konjungtivitis dan keratitis

8/15/2019 Konjungtivitis Dan Keratitis

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CONJUNGTIVITIS AND

KERATITIS



Overview

Conjungtivitis Keratitis1. Viral Conjungtivitis

Pharingokonjungtival Fever

Epidemica KeratoKonjungtivitis

Herpes Simplex Conjungtivitis

cute Hemorrhagic Conjungtivitis

!. "acterial Conjungtivitis

#. Chlamidial Conjungtivitis

$ %rachoma

$ &nclusion Conjungtivitis

'. llergic Conjungtivitis

topic Conjungtivitis

Ha( Fever Conjungtivitis

Vernal Conjungtivitis

). &ritation Conjungtivitis

"acterial Keratitis Viral Keratitis *(cotic Keratitis canthamoe+a Keratitis Super,icial Punctate

Keratitis -europaral(tic Keratitis Exposure Keratitis



CONJUNGTIVITIS



Conjunctivitis is an in,lammation o, the conjunctiva that is

characteried +( vascular dilatation/ cellular in,iltration and

exudation/ or in,lammation o, the mucous mem+rane covering the

+ack o, the e(elid and e(e+all.

DEFINITION



Conjunctiva is the outer la(er o, the e(e consisting o, a thin mucous mem+ranethat lines the e(elids

&n anatom( classi,ication/ the conjunctiva is divided into three parts/ conjunctiva

+ul+aris/ conjunctival palpe+ra/ and conjunctiva ,ornix

Conjunctival l(mph vessels are arranged in la(ers and the super,icial and

pro,undus la(er continuous 0ith the l(mph vessels to ,orm a plexus o, l(mph palpe+ra a lot.

Conjunctiva receive innervation ,rom the ,irst +ranch ophthalmic2 trigeminal

nerve. %hese nerves are onl( have a relative ,e0 pain ,i+ers

ANATOMY1



1. Forniks superior &inferior

2. Konjungtiva tarsal sup &

inf 3. Kripte henle4. Gl.Krause5. Gl.Wolfring

6. Gl.akri!al". Gl.#an$%. arsus superior

ANATOMY 2



ANATOMY 3

. anterior ciliar( +ranch o,

a.ophtalmica2

. episclera/ anastomosis 0ith a.ciliar(is posterior longus

,orming a. circularis major iris

and ciliar( +od(2

. episclera sclera/ intraocular2Pericorneal plexus cornea2

. posterior conjunctiva supplies the

conjunctiva



&n,ection viral/+acterial/or chlam(dia2

llergic reactions to dust/ pollen/ animal dander

&rritation +( the 0ind/ dust/ smoke and other air pollutants3

ultraviolet ra(s ,rom sunlight or electric 0elding.

ETIOLOGY



S(mptomps4

5ed e(es

Feeling o, lump

6irt( e(es

&tch(

7ater(

.Signs

Conjunctival injection

6icharge8secret

%here are patologic structure in conjunctivaChemosis

Signs & Syptomps



Congestion o, conjuctival aa8vvposterior conjunctiva2

Causes4 mechanical/ irritation/ allerg(/

in,ection

Signs4*o+ile ,rom its +ase

Cali+re increases to the peripher(

Fresh +lood color/ constricts 0ith

topical adrenalin

CONJUNCTIVAL INJECTION



Congestion o, pericornea vesselsa. anterior ciliaris2

Causes4$ corneal in,lammation keratitis/

corneal ulcer2

$ uveitis$ acute glaucoma$ endophthalmitis$ panophthalmitis

Signs4$ does not ,ollo0 movement o, conjuctiva$ ,ine/ small vessels surrounding the cornea$ cali+re decreases to0ards the ,ornices$ dark red color/ unchanged 0ith topical adrenalin

SILIAR INJECTION



Various kind o, discharge4 Serous clear li9uid2 *ucoid clear li9uid3 elastic viscous2 Purulent cloud( (ello0 li9uid2

Discharge



Pathologic Structure



Causa "acteria

Virus

Chlam(dia

lergic

&ritation

Clinical pattern

Conjungtivitis kataral

Conjungtivitis purulent

Conjungtivitis mem+ran

Conjungtivitis ,olikel Conjungtivitis ,likten

Conjungtivitis vernal

%rachoma

lassi!cation



VIRAL CONJUNCTIVITIS



Viral conjunctivitis commonl( is associated 0ith upper respirator( tract in,ections and is

usuall( caused +( an adenovirus. %his is the t(pe o, conjunctivitis that occurs in epidemics

o, “pin e!e"#

History :%he patient normall( complains o, +oth e(es +eing gritt( and uncom,orta+le/

although s(mptoms ma( +egin in one e(e. %here ma( +e associated s(mptoms o, a cold anda cough. %he discharge is usuall( 0ater(.

Viral conjunctivitis usuall( lasts longer than +acterial conjunctivitis and ma( go on ,or man(

0eeks3 patients need to +e in,ormed o, this. Photopho+ia and discom,ort ma( +e severe i,

the patient goes on to develop discrete corneal opacities.

Vir$% &'n()n&*ivi*i+



Examination :"oth e(es are red 0ith di,,use conjunctival injectionengorged conjunctival vessels2 and there ma( +e a clear discharge. Small

0hite l(mphoid aggregations ma( +e present on the conjunctiva ,ollicles2.

