Download MBBS Ophthalmology PPT 11 Baterial And Fungal Corneal Ulcers Lecture Notes

Bacterial and fungal

corneal ulcer/ Suppurative

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keratitis

Dept. Of Ophthalmology

?Keratitis-Inflammation of cornea

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?Corneal ulcer- Loss of corneal

epithelium with inflammation of

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surrounding tissue and stroma and

suppuration, with or without

hypopyon

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CORNEAL ULCER

?One the common cause of blindness

?Included in National Programme for

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Control of Blindness

Classification of Keratitis

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Bacterial

A] Superficial

Infective

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l

Fungal

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Non-infective

Viral

Central

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Peripheral

Acanthamoebal

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B] Deep Keratitis
Causative Organisms
Infections are almost always exogenous

Causative organism

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?(BACTERIAL):
S. aureus, S. epidermidis, S. pneumoniae,
Pseudomonas aeruginosa.
Uncommon: Neisseria gonorrhoeae, E. Coli

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?FUNGAL : Aspergillus and Fusarium sp.(most
common), Candida sp

Predisposing factors

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?Trauma: e.g. Contact lenses, trichiasis, surgery

(in fungal typical history of trauma with vegetable

matter, mostly in harvesting season)

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?Topical steroids
?Lagophthalmos : e.g. Facial nerve palsy
Predisposing factors

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?Neurotrophic keratitis resulting from viral

infections and lesions of ophthalmic division of

Trigeminal nerve

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?Dry eye syndrome
?Deficiency states ( Vit. A ) and metabolic diseases (

DM)

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?Poor local hygiene and local infection ( chronic

dacryocystitis)

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Pathophysiology of ulcer

Progressive

? Lymphocytes infiltrates in epithelium

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? Necrosis

infiltration

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? Greyish infiltration with circumcorneal

Active

hyperaemia

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ulceration

? Hypopyon and descemetocele

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? Phagocytosis

Regression

? Ulcers begin to heal

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? Epithelium covers the ulcers

Cicatrization

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? Scars and opacities formation


Stages of corneal ulcer

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Assessment of Corneal ulcer

? History, general, and systemic examination
? Visual acuity: may be low
? Eye and Ocular adnexa: Eye lid , lacrimal sac

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? Conjunctiva: circumcorneal congestion, chemosis
? Corneal ulcer: size, site ,surface, margin, slough, corneal sensation,

thinning , satellite lesions

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? Anterior chamber: Cells, flare, hypopyon
? Pupil


Clinical Features of Corneal ulcer

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SYMPTOMS:

1. Pain/Foreign body

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sensation

2. photophobia

3. DV/Blurred vision

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4. Discharge/Watering

5. Redness

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6. White spot on Cornea

Clinical Features of Corneal ulcer

Signs:

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1. Bleparospasm
2. Lid edema
3. Ciliary congestion of

conjunctiva

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4. Ulcer with greyish-

white necrotic slough

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5. Hypopyon+-


Symptoms in Mycotic Corneal Ulcer

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are less prominent than an equal

size Bacterial ulcer

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signs

SIGNS

BACTERIAL

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FUNGAL

Lids

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Swelling of lids

Might be present

Blepharospasm

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present

present

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Conjunctival chemosis

Present+++

Present++

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and hyperemia
Ciliary congestion

+++

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+++

Ulcer

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Greyish-white

Elevated rolled out

circumscribed infiltrate,

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margins

Yellowish-white oval/

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Satellite lesion

irregular area of ulcer.

Dense suppuration

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Stromal edema

Endothelial palque

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Hypopyon

Hypopyon

Hypopyon(infected,imm

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(sterile, whitish, mobile

obile,yellowish),

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common

Complications

Corneal perforation

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Endophthalmitis

,endophthalmitis

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Symptoms are less as compared to signs

FUNGAL CORNEAL ULCER

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Differential Diagnosis of ulcer

? Acute conjunctivitis
? Acute iridocyclitis
? Acute congestive glaucoma

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? Corneal Opacity

Complications of Corneal Ulcer

I.

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Descematocele


II. Perforation and its complications : Anterior synechia , Iris

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prolapse, expulsion of lens and vitreous, Intraocular hemorrhage,

i i. Endophthalmitis / panophthalmitis

iv. Secondary glaucoma

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v. Anterior capsular cataract

vi. Staphyloma formation

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VII. Corneal opacity
Microbiological Investigations

? The majority are managed without smears or cultures.

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? Scraping done: from ulcer margins and base of ulcer

? Examination of Smear stained with Gram stain, Giemsa stain,

KOH mount for fungi.

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? Culture on blood agar, chocolate agar, thioglycollate broth, and

Sabouraud's dextrose agar

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Management

Principles:
? Control of infection
? Symptomatic relief

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? Prevention of complications
Control of Infection(for bacterial ulcer)

? Topical antibiotics
Fluoroquinolone eye drop:

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? Cipro/ ofloxacin
? moxifloxacin(0.5%) drop.
? Gatifloxacin 0.3 % drop.

Alternatives

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? Fortified cephazolin eye drop
? Fortified tobramycin eye drop
? Fortified vancomycin eye drop

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Antimicrobials for Fungal corneal ulcer

? Topical antifungal drops:
? - Natamycin 5 % 1 hourly by day and 2 hourly by night for 6 weeks to 6

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months

? - Amphotericin B 0.15/ 0.3 % frequent instil ation

? Oral antifungal agents; Ketoconazole 200-600 mg/ day .Fluconazole 200-

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400mg/ day

? Scrapping done to help removal of slough and penetration of the drug

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? Along with antibiotics support to prevent secondary bacterial infections
Treatment

?Cycloplegics : Atropine 1 % eye drop t.i.d.
?Hot fomentation

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?Systemic analgesics : Anti-inflammatory drugs

such as paracetamol & ibuprofen

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?Removal of local predisposing factor

?Vitamins ( A, B-complex & C)

Treatment ( Non Healing Corneal Ulcer)

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?Debridement of ulcer
?Chemical Cuterization
?Cyano acrylate glue
?Therapeutic penetrating keratoplasty

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?Treatment of complications: perforation,

secondary glaucoma
Outcome of corneal ulcer

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? Healing with out opacity
? Healing with opacity
? Staphyloma
? Secondary glaucoma
? Cataract

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? Phthisis bulbi

Source
Text-Kanski, Parson's, Samar Basak, Pradeep

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Sharma

Photographs- above , Archives & Website