Keratitis 09

8/8/2019 Keratitis 09

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KeratitisKeratitis


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Cornea.Cornea.

TheThe corneacornea isis thetheeyeseyes opticaloptical windowwindow

thatthat makesmakes itit possiblepossible

forfor humanshumans toto seesee..

TheThe corneacornea tissuetissue

consistconsist ofof fivefive layerslayers..

1.1. The surfase of theThe surfase of the

cornea is formed bycornea is formed by

stratifiedstratified

nonkeratinizednonkeratinized

squamoussquamous

epithelium.epithelium.


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The cornea tissue consist offive layers.The cornea tissue consist offive layers.

2. A thin basement2. A thin basement

membrane anchors themembrane anchors the

basal cells of thebasal cells of the

stratified squamousstratified squamous

epithelium toepithelium to

BowmanBowmans layers layer..

3. The stroma is a highly3. The stroma is a highly

bradytrophic tissuebradytrophic tissue


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The cornea tissue consist offive layers.The cornea tissue consist offive layers.

4. Descemets4. Descemetsmembrane is amembrane is a

relatively strongrelatively strong

membranemembrane

5. The corneal5. The corneal

endothelium isendothelium is

responsible for theresponsible for the

transparency of thetransparency of the

cornea. The cornealcornea. The corneal

endothelium does notendothelium does not

regenerate.regenerate.


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Infectious Keratitis (purulent ulcerof theInfectious Keratitis (purulent ulcerof the

cornea)cornea)

Protective Mechanisms of the CorneaProtective Mechanisms of the Cornea * Reflexive eye closing.* Reflexive eye closing.

* Flushing effect of tear fluid (lysozyme).* Flushing effect of tear fluid (lysozyme).

* Its hydrophobic epithelium forms a diffusion barrier.* Its hydrophobic epithelium forms a diffusion barrier.

* Epithelium can regenerate quickly and completely.* Epithelium can regenerate quickly and completely.Pathogens causing corneal infections mayPathogens causing corneal infections may

include:include: Viruses.Viruses.

Bacteria.Bacteria.

Acanthamoeba.Acanthamoeba.

Fungi.Fungi.


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Pathogenesis:Pathogenesis:

Once these pathogens have invaded theOnce these pathogens have invaded the

bradytrophic tissue through a superficialbradytrophic tissue through a superficialcorneal lesion, a typical chain of events willcorneal lesion, a typical chain of events will

ensue:ensue:

Corneal lesion.Corneal lesion. Pathogens invade andPathogens invade and colonize the cornealcolonize the corneal

stromastroma (red eye).(red eye).

Antibodies will infiltrateAntibodies will infiltrate the site.the site.

As a result, the cornea will opacity and theAs a result, the cornea will opacity and thepoint of entry will open further, revealing thepoint of entry will open further, revealing the

cornea infiltrate.cornea infiltrate.


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Irritation of the anteriorIrritation of the anterior

chamber with hypopyonchamber with hypopyon(typically pus will(typically pus will

accumulate on the floor ofaccumulate on the floor of

the anterior chamber).the anterior chamber).

The pathogens will infestThe pathogens will infest

the entire cornea.the entire cornea.

As a result the stroma willAs a result the stroma will

melt down to Descemet'smelt down to Descemet's

membrane, which ismembrane, which is

relatively strong This isrelatively strong This isknown as aknown as a

descemetocele;descemetocele; onlyonly

DescemetDescemets membrane iss membrane is

still intact.still intact.


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As the disorderAs the disorderprogresses, perforation ofprogresses, perforation of

DescemetDescemets membranes membrane

occurs and the aqueousoccurs and the aqueous

humor will be seen tohumor will be seen to

leak. This is referred to asleak. This is referred to as

aa per-foratedper-forated cornealcorneal

ulcerulcerand is an indicationand is an indication

for immediate surgicalfor immediate surgical

intervention (emergencyintervention (emergencykeratoplasty).keratoplasty).


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Prolapse of the irisProlapse of the iris (the iris(the iriswill prolapse into the newlywill prolapse into the newly

created defect) closing thecreated defect) closing the

corneal perforationcorneal perforation

posteriorly.posteriorly.

This rapidly progressing formThis rapidly progressing formof infectious corneal ulcerof infectious corneal ulcer

(usually bacterial) is referred(usually bacterial) is referred

to as a serpiginous cornealto as a serpiginous corneal

ulcer.ulcer. It penetrates theIt penetrates the

cornea particularly rapidlycornea particularly rapidlyA serpiginous corneal ulcer isA serpiginous corneal ulcer is

one of the most dangerousone of the most dangerous

clinical syndromes as it canclinical syndromes as it can

rapidly lead to loss of therapidly lead to loss of the

eye.eye.


