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Background
Corneal scar is a significant cause of visual impairment and blindness in the
developing world
Corneal infections are responsible for a large proportion of this scarring of
impairment
Only a small scar is formed if the ulcer is treated at the early stage. If
treatment is delayed, the ulcer leaves a dense scar, which leads to poor
visual prognosis
Corneal ulcers are most commonly caused by an infection with bacteria,
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Anatomy
Transparent
Surrounded by limbus
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Definition
Corneal ulcer may be defined as a discontinuation in
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Once the corneal epithelium is invaded by the offending agents, the sequence
OF
OF
OF
OF
INFILTRATION
ACTIVE ULCERATION
REGRESSION
CICATRIZATION.
.Depending upon the circumstances, the course of the bacterial ulcer may take
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Pathophysiology
1. STAGE OF PROGRESSIVE INFILTRATION:
. Characterized by Infiltration of lymphocytes into the epithelium from
the peripheral circulation and the underlying
. Subsequently, necrosis of the involved tissue may occur
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2. STAGE OF ACTIVE ULCERATION:ACTIVE ULCERATION :
Results from necrosis and sloughing of the epithelium, Bowmans
membrane and the involved stroma.
The walls of the ulcer project owing to swelling of the lamellae by
imbibition of fluid and packing of masses of leucocytes between
them.
Hyperemia of circumcorneal vessels resulting in accumulation of
purulent exudates of the cornea.
Exudation into the anterior chamber from vessels of iris and ciliary
body lead to hypopion formation.
ULCER MAY FURTHER PROGRESS AS FOLLOWS:
- By lateral extension resulting in diffuse superficial ulceration
- Or it may progress by deeper penetration leading to decemetocoele
fomation & a possible corneal perforation.
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3. STAGE OF REGRESSION:
Induced by natural hist defence mechanism and treatment that
augments the normal host response.
A line of demarcation develops around the ulcer which consists of
lucocytes that phagocytose the offending agents.
The digestion of necrotic debri may result in initial enlargement of
the ulcer.
This process may be accompanied by vascularization that increase
the immune response.
The ulcer now begins to heal and epithelium begins to grow over the
edges.
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4. STAGE OF CICATRIZATION:
In this stage, healing continues by progressive epithelization which
forms a permanent covering.
Beneath the epithelium, fibrous tissue is laid down, partly by the
corneal fibroblasts and partly by the endothelium of new vessels.
The stroma thus thickens, pushing the epithelial surface anteriorly.
The degree of scarring from healing varies:
- If the ulcer was very superficial involving only the epithelium, it heals
without scar .
- When the ulcer involves Bowmans membrane, the ulcer is called a
NEBULA.
- MACULA results from ulcers involving 1/3rd of corneal stroma.
- LEUCOMA results from ulcers involving more than 1/3 rd of the stroma.
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Etiology
Infection
Non-Infection
Immunology
Bacterial
Fungal
Viral
Acanthamoeba
Chemical substance
Heat or radiation
Vitamin A Deficiency
Drugs (Steroid)
Trauma
Granulomatosa wagener
Rheumathoid arthritis
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Classification
Location
Bacterial
Cornea Ulcer
Fungal
Cornea Ulcer
Marginal ulcer
Mooren Ulcer
Ring ulcer
Dendritic
Cornea Ulcer
Mooren Ulcer
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Sign and symptoms
Subjective
Conjunctiva hyperemia
Mukopurulent secrets
Foreign body sensation
Blurry vision
Watery
White spot in cornea
Photophobia
Pain
Objective
PCVI
Lost of some corneal tissue
Hypopion
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Diagnosis
Anamnesis
S7 B4
History of trauma, foreign body, abrasion, keratitis,
history of using steroid, and immunocompromised
condition
Physical
Examination
Lab
Examination
Gram staining
KOH staining
Culture
Visual acuity
Anterior segment (fluorescein, slit lamp)
Intraocular pressure
Posterior segment (funduscopy)
Cornea sensitivity
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Treatment
Local:
Sulfa atrophin
paralyze M. Ciliary and release
Antibiotic
prevent bacteria infectin
Anti fungal
kill fungal
Anti viral
kill virus
Prevent spreading ulceration:
Cautherization
prevent ulcer extended
Paracentese
replace aqueous humor
Keratoplasty
cornea transplant
Additional systemic drug:
Analgetic
relieve pain
Vitamin C
help re-epitelisation
synechia
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Prevention
Wear eye protection when exposed to small particles that
can enter your eye.