Small ,ocal areas o, corneal in,lammation 0ith erosions and associated

opacities ma( give rise to pronounced s(mptoms/ +ut these are di,,icult to

see 0ithout high magni,ication. %here ma( +e associated head and neckl(mphadenopath( 0ith marked pre$auricular l(mphadenopath(




Management :Viral conjunctivitis is generall( a sel, limiting condition/ +ut anti+iotic e(edrops ,or example/ chloramphenicol2 provide s(mptomatic relie, and help prevent

secondar( +acterial in,ection. Viral conjunctivitis is extremel( contagious/ and strict

h(giene measures are important ,or +oth the patient and the doctor3 ,or example/ 0ashing

o, hands and sterilising o, instruments.




Management $ %he period o, in,ection is o,ten longer than

0ith +acterial pathogens and patients should +e 0arned that

s(mptoms ma( +e present ,or several 0eeks. &n some

patients the in,ection ma( have a chronic/ protracted course

and steroid e(e drops ma( +e indicated i, the corneallesions and s(mptoms are persistent. Steroids must onl( +e

prescri+ed 0ith ophthalmological supervision/ +ecause o,

the real danger o, causing cataract or irreversi+le

glaucomatous damage. Furthermore/ i, long term steroidsare re9uired/ patients should remain under continuous

ophthalmological supervision




&n,ections caused +( adenovirus virus !.'/ and ;.

Si,n - S!.p*'.p+

Fever ,rom #<.# to '= C/⁰

sore throat

Follicular conjunctivitis in one or t0o e(es5ed e(es and 0ater( e(es are common/ and sometimes a little tur+idit(

su+epithelial area

Enlargement l(mphadenopath( preaurikuler

Tre$*.en*%here is no speci,ic treatment. Konjungtivitisn(a recover on their o0n/

generall( 0ithin a+out 1= da(s. %reatment is usuall( s(mptomatic and

anti+iotics to prevent secondar( in,ection

A" #aringo$on%ungtial #eer



Caused +( adenovirus virus t(pe #/;/</ and 1>

Si,n+ $n/ +!.p*'.+4

Epidemika keratoconjunctivitis generall( +ilateral

t ,irst the patient ,eels there is an in,ection 0ith pain and 0ater( e(es/ ,ollo0ed in )$1'da(s +( photopho+ia/epithelial keratitis/ and su+epithelial opacities round.

-ormal corneal sensation.

%ender l(mph preaurikuler 0hich is t(pical.

Palpe+ra edema/ kemosis/ and conjunctival h(peremia mark

the acute phase.

Follicles and conjunctival hemorrhage o,ten appear 0ithin '< hours.

Pseudomem+rane ma( ,orm and ma( +e ,ollo0ed +( a ,lat scar or s(m+lepharon

,ormation

'" Epi(emica )eratocon%unctiitis



0reven*i'n

7ash (our hands regularl( +et0een the inspection and cleaning and steriliation tools

tonometer touches the e(e in particular is also a must.

planasi tonometer should +e cleaned 0ith alcohol or h(pochlorite/ then rinsed 0ith sterile

0ater and dried care,ull(

Tre$*.en*4 Currentl( there is no speci,ic treatment/ +ut a cold compress 0ill reduce some

s(mptoms despite having care,ull( as it 0ill likel( lead to the gro0th o, +acteria orsecondar( in,ections. corticosteroids ,or acute conjunctivitis ma( prolong corneal

involvement should +e avoided. nti+acterial agent should +e given in case o, +acterial

superin,ection

C'.p%i&$*i'n+ can occur corneal opacities that persisted

". Keratokonjungtivitis epidemika1



?suall( in children under the age o, ! (ears

accompanied +( ginggivostomatitis.

Si,n+ $n/ +!.p*'.+4unilateral dilation o, +lood vessels/ irritation/ mucoid +ertahi e(es/

pain/ and mild photopho+ia

@n corneal epithelial lesions appear generall( separate ,used to ,orm

a ulcer or ulcer$epithelial ulcers are highl( +ranched dendritic2Herpes vesicles sometimes appeared at the edge palpe+ra palpe+ra

and/ accompanied +( severe edema palpe+ra. %here is a node

preaurikuler t(pical pain,ul i, pressed

C"erpe+ +i.p%e+ &'n()n&*ivi*i+



Tre$*.en*

Aocal and s(stemic anti$virus should +e given to prevent cornea involvemet

For corneal ulcers ma( +e re9uired corneal de+ridement care,ull( +(

ru++ing the ulcer 0ith a sterile cotton s0a+ sticks/ dripping 0ith antiviral

drugs/ and closed ,or !' hours.

%opical antiviral should +e given ;$1= da(s4 tri,luridine ever( ! hours

0hile a0ake or ra+ine vida ointment ,ive times a da(/ or idoxuridine

=.1B/ 1 drop ever( hour 0hile a0ake and 1 drop ever( ! hours during the

night.Herpes keratitis can also +e treated 0ith ac(clovir ointment #B ,ive times

dail( ,or 1= da(s or 0ith oral ac(clovir/ '== mg ,ive times dail( ,or ;

da(s

C"erpe+ +i.p%e+ &'n()n&*ivi*i+



E*i'%',! are Picorna viral and enterovirus ;=

Si,n+ $n/ +!.p*'.+4 e(e pain/ photopho+ia/ ,oreign +od( sensation/ a lot o, tears/ red/ palpe+ra edema/ and

hemorrhage su+konjungtival. &t sometimes happens

kemosis conjunctiva.

Ter$p!

%reatment is usuall( s(mptomatic. %he use o,

anti+iotics can +e used to prevent secondar( in,ection.