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Treatment: Conservative therapy.Treatment: Conservative therapy.

Treatment is initiated with topical antibioticsTreatment is initiated with topical antibiotics:: Eye drops:Eye drops: 0,25%0,25% Laevomycetin, 0,5%Laevomycetin, 0,5%

Gentamycin, 1% Erythromycin, 0,5% Neomycin,Gentamycin, 1% Erythromycin, 0,5% Neomycin,

0,3% Ciprolet, 0,3% Ciromed, 0,3% Ocacin, 0,3%0,3% Ciprolet, 0,3% Ciromed, 0,3% Ocacin, 0,3%

Tobramycin, 0,3%FloxalTobramycin, 0,3%Floxal

Ointments:0,3% Tobramycin, 0,3%FloxalOintments:0,3% Tobramycin, 0,3%Floxal

Mydriatics: 1% Atropin, 0,1%Mydriatics: 1% Atropin, 0,1%--0,25% Scopolamin,0,25% Scopolamin,

0,5% Homotropin, 0,1%P

latyphyllin, 0,1%0,5% Homotropin, 0,1%P

latyphyllin, 0,1%Adrenalin,0,5% Mydriacyl, 1% Tropicamide, 1%Adrenalin,0,5% Mydriacyl, 1% Tropicamide, 1%

Ciclomed, 2,5% EryphrinCiclomed, 2,5% Eryphrin


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Treatment:Treatment:

NonNon--steroid drags: diclofenac, naclof, diclofsteroid drags: diclofenac, naclof, diclof

Actovegin gele 20%, solcoseril gele.Actovegin gele 20%, solcoseril gele.

Subconjunctival application of antibioticsSubconjunctival application of antibiotics

may be required to increase themay be required to increase theeffectiveness of the treatmenteffectiveness of the treatment


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Surgical treatment.Surgical treatment.Emergency keratoplasty isEmergency keratoplasty is

indicated to treat aindicated to treat a

descemetocele or adescemetocele or a

perforated corneal ulcerperforated corneal ulcer

(see emergency(see emergency

keratoplasty). Broad areaskeratoplasty). Broad areasof superficial necrosis mayof superficial necrosis may

require a conjunctival flaprequire a conjunctival flap

to accelerate healing.to accelerate healing.

Stenosis or blockage of theStenosis or blockage of the

lower lacrimal system thatlower lacrimal system thatmay impair healing of themay impair healing of the

ulcer should be surgicallyulcer should be surgically

corrected.corrected.


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Viral KeratitisViral Keratitis

Viral keratitis is frequently caused by:Viral keratitis is frequently caused by:

1. Herpes simplex virus.1. Herpes simplex virus.2. Varicella2. Varicella--zoster virus.zoster virus.

3. Adenovirus.3. Adenovirus.

Herpes Simplex KeratitisHerpes Simplex Keratitis

Epidemiology and pathogenesis:Epidemiology and pathogenesis: HerpesHerpes

simplex keratitis is among the moresimplex keratitis is among the more

common causes of corneal ulcer.common causes of corneal ulcer.


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Herpes Simplex KeratitisHerpes Simplex Keratitis

Symptoms:Symptoms: HerpesHerpessimplex keratitis issimplex keratitis is

usuallyusually very painfulvery painfulandand

associated withassociated with

photophobia,photophobia,lacrimation, andlacrimation, and

swelling of the eyelids.swelling of the eyelids.

Vision may be impairedVision may be impaired

depending on thedepending on thelocation of findingslocation of findings


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Forms and diagnosis ofherpesForms and diagnosis ofherpes

simplex keratitis:simplex keratitis:

The following forms of herpes simplexThe following forms of herpes simplex

keratitis are differentiated according tokeratitis are differentiated according to

the specific layer of the cornea in whichthe specific layer of the cornea in whichthe lesion is located.the lesion is located.


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Dendritic keratitis.Dendritic keratitis.

This is characterized byThis is characterized bybranching epithelial lesionsbranching epithelial lesions

(necrotic and vesicular(necrotic and vesicular

swollen epithelial cells).swollen epithelial cells).

These findings will beThese findings will be

visible withvisible with the unaided eyethe unaided eye

after application ofafter application of

fluorescein dye and arefluorescein dye and are

characteristic of dendriticcharacteristic of dendritic

keratitis. Corneal sensitivitykeratitis. Corneal sensitivityis usually reduced. Dendriticis usually reduced. Dendritic

keratitis may progress tokeratitis may progress to

stromal keratitis.stromal keratitis.


