keratitis 09
TRANSCRIPT
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KeratitisKeratitis
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Cornea.Cornea.
TheThe corneacornea isis thetheeyeseyes opticaloptical windowwindow
thatthat makesmakes itit possiblepossible
forfor humanshumans toto seesee..
TheThe corneacornea tissuetissue
consistconsist ofof fivefive layerslayers..
1.1. The surfase of theThe surfase of the
cornea is formed bycornea is formed by
stratifiedstratified
nonkeratinizednonkeratinized
squamoussquamous
epithelium.epithelium.
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The cornea tissue consist offive layers.The cornea tissue consist offive layers.
2. A thin basement2. A thin basement
membrane anchors themembrane anchors the
basal cells of thebasal cells of the
stratified squamousstratified squamous
epithelium toepithelium to
BowmanBowmans layers layer..
3. The stroma is a highly3. The stroma is a highly
bradytrophic tissuebradytrophic tissue
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The cornea tissue consist offive layers.The cornea tissue consist offive layers.
4. Descemets4. Descemetsmembrane is amembrane is a
relatively strongrelatively strong
membranemembrane
5. The corneal5. The corneal
endothelium isendothelium is
responsible for theresponsible for the
transparency of thetransparency of the
cornea. The cornealcornea. The corneal
endothelium does notendothelium does not
regenerate.regenerate.
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Infectious Keratitis (purulent ulcerof theInfectious Keratitis (purulent ulcerof the
cornea)cornea)
Protective Mechanisms of the CorneaProtective Mechanisms of the Cornea * Reflexive eye closing.* Reflexive eye closing.
* Flushing effect of tear fluid (lysozyme).* Flushing effect of tear fluid (lysozyme).
* Its hydrophobic epithelium forms a diffusion barrier.* Its hydrophobic epithelium forms a diffusion barrier.
* Epithelium can regenerate quickly and completely.* Epithelium can regenerate quickly and completely.Pathogens causing corneal infections mayPathogens causing corneal infections may
include:include: Viruses.Viruses.
Bacteria.Bacteria.
Acanthamoeba.Acanthamoeba.
Fungi.Fungi.
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Pathogenesis:Pathogenesis:
Once these pathogens have invaded theOnce these pathogens have invaded the
bradytrophic tissue through a superficialbradytrophic tissue through a superficialcorneal lesion, a typical chain of events willcorneal lesion, a typical chain of events will
ensue:ensue:
Corneal lesion.Corneal lesion. Pathogens invade andPathogens invade and colonize the cornealcolonize the corneal
stromastroma (red eye).(red eye).
Antibodies will infiltrateAntibodies will infiltrate the site.the site.
As a result, the cornea will opacity and theAs a result, the cornea will opacity and thepoint of entry will open further, revealing thepoint of entry will open further, revealing the
cornea infiltrate.cornea infiltrate.
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Pathogenesis:Pathogenesis:
Irritation of the anteriorIrritation of the anterior
chamber with hypopyonchamber with hypopyon(typically pus will(typically pus will
accumulate on the floor ofaccumulate on the floor of
the anterior chamber).the anterior chamber).
The pathogens will infestThe pathogens will infest
the entire cornea.the entire cornea.
As a result the stroma willAs a result the stroma will
melt down to Descemet'smelt down to Descemet's
membrane, which ismembrane, which is
relatively strong This isrelatively strong This isknown as aknown as a
descemetocele;descemetocele; onlyonly
DescemetDescemets membrane iss membrane is
still intact.still intact.
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Pathogenesis:Pathogenesis:
As the disorderAs the disorderprogresses, perforation ofprogresses, perforation of
DescemetDescemets membranes membrane
occurs and the aqueousoccurs and the aqueous
humor will be seen tohumor will be seen to
leak. This is referred to asleak. This is referred to as
aa per-foratedper-forated cornealcorneal
ulcerulcerand is an indicationand is an indication
for immediate surgicalfor immediate surgical
intervention (emergencyintervention (emergencykeratoplasty).keratoplasty).
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Pathogenesis:Pathogenesis:
Prolapse of the irisProlapse of the iris (the iris(the iriswill prolapse into the newlywill prolapse into the newly
created defect) closing thecreated defect) closing the
corneal perforationcorneal perforation
posteriorly.posteriorly.
This rapidly progressing formThis rapidly progressing formof infectious corneal ulcerof infectious corneal ulcer
(usually bacterial) is referred(usually bacterial) is referred
to as a serpiginous cornealto as a serpiginous corneal
ulcer.ulcer. It penetrates theIt penetrates the
cornea particularly rapidlycornea particularly rapidlyA serpiginous corneal ulcer isA serpiginous corneal ulcer is
one of the most dangerousone of the most dangerous
clinical syndromes as it canclinical syndromes as it can
rapidly lead to loss of therapidly lead to loss of the
eye.eye.
