1. Diseases of the Cornea

2. Keratitis Infectious Physical Bacterial (Streptococcus pneumoniae)
Bacterial (Pseudomonas aeruginosa)
Fungal
Herpes simplex
Physical
Abrasion

3. Bacterial (Streptococcus pneumoniae)
Streptococcus pneumoniae: lancet-shaped, encapsulated, gram + diplococci
Serpingous, gray-white stromal infiltrate and hypopyon (pus)
Distinct borders with overhanging edges; usually with overhanging defect or ulcer
Suppuration not usually extend over the entire corneal surface
Sterile hypopyon is common

4. Bacterial (Streptococcus pneumoniae)

5. Bacterial (Streptococcus pneumoniae)
History of the patient: trauma or URTI for 5-7 days
Pneumococcal ulcer manifests hrs after inoculation of the abraded cornea
Spread erratically from original site towards the center
Advancing border shows active ulceration as the trailing border begins to heal  acute serpingous ulcer
Superficial corneal layers involved first then the deep parenchyma

6. Bacterial (Streptococcus pneumoniae)
Topical erythromycin
Chloramphenicol
4th gen fluroquinolones (Moxifloxacin and Gatifloxacin)
Oral cephalosporins and erythromycin
Concurrent dacrocystitis and nasolacrimal duct obstruction should be treated

7. Bacterial (Pseudomonas aeruginosa)
Gram (-) corneal ulcer
Rapid evolution; marked tendency to spread
Common among immunocompromised, soft contact lens with faulty hygiene, contaminated fluorescein solution or eye drops

8. Bacterial (Pseudomonas aeruginosa)

9. Bacterial (Pseudomonas aeruginosa)
Begins as a gray or yellow mucopurulent discharge adherent to ulcer surface  bluish green
Ulcer is diffused with uniform penetration  severe pain
More discharge
Opacification and edema around the ulcer
Rapid stromal necrosis due to proteolytic enzymes
Corneal perforation and severe intraocular infection

10. Bacterial (Pseudomonas aeruginosa)
Moxifloxacin, Gatifloxacin, Ciprofloxacin, Tobramycin, Gentamycin
Other fluoroquinolones, polymyxin B or carbenicillin

11. Fungal Keratitis Indolent or slow-type (usually months) Filamentous
Gray white
Feathery border
Satellite infiltrates
Deep: endothelial plaque
Yeast
Focal
Dense suppuration similar to Pneumococcus

12. Fungal Keratitis Intense suppuration, progressive hypopyon
Anterior chamber membranes
Gray infiltrate with irregular edges
Marked inflammation of the globe with superficial ulceration
Endothelial plaque with corneal abscess

13. Fungal Keratitis

14. Fungal Keratitis
Candida, Fusarium, Aspergillus, Penicillium, Cephalosporium
Except Candida: Hyphal elements
Candida: pseudohyphae or budding

15. Fungal Keratitis No effective topical agent
Combination of anti-fungal tablets (Amikacin, Cefaxolin, Gentamicin, Neomycin, etc)
Oral tablets (Amphotericin B with saline) dropped every 5 mins
Debridement to remove dead tissue and to increase drug absoprtion
Candida: Natamycin, Ketoconazole, Voriconazole, Amphotericin B

16. Herpes simplex Keratitis
Discrete punctate epithelial keratitis  coalesce into branching or dendritic lesion (swollen, opaque epithelial cells)
Terminal bulbs
Ulcer in the center of dendrite due to lysis and desanquamation of infected cells
Centrifugal spread (center to peripheral)  geographic ulcer

17. Herpes simplex Keratitis

18. Herpes simplex Keratitis
Usually among young children
Mild stromal edema and subepitelial infiltrates
Irritation, photophobia, tearing
If central cornea affected  reduction in vision
Can have fever, blisters

19. Herpes simplex Keratitis
Debridement
Idoxuridine, Trifluridine, Vidarabine, Acyclovir
Penetrating keratoplasty: only for inactive infections
Control reactivation of HSV infection
Aspirin for fever
Avoid exposure to ultraviolet light
Prophylactic antivirals

20. Corneal Abrasion
Scraping of the superficial part that may heal in a matter of hours
Acute pain after trauma
Photophobia, tearing, blepharospasm (eyelid spasm), foreign body sensation, blurred vision
Adjacent cells expand and fill the defect  basal epithelial cells undergoes mitosis
Patching/bandage, topical antibiotics, cycloplegic

21. Corneal Abrasion

22. Glaucoma

23. Glaucoma (Acute angle closure)
True emergency!!
Route of aqueous humor: cilliary body  drains anteriorly from iris  pupil  canal of Schlemm
Occlusion at the anterior chamber angle by the peripheral iris  increase IOP
Pupillary block: from posterior to anterior chamber  peripheral iris balloon forward
Plateau iris: peripheral iris lax  contact with the angle

24. Glaucoma (Acute angle closure)
Ocular pain, headache
Unilateral blurring of vision
Iridescent vision (halos)
Nausea and vomiting
Redness

25. Glaucoma (Acute angle closure)
Elevated IOP (60-80 mmHg)  on tonometry “rock hard”
Deep circumlimbal conjunctiva and episcleral injection  ciliary flush
Fixed, mid-dilated pupil
Edematous or steamy cornea
Shallow anterior chamber
Thinning out or excavation of optic disc “glaucomatous cupping”  chronic cases

26. Glaucoma (Acute angle closure)

27. Glaucoma (Acute angle closure)
Increased IOP  acute ischemic changes in iris  corneal edema  optic nerve damage
Primary open-angle glaucoma
IOP doesn’t increase >30 mmHg
Retinal damage develops over a period of time
Normal-tension glaucoma
Retinal ganglion cells susceptible to changes in IOP
Optic nerve ischemia

28. Glaucoma (Acute angle closure)
Carbonic anhydrase inhibitors
Hyperosmotic agents
Oral glycerin
IV mannitol
Pilocarpine
Supportive: corticostroids, analgesics

29. Uveitis

30. Uveitis (Iridocyclitis)
Anterior chamber
Inflammation of the iris, ciliary body, choroid
Deep, dull pain
Photophobia may be severe
Ciliary body controls the opening and closing of the iris muscles
Tearing

31. Uveitis (Iridocyclitis)
Visual acuity not significantly impaired
Reading difficulty
Ciliary flush
Mildly edematous cornea
Sterile hypopyon if severe

32. Uveitis (Iridocyclitis)
Hallmark: cells and flare
Cells
Leukocytes floating in aqueous
Flare
Protein from inflamed iris or ciliary body
Keratic precipitates (clumps of white cells and inflamatory debris) in active inflammation
Koeppe nodules (granulomatous nodules in iris)
Busacca nodules (within iris stroma)
Berlin’s nodules (anterior chamber angle)

33. Uveitis (Iridocyclitis)

34. Uveitis (Iridocyclitis)
Underlying systemic disease
TB, Ankylosing spondylitis, Behcet’s syndrome, JRA, syphilis
Treatment
Immobilize iris and ciliary body to decrease pain
Cycloplegia (atropine, cyclopentolate)
Topical steroids
Treat underlying systemic disease