If you have dry eyes or if your eyelids do not close
completely, use artificial teardrops to keep your eyes
lubricated.
If you wear contact lenses, be extremely careful about the
way you clean and wear your lenses.
Always wash your hands before handling the lenses. Never
use saliva to lubricate your lenses because your mouth
contains bacteria that can harm your cornea.
Remove your lenses from your eyes every evening or before
sleep and carefully clean them. Never use tap water to clean
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Prognosis
A corneal ulcer is a true emergency. Without treatment, the
ulcer can spread to the rest of your eyeball, and you can
become partially or completely blind in a very short period
of time. Your cornea may also perforate, or you could
develop scarring, cataracts or glaucoma.
With the proper treatment, corneal ulcers should improve
Case Report
Patients Identity
Name
: I Nyoman Raspa
Gender
: Laki-laki
Age
: 42 tahun
Religion
: Hindu
Race
: Bali
Nationality
: Indonesia
Job
: Pedagang
Address
: Jalan Dukuh Sari no 28 A
Date of admission : 12 Mei 2015
Chief Complaint:
Red eye on the right eye
Case Report
Present Illness History
Patient came with chief complaint of sudden red eye on the right side
since yesterday morning. The patient said the right eye is painful
and the pain is continuously felt by him. The red eye on the right side
accompanied with swollen of the palpebra since yesterday evening.
The swollen of the palpebra didnt get bigger. In addition, patient also
complained about continuously watery eyes on the right side since
yesterday evening. Patient also complained of having glare especially
on the right eye until it disturbs patients daily activities. Plus, patient
also complained of blurry vision appeared along with the red eye.
Patient told there is nothing that make the complaints better. Patient
bought xytrol and rohto yesterday evening at the pharmacy. Patient
used the medication but the red eye is not getting better.
Case Report
Past Illness History
1.
2.
3.
4.
Case Report
Family Illness History
- No family members who suffer from similar complaints
Social History
- Patient is a food seller in a stall. Patient claimed he rarely go outside
of the house but patient told he went to Karangasem 2 days before
came to hospital for sightseeing and he didnt use any spectacles to
cover the eye during riding the bike for the long journey.
Case Report
Physical Examination
General Examination
Consciousness
Vital sign
CM
:
BP
RR
Temperature
: 130/80
: 16x/ min
: 36o C
Case Report
RE
2/60
Edema
CVI (+), PCVI (+)
Edema, Ulcus central
elevated edge
Normal
Round, Regular
Examination
AV
Palpebra
Conjunctiva
COA
Iris
Normal
Round, Regular
RP (+)
Pupil
RP (+)
Clear
Clear
Reflex (+)
n/p
Lens
Vitreous
Funduscopy
Intraocular
pressure
Clear
Clear
Reflex (+)
n/p
Cornea
LE
6/6
Normal
Normal
Clear
Case Report
Differential Diagnosis
- OD konjungtivitis
- OD Uveitis
- OD Glaukoma
- OD Ulkus Kornea ec suspect bakteri
- OD Ulkus Kornea ec suspect jamur
- OD Ulkus Kornea ec suspect viral
Diagnosis
OS Ulkus Kornea ec suspect bakteri
Examination Proposed
- Gram, KOH, Culture from scrape of the cornea ulcer
- Slit lamp
- Keratometry
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Treatment
Prognosis
Ad vitam : Dubius ad bonam
Ad fungsionam : Dubius ad malam
Ad Recovery
: Dubius ad bonam
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Discussion
Theory
Etiology
Symptom
Conjunctiva hyperemii,
blepharospasme,
mukopurulent secrets,
foreign body sensation,
blurry vision, watery,
white spot in cornea,
photophobia, Pain
Sign
Case
Infection
Pain in right eye, redness,
swollen, blurry vision, there is
white spot in black part, glare,
blepharospasme, photophobia,
watery eyes
Case Report
Theory
Case
Therapy
Sulfa Atrophin
Analgetic
Antibiotic
Anti fungal
Anti viral
Vitamin C
Prognosis
Case Report
Summary
Corneal ulcer is the discontinuities corneal tissue that can occur from the epithelium
to stroma
Etiology: Infection and non infection
Based on location: central and peripher ulcer
Sign and symptom: odeme palpebra, conjungtival hyperemic, mucopurulent secret,
felt like foreign body, blurry vision, watery, white spot on cornea, glare, pain,
infiltrate, hypopion, discontinuities corneal tissue,
Diagnosed based on anamnesis, physical examination, supporting examination
Treatment: antiobiotics, artificial tears, cycloplegic
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