Keratitis_III - Keratitis Complicated Corneal Ulcer...

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Unformatted text preview: Keratitis Complicated Corneal Ulcer Complicated Perforated Corneal Ulcer Healed Keratocele Hypopyon Ulcer Hypopyon Types Corneal Ulcer (Superficial Purulent Keratitis) Corneal with Hypopyon Ulcer Serpen Hypopyon Ulcer Hypopyon There is always an associated iritis in all cases There of Corneal Ulcer due to diffusion of toxins of infecting bacteria into the eye. infecting Sometimes iridocyclitis is so severe that it is Sometimes accompanied by outpouring of leucocytes from uveal blood vessels and these cells gravitate to bottom of the anterior chamber to form hypopyon (pus in anterior chamber) Introduction Introduction The hypopyon which forms in bacterial keratitis is The sterile as the leucocyte secretion is due to irritation by toxins and not by the bacteria Hypopyon may develop in hours and it may change Hypopyon in quantity and may also rapidly disappear. in Hypopyon in bacterial keratitis is fluid and changes Hypopyon its position with change in head posture its Etiology Etiology Predisposing Factors Predisposing 1. 2. 3. 3. 4. 4. 5. 5. 6. High Virulence of infecting organism Resistance of the tissues, which is low Resistance Dacryocystitis Dacryocystitis Ocular trauma Ocular Old, debilitated or alcoholic Measles or scarlet fever Measles Organisms Organisms Pyogenic organisms like Staphylococci, Pyogenic Streptococci, Gonococci, Moraxella, Pseudomonas and Pneumococci Pseudomonas Hypopyon Ulcer Hypopyon Ulcus Serpen Ulcus Ulcus Serpen is hypopyon ulcer caused by Ulcus Pneumococci in adults and has tendency to creep over the cornea in serpiginous fashion creep Symptoms Sever pain, photophobia, marked diminution Sever of vision, watering, foreign body sensation (grittiness) Signs Signs Grayish white or yellowish disc like lesion Grayish near centre of cornea. Opacity is marked at edges than at the centre and more marked in one direction (where it is progressive). In the direction of progression there is cloudiness (grey coloured) and fine line ahead of disc Cornea may be lusterless. There is severe iritis Cornea and aqueous is hazy or there may be rank hypopyon amount which varies Signs Signs Untreated ulcer increases in depth and spread towards Untreated the side of dense infiltration, while on the other side simultaneously healing (cicatrization) takes place. simultaneously There is infiltration just anterior to Descemets’ There membrane underneath the floor of ulcer with normal intervening lamellae, due to which there is tendency for perforation of cornea. Intra-ocular tension is usually raised in these cases. usually Complications Complications Untreated cases progresses to increase in Untreated hypopyon which becomes fibrinous leading to perforation → Iris prolapse through large opening →whole cornea may slough leaving peripheral cornea which is nourished by limbal vascular loops. Eventually panophthalmitis develops which destroys the eye Treatment Treatment Routine treatment of Corneal Ulcer Routine Tab Acetazolamide Tab Local Betablocker Local Therapeutic keratoplasty Control of infection results in absorption of Control hypopyon hypopyon Fungal Keratitis Fungal Fungal Keratitis Fungal Fungal keratitis is challenging corneal disease and Fungal presents as very difficult form bacterial keratitis. Difficulty arise in making correct clinical and laboratory diagnosis. The treatment of fungal keratitis is also difficult due to poor availability of antifungal drugs and delay in starting treatment. Treatment is required on long term basis, intensively and often cases require therapeutic keratoplasty. Fungal Keratitis Fungal Fungi enter into corneal stroma through epithelial Fungi defect, which may be due to trauma, contact lens wear, bad ocular surface or previous corneal surgery. wear, In stroma fungi multiply and causes tissue necrosis In and inflammatory reaction. and Organisms enter deep into the stroma and through an Organisms intact Descemets membrane into the anterior chamber and iris. They can also involve Sclera. Fungal Keratitis Fungal The spread is due to the fact that the blood The borne growth inhibiting factors may not reach the avascular tissue like cornea and sclera. Risk Factors Risk 1. 