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Complicated Corneal Ulcer

Perforated Corneal Ulcer

Healed Keratocele

Hypopyon Ulcer
Corneal Ulcer (Superficial Purulent Keratitis)
with Hypopyon
Ulcer Serpen

Hypopyon Ulcer

There is always an associated iritis in all cases

of Corneal Ulcer due to diffusion of toxins of
infecting bacteria into the eye.
Sometimes iridocyclitis is so severe that it is
accompanied by outpouring of leucocytes
from uveal blood vessels and these cells
gravitate to bottom of the anterior chamber to
form hypopyon (pus in anterior chamber)


The hypopyon which forms in bacterial keratitis is

sterile as the leucocyte secretion is due to irritation by
toxins and not by the bacteria
Hypopyon may develop in hours and it may change
in quantity and may also rapidly disappear.
Hypopyon in bacterial keratitis is fluid and changes
its position with change in head posture


Predisposing Factors

High Virulence of infecting organism

Resistance of the tissues, which is low
Ocular trauma
Old, debilitated or alcoholic
Measles or scarlet fever


Pyogenic organisms like Staphylococci,

Streptococci, Gonococci, Moraxella,
Pseudomonas and Pneumococci

Hypopyon Ulcer

Ulcus Serpen

Ulcus Serpen is hypopyon ulcer caused by

Pneumococci in adults and has tendency to
creep over the cornea in serpiginous fashion


Sever pain, photophobia, marked diminution

of vision, watering, foreign body sensation


Grayish white or yellowish disc like lesion

near centre of cornea. Opacity is marked at
edges than at the centre and more marked in
one direction (where it is progressive). In the
direction of progression there is cloudiness
(grey coloured) and fine line ahead of disc
Cornea may be lusterless. There is severe iritis
and aqueous is hazy or there may be rank
hypopyon amount which varies


Untreated ulcer increases in depth and spread towards

the side of dense infiltration, while on the other side
simultaneously healing (cicatrization) takes place.
There is infiltration just anterior to Descemets
membrane underneath the floor of ulcer with normal
intervening lamellae, due to which there is tendency
for perforation of cornea. Intra-ocular tension is
usually raised in these cases.


Untreated cases progresses to increase in

hypopyon which becomes fibrinous leading to
perforation Iris prolapse through large
opening whole cornea may slough leaving
peripheral cornea which is nourished by limbal
vascular loops. Eventually panophthalmitis
develops which destroys the eye


Routine treatment of Corneal Ulcer

Tab Acetazolamide
Local Betablocker
Therapeutic keratoplasty
Control of infection results in absorption of

Fungal Keratitis

Fungal Keratitis
Fungal keratitis is challenging corneal disease and
presents as very difficult form bacterial keratitis.
Difficulty arise in making correct clinical and
laboratory diagnosis. The treatment of fungal keratitis
is also difficult due to poor availability of antifungal
drugs and delay in starting treatment.
Treatment is required on long term basis, intensively
and often cases require therapeutic keratoplasty.

Fungal Keratitis

Fungi enter into corneal stroma through epithelial

defect, which may be due to trauma, contact lens
wear, bad ocular surface or previous corneal surgery.
In stroma fungi multiply and causes tissue necrosis
and inflammatory reaction.
Organisms enter deep into the stroma and through an
intact Descemets membrane into the anterior chamber
and iris. They can also involve Sclera.

Fungal Keratitis

The spread is due to the fact that the blood

borne growth inhibiting factors may not reach
the avascular tissue like cornea and sclera.

Risk Factors


Trauma outdoor/ or the one which involves

plant matter (including contact lenses)
Topical medications: corticosteroids,
anaesthetic drug abuse and topical broad
spectrum antibiotics use for long time
(resulting in non-competitive environment
for growth)

Risk Factors
3. Systemic use of steroids
4. Corneal surgeries (Penetrating keratoplasty,
refractive surgery)
5. Chronic keratitis (herpes simplex, herpes
zoster, Vernal or allergic keratoconjunctivitis,
and neurotrophic ulcer)
6. Diabetes , Chronically ill / hospitalised
patients, AIDS and leprosy

Causative fungi


Yeast: Candida species (albicans),

Filamentous septated
A. Non-pigmented hyphae: Fusarium
species (solani), Aspergillus species
(fumigatus, flavus, niger)
B. Pigmented hyphae (dematiaceous):
Alternaria, Curularia , Cladosporium

Causative fungi
III. Filamentous non-septated : Mucor and
Rhizopus species
IV. Diphasic forms: Histoplasma, Coccidiodes,

Clinical Features


Onset is slow
Symptoms are less compared to signs
Diminution of vision, pain, foreign body


Diminution of vision, depending on location of

Conjunctival and ciliary congestion
Epithelial defect
Stromal infiltrates
Elevated areas, hypate (branching) ulcers,
irregular feathery margins
Dry and rough texture

Fungal Keratitis with Hypopyon


Satellite lesions
Brown pigmentation due to dematiaceous
fungus (Curvularia lunata)
Intact epithelium with stromal infiltrates
Anterior chamber reaction

Fungal Keratitis

Fungal Keratitis Pigmented Lesion

Case of Fungal+ Bacterial Keratitis

Laboratory Diagnosis

The Gram and Giemsa stains are used as initial

Potassium Hydroxide (10-20 %) wet mounts
Culture Media: Sheep blood agar, Chocolate
agar, Sabouraud dextrose agar, Thioglycollate
Anterior chamber tap under aseptic conditions
to aspirate hypopyon and or endothelial plaque


Natamycin 5% suspension: frequency will

depend on severity of condition
Candida species respond better to
Amphotericin B 0.15%
Fluconazole 2%
Miconazole 1%
Scrapping every 24 to 48 hours
Treatment is required for 4 6 weeks


Sub-conjunctival injection of Miconazole 5

10 mgm of 10 mgm/ml suspension (indicated
in severe form of keratitis, scleritis and
Fluconazole or Ketoconazole is indicated in
severe form of keratitis, scleritis and

Surgical Treatment



Daily debridement with spatula/ blade every

24 48 hours
Surgical treatment is required in
approximately 1/3rd cases of fungal keratitis
due to failure of medical treatment or
Surgical treatment in the form of :
therapeutic keratoplasty, conjunctival flap or
lamellar keratoplasty

Surgical Treatment

Surgery is usually indicated within 4 weeks

due to failure of medical treatment or
recurrence of infection
Unfavorable outcome is due to scleritis,
endophthalmitis and recurrence
Cryotherapy with topical antifungal treatment
or corneoscleral graft in cases of fungal
scleritis and keratoscleritis