Reported by:

Mae Argailyn I. Guzman

Review:
Outline
Physiology
Symptoms
Laboratory Studies
Corneal ulceration
Infectious
Non infectious
Epithelial keratitis
Degenerative corneal conditions
Miscellaneous corneal disorders

Physiology
protective barrier
window through which light rays pass
to retina
Transparent due to :
-uniform structure
- avascularity
- deturgescence
state of relative dehydration of the corneal
tissue
Endothelium
- edema of the cornea
- loss of transparency, persists
Epithelium
- transient, localized edema
- clears with rapid regeneration

Penetration by drugs
- biphasic
- fat-soluble epithelium
-water-soluble intact stroma
- THUS, to pass through cornea,
drugs must be water and lipid
soluble
Resistance to Infection
Traumatized epithelium > avascular
stroma and Bowmans layer become
susceptible to infection
Streptococcus pneumoniae true
bacterial pathogen
Corticosteroids modify host immune
reaction
Symptoms
Keys to exam: adequate illumination,
instillation of local anesthetic and
magnification (slit lamp)
Pain pain fibers, worsened by
movement of lids,
Photophobia due to painful
contraction of inflamed iris
Blurred vision
No discharge except in purulent
bacterial ulcers
Investigation of Corneal Disease
Past medical history:
Trauma
Two most common lesion: foreign
bodies, abrasion
History corneal disease
Use of topical medications
Systemic diseases

Laboratory Studies
Appropriate therapy is instituted as
soon as the necessary specimens
have been obtained
Examination of corneal scrapings
(Gram and Giemsa stain)
PCR
Culture

Morphologic Diagnosis of Corneal
Lesions
Epithelial Keratitis
- most types
- edema, vacuolation to minute
erosions, filament formation, partial
keratinization

Subepithelial Keratitis
- secondary
Stromal Keratitis
- infiltration
- edema manifested by corneal
thickening, opacification
- melting/ necrosis- thinning/ perforation
- vascularization
Endothelial Keratitis
- edema
- initially involving the stroma then
epithelium

I. Corneal Ulceration
Major cause of blindness and impaired
vision throughout the world.
May be:
A. Infectious
B. Non-infectious

A. Infectious Corneal Ulcers

- lesion situated centrally
- Hypopyon collection of inflammatory
cells seen as a pale layer in the inferior
anterior chamber
-contact lens wear most common
predisposing factor

Hypopyon
A. Infectious Corneal Ulcers
1. Bacterial Keratitis
2. Fungal Keratitis
3. Viral Keratitis
4. Acanthamoeba Keratitis
1. Bacterial Keratitis
Streptococcus pneumoniae
- manifests in 24-48 hrs
- gray, fairly well-circumscribed ulcer that tends
to spread erratically from original site to center
- Acute serpiginous ulcer
- superficial corneal layers, deep parenchyma
- scrapings: gram positive lancet- shaped
diplococci
- Moxifloxacin, Gatifloxacin, Cefazolin

Pseudomonas aeruginosa
- gray or yellow infiltrate at the site of a break
- severe pain
- spread rapidly in all directions due to
proteolytic enzymes
-superficial, entire cornea
-consequences: corneal perforation and
severe intraocular infection
- infiltrate and exudate bluish-green colors
(pathognomonic)
-Associated with soft contact lenses (esp
extended-wear lenses)
-Scrapings: long, thin, gram-neg rods
-Tx: Moxifloxacin, gatifloxacin,
ciprofloxacin, tobramycin, gentamicin

Moraxella liquefaciens
- diplobacillus of Petit
-indolent oval ulcer
- inferior cornea, deep stroma in days
- no hypopyon or a small one
- surrounding cornea clear
- alcoholics, DM, immunosuppression
- scrapings: large, square-ended Gram neg
diplobacilli
- Tx: moxifloxacin, gatifloxacin, tobramycin
Group A Streptococcus Corneal Ulcer
- no identifying features
- surrounding corneal stroma often
infiltrated and edematous
- moderately large hypopyon
- Scraping: gram positive cocci in chains
- Tx: Vancomycin
Staphylococcus aureus, epidermidis, and
Alpha-Hemolytic Streptococcus
-central corneal ulcer
-compromised by topical corticosteroids
-indolent, hypopyon, surrounding corneal
infiltration
-superficial, ulcer bed feels firm when scraped
-scrapings: gram positive cocci singly, in pairs
or chains
-Infectious crystalline keratopathy - in long term
therapy with topical steroids