D"K'n()n,*ivi*i+ e.'r$,i$ A)*



4ACTERIAL CONJUNCTIVITIS



History :%he patient usuall( has discom,ort and a purulentdischarge in one e(e that characteristicall( spreads to the other

e(e. %he e(e ma( +e di,,icult to open in the morning+ecause

the discharge sticks the lashes together. %here ma( +e a

histor( o, contact 0ith a person 0ith similar s(mptoms.

4$&*eri$% &'n()n&*ivi*i+



Examination : %he vision should +e normal a,ter thedischarge has +een +linked clear o, the cornea. %he discharge

usuall( is mucopurulent and there is uni,orm engorgement o,

all the conjunctival +lood vessels. 7hen ,luorescein drops are

instilled in the e(e there is no staining o, the cornea.

4$&*eri$% &'n()n&*ivi*i+



Management :%opical anti+iotic e(e drops ,or example/chloramphenicol2should +e instilled ever( t0o hours ,or the ,irst !' hours to hasten

recover(/ decreasing to ,our times a da( ,or one 0eek. Chloramphenicol

ointment applied at night ma( also increase com,ort and reduce the

stickiness o, the e(elids in the morning. Patients should +e advised a+out

general h(giene measures3 ,or example/ not sharing ,ace to0els

4$&*eri$% &'n()n&*ivi*i+



CLAMYDIAL CONJUNCTIVITIS



History :Patients usuall( are (oung 0ith a histor( o, a chronic +ilateral

conjunctivitis 0ith a mucopurulent discharge. %here ma( +e associated

s(mptoms o, venereal disease. Patients generall( do not volunteer genitourinar(

s(mptoms 0hen presenting 0ith conjunctivitis3 these need to +e elicited through

9uestioning.

C%$.!/i$% &'n()n&*ivi*i+



Examination :%here is +ilateral di,,use conjunctival injection0ith a mucopurulent discharge. %here are man( l(mphoid

aggregates in the conjunctiva ,ollicles2. %he cornea usuall( is

involved keratitis2 and an in,iltrate o, the upper cornea pannus2

ma( +e seen.

C%$.!/i$% &'n()n&*ivi*i+



Management :%he diagnosis is o,ten di,,icult and special +acteriological testsma( +e necessar( to con,irm the clinical suspicions. %reatment 0ith oral

tetrac(cline or a derivative ,or at least one month can eradicate the pro+lem/

+ut poor compliance can lead to a recurrence o, s(mptoms. S(stemic

tetrac(cline can a,,ect developing teeth and +ones and should not +e used in

children or pregnant 0omen. ssociated venereal disease should also +etreated/ and it is important to check the partner ,or s(mptoms or signs o,

venereal disease a,,ected ,emales ma( +e as(mptomatic2. &t o,ten is help,ul to

discuss cases 0ith a genitourinar( specialist +e,ore commencing treatment/ so

that all relevant micro+iological tests can +e per,ormed at an earl( stage.

C%$.!/i$% &'n()n&*ivi*i+



'arious Chla!i()a tra*ho!atis serot)pes thatare o+ligate intra*ellular organis! *auses t,oe)e infe*tions are-

a" Trachoma

*" Inclusiuon on%uctiitis



ra*o!a is a for! of *hroni* folli*ular *onjun*tivitis *ause( +)Cla!)(ia tra*ho!atis. his (isease *an ae*t an) age +ut !ore*o!!on on )oung people an( *hil(ren

#o(es of trans!ission of this (isease is through (ire*t

*onta*t ,ith se*retions or through a tra*ho!a patients(ail) ne*essities su*h as to,els/ toilet arti*les an((eo(ori$e(.

he average in*u+ation perio( of " (a)s 0range 5 to 14

(a)s

T+A,OMA



**or(ing to the *lassi*ation #a* Callan*lini*al pi*ture of this (isease is (ivi(e( intoseveral stages.tage *alle( insipien sta(iu!tage *alle( esta+lishe(tage is *alle( staging grate(tage ' *alle( the stage of healing

7C89#



%o ensure trachoma endemic in ,amil( or communit(/ anum+er o, children must sho0 at least $ least t0o signs o,

the ,ollo0ing4

12 Five or more ,ollicles on the tarsal conjunctiva palpe+ra

superior to the average e(e.

!2 rate the tarsal conjunctiva conjunctiva at the superior

characteristic.

#2 ,ollicles or sekuelen(a lim+us Her+ert 0ells2.'2 %he expansion o, +lood vessels onto the cornea/ the clear

upper lim+us.

%5CH@*



For control/ the 7orld Health @rganiation hasdeveloped a simple 0a( to check the disease. &t

includes a sign $ a sign as ,ollo0s

%5CH@*



%F 4 ,ive or more ,ollicles on the upper tarsal

conjunctiva.

7C89#



%& 4 6i,,use in,iltrate and h(pertroph( papil on theconjuctiva tarsalis superior at least )=B o, normal deep

veins.

7C89#



%S 4 %rachomatosa conjunctival scarring. 7C89#



%% 4 %rikiasis or entropioninverted e(elashes2 7C89#



C@ 4 Corneal +lurred.

7C89#



%F and %i sho0 an active in,ectious trachoma that must

+e treated.

%S is evidence o, injur( ,rom this disease.

%% is potentiall( +linding and indications ,or surger(

kokreasi palpe+ra.

C@ is the ,inal +linding lesion o, trachoma.

%5CH@*



S)pp'r* inve+*i,$*i'n &nclusi +od( o, chlam(dia can +e ,ound in the conjunctival

scrapings in sleeping 0ith iemsa/ +ut not al0a(s exist.

