GOOD MORNING CONGRATULATION M R SHOJA 1 M

GOOD MORNING & CONGRATULATION M. R. SHOJA 1

M. R. SHOJA Professor Of Ophthalmology M. R. SHOJA 2

BACTERIAL KERATITIS n An ocular emergency n Prompt diagnosis n Initiation of approtiate antibiotic n Limit amount of tissue destruction n Improve patient, s visual prognosis M. R. SHOJA 3

§ Most important defense barrier for cornea is intact epithelial layer § Major risk factors for infectious keratitis is compromised epithelium protective layer. § Precipitating event is epithelial defect produced by trauma, contact lens wear or a chronic corneal disorders M. R. SHOJA 4

Ocular Defense Mechanism Chemical Mechanical Abnormality of tear film • Intact corneal epitheliuma Lysozym (first line of defence) Lactoferin • Blinking reflex immunoglubulin. A • (reduced bacterial colonization) Mucin deficiency

Pathogenesis Proliferation of Bacteria Adherence to ulcerated epithelium invasion into stroma Migration of neutrophile Production of proteinase Inflammatory necrosis Neovascular scar formation Corneal perforation M. R. SHOJA 6

Risk factors (Corneal) § § § Trauma Contact lens wear Previous ocular surgery Ocular adnexal disorders Chronic surface disease of cornea Decreased corneal sensation M. R. SHOJA 7

Risk Factors Systemic condition • Diabetes • Systemic infections • Collagen vascular diseases • Immuno suppressive drug • Pregnancy • Chronic alcholism • Extensive body burns • Drug addiction • AIDS Local Topical: Steroid Antiviral Antibiotic Anesthestics

Chronic Corneal Surface Disease § Bullous keratitis § Exposure keratopathy § Keratoconjunctivitis sicca § Neurotrophic keratopathy M. R. SHOJA 9

Previous ocular surgery n Cataract extraction n Keratoplasty n Pterygium excision n Loose corneal sutures n Refractive surgery M. R. SHOJA 10

Ocular Adnexal Conditions n Entropion n Ectropion n Trichiasis n Blepharitis / Rosacea M. R. SHOJA 11

Normal flora of ocular surface n GRAM POSITIVE: n Staphylococcus Aureus (more common) Staphylococcus Epidermidis (more common) Propionibacterium acnes. Streptococcus Viridans n GRAM NEGATIVE n n n n (less common) Escheria Coli Klebsiella Proteus Moraxella M. R. SHOJA 12

Causes of Bacterial keratitis (87%) Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniea Pseudomonas aeruginosa Most common organism in soft contact lens Enterobacteriaceae (proteus, enterobacter) M. R. SHOJA 13

ETIOLOGY Now york London S. aureus Pseudomonas S. pneumonia Moraxella Pseudomonas M. R. SHOJA 14

Organisms penetrate intact epithelium § Neisseria gonorroae § Haemophilus agegyptius § Corynebacterium diphteria § Listeria M. R. SHOJA 15

Clinical presentation Rapid onset of pain n Conjunctival injection (Redness) n Photophobia n Decreased vision n Discharge and lid edema n M. R. SHOJA 16

Clinical features of G+ & G- keratitis Feature Gram positive Gram negative Appearance Mild to dense infiltrate Dense infiltrate necrosis Borders Distinct infiltrate borders Indistinct borders Surrounding cornea hypopyon Generally clear less common M. R. SHOJA Often hazy more common 17

CORNEAL PERFORATION IN PSEUDOMONAS & GONOCOCCAL KERATITIS. n SYMPTOMS: SUDDEN LOSS OF HYPOPYON RADIAL FOLD IN DESCEMET MEMBRANE PROTRUSION OF CORNEA AND DESMATOCELE FORMATION. TREATMENT: PATCH GRAFT OR PENETRATING K. M. R. SHOJA 18

Pseudomonas Keratitis (G -) n n n n Most common in Scls wear, burn , comatose , mechanical respiratory patients. Yellowish green hue with resistant to treatment. Most common in children < 3 years Contaminant in hospital, fluoresnce solutions. Rapidly progressive, destructive keratitis. May cause infectious Scleritis. Within 24 -48 h perforation may occur. Systemic antibiotic is necessary. M. R. SHOJA 19

