Bacteril Keratitis

8/9/2019 Bacteril Keratitis

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M.R.SHOJAM.R.SHOJA 11

GOOD MORNING &GOOD MORNING &

CONGRATULATIONCONGRATULATION


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M.R. SHOJAM.R. SHOJA

Professor OfProfessor OfOphthalmologyOphthalmology


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BACTERIAL KERATITISBACTERIAL KERATITIS

An ocular emergencyAn ocular emergency

Prompt diagnosisPrompt diagnosis

Initiation of approtiate antiioticInitiation of approtiate antiiotic

!imit amount of tissue destruction!imit amount of tissue destruction

Impro"e patient#s "isual prognosisImpro"e patient#s "isual prognosis


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M.R.SHOJAM.R.SHOJA $$

Most important defenseMost important defense

arrier for cornea is intactarrier for cornea is intactepit%elial layerepit%elial layer

Ma&or ris' factors for infectiousMa&or ris' factors for infectious

'eratitis is compromised'eratitis is compromised

epit%elium protecti"e layer .epit%elium protecti"e layer .

Precipitating e"ent is epit%elialPrecipitating e"ent is epit%elialdefect produced y trauma#defect produced y trauma#

contact lens (ear or a c%roniccontact lens (ear or a c%ronic

corneal disorderscorneal disorders


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OcularOcular

DefenseDefenseMechanismMechanism

ChemicalChemical MechanicalMechanical

Abnormality of tear filmAbnormalit

y of tear film

Lysozym

Lactoferin

immunoglubulinA

Mucin deficienc

Intact corneal epitheliuma

(first line of defence)

Blinking reflex

(reduced bacterial colonization)


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M.R.SHOJAM.R.SHOJA ))

Pathogenesis

roliferation of Bacteria

Adherence to ulcerated epithelium

in!asion into stroma

Migration of neutrophile roduction of proteinase

Inflammatory

necrosis

Neovascular scar formation Corneal perforation


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M.R.SHOJAM.R.SHOJA **

Ris'Ris'factorsfactors+,orneal-+,orneal-

raumarauma

,ontact lens (ear,ontact lens (ear

Pre"ious ocular surgeryPre"ious ocular surgery Ocular adne/al disordersOcular adne/al disorders

,%ronic surface disease of,%ronic surface disease of

corneacornea 0ecreased corneal sensation0ecreased corneal sensation


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RiskRisk

FactorsFactors

SystemicSystemicconditioncondition ocalocal

DiabetesSystemic infectionsCollagen vascular diseasesImmuno suppressive drug

PregnancyChronic alcholismExtensive body burns

Drug addictionAIDS

TopicalSteroidAntiviral

Antibiotic

Anesthestics


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M.R.SHOJAM.R.SHOJA

Chronic CornealChronic Corneal

Surface DiseaseSurface Disease ullous 'eratitisullous 'eratitis

/posure 'eratopat%y/posure 'eratopat%y

4eratocon&uncti"itis sicca4eratocon&uncti"itis sicca

5eurotrop%ic5eurotrop%ic

'eratopat%y'eratopat%y


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Previous ocular surgeryPrevious ocular surgery

Cataract extractionCataract extraction

KeratoplastyKeratoplasty

Pterygium excisionPterygium excision

Loose corneal suturesLoose corneal sutures

Refractive surgeryRefractive surgery


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Ocular Adnexal ConditionsOcular Adnexal Conditions

EntropionEntropion

EctropionEctropion

TrichiasisTrichiasis

Blepharitis /Blepharitis /RosaceaRosacea


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Normal fora o ocular suraceNormal fora o ocular surace

7RAM POSII897RAM POSII89 Stap%ylococcus Aureus +more common-Stap%ylococcus Aureus +more common-

Stap%ylococcus pidermidis +more common-Stap%ylococcus pidermidis +more common-

Propioniacterium acnes.Propioniacterium acnes.