2. Trauma outdoor/ or the one which involves Trauma plant matter (including contact lenses) plant Topical medications: corticosteroids, Topical anaesthetic drug abuse and topical broad spectrum antibiotics use for long time (resulting in non-competitive environment for growth) for Risk Factors Risk 3. Systemic use of steroids 3. 4. Corneal surgeries (Penetrating keratoplasty, refractive surgery) refractive 5. Chronic keratitis (herpes simplex, herpes 5. zoster, Vernal or allergic keratoconjunctivitis, and neurotrophic ulcer) 6. Diabetes , Chronically ill / hospitalised patients, AIDS and leprosy patients, Causative fungi I. I. II. Yeast: Candida species (albicans), Yeast: Cryptococcus Cryptococcus Filamentous septated Filamentous A. Non-pigmented hyphae: Fusarium species (solani), Aspergillus species (fumigatus, flavus, niger) (fumigatus, B. Pigmented hyphae (dematiaceous): B. Alternaria, Curularia , Cladosporium species Causative fungi Causative III. Filamentous non-septated : Mucor and III. Rhizopus species IV. Diphasic forms: Histoplasma, Coccidiodes, Blastomyces Blastomyces Clinical Features Clinical Symptoms Symptoms Onset is slow Symptoms are less compared to signs Diminution of vision, pain, foreign body Diminution sensation Signs Signs Diminution of vision, depending on location of Diminution ulcer ulcer Conjunctival and ciliary congestion Epithelial defect Stromal infiltrates Elevated areas, hypate (branching) ulcers, Elevated irregular feathery margins irregular Dry and rough texture Dry Fungal Keratitis with Hypopyon Fungal Signs Signs Satellite lesions Brown pigmentation due to dematiaceous Brown fungus (Curvularia lunata) fungus Intact epithelium with stromal infiltrates Anterior chamber reaction Anterior Fungal Keratitis Fungal Fungal Keratitis – Pigmented Lesion Case of Fungal+ Bacterial Keratitis Case Laboratory Diagnosis Laboratory The Gram and Giemsa stains are used as initial The stains Potassium Hydroxide (10-20 %) wet mounts Potassium Culture Media: Sheep blood agar, Chocolate Culture agar, Sabouraud dextrose agar, Thioglycollate broth Anterior chamber tap under aseptic conditions Anterior to aspirate hypopyon and or endothelial plaque to Treatment Treatment Natamycin 5% suspension: frequency will Natamycin depend on severity of condition depend Candida species respond better to Candida Amphotericin B 0.15% Amphotericin Fluconazole 2% Miconazole 1% Scrapping every 24 to 48 hours Scrapping Treatment is required for 4 – 6 weeks Treatment Treatment Treatment Sub-conjunctival injection of Miconazole 5 – Sub-conjunctival 10 mgm of 10 mgm/ml suspension (indicated in severe form of keratitis, scleritis and endophthalmitis) Systemic: Systemic: Fluconazole or Ketoconazole is indicated in severe form of keratitis, scleritis and endophthalmitis endophthalmitis Surgical Treatment Surgical 1. 2. 2. 3. 3. Daily debridement with spatula/ blade every Daily 24 – 48 hours Surgical treatment is required in Surgical approximately 1/3rd cases of fungal keratitis approximately due to failure of medical treatment or perforation Surgical treatment in the form of : therapeutic keratoplasty, conjunctival flap or therapeutic lamellar keratoplasty Surgical Treatment Surgical Surgery is usually indicated within 4 weeks Surgery due to failure of medical treatment or recurrence of infection Unfavorable outcome is due to scleritis, Unfavorable endophthalmitis and recurrence Cryotherapy with topical antifungal treatment Cryotherapy or corneoscleral graft in cases of fungal scleritis and keratoscleritis ...
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