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Corneal Ulcers: Diagnosis and Management
Rasik B Vajpayee, Namrata Sharma
SECTION 1: APPLIED BASIC SCIENCES
CHAPTER 1:
Anatomy and Physiology
Applied Physiology of Cornea
Corneal transparency
Normal Defense Mechanism
CHAPTER 2:
Pathogenesis of Corneal Ulceration
Introduction
STAGES OF CORNEAL ULCER
Stage 1: Progressive Stage
Stage 2: Regressive Stage
Stage 3: Healing Stage
SEQUEL AND COMPLICATIONS
Corneal Opacification
Descemetocele
Perforation
Ectatic Cicatrix
Corneal Fistula
Hemorrhage
Endophthalmitis
CHAPTER 3:
Microbiology
Introduction
Protozoa
Acanthamoeba
Microsporidia
Mycology
FILAMENTOUS FUNGI
YEASTS
DIMORPHIC FUNGI
Moniliaceae
ASPERGILLUS
FUSARIUM
DEMATIACEAE
Bacteriology
Specific Bacteria
GRAM-POSITIVE BACTERIA
Staphylococcus aureus
Coagulase Negative Staphylococci
MICROCOCCUS SPECIES
Streptococcus and Related Bacteria
Antibiotic Susceptibility
Enterococcus
Diphtheroids
Mycobacterium
Bacillus
Nocardia
GRAM-NEGATIVE BACTERIA
Pseudomonas aeruginosa
SERRATIA MARCESCENS
MORAXELLA
HAEMOPHILUS
GLUCOSE FERMENTERS AND NON-FERMENTERS
Stains and Culture Media
STAINING METHODS
Potassium Hydroxide Wet Mount Preparation
Gram's Stain
Giemsa Stain
Ziehl-Neelsen Acid-fast Stain
Fluorochromatic Stains
Modified Grocott-Gomori Methenamine-Silver Nitrate Stain
CULTURE MEDIA
Nutrient agar
CHAPTER 4:
Pharmacology
Antibacterial Agents
ANTIBACTERIAL AGENTS
Beta Lactam Antibiotics
Cephalosporins
Tetracyclines
Glycopeptides
Aminoglycosides
Macrolides
Fluoroquinolones
PREPARATION OF FORTIFIED TOPICAL ANTIBIOTICS
Antifungal Agents
CLASSIFICATION OF ANTIFUNGAL AGENTS
POLYENES
Mechanism of Action
Nystatin
Natamycin
Amphotericin B
AZOLES
Imidazoles
Clotrimazole
Miconazole
Ketoconazole
Triazoles
Fluconazole
Itraconazole
Voriconazole
Antiviral Agents
IDOXURIDINE
VIDARABINE
TRIFLURIDINE
ACYCLOVIR
VALACYCLOVIR
Adjuvants
CORTICOSTEROIDS
Topical Corticosteroids
Cycloplegics
TYPES OF CYCLOPLEGICS
Atropine
Homatropine
Anti-glaucoma Medications
TOPICAL ROUTE
SYSTEMIC ROUTE
Acetazolamide
Mannitol
SECTION 2: WORK UP OF CORNEAL ULCER
CHAPTER 5:
Clinical Examination
Introduction
History and Symptoms
PAIN
REDNESS AND PHOTOPHOBIA
DISCHARGE
DECREASED VISUAL ACUITY
Onset of Disease
PREDISPOSING FACTORS
Ocular Factors
TRAUMA
CONTACT LENS
LID AND ADNEXAL INFECTIONS
OCULAR SURFACE DISEASES
BULLOUS KERATOPATHY
TOPICAL MEDICATIONS
PRIOR OCULAR SURGERY
Systemic Factors
Diabetes Mellitus
Acquired Immunodeficiency Syndromes and Advanced Malignancies
Connective Tissue Diseases
Other Systemic Factors
Occupational Factors
Clinical Examination and Signs
Record of Visual Acuity
External Ocular Examination
EYELIDS
LACRIMAL SAC
Slit-lamp Biomicroscopy
CONJUNCTIVA
PRECORNEAL TEAR FILM
CORNEA
Corneal Ulcer
LOCATION OF CORNEAL ULCER
SHAPE OF THE ULCER
MARGINS OF ULCER
SIZE OF CORNEAL ULCER
EPITHELIAL DEFECT
INFILTRATION
Corneal Sensations
Special Characteristics
CORNEAL THINNING/PERFORATION
DOCUMENTATION
Color Photographs
Schematic Drawings
ANTERIOR CHAMBER
IRIS
PUPIL AND LENS
Scleral Involvement
POSTERIOR SEGMENT
INTRAOCULAR PRESSURE
Ultrasonography
Varying Clinical Picture
CHAPTER 6:
Investigations
Systemic Investigations
Ocular Investigations
Clinical Investigations
INTRAOCULAR PRESSURE
ULTRASONOGRAPHY