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Treatment: Conservative therapy.Treatment: Conservative therapy.
Treatment is initiated with topical antibioticsTreatment is initiated with topical antibiotics:: Eye drops:Eye drops: 0,25%0,25% Laevomycetin, 0,5%Laevomycetin, 0,5%
Gentamycin, 1% Erythromycin, 0,5% Neomycin,Gentamycin, 1% Erythromycin, 0,5% Neomycin,
0,3% Ciprolet, 0,3% Ciromed, 0,3% Ocacin, 0,3%0,3% Ciprolet, 0,3% Ciromed, 0,3% Ocacin, 0,3%
Tobramycin, 0,3%FloxalTobramycin, 0,3%Floxal
Ointments:0,3% Tobramycin, 0,3%FloxalOintments:0,3% Tobramycin, 0,3%Floxal
Mydriatics: 1% Atropin, 0,1%Mydriatics: 1% Atropin, 0,1%--0,25% Scopolamin,0,25% Scopolamin,
0,5% Homotropin, 0,1%P
latyphyllin, 0,1%0,5% Homotropin, 0,1%P
latyphyllin, 0,1%Adrenalin,0,5% Mydriacyl, 1% Tropicamide, 1%Adrenalin,0,5% Mydriacyl, 1% Tropicamide, 1%
Ciclomed, 2,5% EryphrinCiclomed, 2,5% Eryphrin
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Treatment:Treatment:
NonNon--steroid drags: diclofenac, naclof, diclofsteroid drags: diclofenac, naclof, diclof
Actovegin gele 20%, solcoseril gele.Actovegin gele 20%, solcoseril gele.
Subconjunctival application of antibioticsSubconjunctival application of antibiotics
may be required to increase themay be required to increase theeffectiveness of the treatmenteffectiveness of the treatment
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Surgical treatment.Surgical treatment.Emergency keratoplasty isEmergency keratoplasty is
indicated to treat aindicated to treat a
descemetocele or adescemetocele or a
perforated corneal ulcerperforated corneal ulcer
(see emergency(see emergency
keratoplasty). Broad areaskeratoplasty). Broad areasof superficial necrosis mayof superficial necrosis may
require a conjunctival flaprequire a conjunctival flap
to accelerate healing.to accelerate healing.
Stenosis or blockage of theStenosis or blockage of the
lower lacrimal system thatlower lacrimal system thatmay impair healing of themay impair healing of the
ulcer should be surgicallyulcer should be surgically
corrected.corrected.
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Viral KeratitisViral Keratitis
Viral keratitis is frequently caused by:Viral keratitis is frequently caused by:
1. Herpes simplex virus.1. Herpes simplex virus.2. Varicella2. Varicella--zoster virus.zoster virus.
3. Adenovirus.3. Adenovirus.
Herpes Simplex KeratitisHerpes Simplex Keratitis
Epidemiology and pathogenesis:Epidemiology and pathogenesis: HerpesHerpes
simplex keratitis is among the moresimplex keratitis is among the more
common causes of corneal ulcer.common causes of corneal ulcer.
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Herpes Simplex KeratitisHerpes Simplex Keratitis
Symptoms:Symptoms: HerpesHerpessimplex keratitis issimplex keratitis is
usuallyusually very painfulvery painfulandand
associated withassociated with
photophobia,photophobia,lacrimation, andlacrimation, and
swelling of the eyelids.swelling of the eyelids.
Vision may be impairedVision may be impaired
depending on thedepending on thelocation of findingslocation of findings
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Forms and diagnosis ofherpesForms and diagnosis ofherpes
simplex keratitis:simplex keratitis:
The following forms of herpes simplexThe following forms of herpes simplex
keratitis are differentiated according tokeratitis are differentiated according to
the specific layer of the cornea in whichthe specific layer of the cornea in whichthe lesion is located.the lesion is located.
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Dendritic keratitis.Dendritic keratitis.
This is characterized byThis is characterized bybranching epithelial lesionsbranching epithelial lesions
(necrotic and vesicular(necrotic and vesicular
swollen epithelial cells).swollen epithelial cells).
These findings will beThese findings will be
visible withvisible with the unaided eyethe unaided eye
after application ofafter application of
fluorescein dye and arefluorescein dye and are
characteristic of dendriticcharacteristic of dendritic
keratitis. Corneal sensitivitykeratitis. Corneal sensitivityis usually reduced. Dendriticis usually reduced. Dendritic
keratitis may progress tokeratitis may progress to
stromal keratitis.stromal keratitis.
