Corneal Disorders

Prof.Dr.Osman Ş. Arslan
 Applied corneal anatomy(1)
ƒ The cornea is a
translucent,round,flat, solid
tissue
ƒ Two faces(anterıor-external and
posterior-internal)
ƒ Peripheric border is the limbus
ƒ Diameter=11,5-12,5mm
ƒ Thickness=500
micron(centrally)
ƒ İnnervation=by sensory fibers
from trigeminal nerve
ƒ No blood and lymphatic vessels
ƒ Refractive power=45-50 D
 Applied Corneal Anatomy (2)
Anatomically, the cornea
consists of the following
five layers.
1.The epithelium consists of
three types of cells:
a)A single layer of basal
columnar cells
b)Two to three rows of
wing cells which have
thin “winglike”
extensions
c)Two layers of long
and thin surface cells
joined by bridges.

2.Bowman layer is an
acellular structure which
represents the superficial
layer of the stroma.
 Applied Corneal Anatomy (3)
3.The stroma makes up about
90% of corneal thickness. It is
principally composed of
regularly orientated layers of
collogen fibrils
4.Descement membrane is
composed of a fine lattice-work
of collagen fibrils.
5.The endothelium consists of a
single layer of hexagonal cells.
It plays a vital role in
maintaining the deturgence of
the cornea. With age, the
number of endothelial cels
gradually decrease but because
they cannot regenerate,
neigbouring cells have to
spread out to fill the space
 Microbial Keratitis

‹ Bacterial keratitis
‹ Fungal keratitis
‹ Viral keratitis
 Bacterial Keratitis (1)

Predisposing Factors
The pathogens able to produce corneal
infection in the presence of an intact epithelium
are Neisseria gonorhoae, Corynebacterium
diphtheriae, Listeria sp. and Haemophilus sp.

Other bacteria are capable of producing

keratitis only after loss of corneal epithelial
integrity
 Bacterial Keratitis (2)

Predisposing Factors
1.Contact lens wear.The infection is often caused
by pseudomonas aeruginosa which requires an
epithelial defect for corneal invasion.Such defects
occur in all contact lens wearers at times.

2.Ocular surface disease which disrupts defence

mechanisms, such as trauma, bullous
keratopathy, corneal exposure, dry eye and
diminished corneal sensation.
 Bacterial Keratitis (3)
Clinical Features
1.Staph. aureus and Strep.pneumoniae tend to
produce oval, yellow-white, densely opaque
stromal suppuration surrounded by relatively
clear cornea.
2.Pseudomonas typically causes thick
mucopurulent exudate, diffuse liquefactive
necrosis and semi-opaque “ground-glass”
appearance of adjacent stroma. The infection may
progress rapidly and result in corneal perforation
within 48 hours
3.Enterobacteriacea usually causes a shallow
ulceration, grey-white pleomorphic suppuration
and diffuse stromal opalescence.
 Bacterial Keratitis (4)

Management (1)
A bacterial corneal ulcer is a sight-thereatening
condition demanding urgent identification and
eradication of the causative organism. This is
best performed with the patient hospitalized
1.Choice of antibiotics:
a)The standard combined therapy with
fortified aminoglycosides and a fortified
cephalosporin
b)Monotherapy with a fluoroquinolone
(ofloxacine, ciprofloxacin)
 Bacterial Keratitis (5)
Management (2)

2.Cyloplegics (atropine), should be used in all

eyes to prevent to formation of posterior
synechiae(between the iris and the lens)and
to reduce pain from ciliary spasm.
3.Steroid therapy is controversial
 Fungal Keratitis (1)
Clinical Features
1.Flamentous fungal keratitis is most prevalent in
agricultural areas and typically preceded by
ocular trauma, most frequently involving organic
matter such as wood.
2.Candida keratitis usually develops in
association with pre-existing chronic corneal
disease or in an immunocompromised or
debiliated patient. It is characterized by a yellow-
white ulcer associated with dense suppuration
 Fungal Keratitis (2)
Management

1.Anti-fungal therapy
a)Initial treatment is with a topical broad-
spectrum agent such as econazole 1% until
sensitivities are obtained
b)Subsequent topical treatment may be with
topical natamycin and imidazole which should
be continued for 6 weeks
c)Systemic ketoconazole may also be helpful
in severe cases
 Viral Keratitis

ƒ Herpes simpleks keratitis

ƒ Herpes zoster oftalmicus
Herpes Simpleks Keratitis (1)

Herpes simplex virus (HSV) is a DNA

virus with humans as the only host.