Microbiological Investigations
COLLECTION OF SAMPLES
Corneal Scraping
EXAMINATION
Routine Smears and Stains
Difficulties in Gram Staining
Special Stains
Ziehl-Neelsen Acid-fast Stain
CULTURE EXAMINATION
Blood Agar
Chocolate Agar
Sabouraud's Agar
Thioglycolate Broth
Pre-reduced Anaerobically Sterilized Media (PRAS)
Brain Heart Infusion (BHI)
Thayer-Martin Media
Lowenstein Jensen Media
Duration of Isolation of Organism
Interpretation of Culture Results
ANTIMICROBIAL SUSCEPTIBILITY TESTING
SEROLOGICAL INVESTIGATIONS
CONFOCAL MICROSCOPY
CORNEAL BIOPSY
SECTION 3: TYPES OF MICROBIAL KERATITS
CHAPTER 7:
Bacterial Keratitis
Risk Factors
CORNEAL TRAUMA
EYELID DISEASE
OCULAR SURFACE DISORDER
TEAR FILM DYSFUNCTION
PREVIOUSLY COMPROMISED LOCAL/ SYSTEMIC DEFENSE MECHANISMS
CONTACT LENS USE
Etiologic Organisms
REGIONAL DIFFERENCES
SPECIFIC ORGANISMS
Staphylococcal Organisms
Streptococcus pneumoniae
Pseudomonas species
Gram-positive aerobic bacilli
Moraxella species
Corynebacterium diphtheriae
Actinomycetes
Spore Forming Anaerobic Bacteria
Nonspore-forming Anaerobic Organisms
Non-tuberculous Mycobacteria
Less Common Organisms
Clinical Features
GENERAL SYMPTOMS
GENERAL SIGNS
SPECIFIC FEATURES
Gram-positive Organisms
Alpha Hemolytic Streptococci
Gram-negative Organisms
Other Gram-negative Rods
Anaerobes
Microbiologic Work Up
Treatment
MEDICAL THERAPY
Choice of Antibiotics
Types of Antibiotic Therapy
ADJUNCTIVE THERAPY
Topical Corticosteroids
MODIFICATION OF THERAPY
SPECIFIC DRUGS
Subconjunctival Route
SYSTEMIC THERAPY
SIGNS OF HEALING
SIGNS OF PROGRESSION/NON-RESPONSE
SURGICAL THERAPY
TISSUE ADHESIVES
PATCH GRAFTS
THERAPEUTIC KERATOPLASTY
CHAPTER 8:
Fungal Keratitis
Epidemiology
INCIDENCE
GEOGRAPHICAL DISTRIBUTION
AGE DISTRIBUTION
SEX DISTRIBUTION
SEASONAL VARIATION
Risk Factors
OCULAR FACTORS
Trauma
Chronic Corneal Inflammation
Contact Lens Wear
Drugs
Corneal Surgery
SYSTEMIC FACTORS
Etiopathogenesis
Clinical Features
GENERAL SYMPTOMS
GENERAL SIGNS
SPECIFIC FEATURES
Dematiacious Fungi
Fusarium
Yeast
Laboratory Diagnosis
DIRECT MICROSCOPY
KOH Wet Mount Preparation
Gram's Stain
Giemsa Stain
Lactophenol Cotton Blue
Grocott's Methenamine-silver Stain
Calcofluor White
FUNGAL CULTURE
NEWER DIAGNOSTIC MODALITIES
Polymerase Chain Reaction
Confocal Microscopy
KERATECTOMY/BIOPSY
Management
MEDICAL THERAPY
Topical Antifungal Agents
Systemic Antifungal Agents
Topical Corticosteroids
Intracameral Therapy
Intrastromal Therapy
SURGICAL THERAPY
Debridement
Biopsy
Therapeutic Keratoplasty
CHAPTER 9:
Viral Keratitis
Herpes Simplex Virus
Epidemiology
Pathophysiology
INFECTION
IMMUNE MECHANISMS
Clinical Features
CONGENITAL OCULAR HERPES
NEONATAL HSV KERATITIS
PRIMARY OCULAR HERPES
RECURRENT OCULAR HERPES
MANIFESTATIONS OF KERATITIS
INFECTIOUS EPITHELIAL KERATITIS
Punctate Keratitis
Dendritic Keratitis
Geographic Ulcers
Marginal Keratitis
Neurotrophic Epithelial Keratitis
HERPES SIMPLEX STROMAL KERATITIS
Immune Mediated Stromal Keratitis
Necrotizing Stromal Keratitis
HERPETIC ENDOTHELITIS
Disciform Keratitis
Diffuse Endothelitis
Linear Endothelitis
HERPES SIMPLEX TRABECULITIS
HERPES SIMPLEX IRIDOCYCLITIS
Laboratory Diagnosis
GIEMSA STAINING
POLYMERASE CHAIN REACTION (PCR)
VIRAL CULTURE
IMMUNOLOGICAL TESTS