Mycobacterium fortuitum-chelonei and
Nocardia
-rare
- follow trauma, contact with soil
- indolent, bed of ulcer has a radiating lines
make it look like cracked windshield


Infectious crystalline keratopathy
2. Fungal Keratitis
Agricultural workers, urban population
Use of corticosteroids not indicated
Gray infiltrate with irregular edges
Marked inflammation of the globe,
superficial ulceration
Satellite lesions
Endothelial plaque assoc with a severe
anterior chamber reaction
Scrapings (except candida): Hyphal
elements
Candida: pseudohyphae or yeast forms
with characteristic budding
Tx: Hyphae Natamycin or voriconazole
Candida Vorionazole, Ampotericin B

3. Viral Keratitis
Herpes Simplex Keratitis
- primary or recurrent
- most common cause of both corneal ulceration
and corneal blindness
- immunocompetent: self-limited;
immunocompromised: chronic and damaging
- HSV I - establishes latency in trigeminal
ganglion
- scrapings: multinucleated giant cells
- Dx: dendritic or geographic ulcers and greatly
reduced/ absent sensation
- attacks of recurrent type triggered by:
- fever, overexposure to UV light, trauma,
onset of menstruation,
immunosuppression
- unilaterality is the rule; bilateral (4-6%)
- first symptoms: irritation, photophobia,
tearing, anesthesia
- Dendritic ulcer- most characteristic lesion
- Geographic ulceration
- Tx: debridement, Ganciclovir and
Anyclovir, penetrating keratoplasty,
control of trigger mechanisms
Varicella- Zoster Viral Keratitis
2 forms: primary (varicella) and recurrent
(herpes zoster)
-Eye lesions
-Varicella: pocks on the lids and lid margins
-Herpes zoster: accompanied by keratouveitis
-Affects stroma and anterior uvea at onset
-Epithelial lesions: blotchy and amorphous
except for occassional linear pseudodendrite


- Loss of corneal sensation, with risk of
neurotrophis keratitis
- Tx: acyclovir, valacyclovir, famciclovir
4. Acanthamoeba Keratitis
- free-living protozoan in polluted water
- assoc. with soft contact lens wear
-pain, redness, photophobia
- characteristic clinical signs: indolent
corneal ulceration, stromal ring, perineural
infiltrates
-Tx: epithelial debridement (early), 1%
propamidine isethionate,
polyhexamethylene biguanide, fortified
neomycin, keratoplasty
B. Non-Infectious Corneal Ulcers
1. Marginal Infiltrates and Ulcers
2. Moorens Ulcer
3. Phlyctenular Keratoconjunctivitis
4. Marginal Keratitis in autoimmune
disease
5. Corneal Ulcer due to Vit A deficiency
6. Neurotrophic Keratitis
7. Exposure Keratitis

B. Non-Infectious Corneal Ulcers
Marginal Infiltrates and Ulcers
benign but extremely painful
- sensitization to bacterial products
-self-limited, 7-10 days
-Tx: topical corticosteroid

Moorens Ulcer
- unknown, may be autoimmune
-unilateral
- painful, progressive excavation of the
limbus and peripheral cornea that often
leads to loss of the eye
-unresponsive to both antibiotics and
corticosteroids
- Tx: surgical excision, lamellar tectonic
keratoplasty
Phlyctenular Keratoconjunctivitis
-delayed hypersensitivity response
- associated with a transient increase in
the activity of childhood TB
-spontaneously regress after 10-14 days
-Tx: topical corticosteroid
Marginal Keratitis in autoimmune
disease

- changes secondary to scleral
inflammation
- vascularization, infiltration and
opacification, peripheral guttering


Corneal Ulcer due to Vit A deficiency
- centrally located, bilateral, gray and indolent, with
a definite lack of corneal luster in the surrounding
area
- keratomalacia cornea becomes soft and
necrotic
-Bitots spot- keratinized epithelium of the
conjunctiva
-Lack of vitamin A causes a generalized
keratinization of the epithelium throughout the body
-conjunctival + corneal changes together are
known as xerophthalmia