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Stromal Keratitis.Stromal Keratitis.
Slit lamp examinationSlit lamp examinationwill reveal centralwill reveal central
diskiformdiskiform cornealcorneal
infiltrates (diskiforminfiltrates (diskiform
keratitis) with or withoutkeratitis) with or withouta whitish stromala whitish stromal
infiltrate. Depending oninfiltrate. Depending on
the frequency ofthe frequency of
recurrence, superficialrecurrence, superficialor deep vascularizationor deep vascularization
may be present.may be present.
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Treatment of the Viral Keratitis :Treatment of the Viral Keratitis :
Viral static agents can be used forViral static agents can be used for
treatment, such astreatment, such as acyclovir,acyclovir, which iswhich isavailable for topical use (in ointment form)available for topical use (in ointment form)
and systemic use.and systemic use.
Corticosteroids are contraindicatedCorticosteroids are contraindicated ininepithelial herpes simplex infections.epithelial herpes simplex infections.
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Endogenous keratitisEndogenous keratitis
I. Tuberculous keratitisI. Tuberculous keratitis TuberculoTuberculo--allergic keratitisallergic keratitis
Hematogenictuberculous keratitisHematogenictuberculous keratitis
) Deep diffused keratitis.) Deep diffused keratitis.
) Deep corneal infiltrate.) Deep corneal infiltrate.
) Sclerosing keratitis) Sclerosing keratitis
II. Parenchymatous syphilitic keratitisII. Parenchymatous syphilitic keratitis
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TuberculoTuberculo--allergic keratitisallergic keratitis
Small phlyctenas (miliary) that are smaller thanSmall phlyctenas (miliary) that are smaller thanmillet in size are more often numerous. Solitarymillet in size are more often numerous. Solitary
phlyctenas look like grayishphlyctenas look like grayish--yellow nodes up to 3yellow nodes up to 3
or4 mm in diameter. Phlyctenas are alwaysor4 mm in diameter. Phlyctenas are always
situated in the superficial layers of the cornea, butsituated in the superficial layers of the cornea, butthey also may involve deep stromal layers. Rightthey also may involve deep stromal layers. Right
after phlyctena appears superficial vesselsafter phlyctena appears superficial vessels
reaching out to the focus in the form of bundlesreaching out to the focus in the form of bundles
are seen on the cornea. Appearance ofare seen on the cornea. Appearance ofphlyctenas is accompanied by severephlyctenas is accompanied by severe
photophobiaphotophobia
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TuberculoTuberculo--allergic keratitisallergic keratitis
Rarely phlyctenas get absorbed without leavingRarely phlyctenas get absorbed without leavingany signs such as ulceration. More commonlyany signs such as ulceration. More commonly
they disintegrate. Disintegration is accompaniedthey disintegrate. Disintegration is accompanied
by craterby crater--shaped ulcers, which bases are quicklyshaped ulcers, which bases are quickly
covered with epithelium (facet stage). After thatcovered with epithelium (facet stage). After thatthey are gradually replaced by the connectivethey are gradually replaced by the connective
tissue and a circumscribed scar forms. Seldomtissue and a circumscribed scar forms. Seldom
disintegration of phlyctemas ends with completedisintegration of phlyctemas ends with complete
destruction of the stroma and appearance ofdestruction of the stroma and appearance of
descemetocele and perforation.descemetocele and perforation.
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Hematogenic tuberculous keratitisHematogenic tuberculous keratitis
Deep diffused keratitis.Deep diffused keratitis. The disease isThe disease ischaracterized by lacrimation, photophobiacharacterized by lacrimation, photophobia
and pericorneal injection. The corneaand pericorneal injection. The cornea
becomes cloudy fast. Against such abecomes cloudy fast. Against such a
background separate big yellowishbackground separate big yellowish--gray focigray fociare apparently seen in deep and mediumare apparently seen in deep and medium
layers. There is a moderate vascularizationlayers. There is a moderate vascularization
of the cornea. As a rule only one eyeof the cornea. As a rule only one eyebecomes affected. Remissions go togetherbecomes affected. Remissions go together
with an acute stage. Forecast is unfavorable.with an acute stage. Forecast is unfavorable.
