CONJUNGTIVITIS AND

KERATITIS

Overview
Keratitis

Conjungtivitis
1. Viral Conjungtivitis
Pharingokonjungtival Fever
Epidemica KeratoKonjungtivitis
Herpes Simplex Conjungtivitis
Acute Hemorrhagic Conjungtivitis
2. Bacterial Conjungtivitis
3. Chlamidial Conjungtivitis
- Trachoma
- Inclusion Conjungtivitis
4. Allergic Conjungtivitis
Atopic Conjungtivitis
Hay Fever Conjungtivitis
Vernal Conjungtivitis
5. Iritation Conjungtivitis

Bacterial Keratitis
Viral Keratitis
Mycotic Keratitis
Acanthamoeba Keratitis
Superficial Punctate
Keratitis
Neuroparalytic Keratitis
Exposure Keratitis

CONJUNGTIVITIS

DEFINITION

Conjunctivitis is an inflammation of the conjunctiva that is

characterized by vascular dilatation, cellular infiltration and
exudation, or inflammation of the mucous membrane covering the
back of the eyelid and eyeball.

ANATOMY1

Conjunctiva is the outer layer of the eye consisting of a thin mucous membrane
that lines the eyelids
In anatomy classification, the conjunctiva is divided into three parts, conjunctiva
bulbaris, conjunctival palpebra, and conjunctiva fornix
Conjunctival lymph vessels are arranged in layers and the superficial and
profundus layer continuous with the lymph vessels to form a plexus of lymph
palpebra a lot.
Conjunctiva receive innervation from the first branch (ophthalmic) trigeminal
nerve. These nerves are only have a relative few pain fibers

ANATOMY2
1.

Forniks superior &

inferior
2. Konjungtiva tarsal sup &
inf
3. Kripte henle
4. Gl.Krause
5. Gl.Wolfring
6. Gl.Lakrimal
7. Gl.Manz
8. Tarsus superior

ANATOMY3
A. anterior ciliary (branch of
a.ophtalmica)
A. episclera, anastomosis with a.
ciliaryis posterior longus
forming a. circularis major (iris
and ciliary body)
A. episclera (sclera, intraocular)
Pericorneal plexus (cornea)
A. posterior conjunctiva supplies the
conjunctiva

ETIOLOGY
Infection (viral,bacterial,or chlamydia)
Allergic reactions to dust, pollen, animal dander
Irritation by the wind, dust, smoke and other air pollutants;
ultraviolet rays from sunlight or electric welding.

Signs & Syptomps

Symptomps:
Red eyes
Feeling of lump
Dirty eyes
Itchy
Watery
.Signs
Conjunctival injection
Dicharge/secret
There are patologic structure in conjunctiva
Chemosis

CONJUNCTIVAL INJECTION
Congestion of conjuctival aa/vv
(posterior conjunctiva)
Causes: mechanical, irritation, allergy,
infection
Signs:
Mobile from its base
Calibre increases to the periphery
Fresh blood color, constricts with
topical adrenalin

SILIAR INJECTION

Congestion of pericornea vessels

(a. anterior ciliaris)

Causes:
- corneal inflammation (keratitis,
corneal ulcer)
- uveitis
- acute glaucoma
- endophthalmitis
- panophthalmitis

Signs:
- does not follow movement of conjuctiva
- fine, small vessels surrounding the cornea
- calibre decreases towards the fornices
- dark red color, unchanged with topical adrenalin

Discharge
Various kind of discharge:
Serous (clear liquid)
Mucoid (clear liquid; elastic viscous)
Purulent (cloudy yellow liquid)

Pathologic Structure

Classification
Causa

Bacteria
Virus
Chlamydia
Alergic
Iritation

Clinical pattern

Conjungtivitis kataral
Conjungtivitis purulent
Conjungtivitis membran
Conjungtivitis folikel
Conjungtivitis flikten
Conjungtivitis vernal
Trachoma

VIRAL CONJUNCTIVITIS

Viral conjunctivitis

Viral conjunctivitis commonly is associated with upper respiratory tract infections and is
usually caused by an adenovirus. This is the type of conjunctivitis that occurs in epidemics
of pink eye.

HistoryThe patient normally complains of both eyes being gritty and uncomfortable,
although symptoms may begin in one eye. There may be associated symptoms of a cold and
a cough. The discharge is usually watery.

Viral conjunctivitis usually lasts longer than bacterial conjunctivitis and may go on for many
weeks; patients need to be informed of this. Photophobia and discomfort may be severe if
the patient goes on to develop discrete corneal opacities.