Tx: Treat underlying cause
Neurotrophic Keratitis
- trigeminal nerve dysfunction
- corneal anesthesia with loss of blink reflex
- Tx: keep eyes closed

Exposure Keratitis
- drying of cornea and its exposure to minor
trauma
- Tx: Provide protection and moisture for entire
corneal surface
II. Epithelial Keratitis
1. Chlamydial keratitis
2. Drug-induced epithelial Keratitis
3. Keratoconjunctivitis Sicca
4. Adenovirus Keratitis
Chlamydial Keratitis
Chlamydial conjunctivitis accompanied by
corneal lesions
Corneal lesions of trachoma
1. Epithelial microerosions affecting the
upper third of the cornea
2. Micropannus
3. subepithelial round opacities, commonly
called trachoma pustules
4. limbal follicles and their cicatricial remains,
known as Herbert's peripheral pits
5. gross pannus
6. extensive, diffuse, subepithelial
cicatrization
Tx: systemic tetracyclines, topical
sulfonamides, tetracycline,
erythromycin, rifampin


Drug-induced Epithelial Keratitis
Coarse, superficial keratitis affecting
predominantly the lower half of the
cornea and interpalpebral fissure, may
cause permanent scarring
Causes: preservatives in eyedrops
(benzalkonium chloride and thimerosal)
Keratoconjunctivitis Sicca (Sjgren's
Syndrome)
autoimmune disease
Cardinal signs: epithelial filaments in the
lower quadrants of the cornea
secretion of the lacrimal and accessory
lacrimal glands is diminished or eliminated
blotchy epithelial keratitis that affects
mainly the lower quadrants
Severe cases: mucous pseudofilaments
that stick to the corneal epithelium
Tx: frequent use of tear substitutes and
lubricating ointments


Adenovirus Keratitis
accompanies all types of adenoviral
conjunctivitis
peak 57 days after onset of the
conjunctivitis
fine epithelial keratitis best seen with the
slitlamp after instillation of fluorescein
Corticosteroid not recommended
III. Degenerative Corneal Conditions
1. Keratoconus
2. Corneal Degeneration
3. Arcus Senilis
Keratoconus
- 2
nd
decade of life
- blurred vision only symptom
- disruptive changes in Bowmans
layer with keratocyte
degeneration and ruptures of
descemets membrane
- cone-shaped cornea

-Vogts lines linear narrow folds
centrally in Descemets membrane
(pathognomonic)
- Fleischers ring iron ring around base
of the cone
- Munsons sign indentation of the lower
lid by the cornea when patient looks
down
- Tx: Rigid contact lens, surgery
(transplant)





Corneal Degeneration
a. Terriens Disease
- marginal thinning of the upper nasal
quadrants of the cornea
- men
- irritation during occasional inflammatory
episodes
- Tx: Tectonic Keratoplasty
b. Band (Calcific) Keratopathy
- deposition of calcium salts in a band-
like pattern in the anterior layers of the
cornea
- Clear margin separates calcific band
from limbus and clear holes
- juvenile idiopathic arthritis


c. Climatic Droplet Keratopathy

- outdoors- UV light
- early stages of fine subepithelial yellow
droplets in peripheral cornea.
- clouding
- Tx: transplant






d. Salzmanns Nodular Degeneration
- preceded by inflammation
-degeneration of superficial cornea
- superficial whitish gray elevated
nodules sometimes occurring in chains



Arcus Senilis

- extremely common, bilateral, benign
peripheral corneal degeneration
- assoc. with hypercholesterolemia and
hypertrigylceridemia
- hazy gray ring about 2 mm in width and
with clear space between it and the
limbus
Miscellaneous Corneal Disorders
Interstitial Keratitis due to congenital
syphilis
- late manifestation of congenital syphilis
- ages 5-20
- edema, infiltration and vascularization
- Hutchinsons triad- interstitial keratitis,
deafness, notched upper central incisors
- saddle nose- another sign
- pain, photophobia and blurring of vision
- salmon patch grayish-pink cornea

Thank You!