Serological Test to Measure Circulating Antibodies
Medical Treatment
Management of Specific Conditions
INFECTIOUS EPITHELIAL KERATITIS
NEUROTROPHIC KERATOPATHY
IMMUNOLOGIC DISEASE
Immune Stromal Keratitis
Necrotizing Stromal Keratitis
IRIDOCYCLITIS AND TRABECULITIS
Surgical Treatment
PREVENTION
Varicella Zoster Virus
EPIDEMIOLOGY
TREATMENT OF OPHTHALMIC VARICELLA ZOSTER
ADENOVIRAL INFECTIONS
Management
CHAPTER 10:
Protozoal Keratitis
Acanthamoeba Keratitis
ETIOLOGY
EPIDEMIOLOGY
RISK FACTORS
Contact Lens Wear
Non-Contact Lens Wearer
Other Risk Factors
SYMPTOMS
SIGNS
CORNEAL INVOLVEMENT
Lids and Conjunctiva Involvement
Iritis and Hypopyon
Cataract and Glaucoma
Scleral Involvement
DIFFERENTIAL DIAGNOSIS
Laboratory Diagnosis
CORNEAL SCRAPING
WET SMEAR
STAINING
CULTURE MEDIA
Method for Examining Contact Lens
POLYMERASE CHAIN REACTION
CORNEAL BIOPSY
CONFOCAL MICROSCOPY
OTHER TESTS
TREATMENT
COMBINATION THERAPY
IMIDAZOLES
NEOMYCIN
ROLE OF CORTICOSTEROIDS
SURGICAL TREATMENT
PENETRATING KERATOPLASTY
LAMELLAR KERATOPLASTY
AMNIOTIC MEMBRANE TRANSPLANTATION
SECTION 4: SPECIFIC TYPE OF KERATITIS
CHAPTER 11:
Pediatric Keratitis
Introduction
Epidemiology
PREVALENCE
REGIONAL DIFFERENCES
Predisposing Factors
TRAUMA
SYSTEMIC FACTORS
CONTACT LENS WEAR
PRE-EXISTING EXTERNAL EYE DISEASE/SURGERY
OTHERS
Etiology
MICROBIAL KERATITIS
Bacteria
Viruses
Fungus
NON-MICROBIAL KERATITIS
Nutritional
Vernal Keratoconjunctivitis
Diagnosis
HISTORY
CLINICAL EXAMINATION
Systemic Examination
Ocular Examination
INVESTIGATIONS
Systemic Investigations
Laboratory Investigations
Management
MEDICAL THERAPY
Bacterial Keratitis
Fungal Keratitis
Herpetic Keratitis
Acanthamoeba Keratitis
FOLLOW-UP
SURGICAL THERAPY
POST-RESOLUTION MANAGEMENT
PREVENTION
CHAPTER 12:
Contact Lens Related Keratitis
Introduction
Epidemiology
Risk Factors
Pathogenesis
ALTERED TEAR DYNAMICS DUE TO CONTACT LENSES
CONTACT LENSES
CONTAMINATION OF CONTACT LENS CARE SYSTEMS
Organisms
CLINICAL FEATURES
Microbial Keratitis
Contact Lens Induced Peripheral Ulcer
Contact Lens Induced Red Eye
Infiltrative Keratitis
Asymptomatic Infiltrative Keratitis
Asymptomatic Infiltrates
Management
MICROBIAL KERATITIS
STERILE INFILTRATES
PREVENTION
CHAPTER 13:
Infectious Crystalline Keratopathy
Introduction
Risk Factors
Etiology
Pathogenesis
Clinical Features
LABORATORY DIAGNOSIS
Microbiological Investigations
Histopathology
Confocal Microscopy
Treatment
CHAPTER 14:
Post-surgical Microbial Keratitis
Keratitis after Pterygium Surgery
Keratitis After Cataract Surgery
PREDISPOSING FACTORS
CLINICAL EXAMINATION
MICROBIOLOGIC EXAMINATION
TREATMENT
Microbial Keratitis After Keratoplasty
PREDISPOSING FACTORS
Indication for Keratoplasty
Donor Factors
Recurrence of Host Infection
Persistent Epithelial Defect
Contact Lens
Dry Eye and Ocular Surface Problems
Suture Related Problems
Systemic Associations
Microbiology of Graft Infection
Clinical Features
Investigations
Management
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
Associated Endophthalmitis
HERPETIC GRAFT INFECTIONS
Graft Survival and Visual Outcome
MICROBIAL KERATITIS AFTER REFRACTIVE SURGERY
Microbial Keratitis After LASIK
CHAPTER 15:
Keratitis and Endophthalmitis
Introduction
Pathogenesis
Predisposing Factors
Clinical Features
SYMPTOMS
SIGNS
Investigations