Viral conjunctivitis

ExaminationBoth eyes are red with diffuse conjunctival injection

(engorged conjunctival vessels) and there may be a clear discharge. Small
white lymphoid aggregations may be present on the conjunctiva (follicles).
Small focal areas of corneal inflammation with erosions and associated
opacities may give rise to pronounced symptoms, but these are difficult to
see without high magnification. There may be associated head and neck
lymphadenopathy with marked pre-auricular lymphadenopathy

Viral conjunctivitis

ManagementViral conjunctivitis is generally a self limiting condition, but antibiotic eye

drops (for example, chloramphenicol) provide symptomatic relief and help prevent
secondary bacterial infection. Viral conjunctivitis is extremely contagious, and strict
hygiene measures are important for both the patient and the doctor; for example, washing
of hands and sterilising of instruments.

Viral conjunctivitis
Management - The period of infection is often longer than
with bacterial pathogens and patients should be warned that
symptoms may be present for several weeks. In some
patients the infection may have a chronic, protracted course
and steroid eye drops may be indicated if the corneal
lesions and symptoms are persistent. Steroids must only be
prescribed with ophthalmological supervision, because of
the real danger of causing cataract or irreversible
glaucomatous damage. Furthermore, if long term steroids
are required, patients should remain under continuous
ophthalmological supervision

A. Faringokonjungtival Fever
Infections caused by adenovirus virus 2.4, and 7.
Sign & Symptomps
Fever from 38.3 to 40 C,
sore throat
Follicular conjunctivitis in one or two eyes
Red eyes and watery eyes are common, and sometimes a little turbidity
subepithelial area
Enlargement lymphadenopathy preaurikuler
Treatment
There is no specific treatment. Konjungtivitisnya recover on their own,
generally within about 10 days. Treatment is usually symptomatic and
antibiotics to prevent secondary infection

B. Epidemica Keratoconjunctivitis
Caused by adenovirus virus type 3,7,8, and 19
Signs and symptoms:
Epidemika keratoconjunctivitis generally bilateral
At first the patient feels there is an infection with pain and watery eyes, followed in 5-14
days by photophobia,epithelial keratitis, and subepithelial opacities round.
Normal corneal sensation.
Tender lymph preaurikuler which is typical.
Palpebra edema, kemosis, and conjunctival hyperemia mark
the acute phase.
Follicles and conjunctival hemorrhage often appear within 48 hours.
Pseudomembrane may form and may be followed by a flat scar or symblepharon
formation

B. Keratokonjungtivitis epidemika1
Prevention
Wash your hands regularly between the inspection and cleaning and sterilization tools
tonometer touches the eye in particular is also a must.
Aplanasi tonometer should be cleaned with alcohol or hypochlorite, then rinsed with sterile
water and dried carefully
Treatment: Currently there is no specific treatment, but a cold compress will reduce some
symptoms despite having carefully as it will likely lead to the growth of bacteria or
secondary infections. corticosteroids for acute conjunctivitis may prolong corneal
involvement should be avoided. Antibacterial agent should be given in case of bacterial
superinfection
Complications can occur corneal opacities that persisted

C.Herpes simpleks conjunctivitis

Usually

in children under the age of 2 years

accompanied by ginggivostomatitis.

Signs

and symptoms:

unilateral dilation of blood vessels, irritation, mucoid bertahi eyes,

pain, and mild photophobia
On corneal epithelial lesions appear generally separate fused to form
a ulcer or ulcer-epithelial ulcers are highly branched (dendritic)
Herpes vesicles sometimes appeared at the edge palpebra palpebra
and, accompanied by severe edema palpebra. There is a node
preaurikuler typical painful if pressed

C.Herpes simpleks conjunctivitis

Treatment
Local and systemic anti-virus should be given to prevent cornea involvemet
For corneal ulcers may be required corneal debridement carefully by
rubbing the ulcer with a sterile cotton swab sticks, dripping with antiviral
drugs, and closed for 24 hours.
Topical antiviral should be given 7-10 days: trifluridine every 2 hours
while awake or rabine vida ointment five times a day, or idoxuridine
0.1%, 1 drop every hour while awake and 1 drop every 2 hours during the
night.
Herpes keratitis can also be treated with acyclovir ointment 3% five times
daily for 10 days or with oral acyclovir, 400 mg five times daily for 7
days

D.Konjungtivitis Hemoragika Akut

Etiology

are Picorna viral and enterovirus 70

Signs

and symptoms: eye pain, photophobia, foreign

body sensation, a lot of tears, red, palpebra edema, and
hemorrhage subkonjungtival. It sometimes happens
kemosis conjunctiva.

