Dr.

Masitha Dewi Sari,SpM

Anatomi segmen anterior
CONJUNCTIVITIS
• Definisi:
peradangan conjunctiva ditandai
dengan discharge (sekret) dapat
berair, mucoid, mucopurulent atau
purulent
KLASIFIKASI BERDASARKAN ETIOLOGI

1. Infective conjunctivitis : bacterial,

chlamydial, viral, fungi, spirochaetal,
protozoal, paracitic,etc,
2. Allergic conjunctivitis
3. Irritative conjunctivitis
4. Keratocinjunctivitis associated with
diseases of skin and mucous membrane
5. Traumatic conjunctivitis
6. Keratoconjunctivitis of unknown
etiology
 Viral Bacteri Chlamydial Allergic
gatal minimal minimal minimal hebat
hyperemia Menye Menye Menye Menyeluruh
luruh luruh luruh (merah muda)

lakrimasi hebat sedang sedang Sedang

sekret minimal Paling hebat Hebat
Hebat
nodule sering jarang Sering pd Tidak ada
inclusion
Scraping, monosit Bacteri PMN < Eosinofil
pewarnaa PMN plasma sel
n
demam kadang kadang Tidak ada Tidak ada
Gejala-gejala umum Conjunctivitis
1. Merasa seperti ada benda asing
2. Merasa panas (burning/scratching
sensation)
3. Perasaan mata bengkak (fullness
around the eye)
4. Gatal
5. Fotofobia (jika terkena kornea)
 Tanda-tanda umum Conjunctivitis
1. Hyperemi
2. Banyak air mata
3. Chemosis (oedem conjunctiva bulbi )
4. Exudation/discharge ( kotoran mata )
5. Pseudoptosis
6. Hypertrophy papil
7. Folicle
8. Pseudomembran
9. Granuloma
10. Preauriculer adenopathy (pembesaran
kelenjar preauriculer)
Bacterial conjunctivitis
Viral conjunctivitis
Allergic conjunctivitis
Chlamydial conjunctivitis
PENANGANAN
• Tergantung kausa
• Hindari faktor iritasi atau alergen
• Antibiotik tetes / salep tergantung
jenis konjungtivitis 3-4x/hari selama
5- 7 hari
Bacterial Conjunctivitis
 Infections

• Conjunctivitis
• Bacterial
– If severe purulent discharge and hyperacute onset
(12-24 hours), need prompt ophtho eval for work-
up of Gonococcal conjunctivitis
Gonococcal Conjunctivitis
 Infections

• Conjunctivitis
• Viral
• Monocular/Binocular watery discharge, chemosis,
conjunctival inflammation
• Associated with
– Viral respiratory symptoms
– Palpable preauricular node
• Fluorescein stain may reveal superficial keratitis
• Treatment:
– Cool compresses
– Naphazoline/pheniramine for conjunctival congestion
– Ophthalmology follow up in 7-14 days
 Infections

• Conjunctivitis
• Allergic
– Monocular/binocular pruritis, watery discharge, chemosis
– History of allergies
– No lesions seen with fluorescein staining, no preauricular
nodes, Conjunctival papillae
– Treatment:
• Eliminate inciting agent
• Cool compresses
• Artificial tears
• Naphazoline/pheniramine
 Infections

• Conjunctivitis
• Allergic
– Monocular/binocular pruritis, watery discharge, chemosis
– History of allergies
– No lesions seen with fluorescein staining, no preauricular
nodes, Conjunctival papillae
– Treatment:
• Eliminate inciting agent
• Cool compresses
• Artificial tears
• Naphazoline/pheniramine
 Infections
• Herpes Simplex Virus
– Classic: Dendritic epithelial defect
– ED care depends on the site of infection
• Eyelid and conjunctiva
– Topical antivirals (trifluorothymidine drops/vidarabine
ointment) 5 times/day
– Topical erythromycin ointment
– Warm soaks
• Cornea
– Topical antivirals 9 times/day
• Anterior chamber
– Cycloplegic agent may be used
– First 3 days of infection: Acyclovir/famcyclovir
 Infections

• Herpes Zoster Ophthalmicus

– Shingles with trigeminal distribution, ocular
involvement, concurrent iritis
– “Pseudodentrite”
• Mucous corneal plaque with epithelial erosion
– Treatment:
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics for pain relief
– Ophthalmology consult mandatory
 Infections

• Herpes Zoster Ophthalmicus

– Shingles with trigeminal distribution, ocular
involvement, concurrent iritis
– “Pseudodentrite”
• Mucous corneal plaque with epithelial erosion
– Treatment:
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics for pain relief
– Ophthalmology consult mandatory
 Infections