ULTRASONOGRAPHY
CORNEAL SCRAPINGS
AQUEOUS AND VITREOUS TAP
Aqueous Tap
Vitreous Tap
TREATMENT
Topical Therapy
Intravitreal Antibiotics
Systemic Therapy
SURGICAL THERAPY
CHAPTER 16:
Neurotrophic Keratitis
Introduction
Etiology
OCULAR CAUSES
SYSTEMIC CAUSES
PATHOGENESIS
Diagnosis
HISTORY
OCULAR EXAMINATION
Slit-lamp Biomicroscopy
Corneal Sensations
Dilated Fundus Examination
Systemic Examination
Differential Diagnosis
Investigations
Treatment
STAGE I
STAGE II
Ocular Lubricants
Growth Factors and Cell Attachment Factors
Transpore Tape or Patching
Tarsorrhaphy
STAGE III
Collagenase Inhibitors
Tissue Adhesive
Conjunctival Flap
Amniotic Membrane Transplantation
Penetrating Keratoplasty
CHAPTER 17:
Peripheral Ulcerative Keratitis
Introduction
Epidemiology
Etiology
Pathogenesis
CLINICAL PICTURE
HISTORY
Examination
SYSTEMIC
OCULAR
Investigations
Imaging Studies
Microbiology Work Up
Biopsy
HISTOLOGIC FINDINGS
Treatment
Medical Therapy
SURGICAL TREATMENT
Tissue Adhesives
FOLLOW-UP
COMPLICATIONS
PROGNOSIS
Specific Diseases
RHEUMATOID ARTHRITIS
WEGENER'S GRANULOMATOSIS
POLYARTERITIS NODOSA
OTHER COLLAGEN VASCULAR DISEASES (CVD)
STAPHYLOCOCCAL MARGINAL KERATITIS
TERRIEN'S MARGINAL DEGENERATION (TMD)
SENILE FURROW DEGENERATION (SFD)
ROSACEA KERATITIS
MOOREN'S ULCER
Definition
Types of Mooren's Ulcer
Pathogenesis
Clinical Features
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
Limbal Conjunctivectomy/Resection
Keratoepithelioplasty
Superficial Keratectomy
Keratoplasty
SECTION 5: SURGICAL MANAGEMENT
CHAPTER 18:
Intracameral Antibiotics
Introduction
Indications of Intracameral Antimicrobials
TECHNIQUE
Preparation of Intracameral Amphotericin B Injection
Dosage
Surgical Technique
Repeat Injections
RESULTS
Summary
CHAPTER 19:
Glue Application
Introduction
Chemical Composition and Characteristics
Biological Effects
Application of the Glue
PATIENT SELECTION
METHOD OF APPLICATION
Materials Required
MODIFICATION OF THE TECHNIQUE
Overlapped Applications
Using a Suture
Viscoelastics
Corneal Patch
POSTOPERATIVE MANAGEMENT
ADVERSE EFFECTS
CHAPTER 20:
Conjunctival Flaps
Introduction
Indications
CONTRAINDICATIONS
TYPES OF CONJUNCTIVAL FLAPS
Partial Conjunctival Flaps
Total Conjunctival Flap (Gunderson Flap)
Postoperative Therapy
Complications
Summary
CHAPTER 21:
Therapeutic Keratoplasty
Introduction
Indications
BACTERIAL KERATITIS
FUNGAL KERATITIS
ACANTHAMOEBA KERATITIS
HERPES KERATITIS
OTHER INDICATIONS
Timing of Surgery
Preoperative Evaluation
HISTORY TAKING
OCULAR EXAMINATION
INVESTIGATIONS
PREOPERATIVE TREATMENT
Anti-microbial Therapy
Steroids
Hypotensive Agents
Our Regime
Surgical Technique
ANESTHESIA
DONOR TISSUE CONSIDERATIONS
HOST TISSUE PREPARATION
Exposure
Recipient Bed Trephination
Anterior Chamber Reconstruction
Lens Surgery
Anterior Vitrectomy
DONOR TISSUE PREPARATION
GRAFT HOST APPOSITION
Postoperative Management
ANTIMICROBIAL THERAPY
STEROIDS
Complications
HEMORRHAGE/HYPHEMA
SECONDARY GLAUCOMA
RECURRENCE OF INFECTION
GRAFT FAILURE
OTHER COMPLICATIONS
SUCCESS OF A THERAPEUTIC GRAFT
Summary
CHAPTER 22:
Phototherapeutic Keratectomy
Introduction
MECHANISM OF ACTION
CASE SELECTION
CASE WORK UP
LASER CHARACTERISTICS
Complications
Conclusion
INDEX
TOC
Index
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