Daniel Ofori, MD Mercyhealth Vision Center Janesville, WI 03/07/20 Objectives  Identify cornea ulcers

 Learn about different types of ulcers

 Learn about different treatment options Background  2010 CDC data on corneal ulcer and contact lens related keratitis  41,000 ER visits  700,000 Office/outpatient visits  Similar incidence across all age groups  Women > men  Cost: $135 million Pathophysiology  Loss of corneal epithelium  Cellular infiltrates  Corneal necrosis  Cornea edema Stages  Infiltration: neutrophils, lymphocytes

 Active ulceration: exudates, necrosis, edema, AC reaction, hypopyon

 Regression: host defense, epithelium healing

 Healing/scarring: Fibrosis Types of corneal ulcers

Bacterial Fungal

Neurotrophic

Herpetic Acanthamoebic Case 1  18 yo M contact lens wearer presents with redness, pain, tearing, photophobia in the right eye x 3 days. Reports decreased vision. Wears extended wear CL, sleeps in them and only takes them out once every 2 weeks

 Uncorrected Va: 20/400, PHNI

What is the diagnosis?  A. Bacterial keratitis

 B. Fungal keratitis

 C. HSV keratitis

 D. Acanthamoebic keratitis

 E. Neurotrophic keratitis Bacterial keratitis  Most common type

 Gram positive

 Gram negative Main agents Special class  Invade corneas with INTACT epithelium  Corynebacterium diphtheria  Haemophilius influenzae  Neisseria gonorrhea  Neisseria meningitidis  Listeria monocytogenes  Serratia marcescens Risk factors  Contact lens wear  Contact lens poor hygiene  Contaminated ocular solutions  Trauma  Dry eye syndrome  Surgery Exam  Conjunctival injection  Epithelial defect  Infiltrates  Necrosis  Thinning/tissue loss/descemetocele  Perforation  Cell and flare  Hypopyon Management  No culture: small, peripheral  Corneal culture: Blood, chocolate, thioglycolate, sabouraud  Gram stain  Broad spectrum fortified antibiotics  Topical steroid: non‐nocardia  Daily visit first week or till improvement  Weekly afterwards Case 2  40 yo M with uncontrolled DM presents to the clinic with redness, pain, tearing, decreased vision OS. Reports chronic lotemax BID for dry eyes.

 scVa 20/200, PH NI

What is the diagnosis?  A. Bacterial keratitis

 B. Fungal keratitis

 C. HSV keratitis

 D. Acanthamoebic keratitis

 E. Neurotrophic keratitis Fungal keratitis Fusarium  Failed antibiotic therapy

 Filamentous  Fusarium  Aspergillus  Curvalaria Aspergillus

 Non‐filamentous  Candida

Candida Risk factors  CL wear  Vegetable matter injury  Tree branches  Chronic topical steroid use  Corneal transplant  Immunocompromised  Diabetics  Chronic eye disease Exam  Grey infiltrate with feathery borders  Multiple satellite lesions  Intact epithelium  Ring infiltrate (Immune ring of Wessely)  Thick hypopyon Management  Corneal culture: Sabouraud  KOH, Giemsa stain  Topical: Natamycin, Amphotericin B, voriconazole  Oral: Voriconazole  NO topical steroid  Daily visit first week, then longer Case 3  30 yo F weekly CL wearer presents with red painful OD for 2 days. Reports photophobia, tearing. H/o asthma and cold sores

 scVa 20/80, PH NI

What is the diagnosis?  A. Bacterial keratitis

 B. Fungal keratitis

 C. HSV keratitis

 D. Acanthamoebic keratitis

 E. Neurotrophic keratitis Viral keratitis  Herpes simplex  Varicella zoster  Adenovirus  Cytomegalovirus

Herpes simplex virus Risk factors  Contact lens wear  Cold sores  Topical/systemic steroid  UV exposure Types of HSV keratitis

HSV disciform keratitis HSV epithelial keratitis

HSV necrotizing keratitis HSV endotheliitis Exam  Dendrites  Branching epithelial lesion with terminal bulbs  Positive fluorescein and rose bengal stains  Geographic dendrites  Large dendrites  Pseudodendrites  Raised lesions  Negative fluorescein stain Management  Viral culture or PCR  HSV epithelial keratitis  Topical or oral antiviral (Acyclovir, Valtrex)  Topical antibiotic  HSV stromal keratitis  Topical or oral antiviral (Acyclovir, Valtrex)  Topical steroid  HSV endotheliitis  Topical or oral antiviral (Acyclovir, Valtrex)  Topical steroid Case 4  26 yo M CL wearer presents for a second opinion. Treated for HSV keratitis for 3 weeks with minimal improvement. Reports redness, severe pain (out of proportion). Cleans CL every night with tap water

 scVa 20/HM, PHNI

What is the diagnosis?  A. Bacterial keratitis

 B. Fungal keratitis

 C. HSV keratitis

 D. Acanthamoebic keratitis

 E. Neurotrophic keratitis Acanthamoebic keratitis  Chronic symptoms (weeks)  Misdiagnosed as viral keratitis  Failed viral therapy  Pain out of proportion to inflammation  AC reaction Risk factors  Soft CL wear  Poor CL hygiene  Tap water as cleaning solution  Swimming in CL  Hot tub Exam  Pseudodendrites  Radial Keratoneuritis  Ring shaped corneal infiltrates  Late finding Management  Gram and Giemsa stains: double walled cyst  Culture: Non‐nutrient algar with E. coli overlay  Corneal biopsy  Confocal microspcopy  Polyhexamethylene biguanide (PHMB)  Chlorhexidine  Brolene  Oral pain meds (NSAIDs) Case 5  80 yo F with brain tumor and facial nerve palsy with irritation, pain, tearing right eye for 1week. Symptoms have not improved with Visine

 scVa 20/80, PH 20/60

What is the diagnosis?  A. Bacterial keratitis

 B. Fungal keratitis

 C. HSV keratitis

 D. Acanthamoebic keratitis

 E. Neurotrophic keratitis Neurotrophic keratitis  Decreased or absent corneal sensation  Sterile ulcer Risk factors  Herpetic keratitis  Topical anesthetic abuse  Corneal surgery (PRK, LASIK, PKP)  Vitrectomy  Panretinal photocoagulation  Diabetes  Cranial nerves 5 and 7 injury  Intracranial tumors  Stroke Exam  Irregular epithelium  Persistent epithelial defect  Raised borders of epithelium  Oval shape  Stromal melting/thinning  Corneal neovascularization Management  Corneal sensitivity testing (cotton swab)  Fluorescein stain  Culture to rule out bacterial, viral, fungal  Aggressive lubrication: non‐preserved tears  Autologous serum tears  Bandage CL with antibiotic coverage  Amniotic membrane  Temporary tarsorrhaphy  Nerve growth factor (Oxervate)  Corneal neurotization  supraorbital/supratrochlear) Outcome of corneal ulcers  Scarring  Irregular astigmatism  Corneal perforation  Endophthalmitis  Loss of vision Perforated ulcer  Cyanoacrylate glue and bandage contact lens  Multi‐layered amniotic membrane graft  Corneal patch graft Visual rehabilitation

References  The Wills Eye Manual  External Disease and Cornea. Basic and Clinical Science Course  Webeye.ophth.uiowa.edu  Cdc.gov  AAO.org  Google images