keratitis

Bacterial keratitis
Most important potential
complication
Early diagnosis and treatment are
key
Close follow up , attention to

Pathophysiology
alteration in the corneas defense
mechanisms that allow bacteria to
invade when an epithelial defect
The severity of the disease depends
on the strain of the organism, the
size of the inoculums, the
susceptibility of the host and immune
response, the antecedent therapy
and the duration of the infection

Etiology
Keratitis may develop as a result of:
1. Exogenous infection Mostly traumatic, the
object causing
injury may carry infection to
cornea or may come from conjunctival sac
(infecting abraded cornea)
2. Endogenous Infection (inflammation): this is
immunological
in nature eg. Phlyctenular
keratitis caused by tubercular
or staphylococcal
hypersensitivity and interstitial keratitis related
to measles or syphilis. These conditions are
commonly noticed at corneal margin (Marginal
Keratitis or Marginal Corneal Ulcer)
3. Spread of Infection from neighboring structures

Symptom

rapid onset of ocular pain,

redness,
photophobia,
discharge, and
decreased vision

Physical
Ulceration of the epithelium; corneal infiltrate with no
significant tissue loss; dense, suppurative stromal
inflammation with indistinct edges; stromal tissue loss; and
surrounding stromal edema
Increased anterior chamber reaction with or without hypopyon
Folds in the Descemet membrane
Upper eyelid edema
Posterior synechiae
Surrounding corneal inflammation that is either focal or diffuse
Conjunctival hyperemia
Adherent mucopurulent exudate
Endothelial inflammatory plaque

Stromal
suppuration
and
hypopyon

Expanding oval,
yellow-white,
dense stromal
infiltrate

Central bacterial corneal ulcer

with hypopyon

Medical theraphy
Topical broad spectrum antibiotic therapy should be
used until culture results are available.
Small non-staining peripheral ulcers may be started on
fluoroquinolone drops every 2 to 6 hours.
For ulcers with epithelial defects and an anterior
chamber reaction, a fluoroquinolone drop every hour
around the clock is recommended.
Large or vision threatening ulcers (with moderate to
severe anterior chamber reaction and/or involving the
visual axis) are usually treated with fortified tobramycin
or gentamicin (15mg/ml) every hour around the clock
alternating with fortified vancomycin (25mg/ml) every
hour around the clock.

Fungal keratitis
Fungal keratitis is a serious ocular
infection with potentially catastrophic
visual results. Caused by any of the
many species of fungi capable of
colonizing human tissue, its occurs
worldwide and its incidence is
increasing in frequency.

Risk factor
Trauma
Topical corticosteroid use
Corneal surgery such as penetrating
keratoplasty, clear cornea (sutureless)
cataract surgery, or laser in situ
keratomileusis (LASIK)
Young males
Previous history of trauma (vegetable
matter)
Agricultural occupations

Pathophysiology
starts when the epithelial integrity is
broken either due to trauma or ocular
surface disease
Proteolitic enzymes, fungal antigens
and toxins are liberated into the
cornea with the resulting necrosis
and damage to its architecture thus
compromising the eye integrity and
function.

Symptom
Symptoms are similar to any corneal
infection including blurred vision,
redness, tearing, photophobia, pain,
foreign body sensation and
secretions.

Physical
the clinical diagnosis of fungal
keratitis is based on risk factor
analysis and characteristic corneal
features.
The most common signs on slit lamp
examination are nonspecific and
include the following:
Conjunctival injection
Fungal corneal ulcer,
with excessive

Marginal ulcer, fungus

positive.

Fungal abcess

Stromal infiltration
Anterior chamber reaction
Pigmented lesion
Hypopyon
Epithelial defect

Treatment
Natamycin 5% suspension: frequency
will depend on severity of condition
Candida species respond better to
Amphotericin B 0.15%
Fluconazole 2%
Miconazole 1%
Scrapping every 24 to 48 hours
Treatment is required for 4 6 weeks

Treatment
Sub-conjunctival injection of
Miconazole 5 10 mgm of 10
mgm/ml suspension (indicated in
severe form of keratitis, scleritis and
endophthalmitis)
Systemic:
Fluconazole or Ketoconazole is
indicated in severe form of keratitis,
scleritis and endophthalmitis

Viral Keratitis
Herpetic epithelial keratitis may
occur unilaterally or bilaterally (most
often in patients with atopic disease)
and may be accompanied by a
blepharoconjunctivitis, involving
lesions of the lid and a follicular
response of the conjunctiva. In
addition, a palpable preauricular
lymph node may be present

Risk factor
Risk factors for development of
primary HSV involve direct contact
with infected lesions, but also may
result as exposure to asymptomatic
viral shedding. Risk factors for
reactivation of disease have been
postulated to include sunlight,
trauma, heat, menstruation, stress,
infectious disease and
immunocompromised states.

Herpes Simplex Keratitis

Epidemiology
- 90% of the population are carriers of HSV
- corneal infection is always a recurrence
Symtomps:
- very painful, photophobia, lacrimation,
and swelling of the eyelids
-vision may be impaired

Forms of herpes simplex keratitis

Dendritic keratitis (epithelial cell)
Stromal Keratitis diskiform corneal
infiltrates
Acute retinal necrosis syndrome
Involvement of the posterior eyeball

Treatment
epithelial keratitis : topical antivirals,
gentle wiping dbridement
Stromal/Endothelial Keratitis :
antiviral prophylaxis

Herpes Simplex Keratitis

Herpes Simplex Keratitis

Herpes Zoster Keratitis

endogenous recurrence of
chickenpox
affected the ophthalmic division of
the trigeminal nerve
Sign and symtomps: red eyewith
dendritic keratitis, stromal keratitis,
and keratouveitis), Hutchinsons sign,
Corneal sensitivity is usually
decreased or absent

Treatment

Acanthamoeba Keratitis
Acanthamoeba is a free-living
protozoan that thrives in polluted
water containing bacteria and
organic material.
usually associated with soft contact
lens wear, including silicone hydrogel
lenses, or overnight wear of rigid
(gas-permeable) contact lenses to
correct refractive errors
(orthokeratology)

symptom
The initial symptoms:
pain out of proportion to the clinical
findings, redness,
and photophobia

clinical signs

indolent corneal ulceration

a stromal ring
perineural infiltrates
often present with changes confined
to the corneal epithelium

Epithelial ridges seen in

Acanthamoeba keratitis

Perineuritis seen in Acanthamoeba

keratitis

Nonspecific infiltration of the corneal stroma

caused by Acanthamoeba infection.

differential diagnosis
herpetic keratitis, with which it is
frequently confused
fungal keratitis
mycobacterial keratitis
nocardia infection of the cornea.

treatment
In the early stages
epithelial debridement

Medical treatment
topical propamidine isethionate (1% solution)
polyhexamethylene biguanide (0.010.02%
solution)
fortified neomycin eyedrops
PS. may have variable drug sensitivities and may
acquire drug resistance, also hampered by the
organisms' ability to encyst within the corneal stroma