@ut0ard appearance o, ,luorescein anti+od( and immuno $

assa( test o, en(mes are commerciall( availa+le and 0idel(used in clinical la+oratorium. %his ne0 test has replaced the

out0ard appearance o, iemsa ,or preparation and isolation

o, the klamidial agents in cell cultures

Di55eren*i$% /i$,n'+i+

Follicularis conjunctivitis/ vernal katarrh.

7C89#



C'.p%i&$*i'n

a. Secondar( in,ection

+. Corneal opacities due to pannus covering the cornea

c. Corneal xxerosis 0ith keratitis Sika

d. Enteropion and trikiasis

e. Sim+le,aron

Tre$*.en*

%reatment o, trachoma 0ith tetrac(cline e(e ointment !$' times a da(/ #$' 0eeks/ a correction

Surger( should +e per,ormed on the e(elashes turn in0ard to prevent scarring

trachoma.

For prevention +( vaccination and eat a nutritious and h(gienicgood to prevent the spread.

7C89#



%he disease is transmitted sexuall( and can last ,orchronic up to 1< months2 unless treated ade9uate

In&%)+i'n C'n()n&*ivi*i+



Si,n - S!.p*'.p+

Patients o,ten complain o, red e(es/ pseudo$ptosis/ and especiall( in the morning

+elekanda(s. &n neonates sho0ed papillar( conjunctivitis and a moderate amount o,

exudate/in cases o, h(peracute/ occasionall( ,ormed 0hich can cause scarring pseudomem+rane. Patients present 0ith ,ollicular conjunctivitis is mucopurulent and there

mikropanusassociated 0ith su+epithelial scarring.

In&%)+i'n C'n()n&*ivi*i+1



E6$.in$*i'n S)pp'r*

5apid diagnostic test direct ,luorescent anti+od( test/ EA&S/ and PC5 0as

replace the out0ard appearance o, iemsa

Di55eren*i$% /i$,n'+i+

ctive ,ollicular trachoma

Tre$*.en*

in in,ants

ive er(trom(cin per oral suspension/ )= mg 8 kg 8 da( in ' divided doses sealam sekurangkurangn(a

1' da(s.

&n adultsHealing is achieved +( dox(c(cline 1== mg orall( t0ice dail( ,or ; da(s/

or er(throm(cin ! g 8 da( ,or ; da(s/ or it could +e aithromcin 1 g 8 dose.

In&%)+i'n C'n()n&*ivi*i+2



ALERGIC CONJUNCTIVITIS



History :he !ain feature of allergi* *onjun*tivitis is it*hing. ;oth e)esusuall) are ae*te( an( there !a) +e a *lear (is*harge. here !a) +e afa!il) histor) of atop) or re*ent *onta*t ,ith *he!i*als or e)e (rops.i!ilar s)!pto!s !a) have o**urre( in the sa!e season in previous)ears. t is i!portant to (ierentiate +et,een an a*ute allergi* rea*tionan( a !ore long ter! *hroni* allergi* e)e (isease.

Allergic con%unctiitis



Examination :%he conjunctivae are di,,usel( injected and ma( +e oedematous

chemosis2. %he discharge is clear and string(. "ecause o, the ,i+rous septa

that tether the e(elid tarsal2 conjunctivae/ oedema results in round s0ellings

papillae2. 7hen these are large the( are re,erred to as co++lestones.

A%%er,i& &'n()n&*ivi*i+



Management :%opical antihistamine and vasoconstrictor e(e drops provide

short term relie,. E(e drops that prevent degranulation o, mast cells also are

use,ul/ +ut the( ma( need to +e used ,or several 0eeks or months to achieve

maximal e,,ect. @ral antihistamines ma( also +e used/ particularl( the ne0er

compounds that cause less sedation. %opical steroids are e,,ective +ut should

not +e used 0ithout regular ophthalmological supervision +ecause o, the risk

o, steroid induced cataracts and glaucoma

A%%er,i& &'n()n&*ivi*i+



Sign & Symptomps ;urning sensation/

<irt) e)es/

7e( e)es an( photopho+ia.

=alpe+ra>s e(ge erite!osa/ an( the *onjun*tiva ,as ,hite as !ilk.

here is a papilla rene(/ +ut not gro,ing like a giant papilla onkerato*onjun*tivitis vernal/ an( !ore often foun( in the inferiortarsus.

A" A*'pi& C'n()n&*ivi*i+



?suall( there is a histor( o, allergies ha( ,ever/ asthma/ or ecema2 in patients

or her ,amil(. *ost patients had su,,ered ,rom atopic dermatitis since

in,anc(.

rate in the ,olds o, ,lexure ,olding el+o0 and 0rist and knee o,ten 0as

,ound. s dermatitisn(a/ atopic keratoconjunctivitis lasts a prolongedando,ten experience exacer+ations and remissions. such as keratoconjunctivitis

vernal/ the disease tends to +e less active 0hen the patient 0as aged )=

(ears.

%$7'r$*'r!Conjunctival scrapings revealed eosinophils/ although not as much as that

seen

as much on vernal keratoconjunctivitis.

. topic Conjunctivitis1



Tre$*.en*

@ral ntihistamine including ter,enadine D=$1!= mg !x a da(2/

astemiole 1=mg ,our times dail(2/ or h(drox(ine )= mg +edtime/ increased to

!==

mg2 proved to +e +ene,icial.

-S&6/ such as ketorolac and iodoxamid/ it can overcome the

s(mptoms in these patients. &n severe cases/ plasmapheresis is an adjunctive therap(.