Therapy:

Treatment is usually symptomatic. The use of

antibiotics can be used to prevent secondary infection.

BACTERIAL CONJUNCTIVITIS

Bacterial conjunctivitis

HistoryThe patient usually has discomfort and a purulent

discharge in one eye that characteristically spreads to the other
eye. The eye may be difficult to open in the morningbecause
the discharge sticks the lashes together. There may be a
history of contact with a person with similar symptoms.

Bacterial conjunctivitis

Examination The vision should be normal after the

discharge has been blinked clear of the cornea. The discharge
usually is mucopurulent and there is uniform engorgement of
all the conjunctival blood vessels. When fluorescein drops are
instilled in the eye there is no staining of the cornea.

Bacterial conjunctivitis

ManagementTopical antibiotic eye drops (for example,chloramphenicol)

should be instilled every two hours for the first 24 hours to hasten
recovery, decreasing to four times a day for one week. Chloramphenicol
ointment applied at night may also increase comfort and reduce the
stickiness of the eyelids in the morning. Patients should be advised about
general hygiene measures; for example, not sharing face towels

CHLAMYDIAL CONJUNCTIVITIS

Chlamydial conjunctivitis
HistoryPatients usually are young with a history of a chronic bilateral
conjunctivitis with a mucopurulent discharge. There may be associated
symptoms of venereal disease. Patients generally do not volunteer genitourinary
symptoms when presenting with conjunctivitis; these need to be elicited through
questioning.

Chlamydial conjunctivitis
ExaminationThere is bilateral diffuse conjunctival injection
with a mucopurulent discharge. There are many lymphoid
aggregates in the conjunctiva (follicles). The cornea usually is
involved (keratitis) and an infiltrate of the upper cornea (pannus)
may be seen.

Chlamydial conjunctivitis
ManagementThe diagnosis is often difficult and special bacteriological tests
may be necessary to confirm the clinical suspicions. Treatment with oral
tetracycline or a derivative for at least one month can eradicate the problem,
but poor compliance can lead to a recurrence of symptoms. Systemic
tetracycline can affect developing teeth and bones and should not be used in
children or pregnant women. Associated venereal disease should also be
treated, and it is important to check the partner for symptoms or signs of
venereal disease (affected females may be asymptomatic). It often is helpful to
discuss cases with a genitourinary specialist before commencing treatment, so
that all relevant microbiological tests can be performed at an early stage.

Various Chlamidya trachomatis serotypes that

are obligate intracellular organism causes two
eye infections are:
a. Trachoma
b. Inclusiuon Conjuctivitis

TRACHOMA

Tracoma is a form of chronic follicular conjunctivitis caused by

Clamydia trachomatis. This disease can affect any age but more
common on young people and children

Modes of transmission of this disease is through direct

contact with secretions or through a trachoma patients
daily necessities such as towels, toilet articles and
deodorized.

The average incubation period of 7 days (range 5 to 14

days)

TRACHOMA
According to the classification Mac Callan
clinical picture of this disease is divided into
several stages.
Stage I; called insipien stadium
Stage II; called established
Stage III is called staging grated
Stage IV; called the stage of healing

TRACHOMA
To ensure trachoma endemic in family or community, a
number of children must show at least - least two signs of
the following:
(1) Five or more follicles on the tarsal conjunctiva palpebra
superior to the average eye.
(2) Grate the tarsal conjunctiva conjunctiva at the superior
characteristic.
(3) follicles or sekuelenya limbus (Herbert wells).
(4) The expansion of blood vessels onto the cornea, the clear
upper limbus.

TRACHOMA

For control, the World Health Organization has

developed a simple way to check the disease. It
includes a sign - a sign as follows

TRACHOMA

TF : five or more follicles on the upper tarsal

conjunctiva.

TRACHOMA

TI : Diffuse infiltrate and hypertrophy papil on the

conjuctiva tarsalis superior at least 50% of normal deep
veins.

TRACHOMA
TS : Trachomatosa conjunctival scarring.

TRACHOMA
TT

: Trikiasis or entropion(inverted eyelashes)

TRACHOMA

CO : Corneal blurred.

TRACHOMA
TF

and Ti show an active infectious trachoma that must

be treated.
TS is evidence of injury from this disease.
TT is potentially blinding and indications for surgery
kokreasi palpebra.
CO is the final blinding lesion of trachoma.

TRACHOMA
Support investigation
Inclusi body of chlamydia can be found in the conjunctival
scrapings in sleeping with Giemsa, but not always exist.
Outward appearance of fluorescein antibody and immuno assay test of enzymes are commercially available and widely
used in clinical laboratorium. This new test has replaced the
outward appearance of Giemsa for preparation and isolation
of the klamidial agents in cell cultures
Differential diagnosis
Follicularis conjunctivitis, vernal katarrh.

