1. Case: Corneal ulcer
서울성모병원
임상강사 황규연

2. 2012.3.10 F/78 C/C tearing, redness, pain (OD) Onset 7일전, trauma Hx(-)
Past Hx
DM(+)
CRVO(OD) NVG(OD) PDR(OU)  blindness(OD)
8년전 cat. Op(OD)
2-3년전 intravit. Avastin Inj(OD) x3
2달전 ppV d/t PDR c vit Hm(OS), phaco+PCL(OS)
BCVA OD LP(-)
OS 0.32(n-c)
Ta OD 25
OS 20mmHg
(O-COSTx2 O-BMDPx2 O-LTPxhs/(OU))

3. 2012.3.10 Irregular epi-defect c infiltraion at center Melting(-)
AC reaction (cell, hypopyon)

5. 생각할 점 각막 궤양의 원인균은 무엇인가? Infection의 방향
Bacterial (G+, G-(pseudomonas), ---)
Fungal
Infection의 방향
Corneal ulcer  endophthalmitis
서로 다른 경로로 발생

6. Classic presentation of corneal ulcer

8. Staphylococcus
Staphylococcus

9. 생각할 점 각막 궤양의 원인균은 무엇인가? Infection의 방향
Bacterial (G+, G-, pseudomonas, ---)
Fungal
Infection의 방향
Corneal ulcer  endophthalmitis
서로 다른 경로로 발생

10. Eye (2009) 23, 945–956

12. impression Corneal ulcer c endophthalmitis(OD)
Cornea smear and culture
Start broad spectrum antibiotics (vigamox + tobramycin x q1hr)
Topical cycloplegics
Paracentesis for culture
Intravit. Vancomycin + fortum injection
Systemic antibiotics (3rd cephalosporin)

13. (HD #4)

14. 검체: cornea smear
검체: anterior chamber

15. Eye (2009) 23, 945–956

16. S. Aureus Etiology rapidly progressive corneal infiltration
More in compromised cornea
Bullous keratopathy, chronic herpetic keratitis, keratoconjunctivitis sicca, ocular rosacea, atopic keratoconjunctivits
rapidly progressive corneal infiltration
moderate AC reactions with hypopyon
Round or oval with dense infiltration and a distinct border
Occasionally a stromal microabscess with an
ill-defined border

17. 2012.3.14 (HD #4) Vigamox x q1hr  q2hr tapering Tobramycin x4
Systemic antibiotics change (nafcillin)

18. ~22 (HD #6~13)
Cornea: decreased infiltration and microabscess
(epi-defect enlarged d/t mechnical trauma)
AC: decreased hypopyon

19. 2012.3.31 (#21) Conjunctival injection : decreased
Epi-defect(+), but infiltration(-)
F-stain: late pooling
vigamox x4 tapering, artificial eyedrops,

20. Review: How to approach to patients?

21. Culture-guided approach
Corneal scrapings for staining and microbiological culture are performed in all cases of microbial keratitis before treatment is started.
The initial therapy is based on the clinical and epidemiological information and may be modified according to microbiological results.
Severe corneal ulcers or infections caused by atypical pathogens.
Beneficial to monitor infectious trends through epidemiological surveys.
The major disadvantage of this approach is the inconvenience and cost.

22. Empirical approach
Pre-existing culture and sensitivity data without obtaining corneal specimens.
Broad-spectrum antibiotics to cover potential causative organisms.
The advantages of this approach are convenience and cost- effectiveness.
The disadvantage
Prolonged and nonelective use of fortified antibiotics may cause ocular discomfort and epithelial toxicity
is no longer be collected for future reference and for monitoring of the potential emergence of resistant organisms.

23. Case-based approach
Clinicians obtain corneal specimens before initial treatment only in selective cases with ulceration involving visual axis or with large, deep ulcers, trauma, or contamination by vegetation materials or unsanitized water.

24. Pathogenesis Gram-positive isolates Gram-positive cocci
Class/organism
Common isolates*
Cases (%)
Gram-positive isolates
29–53
Gram-positive cocci
Staphylococcus aureus
4–19
Coagulase-negative staphylococci
1–45.5
Streptococcus pneumoniae
0–3
Streptococcus viridans group
1–6
Gram-positive bacilli
Propionibacterium species
4–7
Mycobacterium species 3
Gram-negative isolates
47–50
Gram-negative bacilli
Pseudomonas aeruginosa
3–33
Serratia marcescens
3–13.5
Proteus mirabilis 4
Enteric Gram-negative bacilli, other
1–10
Gram-negative
Haemophilus influenzae, other Haemophilus species
2.5
Coccobacillary organisms
Moraxella species and related species 1
Gram-negative cocci
Neisseria species
2008 ophthalmology

25. Treatment Antibiotic therapy of bacterial keratitis Organism
Topical
concentration
Subconjunctival
dose
No organism identified or multiple types of organisms
Cefazolin with
Tobramycin or gentamicin or Fluoroquinolones*
50 mg/mL
9–14 mg/mL
Various
100 mg in 0.5 mL
20 mg in 0.5 mL
Gram-positive cocci
Cefazolin
Vancomycin
Bacitracin
Fluoroquinolones*
15–50 mg/mL
10000 IU
25 mg in 0.5 mL
Gram-negative rods
Tobramycin or Gentamicin
Ceftazidime Fluoroquinolones
Gram-negative cocci
Ceftriaxone
Nontuberculous mycobacteria
Amikacin Clarithromycin Azithromycin Fluoroquinolones
20–40 mg/mL
10 mg/mL
Antibiotic therapy of bacterial keratitis

26. Evolution of the Quinolones
Norfloxacin
Lomefloxacin
Ciprofloxacin
Ofloxacin
Sparfloxacin
Grepafloxacin
Levofloxacin
Gatifloxacin
Moxifloxacin
Nalidixic Acid
H3C N
C2H5 O
COOH
H3C-N F
CH3 N O
COOH H HN N F O
COOH O F
COOH H HN N N
OCH3 H
Extended spectrum
Enhanced activity against
Gram-positives, streptococci,
anaerobes, atypical mycobacteria
Improved pharmacokinetic
properties
Extended spectrum
Enhanced activity against
Gram-negatives
Limited spectrum
of activity
American Pharmaceutical Association; 2000.

27. Treatment
* Initial management of microbial keratitis.

28. Clinical features suggestive of a positive response to antibiotic Tx
1) reduction in pain
2) reduced amount of discharge
3) less eyelid edema or conjunctival injection
4) consolidation and sharper demarcation of the perimeter of the stromal infiltrate
5) decreased density of the stromal infiltrate
6) reduced stromal edema and endothelial inflammatory plaque
7) reduced anterior chamber inflammation and reepithelialization.

29. Treatment
* Reevaluation after 1 week of antimicrobial therapy.