Streptococcus 8iridansStreptococcus 8iridans

7RAM 57AI87RAM 57AI8 +less common- +less common- sc%eria ,olisc%eria ,oli

4lesiella4lesiella ProteusProteus

Mora/ellaMora/ella


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Causes of Bacterial keratitisCauses of Bacterial keratitis

(!"#(!"#Stap%ylococcus aureusStap%ylococcus aureus

Stap%ylococcus epidermidisStap%ylococcus epidermidis

Streptococcus pneumonieaStreptococcus pneumoniea

Pseudomonas aeruginosaPseudomonas aeruginosa

Most common organism in soft contact lensMost common organism in soft contact lens

nteroacteriaceaenteroacteriaceae +proteus#+proteus#enteroacter-enteroacter-


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M.R.SHOJAM.R.SHOJA 1$1$

No$ %orkNo$ %ork

Lo'oLo'o

S.aureusS.aureus S.aureusS.aureus

Pseudomonas Mora/ellaPseudomonas Mora/ellaS.pneumoniaS.pneumonia

PseudomonasPseudomonas

ETIOLOGY


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M.R.SHOJAM.R.SHOJA 1:1:

OrOrgganismsanismspenetrate intactpenetrate intactepit%eliumepit%elium

5eisseria gonorroae5eisseria gonorroae

Haemop%ilus agegyptiusHaemop%ilus agegyptius

,oryneacterium dip%teria,oryneacterium dip%teria

!isteria!isteria


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M.R.SHOJAM.R.SHOJA

1)1)

Cliical resetatioCliical resetatio

Rapid onset of painRapid onset of pain

,on&uncti"al in&ection +,on&uncti"al in&ection +RednessRedness--

P%otop%oiaP%otop%oia

0ecreased "ision0ecreased "ision

0isc%arge and lid edema0isc%arge and lid edema


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M.R.SHOJAM.R.SHOJA

1*1*

,linical features of 7,linical features of 7;;< 7< 7=='eratitis'eratitis

>eature>eature 7ram positi"e7ram positi"e 7ram7ram

negati"enegati"e

AppearanceAppearance Mild to denseMild to densein?ltratein?ltrate

0ense in?ltrate0ense in?ltratenecrosisnecrosis

ordersorders 0istinct in?ltrate0istinct in?ltrateordersorders

Indistinct ordersIndistinct orders

SurroundingSurrounding

cornea %ypopyoncornea %ypopyon7enerally clear less7enerally clear less

commoncommonOften %a@y moreOften %a@y more

commoncommon


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CORNEAL )ER*ORATIONCORNEAL )ER*ORATION

I5 PSB0OMO5AS < 7O5O,O,,A! 4RAIIS.I5 PSB0OMO5AS < 7O5O,O,,A! 4RAIIS.

SCMPOMS9SCMPOMS9

SB005 !OSS O> HCPOPCO5SB005 !OSS O> HCPOPCO5

RA0IA! >O!0 I5 0S,M MMRA5RA0IA! >O!0 I5 0S,M MMRA5PRORBSIO5 O> ,OR5A A50PRORBSIO5 O> ,OR5A A50

0SMAO,! >ORMAIO5.0SMAO,! >ORMAIO5.

RAM59RAM59

PA,H 7RA> ORPA,H 7RA> OR

P5RAI57 4.P5RAI57 4.


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PseudomonasPseudomonas

Keratitis (GKeratitis (G --)) Most common in Scls wearMost common in Scls wear,burn ,comatose ,,burn ,comatose ,

mechanicalmechanicalrespiratory patients.respiratory patients. Yellowish green hue with resistant to treatment.Yellowish green hue with resistant to treatment.

Most common in childrenMost common in children


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Goococci KeratitisGoococci Keratitis

Hyperacute con&uncti"itis # preauricularHyperacute con&uncti"itis # preauricularadenopat%yadenopat%y

PPenetrate intact epit%elium #produce rapidenetrate intact epit%elium #produce rapid

corneal ulceration and perforation as 2$ tocorneal ulceration and perforation as 2$ to$ %ours after infection.$ %ours after infection.

,%oice of treatment is 1 g ceftria/one IM or,%oice of treatment is 1 g ceftria/one IM or

I8 for 3 to : days for 'eratitis.I8 for 3 to : days for 'eratitis.

>reDuent irrigation is necessary.>reDuent irrigation is necessary.

Se/ual partners s%ould e e"aluated.Se/ual partners s%ould e e"aluated.