&n the case o, advanced 0ith severe corneal complications/ corneal

transplant ma( +e necessar( to

restore the sharpness o, his e(esight

. topic Conjunctivitis!

4 $! Fever C'n()n&*ivi*i+



Si,n+ $n/ +!.p*'.+

&n,lammation o, conjunctivitis non$speci,ics light0eight generall( accompanies the ha(

,everrhinitis llergic2.

?suall( there is a histor( o, allerg( to pollen/ grass/ ,eathers animals/ and others. Patients

complains a+out the itch($itch(/ 0ater( / red e(e/and o,ten said that his e(es as i, sink into

the surrounding tissue2

L$7'r$*'r!

Hard to ,ind eosinophils in conjunctival scrapings.

Ter$p!

Shed a vasoconstrictor local domain on stage o, acute epineprin/ solution o, 141=== given

topicall(/ 0ill eliminate kemosis and s(mptoms in #= minutes2.

Cold compresses help 0ith the itching and antihistamine onl(little +ene,it.

6irect response to the treatment ,airl( 0ell.

4"$! Fever C'n()n&*ivi*i+



n in,lammation o, the e(es o, the outside o, the seasonaland considered to +e an allerg(.

Conjunctiva contains man( cells o, the immune s(stem

mast cells2 the release o, chemical compounds mediators2in response to various stimuli such as pollen or dust mites2.

%hese mediators cause in,lammation the e(e/ 0hich ma(

last a minute or longer. pproximatel( !=B o, people have

high levels o, red e(e allerg(.

C" Vern$% C'n()n&*ivi*i+



Di$,n'+i+

Found an( signs o, in,lammation o, the conjunctiva

Found an( giant papil the superior conjunctiva palpe+ra

Found an( tantras dot on the corneal lim+us

Sometimes accompanied +( shield ulcer

5ecurrent

Si,n - S!.p*'.p+

5ed e(es usuall( recurrent2Sometimes accompanied +( intense itching

histor( o, allerg(

%he existence o, di,,use papil h(pertroph( especiall( o, the conjunctiva tarsal superior

%hickening o, lim+us 0ith dot tantras

*ucoid to mucopurulent discharge i, there is secondar( in,ection



Tre$*.en*

Mi%/ &$+e+4

educational therap( avoiding allergens/ cold compresses/ cool room/ lu+rication/ e(e ointment2/

giving antihistamines topical levoka+astin/ emestadine2/

vasoconstrictor phenileprine/ tetrahidroloine2/

mast cell sta+ilier 'B sodium cromolin alomide2

M'/er$*e8+evere &$+e+

mast cell sta+ilier sodium 'B alomide cromolin2/

topical steroid anti$in,lammator( ketorolac =.)B2/

topical corticosteroids or agents

modulator c(closporine.



H(persensitivit( reaction to micro+ial protein suchas protein *.t+c/ Sta,ilokok/ Candida2

Small lesions 1$#mm2/ hard/ red/ surrounded +(

prominent local h(peremia

&, the lim+us $G triangular 0ith the peak in the

direction o, the cornea $G recover ,orm jar.parut.

6.Flikten Conjunctivitis



IRITATION

CONJUNCTIVITIS

I t i % ti iti



Follicular conjunctivitis Conjunctivitis toxic or non$speci,ic in,iltrate/0hich

,ollo0ed the ,ormation o, scar tissue/ o,ten caused +( long using o, dipive,rin/

miotika/ idoxuridine/ neom(cin/ and other drugs are prepared in vehikel

preservatives or toxic that cause irritation.

Silver nitrate is dripped into the saccus conjingtiva at +irth is o,ten a causes a mildchemical conjunctivitis. &, tear production is reduced due to continuous irritation/

conjunctival injur( +ecause there 0ould then exist dilution o, the agents that

damage 0hen dropped into the saccus conjungtivae.

Conjunctival scrapings o,ten contain keratinied epithelial cells/ a ,e0

pol(morphonuclear neutrophils/ and occasional odd$shaped cells.

Iatrogenic on%unctiitis-Topical (rug a(ministration.

C ( *i i*i / 7 C i % /



cid/ alkali/ smoke/ 0ind/ and almost an( irritant su+stance that makes the saccusconjungtiva can cause conjunctivitis. Some common irritants is ,ertilier/ soap/

deodorant/ hair spra(/ to+acco/ ingredients make$up/ and various acid and alkali. &n

certain areas/ smog a mixture o, smoke and ,og2 %he main cause o, a mild

chemical conjunctivitis. Speci,ic irritant in smog can not +e positivel( determined/

and non$speci,ic treatment. -o a permanent e,,ect on the e(e/ +ut the a,,ected e(e

is o,ten red and distur+ing is chronic.

C'n()n&*ivi*i+ &$)+e/ 7! Ce.i&$%+ $n/

irri*$n*+1

C ( *i i*i / 7 C i % /



@n the injur( acid/ it changes the nature and e,,ect o, protein net0orks directl(.lkali does not change the nature o, the protein and tend to 9uickl( in,iltrate

net0ork and settled into the conjunctival tissue. Here the( continued to damage

sustained ,or hours or da(s old/ depending on molar concentration o, the alkali and

the amount o, intake. attachment +et0een +ul+i conjunctiva and cornea leokoma

palpe+ra and more than likel( occur i, the cause is an alkali agent. t an( event/

the main s(mptom chemical injur( are pain/ +lood vessel dilation/ photopho+ia/and +lepharospasm. Histor( o, the trigger events can usuall( +e disclosed.

.