Gonococci Keratitis n Hyperacute conjunctivitis , preauricular adenopathy n Penetrate intact epithelium , produce rapid n n corneal ulceration and perforation as 24 to 48 hours after infection. Choice of treatment is 1 g ceftriaxone IM or IV for 3 to 5 days for keratitis. Frequent irrigation is necessary. Sexual partners should be evaluated. In all hyperacute conjunctivitis the entire cornea must be evaluated for ulceration M. R. SHOJA 20

Gonococci Conjunctivitis & Keratitis M. R. SHOJA 21

Clinical signs of resolution Improved patient comfort Progressive re-epithelialization over infiltrate Decreasing size and density of infiltration. Loss of adherent mucopurulent discharge Reduction in hypopyon Reduction of stromal edema surrounding infiltrate Development of well-defined infiltrate borders M. R. SHOJA 22

Stain or culture media § Stains § Gram stain Giemsa stain Calcofluor white stain Acid fast stain § Culture media § § § § Blood agar Sabourauds agar Chocolate agar Thioglycolate broth M. R. SHOJA 23

Goals of therapy Rapid elimination of bacteria n Reduction of inflammatory response n Prevent of structural damage n Promotion healing of epithelial n M. R. SHOJA 24

Hospitalization Monotherapy Fluroquinolone Treatment Systemic Antibiotic Fortified combined drops Corneal Graft Drug penetartion in to cornea increased with higher concentration and frequent application M. R. SHOJA 25

Treatment (Imprical) Loading dose : 5 application every 2 Min Frequent instillation every 30 Min Fortified cephalosporin (50 mg/dl) + gentamycin or tobramycin (15 mg/ml) Modification of initial AB is based on culture results and clinical response For (G +) Vancomycin is alternative For (G-) Ceftazidime or Amikacine M. R. SHOJA 26

Initial therapy for bacterial keratitis Organism Antibiotic Topical dose Gram- positive cocci Cefazolin Vancomycin * 50 mg/ml Gram- negative rods Tobramycin Ceftazidime Gentamycin 9 -14 mg/ml 50 mg/ml 14 mg/ml No organism or multiple types of organisms Cefazolin With Tobramycin or Fluoroquinolones 50 mg/ml Ceftriaxone ceftazidime 50 mg/ml Gram-negative cocci M. R. SHOJA 3 mg/ml 27

Antibiotics n n The choice of antibiotics is standard topical, commercially unavailable, fortified aminoglycoside and fortified cephalosporin drops (ie gentamicin 1. 5% and cefuroxime 5%) or the new regime of fluoroquinolone monotherapy with commercially available ciprofloxacin or ofloxacin 0. 3%. Currently both the standard and fluoroquinolone regimen encounter bacterial resistance in about 5% of cases M. R. SHOJA 28

Treatment Subconjunctival injection for impending corneal perforation n Hydrophilic soft contact lens n Parenteral n 1 -Impending perforation n 2 -Perforated infection n 3 -Scleral involvement n M. R. SHOJA 29

Topical Corticosteroid Inhibit chemotaxis & phagocytosis Reduced stromal inflammatory reaction Recurrent of infection Limit tissue destruction by PMN and neovascuarization with scar • Not to be use in initial phase • Favourable response to antibiotic is advised. • Prednisolone acetate 1% QID • Patient must have frequent follow-up M. R. SHOJA 30

Corneal Exposure M. R. SHOJA 31

Corneal Melt M. R. SHOJA 32

Corneal Ulcer M. R. SHOJA 33

Hypopion Ulcer M. R. SHOJA 34

Fungal Keratitis Fungal keratitis is challenging corneal disease and 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. M. R. SHOJA 35

Fungal Keratitis n n n Fungi enter into corneal stroma through epithelial defect, which may be due to trauma, contact lens wear, bad ocular surface or previous corneal surgery. In stroma fungi multiply and causes tissue necrosis and inflammatory reaction. Organisms enter deep into the stroma and through an intact Descemets membrane into the anterior chamber and iris. They can also involve Sclera. M. R. SHOJA 36

Risk Factors 1. 2. 3. 4. 5. Trauma outdoor/ or the one which involves plant matter (including contact lenses) Topical medications: corticosteroids, anaesthetic drug abuse topical broad spectrum antibiotics use for long time M. R. SHOJA 37