In all %yperacute con&uncti"itis t%e entireIn all %yperacute con&uncti"itis t%e entire

cornea must e e"aluated for ulcerationcornea must e e"aluated for ulceration


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Goococci CGoococci Co+ucti,itiso+ucti,itis &&

KeratitisKeratitis


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Cliical si-s ofCliical si-s of

resolutioresolutioImpro"ed patient comfortImpro"ed patient comfort

Progressi"e re=epit%eliali@ation o"er in?ltrateProgressi"e re=epit%eliali@ation o"er in?ltrate

0ecreasing si@e and density of in?ltration.0ecreasing si@e and density of in?ltration.!oss of ad%erent mucopurulent disc%arge!oss of ad%erent mucopurulent disc%arge

Reduction in %ypopyonReduction in %ypopyon

Reduction of stromal edema surroundingReduction of stromal edema surroundingin?ltratein?ltrate

0e"elopment of (ell=de?ned in?ltrate0e"elopment of (ell=de?ned in?ltrateordersorders


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Stain or culture mediaStain or culture media

StainsStains 7ram stain7ram stain 7iemsa stain7iemsa stain

,alcoEuor (%ite stain,alcoEuor (%ite stain Acid fast stainAcid fast stain

Culture mediaCulture media lood agarlood agar Saourauds agarSaourauds agar ,%ocolate agar,%ocolate agar %ioglycolate rot%%ioglycolate rot%


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Goals o therapyGoals o therapy

Rapid elimination of acteriaRapid elimination of acteriaReduction of inEammatoryReduction of inEammatory

responseresponse

Pre"ent of structural damagePre"ent of structural damagePromotion %ealing of epit%elialPromotion %ealing of epit%elial


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M.R.SHOJAM.R.SHOJA 2:2:

Treatment

Hospitalization

Systemic Antibiotic Corneal Graft

Fortified

combined drops

Monoterapy

Fl!ro"!inolone

Drug penetartion in to cornea increased with

higher concentration and frequent application


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M.R.SHOJAM.R.SHOJA 2)2)

reatmentreatment ++ImpricalImprical--

!oading dose 9 : application e"ery 2!oading dose 9 : application e"ery 2

MinMin

>reDuent instillation e"ery 36 Min>reDuent instillation e"ery 36 Min

*orti.e' ce/alosori (*orti.e' ce/alosori (012-3'l# 4012-3'l# 4

-eta2%ci or to5ra2%ci (-eta2%ci or to5ra2%ci (602-32l#602-32l#

Modi?cation of initial A is ased onModi?cation of initial A is ased on

culture results and clinical responseculture results and clinical response

For (G +) Vancomycin is alternativeFor (G +) Vancomycin is alternative

For (G-) Cetazidime or AmiacineFor (G-) Cetazidime or Amiacine


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M.R.SHOJAM.R.SHOJA 2*2*

Initial t%erapy for acterial 'eratitisInitial t%erapy for acterial 'eratitis

OrganismOrganism AntiioticAntiiotic opicalopical

dosedose

7ram= positi"e cocci7ram= positi"e cocci ,efa@olin,efa@olin

8ancomycin F8ancomycin F

:6 mgGml:6 mgGml

:6 mgGml:6 mgGml7ram= negati"e rods7ram= negati"e rods oramycinoramycin

,efta@idime,efta@idime

7entamycin7entamycin

=1$=1$

mgGmlmgGml

:6 mgGml:6 mgGml

1$ mgGml1$ mgGml

5o organism or5o organism or

multiple types of organismsmultiple types of organisms

,efa@olin it%,efa@olin it%

oramycin ororamycin or

>luoroDuinolones>luoroDuinolones

:6 mgGml:6 mgGml

3 mgGml3 mgGml

7ram=negati"e cocci7ram=negati"e cocci ,eftria/one,eftria/one

cefta@idimecefta@idime

:6 mgGml:6 mgGml

:6 mgGml:6 mgGml


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Ati5ioticsAti5iotics %e c%oice of antiiotics is standard%e c%oice of antiiotics is standard

topical# commercially una"ailale#topical# commercially una"ailale#forti?ed aminoglycoside and forti?edforti?ed aminoglycoside and forti?ed

cep%alosporin drops +ie gentamicin 1.:cep%alosporin drops +ie gentamicin 1.:

and cefuro/ime :- or t%e ne( regime ofand cefuro/ime :- or t%e ne( regime of

EuoroDuinolone monot%erapy (it%EuoroDuinolone monot%erapy (it%commercially a"ailale ciproEo/acin orcommercially a"ailale ciproEo/acin or

oEo/acin 6.3.oEo/acin 6.3.