TRACHOMA
Complication
a. Secondary infection
b. Corneal opacities due to pannus covering the cornea
c. Corneal xxerosis with keratitis Sika
d. Enteropion and trikiasis
e. Simblefaron
Treatment
Treatment of trachoma with tetracycline eye ointment 2-4 times a day, 3-4 weeks, a correction
Surgery should be performed on the eyelashes turn inward to prevent scarring
trachoma.
For prevention by vaccination and eat a nutritious and hygienic
good to prevent the spread.

Inclusion Conjunctivitis

The disease is transmitted sexually and can last for

chronic (up to 18 months) unless treated adequate

Inclusion Conjunctivitis1
Sign & Symptomps
Patients often complain of red eyes, pseudo-ptosis, and especially in the morning
belekandays. In neonates showed papillary conjunctivitis and a moderate amount of
exudate,in cases of hyperacute, occasionally formed which can cause scarring
pseudomembrane. Patients present with follicular conjunctivitis is mucopurulent and there
mikropanusassociated with subepithelial scarring.

Inclusion Conjunctivitis2
Examination Support
Rapid diagnostic test direct fluorescent antibody test, ELISA, and PCR was
replace the outward appearance of Giemsa
Differential diagnosis
Active follicular trachoma
Treatment
in infants
Give erytromycin per oral suspension, 50 mg / kg / day in 4 divided doses sealam sekurangkurangnya
14 days.
In adults
Healing is achieved by doxycycline 100 mg orally twice daily for 7 days,
or erythromycin 2 g / day for 7 days, or it could be azithromcin 1 g / dose.

ALERGIC CONJUNCTIVITIS

Allergic conjunctivitis
HistoryThe main feature of allergic conjunctivitis is itching. Both eyes
usually are affected and there may be a clear discharge. There may be a
family history of atopy or recent contact with chemicals or eye drops.
Similar symptoms may have occurred in the same season in previous
years. It is important to differentiate between an acute allergic reaction
and a more long term chronic allergic eye disease.

Allergic conjunctivitis
ExaminationThe conjunctivae are diffusely injected and may be oedematous
(chemosis). The discharge is clear and stringy. Because of the fibrous septa
that tether the eyelid (tarsal) conjunctivae, oedema results in round swellings
(papillae). When these are large they are referred to as cobblestones.

Allergic conjunctivitis
ManagementTopical antihistamine and vasoconstrictor eye drops provide
short term relief. Eye drops that prevent degranulation of mast cells also are
useful, but they may need to be used for several weeks or months to achieve
maximal effect. Oral antihistamines may also be used, particularly the newer
compounds that cause less sedation. Topical steroids are effective but should
not be used without regular ophthalmological supervision because of the risk
of steroid induced cataracts and glaucoma

A. Atopic Conjunctivitis
Sign & Symptomps
Burning sensation,
Dirty eyes,
Red eyes and photophobia.
Palpebras edge eritemosa, and the conjunctiva was white as milk.
There is a papilla refined, but not growing like a giant papilla on
keratoconjunctivitis vernal, and more often found in the inferior
tarsus.

A. Atopic Conjunctivitis1
Usually

there is a history of allergies (hay fever, asthma, or eczema) in

patients
or her family. Most patients had suffered from atopic dermatitis since
infancy.
Grate in the folds of flexure folding elbow and wrist and knee often was
found. As dermatitisnya, atopic keratoconjunctivitis lasts a prolongedand
often experience exacerbations and remissions. such as keratoconjunctivitis
vernal, the disease tends to be less active when the patient was aged 50
years.
laboratory
Conjunctival scrapings revealed eosinophils, although not as much as that
seen
as much on vernal keratoconjunctivitis.

A. Atopic Conjunctivitis2
Treatment
Oral

Antihistamine including terfenadine (60-120 mg 2x a day),

astemizole (10
mg four times daily), or hydroxyzine (50 mg bedtime, increased to
200
mg) proved to be beneficial.
NSAID, such as ketorolac and iodoxamid, it can overcome the
symptoms in these patients.
In severe cases, plasmapheresis is an adjunctive therapy.
In the case of advanced with severe corneal complications, corneal
transplant may be necessary to
restore the sharpness of his eyesight

B.Hay Fever Conjunctivitis

Signs and symptoms
Inflammation of conjunctivitis non-specifics lightweight generally accompanies the hay
fever(rhinitis Allergic).
Usually there is a history of allergy to pollen, grass, feathers animals, and others. Patients
complains about the itchy-itchy, watery , red eye,and often said that his eyes as if (sink into
the surrounding tissue)
Laboratory
Hard to find eosinophils in conjunctival scrapings.
Therapy
Shed a vasoconstrictor local domain on stage of acute (epineprin, solution of 1:1000 given
topically, will eliminate kemosis and symptoms in 30 minutes).
Cold compresses help with the itching and antihistamine onlylittle benefit.
Direct response to the treatment fairly well.

