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

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 11 Baterial And Fungal Corneal Ulcers Lecture Notes

Bacterial and fungal

corneal ulcer/ Suppurative

keratitis

Dept. Of Ophthalmology

?Keratitis-Inflammation of cornea

?Corneal ulcer- Loss of corneal

epithelium with inflammation of

surrounding tissue and stroma and

suppuration, with or without

hypopyon
CORNEAL ULCER

?One the common cause of blindness

?Included in National Programme for

Control of Blindness

Classification of Keratitis

Bacterial

A] Superficial

Infective

l

Fungal

Non-infective

Viral

Central

Peripheral

Acanthamoebal

B] Deep Keratitis
Causative Organisms
Infections are almost always exogenous

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

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

Predisposing factors

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

(in fungal typical history of trauma with vegetable

matter, mostly in harvesting season)

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

?Neurotrophic keratitis resulting from viral

infections and lesions of ophthalmic division of

Trigeminal nerve

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

DM)

?Poor local hygiene and local infection ( chronic

dacryocystitis)

Pathophysiology of ulcer

Progressive

? Lymphocytes infiltrates in epithelium

? Necrosis

infiltration

? Greyish infiltration with circumcorneal

Active

hyperaemia

ulceration

? Hypopyon and descemetocele

? Phagocytosis

Regression

? Ulcers begin to heal

? Epithelium covers the ulcers

Cicatrization

? Scars and opacities formation


Stages of corneal ulcer

Assessment of Corneal ulcer

? History, general, and systemic examination
? Visual acuity: may be low
? Eye and Ocular adnexa: Eye lid , lacrimal sac
? Conjunctiva: circumcorneal congestion, chemosis
? Corneal ulcer: size, site ,surface, margin, slough, corneal sensation,

thinning , satellite lesions

? Anterior chamber: Cells, flare, hypopyon
? Pupil


Clinical Features of Corneal ulcer

SYMPTOMS:

1. Pain/Foreign body

sensation

2. photophobia

3. DV/Blurred vision

4. Discharge/Watering

5. Redness

6. White spot on Cornea

Clinical Features of Corneal ulcer

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

conjunctiva

4. Ulcer with greyish-

white necrotic slough

5. Hypopyon+-


Symptoms in Mycotic Corneal Ulcer

are less prominent than an equal

size Bacterial ulcer


signs

SIGNS

BACTERIAL

FUNGAL

Lids

Swelling of lids

Might be present

Blepharospasm

present

present

Conjunctival chemosis

Present+++

Present++

and hyperemia
Ciliary congestion

+++

+++

Ulcer

Greyish-white

Elevated rolled out

circumscribed infiltrate,

margins

Yellowish-white oval/

Satellite lesion

irregular area of ulcer.

Dense suppuration

Stromal edema

Endothelial palque

Hypopyon

Hypopyon

Hypopyon(infected,imm

(sterile, whitish, mobile

obile,yellowish),

common

Complications

Corneal perforation

Endophthalmitis

,endophthalmitis

Symptoms are less as compared to signs

FUNGAL CORNEAL ULCER


Differential Diagnosis of ulcer

? Acute conjunctivitis
? Acute iridocyclitis
? Acute congestive glaucoma
? Corneal Opacity

Complications of Corneal Ulcer

I.

Descematocele


II. Perforation and its complications : Anterior synechia , Iris
prolapse, expulsion of lens and vitreous, Intraocular hemorrhage,

i i. Endophthalmitis / panophthalmitis

iv. Secondary glaucoma

v. Anterior capsular cataract

vi. Staphyloma formation

VII. Corneal opacity
Microbiological Investigations

? The majority are managed without smears or cultures.

? Scraping done: from ulcer margins and base of ulcer

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

KOH mount for fungi.

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

Sabouraud's dextrose agar

Management

Principles:
? Control of infection
? Symptomatic relief
? Prevention of complications
Control of Infection(for bacterial ulcer)

? Topical antibiotics
Fluoroquinolone eye drop:
? Cipro/ ofloxacin
? moxifloxacin(0.5%) drop.
? Gatifloxacin 0.3 % drop.

Alternatives

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

Antimicrobials for Fungal corneal ulcer

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

months

? - Amphotericin B 0.15/ 0.3 % frequent instil ation

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

400mg/ day

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

? Along with antibiotics support to prevent secondary bacterial infections
Treatment

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

?Systemic analgesics : Anti-inflammatory drugs

such as paracetamol & ibuprofen

?Removal of local predisposing factor

?Vitamins ( A, B-complex & C)

Treatment ( Non Healing Corneal Ulcer)

?Debridement of ulcer
?Chemical Cuterization
?Cyano acrylate glue
?Therapeutic penetrating keratoplasty
?Treatment of complications: perforation,

secondary glaucoma
Outcome of corneal ulcer

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

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

Sharma

Photographs- above , Archives & Website