CHAPTER I

INTRODUCTION
Corneal disease that ends with scar tissue is the second position after
cataract as a cause of blindness and decreased visual acuity in many developing
countries especially in the Asia, Africa and the Middle East (Whitcher and
Srinivasan, 1!"# $lindness in %ndonesia can be caused by a factor of corneal
opacification# Senses &ealth Survey in 1'(1) showed 1#*+ of %ndonesia,s
population are blind due to cataract (*-+", glaucoma (1'#.+", refractive disorders
(#*+", retinal disorders (/#*+", corneal abnormalities (/#.+" and other eye
diseases (%mpaired vision is still a health issue, -01-"# $angun (-00" concluded
that blindness mainly caused by an infection of the cornea#
1ummularis 2eratitis is also called 2eratitis or 2eratitis pungtata tropical
sawahica suspected caused by virus# Suspected of virus that enters through
wounds in the corneal epithelium after trauma# 3irus replication in epithelial cells
followed by the spread of the to4in in the corneal stroma resulting in opacities or
round infiltrates li2e a coin(shaped (%lyas, -000"# 5pacities or infiltrates can
disrupt the function of vision and can last for months or years (&illen2amp et al#,
-00)"# %n fact, the disease can be prevented or treated appropriately ($iswell,
-010"# 6esearch on nummularis 2eratitis is still very low, both globally and in
%ndonesia#
1
CHAPTER II
LITERATURE REVIEW
-#1# Cornea
-#1#1# Anatomy and histology
7he cornea is the transparent, avascular, and highly innervated anterior
portion of the fibrous tunic that bulges out anteriorly from the orb# %t is slightly
thic2er than the sclera and is composed of five histologically distinct layers
1
8
Corneal epithelium
$owman,s membrane
Stroma
9escemet,s membrane
Corneal endothelium
7he corneal epithelium, the continuation of the con:unctiva (a mucous
membrane covering the anterior sclera and lining the internal surface of the
eyelids", is a stratified, s;uamous, non2eratini<ed epithelium, composed of five to
seven layers of cells, that covers the anterior surface of the cornea# 7he larger
superficial cells have microvilli and e4hibit <onulae occludentes# 7he remaining
cells constituting the corneal epithelium interdigitate with and form desmosomal
contacts with one another# 7heir cytoplasm contains the usual array of organelles
along with intermediate filaments# 7he corneal epithelium is highly innervated by
-
numerous free nerve endings# Mitotic figures are observed mostly near the
periphery of the cornea, with a turnover rate of appro4imately ! days#
9amage to the cornea is repaired rapidly as cells migrate to the defect to
cover the in:ured region# Subse;uently, mitotic activity replaces the cells that
migrated to the wound# 7he corneal epithelium also functions in transferring water
and ions from the stroma into the con:unctival sac#

(=artner, -00!"
$owman,s membrane lies immediately deep to the corneal epithelium#
Electron micrographs reveal it to be a fibrillar lamina, ) to '0 >m thic2, composed
of type % collagen fibers arranged in an apparently random fashion# %t is believed
that $owman,s membrane is synthesi<ed by both the corneal epithelium and cells
of the underlying stroma# Sensory nerve fibers pass through this structure to enter
and terminate in the epithelium# (=artner, -00!"
7he transparent stroma is the thic2est layer of the cornea, constituting
about 0+ of its thic2ness# %t is composed of collagenous connective tissue,
consisting mostly of type % collagen fibers that are arranged in -00 to -*0
lamellae, each about - >m in thic2ness# 7he collagen fibers within each lamella
are arranged parallel to one another, but fiber orientation shifts in ad:acent
lamellae# 7he collagen fibers are interspersed with thin elastic fibers, embedded in
ground substance containing mostly chondroitin sulfate and 2eratan sulfate# ?ong,
slender fibroblasts are also present among the collagen fiber bundles# 9uring
inflammation, lymphocytes and neutrophils are also present in the stroma# At the
limbus (sclerocorneal :unction" is a scleral sulcus whose inner aspect at the stroma
is depressed and houses endothelium(lined spaces, 2nown as the trabecular
meshwor2, that lead to the canal of Schlemm# 7he canal of Schlemm is the site of
outflow of the a;ueous humor from the anterior chamber of the eye into the
venous system# (=artner, -00!"
