CORNEAL DISEASES

Ayman Elghonemy, FRCS/FRCOphth Final Exam Course 2013-2014

CORNEAL ULCER
Infectious Vs Non Infectious:
N.B.: PEDAL:
Pain Epithelial defect Discharge A.C. reaction Localised infiltrate.

INFECTIOUS:
Bacterial.
Viral
Fungal
Parasitic (Acanthamoeba)

NON-INFECTIOUS:
Post infection.
Ocular surface dis:
Lid: trichiasis/ entropion or ectropion
Dry eye
Acne Rosacae

Exposure: (VII, lagophthalmos, proptosis )

Neurotrophic keratits (DM, V CN palsy, HZ)
Allergic :
Spring catarrh
Phlyctenulosis
Marginal keratits

Autoimmune:
Collagen vascular dis: R.A. SLE PAN Wegener.
Isolated: Moorens, Terrien

Iatrogenic/trauma:
Post surgery
Drops
Injury: Chemical, thermal, radiation.

Ayman Elghonemy, FRCS/FRCOphth Final Exam Course 2013-2014

WORK-UP of keratitis (corneal ulcer):

History:
Personal: agriculture job.
HPI: OCD pain recurrent attacks trauma
Past H. : C.L. Steroids systemic disease - antimicrobial medications.

Examination:
Routine with specal concern on : .
PEDAL corneal sensation stain (Fl. & R.B.) IOP - document exposure-dryness

Further management:
If sure non-infectious: Inv. & ttt systemic condition + Topical "accordingly"+referral
If infectious (or in doubt): _
This is a vision threatening condition need urgent management +/- Hospitalization.

Inv.:

Scraping:
Stain: Routine: Gram Giemsa.
If suspicion: Calcofluor white - Acid-fast - Gomori methenamine.
Culture : Routine : Blood agar sabouraud dextrose Thioglycolate broth
Chocolate agar.
If suspicion: L-J Non-nutrient agar with E coli overlay.

Treatment:
Bacterial until proved otherwise.
A) Antimicrobials: Prepare your own regimen & say it FLUENTLY.
Examples:
Antibiotics:
Non-vision threatening: ofloxacin 0.3% hourly, waking hours, then ...
Vision threatening: Fortified gentamicin 15mg/ml + fort. Cephazoline 50mg/ml
hourly around the clock, then...
+/- Oral ciprofloxacin 500mg twice daily in cases...
Antifungals:
Natamycin 5% ED +/- Amphotericin B 0.15% hourly around the clock, then...
+/- Oral Ketoconazol (200 mg once daily)

B)Adjuvant :
Cycloplegics - Topical steroids : Indications? - Oral pain
medications
D) Shield (Not patch)
E) No C.L. wear.

Follow up:
- Signs of improvement. ( PEDAL)
- No improvement :
Bad Compliance Hospitalize.
Wrong diagnosis: C/S Reculture Biopsy -?non-infectious?
Drug toxicity: clean edge persistent defect stop drug artificial tears.
- Perforated ulcer: EMERGENCY
Small < 1mm : Cyanoacrylate.
Large: Tectonic graft: Scleral graft +/- conjunctivoplasty.
3

Ayman Elghonemy, FRCS/FRCOphth Final Exam Course 2013-2014

Causes of peripheral corneal thinning or ulcer:

See above! Then according to site:
Superior: VKC SLK Terrien post ECCE.
Inferior: Atopic Acne exposure neurotrophic dry eye - Pellucid.
Anywhere: Infectious - Dellen marginal Phlycten Immune.

Causes of Corneal oedema:

Epithilial:

IOP. - Epithilial toxicity Severe stromal oedema.

Stromal:

Inherited & congenital: CHED Fuch's - congenital glaucoma

Post-op.: trauma DM detachment chemical toxicity.
Inflammation: ulcer uveitis endophthalmitis graft rejection.
Others: Chronic IOP- Hydrops forceps delivery C.L. over-wear

Central corneal oedema:

Inherited: Fuch's
Post-op.: trauma.
Inflammation: Disciform keratitis.
Others: Acute hydrops trauma.

Cloudy cornea at birth:

- Congenital glaucoma (until proved otherwise)
- Cong. anomalies: Peter's sclerocornea -dermoid
- Dystrophies: CHED - PPD
- Metabolic: MPS Cystinosis.
- Infection: TORCH.- I.K.
- Trauma : forceps delivery.
N.B.: Those in italics are "oedema"

Causes of pannus:
Contact lenses: over-wear tight C.L.
Trachoma
SLK (micropannas)
VKC
Rosacea
Phlyctenule
Marginal K.
Chemical burn.

Ayman Elghonemy, FRCS/FRCOphth Final Exam Course 2013-2014

Kanski:
The whole chapter

From Wong:
Topic (4) Corneal scarring.
Topic (5) Corneal ulcer (V.Imp.)
Topic (6) Herpetic Eye Diseases. The 2 studies
Topic (10): Keratoconus.
Topic (11): Crystalline keratopathy & MPS.
Topic (13): Grafts (Reading)
Topic (16): Biopsy Glueing.
Section "8: Uveitis" Topic (6): Connective tissue diseases.

From Wills:
Section"4" Topic 4.11 : Bacterial Keratitis.
Section"4" Topic 4.12 : Fungal Keratitis.
Section"4" other topics: reading

Ayman Elghonemy, FRCS/FRCOphth Final Exam Course 2013-2014