C. Vernal Conjunctivitis
An

inflammation of the eyes of the outside of the seasonal

and considered to be an allergy.

Conjunctiva

contains many cells of the immune system

(mast cells) the release of chemical compounds (mediators)
in response to various stimuli (such as pollen or dust mites).

These

mediators cause inflammation the eye, which may

last a minute or longer. Approximately 20% of people have
high levels of red eye allergy.

Diagnosis
Found any signs of inflammation of the conjunctiva
Found any giant papil the superior conjunctiva palpebra
Found any tantras dot on the corneal limbus
Sometimes accompanied by shield ulcer\
Recurrent
Sign & Symptomps
Red eyes (usually recurrent)
Sometimes accompanied by intense itching
A history of allergy
The existence of diffuse papil hypertrophy especially of the conjunctiva tarsal superior
Thickening of limbus with dot tantras
Mucoid to mucopurulent discharge if there is secondary infection

Treatment
Mild cases:
educational therapy (avoiding allergens, cold compresses, cool room, lubrication, eye ointment),
giving antihistamines (topical levokabastin, emestadine),
vasoconstrictor (phenileprine, tetrahidrolozine),
mast cell stabilizer (4% sodium cromolin alomide)
Moderate-severe cases:

mast cell stabilizer (sodium 4% alomide cromolin),

topical steroid anti-inflammatory (ketorolac 0.5%),
topical corticosteroids or agents
modulator cyclosporine.

D.Flikten Conjunctivitis

Hypersensitivity reaction to microbial protein (such

as protein M.tbc, Stafilokok, Candida)
Small lesions (1-3mm), hard, red, surrounded by
prominent local hyperemia
If the limbus -> triangular with the peak in the
direction of the cornea -> recover form jar.parut.

IRITATION
CONJUNCTIVITIS

Iatrogenic Conjunctivitis
(Topical drug administration)

Follicular conjunctivitis Conjunctivitis toxic or non-specific infiltrate,which

followed the formation of scar tissue, often caused by long using of dipivefrin,
miotika, idoxuridine, neomycin, and other drugs are prepared in vehikel
preservatives or toxic that cause irritation.

Silver nitrate is dripped into the saccus conjingtiva at birth is often a causes a mild
chemical conjunctivitis. If tear production is reduced due to continuous irritation,
conjunctival injury because there would then exist dilution of the agents that
damage when dropped into the saccus conjungtivae.

Conjunctival scrapings often contain keratinized epithelial cells, a few

polymorphonuclear neutrophils, and occasional odd-shaped cells.

Conjunctivitis caused by Chemicals and

irritants1

Acid, alkali, smoke, wind, and almost any irritant substance that makes the saccus
conjungtiva can cause conjunctivitis. Some common irritants is fertilizer, soap,
deodorant, hair spray, tobacco, ingredients make-up, and various acid and alkali. In
certain areas, smog (a mixture of smoke and fog) The main cause of a mild
chemical conjunctivitis. Specific irritant in smog can not be positively determined,
and non-specific treatment. No a permanent effect on the eye, but the affected eye
is often red and disturbing is chronic.

Conjunctivitis caused by Chemicals and

irritants

On the injury acid, it changes the nature and effect of protein networks directly.
Alkali does not change the nature of the protein and tend to quickly infiltrate
network and settled into the conjunctival tissue. Here they continued to damage
sustained for hours or days old, depending on molar concentration of the alkali and
the amount of intake. attachment between bulbi conjunctiva and cornea leokoma
palpebra and more than likely occur if the cause is an alkali agent. At any event,
the main symptom chemical injury are pain, blood vessel dilation, photophobia,
and blepharospasm. History of the trigger events can usually be disclosed.

Conjunctivitis caused by Chemicals and

irritants

Immediate and thorough flushing with water or saccus conjungtivae salt solution is very
important, and any solid material must be removed in mechanics. Do not use chemical
antidotum.

Symptomatic common action is a cold compress for 20 minutes every hour, 1% atropine drops
twice day, and give systemic analgesics if necessary. Bacterial conjunctivitis can be treated
with appropriate antibacterial agents. Scarring of the cornea may require corneal
transplantation, and symblepharon may require plastic surgery of the conjunctiva.