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Stromal Keratitis.Stromal Keratitis.

Slit lamp examinationSlit lamp examinationwill reveal centralwill reveal central

diskiformdiskiform cornealcorneal

infiltrates (diskiforminfiltrates (diskiform

keratitis) with or withoutkeratitis) with or withouta whitish stromala whitish stromal

infiltrate. Depending oninfiltrate. Depending on

the frequency ofthe frequency of

recurrence, superficialrecurrence, superficialor deep vascularizationor deep vascularization

may be present.may be present.


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Treatment of the Viral Keratitis :Treatment of the Viral Keratitis :

Viral static agents can be used forViral static agents can be used for

treatment, such astreatment, such as acyclovir,acyclovir, which iswhich isavailable for topical use (in ointment form)available for topical use (in ointment form)

and systemic use.and systemic use.

Corticosteroids are contraindicatedCorticosteroids are contraindicated ininepithelial herpes simplex infections.epithelial herpes simplex infections.


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Endogenous keratitisEndogenous keratitis

I. Tuberculous keratitisI. Tuberculous keratitis TuberculoTuberculo--allergic keratitisallergic keratitis

Hematogenictuberculous keratitisHematogenictuberculous keratitis

) Deep diffused keratitis.) Deep diffused keratitis.

) Deep corneal infiltrate.) Deep corneal infiltrate.

) Sclerosing keratitis) Sclerosing keratitis

II. Parenchymatous syphilitic keratitisII. Parenchymatous syphilitic keratitis


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TuberculoTuberculo--allergic keratitisallergic keratitis

Small phlyctenas (miliary) that are smaller thanSmall phlyctenas (miliary) that are smaller thanmillet in size are more often numerous. Solitarymillet in size are more often numerous. Solitary

phlyctenas look like grayishphlyctenas look like grayish--yellow nodes up to 3yellow nodes up to 3

or4 mm in diameter. Phlyctenas are alwaysor4 mm in diameter. Phlyctenas are always

situated in the superficial layers of the cornea, butsituated in the superficial layers of the cornea, butthey also may involve deep stromal layers. Rightthey also may involve deep stromal layers. Right

after phlyctena appears superficial vesselsafter phlyctena appears superficial vessels

reaching out to the focus in the form of bundlesreaching out to the focus in the form of bundles

are seen on the cornea. Appearance ofare seen on the cornea. Appearance ofphlyctenas is accompanied by severephlyctenas is accompanied by severe

photophobiaphotophobia


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TuberculoTuberculo--allergic keratitisallergic keratitis

Rarely phlyctenas get absorbed without leavingRarely phlyctenas get absorbed without leavingany signs such as ulceration. More commonlyany signs such as ulceration. More commonly

they disintegrate. Disintegration is accompaniedthey disintegrate. Disintegration is accompanied

by craterby crater--shaped ulcers, which bases are quicklyshaped ulcers, which bases are quickly

covered with epithelium (facet stage). After thatcovered with epithelium (facet stage). After thatthey are gradually replaced by the connectivethey are gradually replaced by the connective

tissue and a circumscribed scar forms. Seldomtissue and a circumscribed scar forms. Seldom

disintegration of phlyctemas ends with completedisintegration of phlyctemas ends with complete

destruction of the stroma and appearance ofdestruction of the stroma and appearance of

descemetocele and perforation.descemetocele and perforation.


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Hematogenic tuberculous keratitisHematogenic tuberculous keratitis

Deep diffused keratitis.Deep diffused keratitis. The disease isThe disease ischaracterized by lacrimation, photophobiacharacterized by lacrimation, photophobia

and pericorneal injection. The corneaand pericorneal injection. The cornea

becomes cloudy fast. Against such abecomes cloudy fast. Against such a

background separate big yellowishbackground separate big yellowish--gray focigray fociare apparently seen in deep and mediumare apparently seen in deep and medium

layers. There is a moderate vascularizationlayers. There is a moderate vascularization

of the cornea. As a rule only one eyeof the cornea. As a rule only one eyebecomes affected. Remissions go togetherbecomes affected. Remissions go together

with an acute stage. Forecast is unfavorable.with an acute stage. Forecast is unfavorable.