9escemet,s membrane is a thic2 basement membrane interposed between
the stroma and the underlying endothelium# Although this membrane is thin (* >m
at birth" and homogeneous in younger persons, electron microscopy has
demonstrated that it becomes thic2er (1! >m" and has cross(striations and
he4agonal fiber patterns in older adults# (=artner, -00!"
'
7he corneal endothelium, which lines the internal (posterior" surface of the
cornea, is a simple s;uamous epithelium# %t is responsible for synthesis of proteins
that are necessary for secreting and maintaining 9escemet,s membrane# 7hese
cells e4hibit numerous pinocytotic vesicles, and their membranes have sodium
pumps that transport sodium ions (1a@" into the anterior chamberA these ions are
passively followed by chloride ions (Cl(" and water# 7hus, e4cess fluid within the
stroma is resorbed by the endothelium, 2eeping the stroma relatively dehydrated,
a factor that contributes to maintaining the refractive ;uality of the cornea#
(=artner, -00!"

-#1#-# Corneal 6esistance to %nfection
7he epithelium is an efficient barrier to the entrance of microorganisms
into the cornea# 5nce the epithelium is traumati<ed, however, the avascular
stroma and $owman,s layer become susceptible to infection with a variety of
organisms, including bacteria, amebas, and fungi# Streptococcus pneumoniae (the
pneumococcus" is a true bacterial corneal pathogenA other pathogens re;uire a
heavy inoculum or a compromised host (eg, immune deficiency" to produce
infection# (3aughan and AsburyBs, -00!"
Moraxella liquefaciens, which occurs mainly in alcoholics (as a result of
pyrido4ine depletion", is a classic e4ample of the bacterial opportunist, and in
recent years a number of new corneal opportunists have been identified# Among
them are Serratia marcescens, Mycobacterium fortuitum-chelonei comple4,
viridans streptococci, Staphylococcus epidermidis, and various coliform and
proteus organisms, along with viruses, amebas, and fungi# (3aughan and
AsburyBs, -00!"
?ocal or systemic corticosteroids modify the host immune reaction in
several ways and may allow opportunistic organisms to invade and flourish#
(3aughan and AsburyBs, -00!"
.
-#1#'# Chysiology of Symptoms
Since the cornea has many pain fibers, most corneal lesions, superficial or
deep (corneal foreign body, corneal abrasion, phlyctenule, interstitial 2eratitis",
cause pain and photophobia# 7he pain is worsened by movement of the lids
(particularly the upper lid" over the cornea and usually persists until healing
occurs# Since the cornea serves as the window of the eye and refracts light rays,
corneal lesions usually blur vision, especially if centrally located# (3aughan and
AsburyBs, -00!"
Chotophobia in corneal disease is the result of painful contraction of an
inflamed iris# 9ilation of iris vessels is a refle4 phenomenon caused by irritation
of the corneal nerve endings# Chotophobia, severe in most corneal disease, is
minimal in herpetic 2eratitis because of the hypesthesia associated with the
disease, which is also a valuable diagnostic sign# Although tearing and
photophobia commonly accompany corneal disease, there is usually no discharge
e4cept in purulent bacterial ulcers (3aughan and AsburyBs, -00!"
-#-# Deratitis
-#-#1 9efinition
Deratitis is an inflammation of the cornea, the transparent membrane that
covers anterior part of eye# Catognomonic symptom of 2eratitis is infiltrate in
cornea# %nfiltrate can deposit in any layer of cornea# Cornea is avascular
compartment of eye, so the defense mechanism in inflammatory process in cornea
could not occur immediately# %nflammatory process in cornea can cause farther
damage to cornea itself# When the inflammatory process in cornea happens
superficially (epithelial" it will heal perfectly, but when it happens in the deeper
layer, there will be a great chance of scar tissue development which can be nebula,
macula, or leucoma# (%lyas S, -00!"