,urrently ot% t%e standard and,urrently ot% t%e standard and

EuoroDuinolone regimen encounterEuoroDuinolone regimen encounteracterial resistance in aout : of casesacterial resistance in aout : of cases


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TreatmentTreatment

Sucon&uncti"al in&ectionSucon&uncti"al in&ectionforfor

impending corneal perforationimpending corneal perforation

Hydrop%ilic soft contact lensHydrop%ilic soft contact lens ParenteralParenteral

1=Impending perforation1=Impending perforation

2=Perforated infection2=Perforated infection

3=Scleral in"ol"ement3=Scleral in"ol"ement


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!ot to be use in initial phase

"avourable response to antibiotic is advised#

Prednisolone acetate $% &ID

Patient must have fre'uent follo()up

Topical

Corticosteroid

Inhibit chemotaxis &

phagocytosis

Recurrent

of

infection

Reduced stromal

inflammatory reaction

Limit tissue destruction by PM

and neo!ascuari"ation with scar


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Corneal !posureCorneal !posure


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Corneal MeltCorneal Melt


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Corneal "lcerCorneal "lcer


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Hypopion "lcerHypopion "lcer


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#ungal $eratitis#ungal $eratitis

>ungal 'eratitis is c%allenging corneal>ungal 'eratitis is c%allenging corneal

disease and presents as "ery dicult formdisease and presents as "ery dicult form

acterial 'eratitis. 0iculty arise in ma'ingacterial 'eratitis. 0iculty arise in ma'ing

correct clinical and laoratory diagnosis. %ecorrect clinical and laoratory diagnosis. %etreatment of fungal 'eratitis is also diculttreatment of fungal 'eratitis is also dicult

due to poor a"ailaility of antifungal drugsdue to poor a"ailaility of antifungal drugs

and delay in starting treatment.and delay in starting treatment.

reatment is reDuired on long term asis#reatment is reDuired on long term asis#intensi"ely and often cases reDuireintensi"ely and often cases reDuire

t%erapeutic 'eratoplasty.t%erapeutic 'eratoplasty.

3:3:M.R.SHOJAM.R.SHOJA


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>ungi enter into corneal stroma t%roug%>ungi enter into corneal stroma t%roug%

epit%elial defect# (%ic% may e due toepit%elial defect# (%ic% may e due to

trauma# contact lens (ear# ad oculartrauma# contact lens (ear# ad ocular

surface or pre"ious corneal surgery.surface or pre"ious corneal surgery. In stroma fungi multiply and causes tissueIn stroma fungi multiply and causes tissue

necrosis and inEammatory reaction.necrosis and inEammatory reaction.

Organisms enter deep into t%e stroma andOrganisms enter deep into t%e stroma and

t%roug% an intact 0escemets memranet%roug% an intact 0escemets memrane

into t%e anterior c%amer and iris. %ey caninto t%e anterior c%amer and iris. %ey can

also in"ol"e Sclera.also in"ol"e Sclera.

3)3)M.R.SHOJAM.R.SHOJA


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Ris% #actorsRis% #actors

1.1. rauma outdoorG or t%e one (%ic%rauma outdoorG or t%e one (%ic%

in"ol"es plant matter +including contactin"ol"es plant matter +including contact

lenses-lenses-

2.2. opical medications9opical medications9

3.3. corticosteroids#corticosteroids#

$.$.

anaest%etic drug auseanaest%etic drug ause:.:. topical road spectrum antiiotics usetopical road spectrum antiiotics use

for long timefor long time

3*3*M.R.SHOJAM.R.SHOJA


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Ris% #actorsRis% #actors

#$ %ystemic use of steroids#$ %ystemic use of steroids

$ 'orneal surgeries (Penetrating )eratoplasty*$ 'orneal surgeries (Penetrating )eratoplasty*

refracti!e surgery+refracti!e surgery+,$ 'hronic )eratitis (herpes simplex* herpes,$ 'hronic )eratitis (herpes simplex* herpes