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TreatmentTreatment

Treatment includes administration ofTreatment includes administration ofspecificspecific antituberculous agentsantituberculous agents such assuch as

Streptomycin, Phthivazide, Metazide,Streptomycin, Phthivazide, Metazide,

Tubazide, Saluzide etc. Medicines used forTubazide, Saluzide etc. Medicines used for

treatment for purulent ulcer of the corneatreatment for purulent ulcer of the cornea

are also prescribed:are also prescribed:

antibioticsantibiotics (Ciprolet, Cipromed, Tobrex),(Ciprolet, Cipromed, Tobrex),

mydriaticsmydriatics (Atropine, Cyclomed, Mesaton,(Atropine, Cyclomed, Mesaton,

Mydriacyl, Irifrin and others),Mydriacyl, Irifrin and others),


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TreatmentTreatment

keratoplastic agentskeratoplastic agents (Actovegin, Solcoseryl,(Actovegin, Solcoseryl,

vitamins A and E),vitamins A and E),

nonsteroid antinonsteroid anti--inflammatory drugsinflammatory drugs (Dycdoph,(Dycdoph,

Nacloph).Nacloph). If epithelial defect is absent application ofIf epithelial defect is absent application of

glucocorticosteroids is possibleglucocorticosteroids is possible (Acetolomide,(Acetolomide,

Dexamethasone, Prednisolone).Dexamethasone, Prednisolone).

Inhibitors of proteolytic enzymesInhibitors of proteolytic enzymes can also becan also be

administered (Cortical, Gordox, Tracylol).administered (Cortical, Gordox, Tracylol).


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Parenchymatous syphilitic keratitisParenchymatous syphilitic keratitis

Clinical features.Clinical features. The disease is characterizedThe disease is characterizedby cyclic course, bilateral lesion, involvement of theby cyclic course, bilateral lesion, involvement of theuveal tract, absence of recurrence and relativelyuveal tract, absence of recurrence and relativelyfavorable outcome. The course of parenchymatousfavorable outcome. The course of parenchymatoussyphilitic keratitis hassyphilitic keratitis has three stages: infiltration,three stages: infiltration,vascularization and absorption.vascularization and absorption.At the first stage aAt the first stage apatient has slight photophobia and lacrimation.patient has slight photophobia and lacrimation.Insignificant pericorneal injection is present on theInsignificant pericorneal injection is present on thefundus. There is diffused grayfundus. There is diffused gray--white infiltration at thewhite infiltration at the

limb in the corneal stroma. The infiltrate consists oflimb in the corneal stroma. The infiltrate consists ofseparate dots, lines and strokes. The surface aboveseparate dots, lines and strokes. The surface abovethe infiltrate is rough. The infiltrate gradually spreadsthe infiltrate is rough. The infiltrate gradually spreadsover the whole cornea. Infiltration period takes 3 to 4over the whole cornea. Infiltration period takes 3 to 4weeks.weeks.


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At the first stage a patient has slightAt the first stage a patient has slightphotophobia and lacrimation. Insignificantphotophobia and lacrimation. Insignificantpericorneal injection is present on thepericorneal injection is present on thefundus. There is diffused grayfundus. There is diffused gray--whitewhite

infiltration at the limb in the corneal stroma.infiltration at the limb in the corneal stroma.The infiltrate consists of separate dots, linesThe infiltrate consists of separate dots, linesand strokes. The surface above the infiltrateand strokes. The surface above the infiltrateis rough. The infiltrate gradually spreadsis rough. The infiltrate gradually spreadsover the whole cornea. Infiltration periodover the whole cornea. Infiltration periodtakes 3 to 4 weeks.takes 3 to 4 weeks.


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In the 5th weeks the vessels begin to appear onIn the 5th weeks the vessels begin to appear onthe cornea. Vascularization is deep. The limb getsthe cornea. Vascularization is deep. The limb getsedematous. Vessel injection is mixed.edematous. Vessel injection is mixed.Vascularization period lasts from 6 to 8 weeks.Vascularization period lasts from 6 to 8 weeks.The vessels run through the whole cornea makingThe vessels run through the whole cornea makingit look like nonit look like non--fresh meat. Absorption period lastsfresh meat. Absorption period lastsfrom 1 to 2 years. Irritation of the eye becomesfrom 1 to 2 years. Irritation of the eye becomesless. Infiltrates get absorbed starting from the limbless. Infiltrates get absorbed starting from the limband ending with the center of the cornea. Theand ending with the center of the cornea. Thecornea becomes transparent again. The vesselscornea becomes transparent again. The vessels

get empty and are seen in the form of thin threadsget empty and are seen in the form of thin threads(vascular pannus).(vascular pannus).

Treatment. Specific therapy with penicillin drugsTreatment. Specific therapy with penicillin drugsand treatment like in usual keratitis.and treatment like in usual keratitis.

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Keratitis 09