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TreatmentTreatment
Treatment includes administration ofTreatment includes administration ofspecificspecific antituberculous agentsantituberculous agents such assuch as
Streptomycin, Phthivazide, Metazide,Streptomycin, Phthivazide, Metazide,
Tubazide, Saluzide etc. Medicines used forTubazide, Saluzide etc. Medicines used for
treatment for purulent ulcer of the corneatreatment for purulent ulcer of the cornea
are also prescribed:are also prescribed:
antibioticsantibiotics (Ciprolet, Cipromed, Tobrex),(Ciprolet, Cipromed, Tobrex),
mydriaticsmydriatics (Atropine, Cyclomed, Mesaton,(Atropine, Cyclomed, Mesaton,
Mydriacyl, Irifrin and others),Mydriacyl, Irifrin and others),
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TreatmentTreatment
keratoplastic agentskeratoplastic agents (Actovegin, Solcoseryl,(Actovegin, Solcoseryl,
vitamins A and E),vitamins A and E),
nonsteroid antinonsteroid anti--inflammatory drugsinflammatory drugs (Dycdoph,(Dycdoph,
Nacloph).Nacloph). If epithelial defect is absent application ofIf epithelial defect is absent application of
glucocorticosteroids is possibleglucocorticosteroids is possible (Acetolomide,(Acetolomide,
Dexamethasone, Prednisolone).Dexamethasone, Prednisolone).
Inhibitors of proteolytic enzymesInhibitors of proteolytic enzymes can also becan also be
administered (Cortical, Gordox, Tracylol).administered (Cortical, Gordox, Tracylol).
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Parenchymatous syphilitic keratitisParenchymatous syphilitic keratitis
Clinical features.Clinical features. The disease is characterizedThe disease is characterizedby cyclic course, bilateral lesion, involvement of theby cyclic course, bilateral lesion, involvement of theuveal tract, absence of recurrence and relativelyuveal tract, absence of recurrence and relativelyfavorable outcome. The course of parenchymatousfavorable outcome. The course of parenchymatoussyphilitic keratitis hassyphilitic keratitis has three stages: infiltration,three stages: infiltration,vascularization and absorption.vascularization and absorption.At the first stage aAt the first stage apatient has slight photophobia and lacrimation.patient has slight photophobia and lacrimation.Insignificant pericorneal injection is present on theInsignificant pericorneal injection is present on thefundus. There is diffused grayfundus. There is diffused gray--white infiltration at thewhite infiltration at the
limb in the corneal stroma. The infiltrate consists oflimb in the corneal stroma. The infiltrate consists ofseparate dots, lines and strokes. The surface aboveseparate dots, lines and strokes. The surface abovethe infiltrate is rough. The infiltrate gradually spreadsthe infiltrate is rough. The infiltrate gradually spreadsover the whole cornea. Infiltration period takes 3 to 4over the whole cornea. Infiltration period takes 3 to 4weeks.weeks.
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Parenchymatous syphilitic keratitisParenchymatous syphilitic keratitis
At the first stage a patient has slightAt the first stage a patient has slightphotophobia and lacrimation. Insignificantphotophobia and lacrimation. Insignificantpericorneal injection is present on thepericorneal injection is present on thefundus. There is diffused grayfundus. There is diffused gray--whitewhite
infiltration at the limb in the corneal stroma.infiltration at the limb in the corneal stroma.The infiltrate consists of separate dots, linesThe infiltrate consists of separate dots, linesand strokes. The surface above the infiltrateand strokes. The surface above the infiltrateis rough. The infiltrate gradually spreadsis rough. The infiltrate gradually spreadsover the whole cornea. Infiltration periodover the whole cornea. Infiltration periodtakes 3 to 4 weeks.takes 3 to 4 weeks.
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Parenchymatous syphilitic keratitisParenchymatous syphilitic keratitis
In the 5th weeks the vessels begin to appear onIn the 5th weeks the vessels begin to appear onthe cornea. Vascularization is deep. The limb getsthe cornea. Vascularization is deep. The limb getsedematous. Vessel injection is mixed.edematous. Vessel injection is mixed.Vascularization period lasts from 6 to 8 weeks.Vascularization period lasts from 6 to 8 weeks.The vessels run through the whole cornea makingThe vessels run through the whole cornea makingit look like nonit look like non--fresh meat. Absorption period lastsfresh meat. Absorption period lastsfrom 1 to 2 years. Irritation of the eye becomesfrom 1 to 2 years. Irritation of the eye becomesless. Infiltrates get absorbed starting from the limbless. Infiltrates get absorbed starting from the limband ending with the center of the cornea. Theand ending with the center of the cornea. Thecornea becomes transparent again. The vesselscornea becomes transparent again. The vessels
get empty and are seen in the form of thin threadsget empty and are seen in the form of thin threads(vascular pannus).(vascular pannus).
Treatment. Specific therapy with penicillin drugsTreatment. Specific therapy with penicillin drugsand treatment like in usual keratitis.and treatment like in usual keratitis.