Infection with HSV is extremely

common and about 90% of the population
are seropositive for HSV antibodies.
 Herpes simpleks keratitis (2)

ƒ Primary ocular infection

ƒ Recurrent ocular infection
-Dendritic ulser
-Disciform keratitis(endothelitis)
 Herpes Simpleks Keratitis (3)

Primary Ocular Infection

Primary ocular infection typically occurs in
children between the ages of 6 months and
5 years
1.Blepharoconjunctivitis is usually benign and
self limited and, in children, it may be the only
manifestation of primary herpetic infection.
2.Keratitis is uncommon. It is characterized by
fine epithelial punctate keratitis which may be
transient.
 Herpes Simpleks Keratitis (4)
Dendritic Ulcer (1)

Sign in chronological order

a)Early cases shows opaque cells arranged in a
coarse, punctate or stellate pattern
b)Following central desquamation a linear-
branching ulcer begins to form. The bed of the
ulcer stains with fluorescein.
c)Occasionally, the continued enlargement of a
dendritic ulcer leads to much larger epithelial
defect which has a geographical or “amoeboid”
configuration
Herpes Simpleks Keratitis (5)
Dendritic Ulcer (2)

Antiviral therapy
a)Acyloguanosine (3% ointment) (aciclovir,
Zovirax) is used five times daily.
b)Trifuluorothymidine (1% drops) is used
every 2 hours during the day.
Herpes Zoster Ophthalmicus (1)

Herpes zoster is a common infection

caused by human herpes virus

Approximately 15% of all cases of

herpes zoster affect the ophthalmic
division of the trigeminal nerve
Herpes Zoster Ophthalmicus (2)
Ocular Lesions

1.The eyelids are frequently involved by the rash.

Ptosis is common and is usually caused by
oedema and inflamation
2.Conjunctivitis is one of the most common
complications
3.Acute epithelial keratitis,dendritic epithelial
lesions
4.Nummular keratitis
5.Disciform keratitis
6.Anterior uveitis
 Corneal Dystrophies (1)

Definition

The corneal dystrophies are a group of

progressive, usually bilateral and mostly
genetically determined corneal opacifying
disorders which develop in the absence of
inflammation.
 Corneal Dystrophies (2)

Classification

1.Anterior dystrophies
-Microcystic (Cogan)
-Reis-Büclers
-Meesmann
-Schnyder
2.Stromal dystrophies
-Lattice I,II, III
-Granular I,II, III
-Macular I, II
3.Posterior dystrophies
-Fuchs endothelial
-Posterior polymorphous
 Corneal Ectasias (1)

‹ Keratoconus
‹ Keratoglobus
‹ Pellucid marginal degeneration
 Corneal Ectasias (2)
Keratoconus

Keratoconus (conical cornea) is a fairly

common, progressive disorder in which the
cornea assumes an irregular conical shape.

The hallmark of keratoconus is central or

paracentral stromal thinning, apical protrusion
and irregulas astigmatism.

The onset is at around puberty and progresses

slowly thereafter, although it may become
stationary at any time
 Corneal Ectasias (3)

Management

1.Spectacle correction
2.Contact lenses
3.Penetrating keratoplasy is indicated in patients
with advanced progressive disease, especially
with significant corneal scarring.
 Principles of Keratoplasy
Keratoplasty, which is also referred to
as corneal transplantation or corneal
grafting, is an operation in which
abnormal host tissue is replaced by
healthy donor corneal tissue.

The graft may be

a) lamellar (partial thickness) or
b) penetrating (full thickness).