corneal ulcer 2.pdf

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CORNEAL ULCER

Z A L D I

DEPARTEMEN ILMU KESEHATAN MATA

FAKULTAS KEDOKTERANUNIVERSITAS MUHAMMADIYAH SUMATERA UTARA

MEDAN

2011

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Dengan menyebut nama Allah

Yang Maha Pengasih Maha Penyayang.

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I. TUJUAN INSTRUKSIONAL UMUM

• Setelah Proses Belajar Mengajar mahasiswa

mampu menegakkan diagnosa penyakit-penyakit

mata bagian kornea dengan melakukan

pemeriksaan sederhana yang akan dipelajari

selama masa perkuliahan secara baik dan benar .

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II. TUJUAN INSTRUKSIONAL KHUSUS

• Setelah Proses Belajar Mengajar mahasiswa

mampu mengetahui gejala-gejala penyakit mata

bagian kornea , faktor resiko, menegakkan

diagnosa , prinsip pengobatan, komplikasi, dan

mengatasi komplikasi secara garis besar secara

baik dan benar sesuai dengan kompetensinya

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THE CORNEA

• Anatomy of the adult cornea

• Ø 11 –12 mm horizontally

and 9 –11 mm vertically

• ± 0.5mm thick centrally and

0.65 –

0.70 mm peripherally• Curvature is 7.5 –8.0 mm centrally

and flatter peripherally.

• The central 4 mm of the diameteris optical zone.

• Refractive power : ± 44 dioptres

• Refractive index : 1,3375

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HISTOLOGY

• Five layers

1. Epithelium

2. Bowman’s membrane

3. Stroma

4. Descemet’s membrane

5. Endothelium.

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Epithelium

• The corneal epithelium comprises5 –6 layers of non-keratinisingsquamous epithelium.

• There is a basal monolayer of columnar cells, two or threelayers of wing cells, and two or

three layers of superficial non-keratinising squamous epithelialcells.

•

Only the basal columnar cellsshow mitotic activity

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Epithelium

• Dendritic cells are also found in theperipheral corneal epithelium, butnot centrally.

• The collagen fibrils formapproximately 300 distinct lamellae,each covering the entire area of thecornea parallel to the surface.

• Transparency of the cornea isattributed to the extremely regularspacing of the collagen fibrils whichare separated by glycosaminoglycans,which are macromolecules with arole in maintaining even hydration of the stroma.

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Bowman’s layer

• Bowman’s layer is at theinterface between theepithelium and the stroma

and comprises a compactionof collagen fibres (mainlytypes I and III) andproteoglycans.

• It is best considered as the

anterior layer of stroma andhas no regenerative powers.

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Stroma

• The stroma provides 90% of thecorneal thickness.

• It comprises collagen, principallycollagen I, and lesser amounts of typeIII,V, and VI glycosaminoglycans,

mainly keratin sulphate.• It also comprises chondroitin and

dermatan sulphate, and cells mainlycorneal fibroblasts or keratocytes,which synthesise collagen andglycosaminoglycans, as well ascollagen degradative enzymes, such

as metalloproteases.

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Descemet’s membrane

• About 5 –7 microns thick, itincreases in thickness fromabout 2 to 3 microns at birth

to 10 or 11 microns in oldage.

• It comprises, principally,collagen type IV and laminin,but at least five types of

collagen have been reported.

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Endothelium

• The endothelium is amonolayer of hexagonalcells which have animportant role inpumping water from thecornea and thus a majorrole in maintaining

corneal transparency.

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PHYSIOLOGY

• WINDOW OF THE

EYEBALL

• REFRACTIVE MEDIA

• BARRIER FROMMICROORGANISMS

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LOSS OF TRANSPARANCY

• EPITHELIAL DAMAGE

• ENDOTHELIAL DAMAGE

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DEFINITION

Inflammation of cornea ,caused by

• microorganism infection

• antigen antibodies / allergicreaction.

• Descemet’s membrane as barrier forbacterial infection to COA .(but not for

fungus)

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ETIOLOGY

– Exogenous :

bacteria ,fungus , virus, parasite

– Endogenous :

allergic reaction.

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ETIOLOGY

• Bacteria :-Pure Pathogen : Streptococcus pneumoniae,

Pseudomonas aeroginosa

-Opportunistic bacteria : -Staphylococcus,Moraxella, Serratia(as flora atconjunctiva

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. Alcoholic/ B6 deficiency

.Topical steroid >>>

. Corneal abrasion

Pathogen bacteria Corneal infection



ETIOLOGY

• Fungus (usually opportunistic)

• Candida, Fusarium, Aspergillus

• Virus – VHS

– VVZ

• Parasite : Acanthamoeba

in Contact lens user

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SIGNS AND SYMPTOMS

• Subjective (patient’s history ) – pain – glare (photophobia) – blur vision –

tearing (lacrimation)

• Objective - loupe or slit lamp examination – blepharospasme – ciliary injection – tearing (lacrimation) – superficial infiltrate or corneal ulcer – hypopyon- in advanced cases.

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SPECIAL EXAMINATION

– Flourescein test for corneal ulcer

– Seidel test for perforating cornea

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LABORATORIUM EXAMINATION

– Etiologic diagnosis.

– Scraping from:

•

infiltrate / edge of the ulcer• fornices of conjunctiva

– Slide Staining :

• Gram ( for bacteria)• Giemsa (for fungus )

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CLINICAL COURSE

Subepithelial /epithelialkeratitis

Recover

without scar

Become

corneal ulcer

Recoverwith scar

Nebula

MakulaLeukoma

Perforating cornea,accompanied bulging of the

cornea & iris prolaps

Recover with scar :

Leukoma adherentstaphyloma cornea

Corneal blindness

Advancedinflamation

-endophtalmitis-panophtalmitis

recover Extirpationof theglobe

Abulbi

Phtysis bulbi

Permanent blindness



TREATMENT

• Anti microorganisms depend on laboratoryfinding (scraping & culture)

– Antibiotic for bacteria

– Anti fungus for fungal infection – Antiviral for viral infection

• High dose Vit. A for keratomalacia

• Steroid for Mooren’s ulcer

• eye bandage

• atropine eye drops

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• Prognosis depends on : – depth & width of the ulcer

Corneal scar

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PROGNOSIS

• Prognosis depends on : – depth & width of the ulcer

corneal scar

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NebulaMakulaLeukomaLeukoma adherent

Central ,-->cornealblindness

-Periphery (No visual

disturbance )

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PREVENTION

• Avoid corneal trauma

•

Avoid overuse of topical steroid• Cure external eye infection as soon as

possible.

•

Avoid trigger factor for relapsingH.simplex keratitis.

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REFFERENCES

• Vaughn D, Asbury T; General

Ophthalmology, 15th edition, Appleton &

Lange

• Miller S; Parson’s Diseases of the eye, 17 thEdition, Churcill Livingstone, 1984

• Kanski JJ, Clinical Ophthalmology, 4th

edition,Oxford Butter Worth Heineman Ltd,

1999

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Segala puji bagi Allah, Tuhan semesta alam.

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