-#-#- Classification
*
Deratitis is classified based on location of lesion in corneal layer and
causal
(1" $ased on location8
a# Superficial 2eratitis8
Epithelial 2eratitis (flouresence test @"
o Deratitis pungtata superficial
o Deratitis &erpes simple2s
o Deratitis &erpes <oster
Subepithelial 2eratitis (flouresence test ("
o 1ummular 2eratitis of 9immer
o 9isiform 2eratitis of Westhoff
Stromal 2eratitis (flouresence test ("
o 1europaraliti2 2eratitis
o Deratitis et lagoftalmus
b# Crofound Deratitis8
Deratitis %nterstitial
Deratitis S2leroti2ans
Deratitis 9isiformis
(-" $ased on causal
$actery8 9iplococcus pneumonia, Streptococcus hemolyticus,
Cseudomonas aeroginosa, etc
3irus 8 &erpes simple2s, &erpes <ooster, etc
fungi 8 Candida, Aspergillus sp#
Allergic reaction
Avitaminosis A
1#3 damage
9irect trauma
9ry eye
)
(%lyas S, -00!"
$acterial Deratitis Eungal Deratitis
Carasiitc Deratitis 3iral Deratitis
!
Morphologic 9iagnosis of Corneal ?esions
(Source8 3aughan and AsburyBs# -00!# =eneral 5phthalmology ed#1!#
Mc=raw&ill"
-#-#'# Catophysiology
Since the cornea is avascular, inflammatory process will not as effective
and immediate as other well vasculari<ed tissues# Wandering cell in corneal
stroma will be the first immunologic cell which response to inflammatory process#
%t will become tissue macrophage# 7his process will then followed by
vasodilatation of blood vessels in limbus (this will be seen as pericorneal
in:ection"# %nfiltration of CM1, macrophages, and plasma cell will cause cornea
loo2s cloudy# (%lyas S, -00!"
Corneal epithelium can be destroyed and form ulcer# Superficial ulcer will
resolve perfectly, but the deeper one will leave scar# %f the iris involved in this
inflammatory response, inflammatory cell will be accumulated in anterior
chamber and can be seen as hypopion# (%lyas S, -00!"
-#-#.# Symptoms of 2eratitis include, but are not limited to8
7earing F redness
Cain
Sensitivity to light
%nflammation of the eyelid
9ecrease in vision (%lyas S, -00!"
/
-#'# 1ummularis 2eratitis
1ummularis 2eratitis is a form of 2eratitis that characteri<ed by groups of
round infiltrates (nummus G coins" and demarcated edges# Deratitis is slow, often
unilateral and were generally found at farmers who wor2ing in the rice fields
(5phthalmologist Association of %ndonesia, -010"# 7he disease was first
discovered by 9immer in 10*## ?esions, as shown below, large, round, and there
are granular deposits :ust below bowman,s membrane surrounded by halo
(Dans2i, -010"#
1ummularis Deratitis
(Source8 Dans2i, HH#, -010, Sign in 5phthalmology8 Causes and 9ifferential
9iagnosis, Chapter *, Mosby Elsevier"

9isciform Deratitis
(Source8 Ianoff F 9uc2er, -00/, 5phthalmology, '
rd
ed# Mosby Elsevier"
Deratitis nummularis have clinical features such as photophobia, red eye,
ciliary in:ection with lacrimation# Multiple round infiltrates contained in the
superficial layers of the cornea, usually does not cause ulceration (%ndonesian
5phthalmologist Association, -010"#
7he cause of 2eratitis nummularis is un2nown e4actly (%ndonesian
5phthalmologist Association, -010"## Dans2i (-010" and Ianoff (-00" says that
the nummularis 2eratitis feature can be found on &erpes Joster 5phthalmicus
disease, Acanthamoeba infections, 5nchocerca volvulus worm infection and
$rucella infection#
?ang (-00-" and 6einhard (-00)" says that the cause of 2eratitis are
adenovirus nummularis# %n the beginning, there was con:unctival in:ection, pain ,
and watery eyesA within *(1. days will be followed by photophobia and round
