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CORNEAL ULCER

KEPANITERAAN KLINIK MADYA (KKM)


BAGIAN/SMF ILMU KESEHATAN MATA
RUMAH SAKIT UMUM PUSAT (RSUP) SANGLAH
DENPASAR
2015

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

the cause of blindness


Corneal ulcer is a discontinuity of tissue that passes more than one layer
Corneal is a transparent membrane discontinuity causing vision

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,

viruses, fungi. Other causes are abrasions or foreign bodies, inadequate


eyelid closure, severe dry eyes, severe allergic eye disease, contact lens
wearers and various other inflammatory disorders.

Literature Review
Anatomy

Transparent

The cornea is the transparent, domeshaped window covering the front of


the eye

Powerful refracting surface, providing


2/3 of the eye's focusing power

Surrounded by limbus

Innervated by sensory neuron from


trigeminal nerve

Nutrition from limbus


vascularization, humour aquos, and
tears

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Literature Review
Definition
Corneal ulcer may be defined as a discontinuation in

the normal epithelial surface of the cornea associated


with necrosis of the surrounding corneal
Characterised by edema and cellular infiltration

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Once the corneal epithelium is invaded by the offending agents, the sequence

of changes occuring in the development of a ulcer can be described under 4 :STAGE


II. STAGE
III. STAGE
IV. STAGE
I.

OF
OF
OF
OF

INFILTRATION
ACTIVE ULCERATION
REGRESSION
CICATRIZATION.

.Depending upon the circumstances, the course of the bacterial ulcer may take

one of the 3 :ULCER MAY HEAL & BECOME LOCALIZED.


II. PENETRATE DEEP LEADING TO CORNEAL PERFORATION.
III. SPREAD FAST IN THE WHOLE COREA AS A SLOUGHING CORNEAL
ULCER.
I.

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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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Literature Review
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


Central Fungal Cornea Ulcer
Viral Cornea Ulcer
Acanthamoeba Cornea Ulcer
Perifer

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

within two to three weeks.


If scars from previous corneal ulcers impair vision, a corneal

transplant may be needed to restore normal vision

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.

History of drug use drops (Rohto and Xytrol)


No history of trauma.
No history of diabetes mellitus and hypertension.
No history using spectacles

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

Case Report
Treatment

Levofloxacin ed 6x1 drop OD


Lyteers ed 6x1 drop OD
Atropin 1 % ed 3x1 drop OD
Natrium Diclofenac 2x50mg
Vitamin C 1 x 1 tab
Control in a week

Prognosis
Ad vitam : Dubius ad bonam
Ad fungsionam : Dubius ad malam
Ad Recovery
: Dubius ad bonam

Case Report
Discussion
Theory
Etiology

Infection, non infectinon,


immunology

Symptom

Conjunctiva hyperemii,
blepharospasme,
mukopurulent secrets,
foreign body sensation,
blurry vision, watery,
white spot in cornea,
photophobia, Pain

Sign

PCVI, lost of some


corneal tissue, hypopion

Case
Infection
Pain in right eye, redness,
swollen, blurry vision, there is
white spot in black part, glare,
blepharospasme, photophobia,
watery eyes

VA 2/60, oedema (+), CVI (+),


PCVI (+), Ulcus, central elevated
edge, RP (+), glare (+)

Case Report
Theory

Case

Therapy

Sulfa Atrophin
Analgetic
Antibiotic
Anti fungal
Anti viral
Vitamin C

Levofloxacin ed 6x1 drop LE


(Antibiotic)
Cendo Lyters ed 6x1 drop LE
(artificial tears)
Atropin 1 % ed 3x1 drop OD
Natrium
Diclofenac
2x50mg
(analgetics)
Vitamin C 1x1 tab

Prognosis

Severity the ulcer


Early treatment
Causal
Complication

Central ulcer need a long


healing process and disturbing
vision.

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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