

Candida species respond better to Candida species respond better to Amphotericin B 0.15%Amphotericin B 0.15%

Fluconazole 2%Fluconazole 2% Miconazole 1%Miconazole 1% Scrapping every 24 to 48 hours Scrapping every 24 to 48 hours Treatment is required for 4 – 6 weeks Treatment is required for 4 – 6 weeks

TreatmentTreatment

Sub-conjunctival injection of Miconazole 5 – Sub-conjunctival injection of Miconazole 5 – 10 mgm of 10 mgm/ml suspension (indicated 10 mgm of 10 mgm/ml suspension (indicated in severe form of keratitis, scleritis and in severe form of keratitis, scleritis and endophthalmitis) endophthalmitis)

Systemic: Systemic:

Fluconazole or Ketoconazole is indicated in Fluconazole or Ketoconazole is indicated in severe form of keratitis, scleritis and severe form of keratitis, scleritis and endophthalmitisendophthalmitis

Surgical TreatmentSurgical Treatment

1.1. Daily debridement with spatula/ blade every Daily debridement with spatula/ blade every 24 – 48 hours 24 – 48 hours

2.2. Surgical treatment is required in Surgical treatment is required in approximately 1/3approximately 1/3rdrd cases of fungal keratitis cases of fungal keratitis due to failure of medical treatment or due to failure of medical treatment or perforation perforation

3.3. Surgical treatment in the form of :Surgical treatment in the form of :therapeutic keratoplasty, conjunctival flap or therapeutic keratoplasty, conjunctival flap or lamellar keratoplasty lamellar keratoplasty

Surgical TreatmentSurgical Treatment

Surgery is usually indicated within 4 weeks Surgery is usually indicated within 4 weeks due to failure of medical treatment or due to failure of medical treatment or recurrence of infection recurrence of infection

Unfavorable outcome is due to scleritis, Unfavorable outcome is due to scleritis, endophthalmitis and recurrence endophthalmitis and recurrence

Cryotherapy with topical antifungal treatment Cryotherapy with topical antifungal treatment or corneoscleral graft in cases of fungal or corneoscleral graft in cases of fungal scleritis and keratoscleritis scleritis and keratoscleritis

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Keratitis III