subepithelial infiltration ($iswell, -010"# &istopathological investigation of the
biopsy revealed focal subepithelial infiltrates consisting of lymphocytes,
histiocytes and fibroblasts is accompanied by disruption of the $owman layer of
collagen fibers# Cathogenesis of these infiltrates is most li2ely due to the
constantly or continously viral replication in the 2eratosit which located at
subepithelial layer that trigger the immunological reactions in the patient,s body
(&illen2amp et#al, -00)"#
10
?ocal corticosteroids on the 2eratitis nummularis give good results which
is mar2ed by the loss of inflammatory infiltrates and lacrimation, but absorption
occurs in a long time, can be one to two years (5phthalmologist Association of
%ndonesia, -010"#
11
CHAPTER III
CASE
1# Catient identity
1ame 8 Mr# S
Se4 8 Male
Age 8 -- years old
Address 8 9usun Darya Murni street Duala Mandor $ (Dubu 6aya(
Ethnic 8 Madura
Hob 8 Salesman
6eligion 8 Moslem
Catient was e4amined on Maret 1
st
, -01-
-# Anamnesis
a# Main complaint 8 $lurry vision in right eye#
b# &istory of disease 8
Catient complains blurry vision in right eye since ' months ago# &e also
complains pain, itchy and da<<led (photophobia" in his right eye# %nitially,
when these symptoms were present, his right eye was red as he wo2e up#
$ecause of that, he too2 the initiative to shed his eye with the eyedrop that
he usually used#
5ne months ago, he ever go to public health center to chec2 his right eye#
&e was not given a drug, and advised to chec2 his right eye to the
ophtalmologist#
Catient wor2 as a salesman# &e is the youngest of five brothers# his parents
are farmers and he often helped them to farm# he was helping on the farm
since he was childhood but the most active at the age of 1! years# When
wor2ed in the rice fields, his eyes usually e4posed to mud splashing#
&e often played football in a muddy field and dusty# &e played twice a
wee2# &is eyes are also often hit by insects when riding motorcycle in his
village, where he was not wearing a helmet#
1-
c# Cast clinical history8 Catient claims that there is no history of the same
symptoms before# &istory of trauma (@" (hit by bug A mud splashing" Kthe
last trauma occurs 1 wee2 before the symptomps presentL, history of using
contact lens ((", history of using another drugs ((" Ksuch as steroid, or
topical traditional drug, etcL, history of s2in diseaseMlessions ((" Ksuch as
varicella, vesicular rash, etcL, history of fever (("# &ypertension history ((",
9M history ((",
d# Eamily history 8 7here are no one of his family have the same complaint#
'# =eneral Chysical Assessment
=eneral condition 8 good
Awareness 8 compos mentis
3ital Signs8
&eart 6ate 8 /04Mminute
6espiration fre;# 8 1)4Mminute
$lood Cressure 8 1'0M/0 mm&g
7emperature 8 '!,*
o
C
.# 5phthalmological status
3isual acuity8
a# 59 8 )M1-
b# 5S 8 )M)
59 5S

1'

Right eye Left eye
ortho Eye ball position 5rtho
ptosis ((", lagoftalmos
((", edema (("
Palpeba ptosis ((", lagoftalmos ((",
edema(("
6edness ((", discharge
((" , fibrovascular
growth (("
Con!"ngti#a 6edness ((", discharge ((" ,
fibrovascular growth (("
Cloudy, there are
multiple round
infiltrates (coin shaped A
whitish spot" with
demarcated edge,
Conea Clear, edema ((", ulcer ((",
infiltrate (("
clear, deep COA clear, deep
%ris colour 8 brown
Cupil8 circular, 'mm,
iso2or, reactive to light
Iis an$ p"pil %ris colour 8 brown
Cupil8 circular, 'mm,
iso2or, reactive to light
Clear Lens Clear
Clear Viteo"s Clear
1ormal papil with
demarcated edge, CM9
ratio 0,.