C'n()n&*ivi*i+ &$)+e/ 7! Ce.i&$%+ $n/

irri*$n*+



)E+ATITIS



'acterial )eratitis



%he most common +acterial pathogens that cause keratitis4

Staphylococcus aureus,Staphylococcus epidermidis,

Streptococcus pneumoniae, Pseudomonas aeruginosa,

Moraxella.

*ost +acteria are una+le to penetrate the cornea as long as the

epithelium remains intact. @nl( gonococci and diphtheria +acteria can penetrate an intact corneal epithelium.



.Symptoms- =atients report !o(erate to severe

pain 0e?*ept in Moraxella infe*tions photopho+ia/i!paire( vision/ tearing/ an( purulent (is*harge.=urulent (is*harge is t)pi*al of +a*terial for!s ofkeratitis viral for!s pro(u*e a ,ater) (is*harge.



Di$,n'+*i& &'n+i/er$*i'n+4 Positive identi,ication o, the

pathogens is crucial. Serpiginous corneal ulcers are ,re9uentl(

associated 0ith severe reaction o, the anterior cham+erincluding accumulation o, cells and pus in the in,erior

anterior cham+er h(pop(on2 and posterior adhesions o, the

iris and lens posterior s(nechia2.

Di55eren*i$% /i$,n'+i+4 Fungi positive identi,ication o, the pathogen is re9uired to exclude a ,ungus in,ection2.



C'n+erv$*ive *er$p! %reatment is initiated 0ithtopical antibiotics 0ith a ver( +road spectrum o,

activit( against most ram$positive and ram$negative

organisms until the results o, pathogen and resistance

testing are kno0n. &mmo+iliation o, the ciliar( +od(and iris +( therapeutic m(driasis is indicated in the

presence o, intraocular irritation mani,ested +(

h(pop(on2.

Tre$*.en*



C(clopegic◦ Com,ort/ Prevent posterior s(nechiae

%opical anti+iotics

◦ Ao0 risk 1mm/ peripheral

Floro9uinolone I'H J8$ to+ram(cin

◦ *oderate risk 1$!mm/ peripheral

Floro9uinolone I1H atc

◦ High risk

%o+ram(cin 1)mg8mA ID=minutes Ce,aolin )=mg8mA or Vancom(cin !)mg8mA ID=minutes

Treatment



S)r,i&$% *re$*.en* Emergenc( keratoplast( is

indicated to treat a descemetocele or a per,oratedcorneal ulcer. "road areas o, super,icial necrosis ma(

re9uire a conjunctival ,lap to accelerate healing.

Stenosis or +lockage o, the lo0er lacrimal s(stemthat ma( impair healing o, the ulcer should +e

surgicall( corrected.



Failure of keratitis to respon( to treat!ent !a)+e (ue to one of the follo,ing *auses/

parti*ularl) if the pathogen has not +eenpositivel) i(entie(- he patient is not appl)ing the anti+ioti* 0poor

*o!plian*e. he pathogen is resistant to the anti+ioti*. he keratitis is not *ause( +) +a*teria +ut +)one of the follo,ing pathogens-

a. 8erpes si!ple? virus. +. Fungi.

*. Acanthamoeba.



/iral )eratitis



Viral keratitis is ,re9uentl( caused +(4

1. Herpes simplex virus.

!. Varicella$oster virus.#. denovirus.

@ther rare causes include cytomegalovirus, measles virus,

or rubella virus.



Herpes simplex keratitis is among the more commoncauses o, corneal ulcer

corneal in,ection is al0a(s a recurrence. primar(

herpes simplex in,ection o, the e(e 0ill present as

+lepharitis or conjunctivitis. 5ecurrences ma( +etriggered external in,luences such as exposure to

ultraviolet light2/ stress/ menstruation/ generalied

immunologic de,icienc(/ or ,e+rile in,ections.

erpe+ +i.p%e6 er$*i*i+



1" 0ri.$r! erpe+ Si.p%e6 Ker$*i*i+ &n,re9uentl( seen *ani,ested as vesicular +lepharoconjunctivitis

occasionall( 0ith corneal involvement ?suall( occurs in (oung children %opical antiviral therap( ma( +e used as proph(laxis

and as therap(

Vaughan & Asburys !eneral "phthalmology #$ th Edition, #%$

FORM SV CLINICAL FINDINGS



2" Re&)rren* *!pe erpe*i& er$*i*i+

ttacks triggered +( Fever

@verexposure to ?V light %rauma @nset o, menstruation Aocal8 s(stemic source o, immunosuppression

"ilateral lesions develop in '$DB o, patients andseen mostl( in atopic patients.

FORM SV CLINICAL FINDINGS

Vaughan & Asburys !eneral "phthalmology #$ th Edition, #%$



Den/ri*i& er$*i*i+" %his is characteried +( +ranchingepithelial lesions. %hese ,indings 0ill +e visi+le 0ith

the unaided e(e a,ter application o, ,luorescein d(e and

are characteristic o, dendritic keratitis. Corneal

sensitivit( is usuall( reduced.6endritic keratitis ma( progress to stromal keratitis.

9SV: /en/ri*i& er$*i*i+"

Tre$*.en*



Should +e directed at eliminating viral replication 0ithin

the cornea/ 0hile minimiing damaging e,,ects o,

in,lammator( response.

6E"5&6E*E-%

Epithelial de+ridement is an e,,ective 0a( to treatdendritic keratitis

&n,ected epithelium is eas( to remove 0ith tightl( 0ound

cotton tip applicator.

djunctive therap( 0ith topical antiviral acceleratesepithelial healing.