Risk Factors 6. Systemic use of steroids 7. Corneal surgeries (Penetrating keratoplasty, refractive surgery) 8. Chronic keratitis (herpes simplex, herpes zoster, Vernal or allergic keratoconjunctivitis, and neurotrophic ulcer) 9. Diabetes , Chronically ill / hospitalised patients, AIDS and leprosy M. R. SHOJA 38

Causative fungi I. II. Yeast: Candida species (albicans), Cryptococcus Filamentous septated A. Non-pigmented hyphae: Fusarium species (solani), Aspergillus species (fumigatus, flavus, niger) M. R. SHOJA 39

Causative fungi III. Filamentous non-septated : Mucor and Rhizopus species IV. Diphasic forms: Histoplasma, Coccidiodes, Blastomyces M. R. SHOJA 40

Symptoms Onset is slow n Symptoms are less compared to signs n Diminution of vision, pain, foreign body sensation n M. R. SHOJA 41

Signs Diminution of vision, depending on location of ulcer n Conjunctival and ciliary congestion n Epithelial defect n Stromal infiltrates n Elevated areas, hypate (branching) ulcers, irregular feathery margins n Dry and rough texture n M. R. SHOJA 42

Fungal Keratitis with Hypopyon M. R. SHOJA 43

Signs Satellite lesions n Brown pigmentation due to dematiaceous fungus (Curvularia lunata) n Intact epithelium with stromal infiltrates n Anterior chamber reaction n M. R. SHOJA 44

Fungal Keratitis – Pigmented Lesion M. R. SHOJA 45

Case of Fungal+ Bacterial Keratitis M. R. SHOJA 46

Laboratory Diagnosis n n The Gram and Giemsa stains are used as initial stains Potassium Hydroxide (10 -20 %) wet mounts Culture Media: Sheep blood agar, Chocolate agar, Sabouraud dextrose agar, Thioglycollate broth Anterior chamber tap under aseptic conditions to aspirate hypopyon and or endothelial plaque M. R. SHOJA 47

Treatment n n n Natamycin 5% suspension: 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 M. R. SHOJA 48

Treatment n n 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 M. R. SHOJA 49

Surgical Treatment 1. 2. 3. Daily debridement with spatula/ blade every 24 – 48 hours Surgical treatment is required in approximately 1/3 rd cases of fungal keratitis due to failure of medical treatment or perforation Surgical treatment in the form of : therapeutic keratoplasty, conjunctival flap or lamellar keratoplasty M. R. SHOJA 50

Surgical Treatment n n n Surgery is usually indicated within 4 weeks due to failure of medical treatment or recurrence of infection Unfavorable outcome is due to scleritis, endophthalmitis and recurrence Cryotherapy with topical antifungal treatment or corneoscleral graft in cases of fungal scleritis and keratoscleritis M. R. SHOJA 51

Viral Keratitis n Herpes Simplex n Large dendrites with central ulceration and terminal bulbs Herpes Zoster Small, medusa-like dendrites WITHOUT central ulceration or terminal bulbs

Herpes Simplex Keratitis: Pathogenesis HSV is a DNA virus that commonly infects humans n Two distinct strains exist n – HSV-1: orofacial and ocular – HSV-2: orogenital STD, neonatal n Recurrent HSV keratitis is one of the most frequent causes of infective corneal blindness in the US

Herpes Simplex Keratitis: Primary Ocular Infection n Most commonly occurs on the mucocutaneous areas of the head innervated by CN V Manifests as a nonspecific URI May travel to the sensory ganglion and remain in a latent nonpathogenic state

HSV: Primary Ocular Infection: Clinical Presentation n n Unilateral vesicular blepharokeratoconjunctivitis Follicular conjuntivitis with occasional membrane formation Cutaneous vesicles on eyelid skin or margin Preauricular nodes 2/3 develop epithelial keratitis

HSV: Primary Ocular Infection Treatment n n Self-limited condition Topical antiviral therapy – Trifluridine (Viroptic) – Vidarabine n Oral antiviral therapy (one week)* – Acyclovir 400 mg 5 x/day – Famcyclovir 500 mg 3 x/day *may reduce recurrence rate