%"n$"s 1ormal papil with
demarcated edge, CM9
ratio 0,.
Eye ball movement
%ntraocular pressure (tonometry digital" 8
59 1ormal (chewy li2e :elly" , 5S 1ormal (chewy li2e :elly"
3isual field test (confrontation" 8 1ormal
1.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
OD
OS
%shihara test A 1ot done
Eluorescein test 8 1ot done
Sensibility test 8 Cositive
*# 6esume
Catient complains of blurry vision in right eye since ' months ago# &e
also complains pain, itchy and da<<led (photophobia" in his right eye# %nitially,
when these symptoms were present, his right eye was red as he wo2e up#
&is parents are farmers and he often helped them to farming# &e was
helping on the farm since he was childhood but the most active at the age of
1! years When wor2ed in the rice fields, his eyes usually e4posed to mud
splashing#
&e often played football in a muddy field and dusty# &is eyes usually
e4posed to mud splashing and dust when played# &e played twice a wee2s# his
eyes are also often hit by insects when driving in his village, where he was not
wearing a glass protective helmet#
3ital signs of this patient are in normal range# 3isual acuity of 59 is
)M1-, and 5S is )M)# Eyelids are normal# Cornea of the right eye has some
multiple round infiltrates (coin shapedA whitish" with demarcated edge# 7he
anterior chamber, lens, and vitreous body of both eyes are clear# %ris and pupil
loo2 normal# %n funduscopy e4amination found no abnormalities#
)# 9iagnose
Wor2ing 9iagnose8
59 8 1umular 2eratitis
5S 8 (
!# Clan for e4amination
1o plans for further information
1*
/# 7reatment8
( 1on medicamentous 8
o Nsing of protective glasses, wear hat#
o Advised to always use the glass protective helmet when
driving#
o As much as possible avoid the mud splashing to the eyes, or if
has been e4posed, immediately washed
( Medicamentous 8
o 59
Colymicin b sulfate
1eomycin sulfate
9e4amethasone sodium phosphate
3itamin C -41 daily per oral
Artificial tears '41 daily topical
# Crognosis
59
Ad vitam 8 bonam
Ad functionam 8 bonam
Ad sanactionam 8 ad dubisan
5S
Ad vitam 8 bonam
Ad functionam 8 bonam
Ad sanactionam 8 bonam
CHAPTER IV
DISCUSSION
1)
6x1 daily topical
A man, -- years old complained blurry vision in his right eye#&e felt
slight pain, itchy, da<<led for about three months# Erom anamnesis there is history
of wor2 in the farm# %t can support the diagnosis of nummularis 2eratitis, because
in some literature said there is a relationship between wor2 in the farm and
nummularis 2eratits## %n this case, chronic iritation because of mud splashing in
the rice field ma2e the cornea defence wea2ened and ma2e it more easily to have
an infection# 7he patient also have another history of trauma , it was mud(
splashing when played soccer and bug crushed when riding motorcycle#
Catient complaint blurry vision# 7his symptom can occurs because
cornea is one of the refraction media, pathway of light to reach the retina
(fotoreseptor", so if there is an abnormality in the cornea it must be followed by
decreased visual acuity# Catient also complaint pain# 7his symptom can occurs
because cornea have so many nerve fibers# We 2now that trigeminal nerve
innervates the cornea# %f there is an irritation in cornea, it will stimulate the nerve
endings in cornea, and it will ma2e pain to the patient# Chotophobia in corneal
disease is the result of painful contraction of an inflamed iris# 9ilatation of iris
vessels is a refle4 phenomenon caused by irritation of the corneal nerve endings#
7he abnormality found in ophtalmological e4amination is the multiple
round infiltrates (coin shaped A whitish spot" with demarcated edge, in patient
right eye cornea# 3irus replication in epithelial cells followed by the spread of the
to4in in the corneal stroma resulting in opacities or round infiltrates li2e a coin(
shaped# %t was becaused there is a imune(mediated response process to viral
particles#
1!