Severe burns and corneal kojungtiva prognosis poor despite surgery. However, if treatment is
started soon enough, grated formed will be minimal and the prognosis is better

KERATITIS

Bacterial Keratitis

The most common bacterial pathogens that cause keratitis:

Staphylococcus aureus,Staphylococcus epidermidis,
Streptococcus pneumoniae, Pseudomonas aeruginosa,
Moraxella.
Most bacteria are unable to penetrate the cornea as long as the
epithelium remains intact. Only gonococci and diphtheria
bacteria can penetrate an intact corneal epithelium.

.
Symptoms: Patients report moderate to severe
pain (except in Moraxella infections) photophobia,
impaired vision, tearing, and purulent discharge.
Purulent discharge is typical of bacterial forms of
keratitis; viral forms produce a watery discharge.

Diagnostic considerations: Positive identification of the

pathogens is crucial. Serpiginous corneal ulcers are frequently
associated with severe reaction of the anterior chamber
including accumulation of cells and pus in the inferior
anterior chamber (hypopyon) and posterior adhesions of the
iris and lens (posterior synechia).
Differential diagnosis: Fungi (positive identification of the
pathogen is required to exclude a fungus infection).

Treatment

Conservative therapy: Treatment is initiated with

topical antibiotics with a very broad spectrum of
activity against most Gram-positive and Gram-negative
organisms until the results of pathogen and resistance
testing are known. Immobilization of the ciliary body
and iris by therapeutic mydriasis is indicated in the
presence of intraocular irritation (manifested by
hypopyon).

Treatment

Cyclopegic
Comfort, Prevent posterior synechiae

Topical antibiotics
Low risk <1mm, peripheral
Floroquinolone Q4H +/- tobramycin

Moderate risk 1-2mm, peripheral

Floroquinolone Q1H atc

High risk
Tobramycin 15mg/mL Q60minutes
Cefazolin 50mg/mL or Vancomycin 25mg/mL Q60minutes

Surgical treatment: Emergency keratoplasty is

indicated to treat a descemetocele or a perforated
corneal ulcer. Broad areas of superficial necrosis may
require a conjunctival flap to accelerate healing.
Stenosis or blockage of the lower lacrimal system
that may impair healing of the ulcer should be
surgically corrected.

Failure

of keratitis to respond to treatment may

be due to one of the following causes,
particularly if the pathogen has not been
positively identified:
The patient is not applying the antibiotic (poor
compliance).
The pathogen is resistant to the antibiotic.
The keratitis is not caused by bacteria but by
one of the following pathogens:
a. Herpes simplex virus.
b. Fungi.
c. Acanthamoeba.

Viral Keratitis

Viral keratitis is frequently caused by:

1. Herpes simplex virus.
2. Varicella-zoster virus.
3. Adenovirus.
Other rare causes include cytomegalovirus, measles virus,
or rubella virus.

Herpes simplex keratitis

Herpes simplex keratitis is among the more common

causes of corneal ulcer
A corneal infection is always a recurrence. A primary
herpes simplex infection of the eye will present as
blepharitis or conjunctivitis. Recurrences may be
triggered external influences (such as exposure to
ultraviolet light), stress, menstruation, generalized
immunologic deficiency, or febrile infections.

FORM HSV: CLINICAL FINDINGS

1. Primary Herpes Simplex Keratitis
Infrequently seen
Manifested as vesicular blepharoconjunctivitis
occasionally with corneal involvement
Usually occurs in young children
Topical antiviral therapy may be used as prophylaxis
and as therapy
Vaughan & Asburys General Ophthalmology 16th Edition, 136

FORM HSV: CLINICAL FINDINGS

2. Recurrent type herpetic keratitis
Attacks triggered by
Fever
Overexposure to UV light
Trauma
Onset of menstruation
Local/ systemic source of immunosuppression
Bilateral lesions develop in 4-6% of patients and
seen mostly in atopic patients.
Vaughan & Asburys General Ophthalmology 16th Edition, 136

(HSV) dendritic keratitis.

Dendritic keratitis. This is characterized by branching

epithelial lesions. These findings will be visible with
the unaided eye after application of fluorescein dye and
are characteristic of dendritic keratitis. Corneal
sensitivity is usually reduced.Dendritic keratitis may
progress to stromal keratitis.

Treatment
Should be directed at eliminating viral replication within
the cornea, while minimizing damaging effects of
inflammatory response.
DEBRIDEMENT
Epithelial debridement is an effective way to treat
dendritic keratitis
Infected epithelium is easy to remove with tightly wound
cotton tip applicator.
Adjunctive therapy with topical antiviral accelerates
epithelial healing.

Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

TREATMENT : DRUGS
Antiviral medicines used in treatment of Herpes Simplex Virus
Ocular Disease

Treatment

Antiviral

Route

Form

Frequency

Action

Idoxuridine

Topical

0.1%
solution

Hourly while
awake

Inhibits viral thymidine

kinase, thymidylate
kinase and DNA
polymerase

Vidarabine

Topical

3%
ointment

5 times daily

Inhibits viral DNA

polymerase

Trifluridine

Topical

1%
solution

Every 2
hours while
awake

Inhibits viral
thymidylate synthetase

Acyclovir

Topical

3%
5 times daily Activated by viral
ointment
thymidine kinase to
inhibit DNA polymerase
200/400/
400 mg 5
2004, (2), 475-482
800Ophthalmology
DT
times daily

Oral

Ophthalmology 2004, 2; 475-482

Treatment
Trifluridine and acyclovir are much more
effective in stromal disease than others.
Idoxuridine and trifluridine are frequently
associated with toxic reactions.
Oral acyclovir may be useful in treatment of
severe herpetic eye disease particularly in
atopic individuals.

Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Treatment
Oral acyclovir : DOSAGE:
For active treatment 400 mg five times daily in
nonimmunocompromised patients.
800 mg five times daily in compromised and atopic
patients.
Prophylactic dosage in recurrent disease is 400 mg
twice daily.

Famciclovir or valacyclovir may also be used.

Topical corticosteroids accelerate corneal thinning,
increasing risk of corneal perforation.

Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Surgical treatment
Penetrating keratoplasty indicated for visual rehabilitation
in patients with sever corneal scarring. Should not be
undertaken until herpetic disease has been inactive for many
months.
Systemic antiviral agents should be used for several months
after keratoplasty to cover use of topical steroids.

Lamellar keratoplasty has advantage over penetrating

keratoplasty of reduced potential for corneal graft rejection.
Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Varicella zoster viral keratitis (VZV)

Occurs in two forms:
Primary ( varicella)
Recurrent ( herpes zoster)

Ocular manifestations are uncommon in varicella but

common in ophthalmic zoster.

Vaughan & Asburys General Ophthalmology 16th Edition, 136-137

Varicella zoster viral keratitis (VZV)

Ocular manifestations
Usual eye lesions are pocks on lids and lid margins.
Keratitis occurs rarely.
Epithelial keratitis with or without pseudodendrites
occurs more rarely.
Disciform keratitis with uveitis of varying duration has
been reported.

Treatment
Intravenous and oral acyclovir have been used successfully
for treatment of herpes zoster ophthalmicus, particularly in
immunocompromised patients.
Oral dosage is 800 mg five times daily for 10-14 days.
Therapy needs to be started within 72 hours after
appearance of the rash.

Mycotic Keratitis

very rare, occurring almost exclusively in farm laborers

Etiology: The most frequently encountered pathogens are
Aspergillus and Candida albicans. The most frequent
causative mechanism is an injury with fungus-infested organic
materials such as a tree branch.
Patients usually have only slight symptoms.

Subacute onset of candida keratitisSevere candidal keratitis in an elderly mal

Severe aspergillus infection

with large area

Severe central aspergillus infection

with a cheesey looking area

of corneal ulceration and

deep stromal involvement

of the lesion and

hypopyon (fluid level of inflammatory
cells in the anterior chamber)

Diagnostic considerations

Slit lamp examination will reveal typical whitish

stromal infiltrates, especially with mycotic keratitis due
to Candida albicans. The infiltrates and ulcer spread
very slowly. Satellite lesions, several adjacent smaller
infiltrates grouped around a larger center, are
characteristic but will not necessarily be present.

Treatment

topical treatment with antimycotic agents such as

natamycin, nystatin, and amphotericin B, azoles
(clotrimazole,micanazole, ketokonazole etc)
Surgical treatment. Emergency keratoplasty is indicated
when the disorder fails to respond or responds too
slowly to conservative treatment and findings worsen
under treatment.

ACANTHAMOEBA
KERATITIS

Etiology: Acanthamoeba is a saprophytic protozoon.

Infections usually occur in wearers of contact lenses,
particularly in conjunction with trauma and moist
environments such as saunas.
Symptoms: Patients complain of intense pain, photophobia,
and lacrimation.