Tre$*.en*

Vaughan & Asburys !eneral "phthalmology #$ th Edition, #%$#%'

T

TREATMENT DRUGS



Treatment

"phthalmology ())*, +(, *'-*(

ntiviral medicines used in treatment o, Herpes Simplex Virus

@cular 6isease

ctivated +( viral

th(midine kinase to

inhi+it 6- pol(merase

) times dail(

'== mg )

times dail(

#B

ointment

!==8'==8

<== 6%

%opical

@ral

c(clovir

&nhi+its viral

th(mid(late s(nthetase

Ever( !

hours 0hile

a0ake

1B

solution

%opical%ri,luridine

&nhi+its viral 6-

pol(merase

) times dail(#B

ointment

%opicalVidara+ine

&nhi+its viral th(midine

kinase/ th(mid(late

kinase and 6-

pol(merase

Hourl( 0hile

a0ake

=.1B

solution

%opical&doxuridine

A&*i'nFre;)en&!F'r.R')*eAn*ivir$%

@ hthalmolo !==' ! ';)$'<!

TREATMENT DRUGS

T



ri@uri(ine an( a*)*lovir are !u*h !oreee*tive in stro!al (isease than others.

(o?uri(ine an( tri@uri(ine are freAuentl)asso*iate( ,ith to?i* rea*tions.

9ral a*)*lovir !a) +e useful in treat!ent ofsevere herpeti* e)e (isease parti*ularl) inatopi* in(ivi(uals.

Treatment




S)r,i&$% *re$*.en*



Penetrating keratoplast( indicated ,or visual reha+ilitationin patients 0ith sever corneal scarring. Should not +e

undertaken until herpetic disease has +een inactive ,or man(

months.

S(stemic antiviral agents should +e used ,or several monthsa,ter keratoplast( to cover use o, topical steroids.

Aamellar keratoplast( has advantage over penetrating

keratoplast( o, reduced potential ,or corneal gra,t rejection.

S)r,i&$% *re$*.en*


V i %% i % i i 9V=V:



@ccurs in t0o ,orms4 Primar( varicella2

5ecurrent herpes oster2

@cular mani,estations are uncommon in varicella +ut

common in ophthalmic oster.

V$ri&e%%$ <'+*er vir$% er$*i*i+ 9V=V:


V i %% * i % *i*i 9V=V:



@cular mani,estations ?sual e(e lesions are pocks on lids and lid margins. Keratitis occurs rarel(. Epithelial keratitis 0ith or 0ithout pseudodendrites

occurs more rarel(. 6isci,orm keratitis 0ith uveitis o, var(ing duration has +een reported.

V$ri&e%%$ <'+*er vir$% er$*i*i+ 9V=V:

Tre$*.en*



&ntravenous and oral ac(clovir have +een used success,ull(

,or treatment o, herpes oster ophthalmicus/ particularl( inimmunocompromised patients.

@ral dosage is <== mg ,ive times dail( ,or 1=$1' da(s.

%herap( needs to +e started 0ithin ;! hours a,ter

appearance o, the rash.

Tre$*.en*



M!&'*i& Ker$*i*i+



ver( rare/ occurring almost exclusivel( in ,arm la+orers

Etiolog(4 %he most ,re9uentl( encountered pathogens are Aspergillus and /andida albicans. %he most ,re9uent

causative mechanism is an injur( 0ith ,ungus$in,ested organic

materials such as a tree +ranch.

Patients usuall( have onl( slight s(mptoms.



evere *an(i(al keratitis in an el(erl) !alu+a*ute onset of *an(i(a keratitis



evere aspergillus infe*tion

,ith large area

of *orneal ul*eration an(

(eep stro!al involve!ent

evere *entral aspergillus infe*tion

,ith a D*heese)E looking areaof the lesion an(

h)pop)on 0@ui( level of in@a!!ator)

*ells in the anterior *ha!+er

Di *i i/ *i



Slit lamp examination 0ill reveal t(pical 0hitishstromal in,iltrates/ especiall( 0ith m(cotic keratitis due

to /andida albicans. 1he in2iltrates and ulcer spread

ver( slo0l(. Satellite lesions, several ad3acent smaller

in,iltrates grouped around a larger center/ arecharacteristic +ut 0ill not necessaril( +e present.

Di$,n'+*i& &'n+i/er$*i'n+

Tre$*.en*



topical treatment 0ith antim(cotic agents such asnatam(cin/ n(statin/ and amphotericin "/ aoles

clotrimaole/micanaole/ ketokonaole etc2

Surgical treatment" Emergenc( keratoplast( is indicated

0hen the disorder ,ails to respond or responds tooslo0l( to conservative treatment and ,indings 0orsen

under treatment.

Tre$*.en*



ACANTAMOE4AKERATITIS

Eti l th + i h ti t



Etiolog(4 canthamoe+a is a saproph(tic protooon.

&n,ections usuall( occur in 0earers o, contact lenses/

particularl( in conjunction 0ith trauma and moistenvironments such as saunas.

S(mptoms4 Patients complain o, intense pain/ photopho+ia/

and lacrimation.





%he patient 0ill o,ten have a histor( o, several 0eeks ormonths o, unsuccess,ul anti+iotic treatment.

&nspection 0ill reveal a unilateral reddening o, the e(e.

?suall( there 0ill +e no discharge. %he in,ection can present

as a su+epithelial in,iltrate/ as an intrastromal disci,ormopaci,ication o, the cornea/ or as a ring$shaped corneal

a+scess.