Wor2ing diagnose of this patient is nummular 2eratitis based on the
clinical features (chronic, unilateral", history (wor2ed in the farm A history of
trauma" and appearance of corneal abnormality that was multiple round infiltrates
(coin shaped A whitish spot" with demarcated edge#
6ecommended therapy for this patient includes non(medicamentous
such as wearing protective glasses, hat to prevent recurrent trauma, avoid the
mud(splashing and other trauma that can lead to an infection# Medicamentous
therapy for this patient aims to prevent secondary bacterial infection with
antibiotic (polymycin and neomycin" , to reduce inflammatory process with
corticosteroid (de4amethasone" and to support the healing of corneal (vitamin c
and artificial tears"
CHAPTER V
CONCLUSION
1/
Male, -- years old, complaint blurry vision in right eye# E4amination
reveal there are multiple round infiltrates (coin shaped Awhitish" with demarcated
edge in his right eye cornea # Wor2ing diagnose for this patient is numularis
2eratitis# 7he therapy include non(medicamentous (wearing protective glasses and
hat" and medicamentous (topical antibiotic,steroid,artificial tears and oral vitamin
c "
RE%ERENCES
1
1# $angun, CII#, -00, Crevalensi Debutaan A2ibat Delainan Dornea di
Dabupaten ?ang2at, Nniversitas Sumatera Ntara, Ea2ultas Dedo2teran,
Sumatera Ntara, (7esis"#
-# $iswell, 6#, -010, Dornea# 9i dalam8 Whitcher, HC# dan 6iordan(Eva, C# (eds",
5ftalmologi Nmum 3aughan dan Asbury, Edisi 1!, Cendit, $N# (alih bahasa",
E=C, Ha2arta, hal# 1-*(1.#
'# =artner ?C, &iatt H?# -00!# Color 7e4tboo2 of &istology# 1ew Ior28 W$
Saunders,
.# &illen2amp, H#A Sundmacher, 6# and 6einhard, 7#, -00), 7reatment of
Adenoviral Deratocon:unctivitis# %n8 6einhard, 7# and ?ar2in, 9EC#, Essentials
in 5phthalmology8 Cornea and E4ternal Eye 9isease# Springer, =ermany,
pp#1)'(1!-#
*# %lyas S#, -000, Sari %lmu Cenya2it Mata#, $alai Cenerbit EDN%, Ha2arta, hal#
.1()-#
)# %lyas S# -00!# %lmu Cenya2it Mata edisi 2etiga# Ha2arta8 $alai Cenerbit EDN%,
!# Dans2i, HH#, -010, Signs in 5phthalmology8 Causes and 9ifferential
9iagnosis, Mosby Elsevier, ND#
/# ?ang, =D#, -000, 5phthalmology8 A Short 7e4tboo2, 7hieme, 1ew Ior2, pp#
'(*#
# Cerhimpunan 9o2ter Spesialis Mata %ndonesia, -010, %lmu Cenya2it Mata8
Nntu2 9o2ter Nmum dan Mahasiswa Dedo2teran, Edisi -, Sagung Seto,
Ha2arta, hal .()A 11'(1-0#
10# 3aughan 9=, et al# -000# Oftalmologi umum edisi 14# Ha2arta8 Widya Medi2a#
11# 3aughan and AsburyBs# -00!, =eneral 5phthalmology ed#1!# Mc=raw&ill
1-# Whitcher, HC# and Srinivasan, M#, 1!, Corneal Nlceration in 9eveloping
World O A Silent Epidemic, $r H 5phthalmol, vol# /1, pp# )--('
1'# Ianoff, M# and 9u2er, HS#, -00# Ianoff and 9u2erBs 5phthalmology# '
rd
Edition, Mosby Elsevier, ND#
-0