Diagnostic considerations
The patient will often have a history of several weeks or
months of unsuccessful antibiotic treatment.
Inspection will reveal a unilateral reddening of the eye.
Usually there will be no discharge. The infection can present
as a subepithelial infiltrate, as an intrastromal disciform
opacification of the cornea, or as a ring-shaped corneal
abscess.

Treatment

Conservative treatment: Topical agents currently include

propamidine and pentamidine. Usually broad-spectrum
antibiotic eyedrops are also administered. Cycloplegia
(immobilization of the pupil and ciliary body) is usually
required as well.
Surgical treatment: Emergency keratoplasty is indicated
when conservative treatment fails.

Superficial Punctate
Keratitis

 Superficial

punctate corneal lesions due to lacrimal

system dysfunction from a number causes.
etiology: Superficial punctate keratoconjunctivitis
is a very frequent finding as it can be caused by
awide variety of exogenous factors such as foreign
bodies beneath the upper eyelid, contact lenses,
smog, etc. It may also appear as a secondary
symptom of many other forms of keratitis . It can
also occur in association with an endogenous
disorder such as Thygesons disease.

Symptoms
Depending on the cause and severity of the superficial corneal
lesions
symptoms range from a nearly asymptomatic clinical course
(such as in neuroparalytic keratitis in which the cornea loses
its sensitivity) to an intense foreign body sensation in which
the patient has a sensation of sand in the eye with typical
signs of epiphora, severe pain, burning, and blepharospasm.
Visual acuity is usually only minimally compromised.

Treatment
Depending on the cause, the superficial corneal changes will
respond rapidly or less so to treatment with artificial tears
whereby every effort should be made to eliminate the
causative agents .
Depending on the severity of findings, artificial tears of
varying viscosity(ranging from eyedrops to high-viscosity
gels) are prescribed and applied with varying frequency.
In exposure keratitis, a high-viscosity gel or ointment is used
because of its long retention time
superficial punctate keratitis is treated with eyedrops.

Keratoconjunctivitis Sicca

This is one of the most

frequent causes of
superficial keratitis. The
syndrome itself is
attributable to dry eyes
due to lack of tear fluid.

Neuroparalytic Keratitis

Keratitis associated with palsy of the ophthalmic division of

the trigeminal nerve.
Palsy of the ophthalmic division of the trigeminal nerve is less
frequent that facial nerve palsy.
Etiology: The trigeminal nerve is responsible for the corneas
sensitivity to exogenous influences. A conduction disturbance
in the trigeminal nerve is usually a sequela of damage to the
trigeminal ganglion from trauma, radiation therapy of an
acoustic neurinoma, or surgery.

It will lead to loss of corneal sensitivity. As a result of this

loss of sensitivity, the patient will not feel any sensation of
drying in the eye, and the blinking frequency drops below the
level required to ensure that the cornea remains moist.
As in exposure keratitis, superficial punctate lesions will form
initially, followed by larger epithelial defects that can progress
to a corneal ulcer if bacterial superinfection occurs.

Symptoms &Treatment
Because patientswith loss of trigeminal function are free of
pain, they will experience only slight symptoms such as a
foreign body sensation or an eyelid swelling.
This is essentially identical to treatment of exposure keratitis.
It includes moistening the cornea, antibiotic protection as
prophylaxis against infection, and, if conservative methods
are unsuccessful, tarsorrhaphy.

Exposure Keratitis

Keratitis resulting from drying of the cornea in the case of

lagophthalmos.
Exposure keratitis is a relatively frequent clinical syndrome.
For example, it may occur in association with facial paralysis
following a stroke.
Etiology: Due to facial nerve palsy, there is insufficient
closure of the eyelids over the eyeball (lagophthalmos), and
the inferior third to half of the cornea remains exposed and
unprotected (exposure keratitis).

Superficial punctate keratitis initially develops in this region

and can progress to corneal erosion or ulcer.
Other causes for exposure keratitis without facial nerve palsy
include:
Uncompensated exophthalmos in Graves disease.
Insufficient eyelid closure following eyelid surgery to correct
ptosis.
Insufficient eye care in patients receiving artificial respiration
on the intensive care ward.

Corneal erosion.

Similar to superficial punctate keratitis (although usually

more severe) but unilateral.
Application of artificial tears is usually not sufficient where
eyelid motor function is impaired. In such cases, highviscosity gels, ointment packings (for antibiotic protection),
and a watch glass bandage are required.
In the presence of persistent facial nerve palsy that shows no
signs of remission, lateral tarsorrhaphy is the treatment of
choice.

Watch glass bandage for paralytic

ectropion
In patients with
lagophthalmos
resulting from facial
paralysis,
a watch glass bandage
creates a moist chamber
that protects the cornea
against desiccation.

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