"oster* -ernal or allergic )eratocon.uncti!itis*"oster* -ernal or allergic )eratocon.uncti!itis*

and neurotrophic ulcer+and neurotrophic ulcer+

/$ Diabetes * 'hronically ill 0 hospitalised/$ Diabetes * 'hronically ill 0 hospitalised

patients* 1ID% and leprosypatients* 1ID% and leprosy

33M.R.SHOJAM.R.SHOJA


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Causati&e fungiCausati&e fungi

I.I. Ceast9 ,andida species +alicans-#Ceast9 ,andida species +alicans-#,ryptococcus,ryptococcus

II.II. >ilamentous septated>ilamentous septatedA. 5on=pigmented %yp%ae9 >usariumA. 5on=pigmented %yp%ae9 >usariumspecies +solani-# Aspergillus speciesspecies +solani-# Aspergillus species+fumigatus# Ea"us# niger-+fumigatus# Ea"us# niger-

33M.R.SHOJAM.R.SHOJA


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Causati&e fungiCausati&e fungi

III. >ilamentous non=septated 9III. >ilamentous non=septated 9

Mucor and R%i@opus speciesMucor and R%i@opus species

I8. 0ip%asic forms9 Histoplasma#I8. 0ip%asic forms9 Histoplasma#,occidiodes# lastomyces,occidiodes# lastomyces

$6$6M.R.SHOJAM.R.SHOJA


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SymptomsSymptoms

Onset is slo(Onset is slo(

Symptoms are less compared toSymptoms are less compared to

signssigns

0iminution of "ision# pain# foreign0iminution of "ision# pain# foreign

ody sensationody sensation



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SignsSigns

0iminution of "ision# depending on0iminution of "ision# depending on

location of ulcerlocation of ulcer

,on&uncti"al and ciliary congestion,on&uncti"al and ciliary congestion pit%elial defectpit%elial defect

Stromal in?ltratesStromal in?ltrates

le"ated areas# %ypate +ranc%ing-le"ated areas# %ypate +ranc%ing-ulcers# irregular feat%ery marginsulcers# irregular feat%ery margins

0ry and roug% te/ture0ry and roug% te/ture



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#ungal $eratitis 'ith#ungal $eratitis 'ith

HypopyonHypopyon



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SignsSigns

Satellite lesionsSatellite lesions

ro(n pigmentation due toro(n pigmentation due to

dematiaceous fungus +,ur"ulariadematiaceous fungus +,ur"ularialunata-lunata-

Intact epit%elium (it% stromalIntact epit%elium (it% stromal

in?ltratesin?ltrates Anterior c%amer reactionAnterior c%amer reaction

$$$$M.R.SHOJAM.R.SHOJA


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Fun!al "eratitis # $i!mented esion

$:$:M.R.SHOJAM.R.SHOJA


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Case of #ungal(Case of #ungal(

)acterial $eratitis)acterial $eratitis

$)$)M.R.SHOJAM.R.SHOJA


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*a+oratory Diagnosis*a+oratory Diagnosis

%e 7ram and 7iemsa stains are used as%e 7ram and 7iemsa stains are used as

initial stainsinitial stains

Potassium Hydro/ide +16=26 - (et mountsPotassium Hydro/ide +16=26 - (et mounts

,ulture Media9 S%eep lood agar#,ulture Media9 S%eep lood agar#

,%ocolate agar# Saouraud de/trose agar#,%ocolate agar# Saouraud de/trose agar#

%ioglycollate rot%%ioglycollate rot%

Anterior c%amer tap under asepticAnterior c%amer tap under asepticconditions to aspirate %ypopyon and orconditions to aspirate %ypopyon and or

endot%elial plaDueendot%elial plaDue

$*$*M.R.SHOJAM.R.SHOJA


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TreatmentTreatment

,atamycin - suspension/,atamycin - suspension/

Candida species respond +etter toCandida species respond +etter to

Amphotericin ) 0.1-Amphotericin ) 0.1- #lucona2ole 3#lucona2ole 3

Micona2ole 1Micona2ole 1

Scrapping e&ery 34 to 45 hoursScrapping e&ery 34 to 45 hours

Treatment is re6uired for 4 7 8Treatment is re6uired for 4 7 8

'ee%s'ee%s

$$M.R.SHOJAM.R.SHOJA


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TreatmentTreatment

Su=con&uncti"al in&ection ofSu=con&uncti"al in&ection of

Micona@ole : K 16 mgm of 16 mgmGmlMicona@ole : K 16 mgm of 16 mgmGml

suspension +indicated in se"ere form ofsuspension +indicated in se"ere form of'eratitis# scleritis and endop%t%almitis-'eratitis# scleritis and endop%t%almitis-