Tre$*.en*



Tre$*.en*

Conservative treatment4 %opical agents currentl( include propamidine and pentamidine. ?suall( +road$spectrum

anti+iotic e(edrops are also administered. C(cloplegia

immo+iliation o, the pupil and ciliar( +od(2 is usuall(

re9uired as 0ell.

Surgical treatment Emergenc( keratoplast( is indicated

0hen conservative treatment ,ails.



S)per5i&i$% 0)n&*$*eKer$*i*i+



Super,icial punctate corneal lesions due to lacrimal

s(stem d(s,unction ,rom a num+er causes. etiolog(4 Super,icial punctate keratoconjunctivitis

is a ver( ,re9uent ,inding as it can +e caused +(

a0ide variet( o, exogenous ,actors such as ,oreign +odies +eneath the upper e(elid/ contact lenses/

smog/ etc. &t ma( also appear as a secondar(

s(mptom o, man( other ,orms o, keratitis . &t canalso occur in association 0ith an endogenous

disorder such as %h(gesons disease.

S!.p*'.+



S!.p*'.+

6epending on the cause and severit( o, the super,icial corneallesions

s(mptoms range ,rom a nearl( as(mptomatic clinical course

such as in neuroparal(tic keratitis in 0hich the cornea loses

its sensitivit(2 to an intense ,oreign +od( sensation in 0hichthe patient has a sensation o, sand in the e(e 0ith t(pical

signs o, epiphora/ severe pain/ +urning/ and +lepharospasm.

Visual acuit( is usuall( onl( minimall( compromised.

Tre$*.en*



Tre$*.en* 6epending on the cause/ the super,icial corneal changes 0ill

respond rapidl( or less so to treatment 0ith arti,icial tears

0here+( ever( e,,ort should +e made to eliminate the

causative agents "

6epending on the severit( o, ,indings/ arti,icial tears o,var(ing viscosit(ranging ,rom e(edrops to high$viscosit(

gels2 are prescri+ed and applied 0ith var(ing ,re9uenc(.

&n exposure keratitis/ a high$viscosit( gel or ointment is used

+ecause o, its long retention time super,icial punctate keratitis is treated 0ith e(edrops.



Ker$*'&'n()n&*ivi*i+ Si&&$



%his is one o, the most

,re9uent causes o,

super,icial keratitis. %he

s(ndrome itsel, isattri+uta+le to dr( e(es

due to lack o, tear ,luid.

Ker$*'&'n()n&*ivi*i+ Si&&$



Ne)r'p$r$%!*i& Ker$*i*i+



&t 0ill lead to loss o, corneal sensitivit(. s a result o, this

loss o, sensitivit(/ the patient 0ill not ,eel an( sensation o,

dr(ing in the e(e/ and the +linking ,re9uenc( drops +elo0 the

level re9uired to ensure that the cornea remains moist.

s in exposure keratitis/ super,icial punctate lesions 0ill ,orm

initiall(/ ,ollo0ed +( larger epithelial de,ects that can progressto a corneal ulcer i, +acterial superin,ection occurs.

S!.p*'.+ -Tre$*.en*



S!.p*'.+ -Tre$*.en*

"ecause patients0ith loss o, trigeminal ,unction are ,ree o, pain/ the( 0ill experience onl( slight s(mptoms such as a

,oreign +od( sensation or an e(elid s0elling.

%his is essentiall( identical to treatment o2 exposure 4eratitis.

5t includes moistening the cornea/ anti+iotic protection as

proph(laxis against in,ection/ and/ i, conservative methods

are unsuccess,ul/ tarsorrhaph(.



E6p'+)re Ker$*i*i+



Keratitis resulting ,rom dr(ing o, the cornea in the case o,

lagophthalmos.

Exposure keratitis is a relativel( ,re9uent clinical s(ndrome.

For example/ it ma( occur in association 0ith ,acial paral(sis

,ollo0ing a stroke.

Etiolog(4 6ue to ,acial nerve pals(/ there is insu,,icientclosure o, the e(elids over the e(e+all lagophthalmos2/ and

the in,erior third to hal, o, the cornea remains exposed and

unprotected exposure keratitis2.

S ,i i l t t k titi i iti ll d l i thi i



Super,icial punctate keratitis initiall( develops in this region

and can progress to corneal erosion or ulcer.

@ther causes ,or exposure keratitis 0ithout ,acial nerve pals(include4

?ncompensated exophthalmos in raves disease.

&nsu,,icient e(elid closure ,ollo0ing e(elid surger( to correct ptosis.

&nsu,,icient e(e care in patients receiving arti,icial respiration

on the intensive care 0ard.

C'rne$% er'+i'n



C'rne$% er'+i'n"

Similar to super,icial punctate keratitis although usuall(



Similar to super,icial punctate keratitis although usuall(

more severe2 +ut unilateral.

pplication o, arti,icial tears is usuall( not su,,icient 0heree(elid motor ,unction is impaired. &n such cases/ high$

viscosit( gels/ ointment packings ,or anti+iotic protection2/

and a 0atch glass +andage are re9uired.

&n the presence o, persistent ,acial nerve pals( that sho0s no

signs o, remission/ lateral tarsorrhaph( is the treatment o,

choice.

>$*& ,%$++ 7$n/$,e 5'r p$r$%!*i&



e&*r'pi'n

&n patients 0ithlagophthalmos

resulting ,rom ,acial

paral(sis/

a 0atch glass +andage

creates a moist cham+er

that protects the cornea

against desiccation.

konjungtivitis dan keratitis

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