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

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Daniel Ofori, MD Mercyhealth Vision Center Janesville, WI 03/07/20 Objectives  Identify Cornea Ulcers 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.
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