Systemic9Systemic9

>lucona@ole or 4etocona@ole is>lucona@ole or 4etocona@ole is

indicated in se"ere form of 'eratitis#indicated in se"ere form of 'eratitis#scleritis and endop%t%almitisscleritis and endop%t%almitis

$$M.R.SHOJAM.R.SHOJA


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Surgical TreatmentSurgical Treatment

1.1. 0aily deridement (it% spatulaG lade e"ery0aily deridement (it% spatulaG lade e"ery2$ K $ %ours2$ K $ %ours

2.2. Surgical treatment is reDuired inSurgical treatment is reDuired in

appro/imately 1G3appro/imately 1G3rdrdcases of fungal 'eratitiscases of fungal 'eratitisdue to failure of medical treatment ordue to failure of medical treatment orperforationperforation

3.3. Surgical treatment in t%e form of 9Surgical treatment in t%e form of 9

t%erapeutic 'eratoplasty# con&uncti"al Eap ort%erapeutic 'eratoplasty# con&uncti"al Eap orlamellar 'eratoplastylamellar 'eratoplasty

:6:6M.R.SHOJAM.R.SHOJA


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9i l $ i i


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9iral $eratitis9iral $eratitis

Herpes Simple/Herpes Simple/ Herpes LosterHerpes Loster

Large dendrites with central ulceration and

terminal bulbs

Small, medusa-like dendrites WITHOUT

central ulceration or terminal bulbs


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Herpes Simple! $eratitis/Herpes Simple! $eratitis/

PathogenesisPathogenesis

HS8 is a 05A "irus t%at commonlyHS8 is a 05A "irus t%at commonlyinfects %umansinfects %umans

(o distinct strains e/ist(o distinct strains e/istK HS8=19 orofacial and ocularHS8=19 orofacial and ocular

K HS8=29 orogenital S0# neonatalHS8=29 orogenital S0# neonatal

Recurrent HS8 'eratitis is one of t%eRecurrent HS8 'eratitis is one of t%emost freDuent causes of infecti"emost freDuent causes of infecti"ecorneal lindness in t%e BScorneal lindness in t%e BS


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Herpes Simple! $eratitis/Herpes Simple! $eratitis/

Primary Ocular :nfectionPrimary Ocular :nfection

Most commonly occurs on t%eMost commonly occurs on t%e

mucocutaneous areas of t%e %eadmucocutaneous areas of t%e %ead

inner"ated y ,5 8inner"ated y ,5 8

Manifests as a nonspeci?c BRIManifests as a nonspeci?c BRI

May tra"el to t%e sensory ganglion andMay tra"el to t%e sensory ganglion and

remain in a latent nonpat%ogenic stateremain in a latent nonpat%ogenic state


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HS9/Primary Ocular :nfection/HS9/Primary Ocular :nfection/

Clinical PresentationClinical Presentation

Bnilateral "esicularBnilateral "esicularlep%aro'eratocon&uncti"lep%aro'eratocon&uncti"itisitis

>ollicular con&unti"itis>ollicular con&unti"itis

(it% occasional(it% occasionalmemrane formationmemrane formation

,utaneous "esicles on,utaneous "esicles oneyelid s'in or margineyelid s'in or margin

Preauricular nodesPreauricular nodes 2G3 de"elop epit%elial2G3 de"elop epit%elial

'eratitis'eratitis


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HS9/ Primary Ocular :nfectionHS9/ Primary Ocular :nfection

TreatmentTreatment

Self=limited conditionSelf=limited condition opical anti"iral t%erapyopical anti"iral t%erapy

K riEuridine +8iroptic-riEuridine +8iroptic-K 8idaraine8idaraine

Oral anti"iral t%erapy +one (ee'-FOral anti"iral t%erapy +one (ee'-FK Acyclo"ir $66mg :/GdayAcyclo"ir $66mg :/Gday

K >amcyclo"ir :66mg 3/Gday>amcyclo"ir :66mg 3/GdayFmay reduce recurrence rateFmay reduce recurrence rate

Bacteril Keratitis

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