• Herpes Zoster Ophthalmicus

– Shingles with trigeminal
distribution, ocular involvement,
concurrent iritis
– “Pseudodentrite”
• Mucous corneal plaque with
epithelial erosion
– Treatment:
• Acyclovir
• Topical antivirals
• Warm compresses
• Oral analgesics or cycloplegics
for pain relief
– Ophthalmology consult
mandatory
Traumatic Eye Injuries
• Conjunctival Foreign Bodies
– Lid eversion
– Remove with a moistened sterile swab
 PENGUICULA
Definisi
Penebalan conjunctiva mata berbentuk
segitiga yang puncaknya menghadap kornea
yang terdapat di conjunctiva bulbi pada celah
mata. Bisa terjadi pada nasal dan temporal sit
Patologinya sama dengan pterygeum
Etiologi :
•Iritasi
•Matahari
•Debu
•Angin
Klinis :
• Penonjolan warna kuning seperti lemak
• PA : hyalin (+) dan suatu elastic
degeneration dari lapisan submucosa
• Penimbunan kalsium pada penguicula tsb

Pengobatan :
• Tidak perlu
• Bila terjadi inflamasi beri steroid topical
• Artificial tears
 PTERYGEUM
•Definisi :
Penebalan conjunctiva berbentuki segitiga
puncaknya dekat ke kornea/mencapai ke kornea
•Klinis :
- Pembuluh darah membesar
- visus menurun oleh karena astigmatisma
irruguler pembiasan tidak pada satu
tempat
- stroma proliferasi
- sering pada bagian nasal, dalam
pertumbuhannya bisa sampai pada pupil
•Gejala :
- panas
- merasa seperti ada benda asing
• Pengobatan :
tidak spesifik, bila ada tanda-tanda inflamasi beri
steroid topikal
• Indikasi Operasi
- pertumbuhannya progressif 2 cm
- Gangguan visus
- gangguan gerakan bola mata
- iritasi berulang merah
- keluhan kosmetik
- apabila recidif, beri sinar beta atau extirpasi,
lakukan transplantasi dari mukosa mulut, kantung
amnion atau conjunctiva lain
• Patologi :
- epitel kornea
- membrana bowmen hilang/rusak
- stroma prokiferasi seperti jaringan granulasi
INFLAMASI PADA KORNEA
• Peradangan pada kornea (keratitis)
dengan karakteristik oedem kornea,
infiltrasi seluler, dan kongesti siliar
 Klasifikasi topographical
(morphological)
A. Ulcerative keratitis (corneal ulcer)
1. Berdasarkan lokasi
(a) ulkus kornea sentral
(b) ulkus kornea perifer
2. Berdasarkan purulen
(a) ulkus kornea purulenta / suppurative
(b) ulkus kornea non purulen
3. Berdasarkan hypopion
(a) ulkus kornea simple (tanpa hypopion)
(b) ulkus kornea hypopion
4. Berdasarkan kedalaman ulkus
(a) superfisial
(b) deep
(c) ulkus kornea dengan impending
perforation
(d) ulkus kornea perforasi
B. Non ulcerative Keratitis
1. Superficial keratitis
(a) diffuse superficial keratitis
(b) superficial punctate keratitis
2. Deep keratitis
(a) non suppurative
(b) suppurative deep keratitis
GEJALA
• Mata merah
• Nyeri
• Fotofobia
• Pandangan kabur
• berair
Pemeriksaan
• Tajam penglihatan menurun
• tes fluorescein (+)
defek
• Pada infeksi berat
hypopion
 KERATITIS SUPERFICIAL PURULENTA
(ULCUS CORNEAL)
• Defenisi
- infeksi cornea dengan adanya infiltrasi dan
hilangnya substansi cornea
- hampir slamanya expgenous oleh
organisme
pyogenik
- penyebab ulcus cornea tanpa lesi epithel :
* gonorrhea
* diphterioe
Bakteri lain harus ada lesi epithel ulcus
cornea stophylococcus menyebabkan
superficial punctate erotion
• PENYEBAB
1. Bakteri
a. Pneumococcus
b. Staphylococcus aureus, Staphylococcus epidermidis
c. Alpha Haemolyticus Streptococcus
d. Nocardia
e. Mycobacterium
f. Streptococcus viridans
g. Klebsiella pneumonia
2. Virus
a. Herpes simplex
b. varicella zoster
c. Variola
d. Adenovirus
3. Fungal
a. Aspergillus
b. Candida
c. Cephalosorium
d. Fusarium
e. Penicillium
4. Autoimmune
5. Amuba
PATOLOGI
• Terjadi nekrose setempat pada lapangan pandang
cornea (sampai stroma) sequestrum lepas danjatuh
pada saccus conjunctiva (sel mati dan mikroorganisme,
sel-sel radang). Sebagian sequestrum menempel pada
permukaan ulcus epitel yang rusak lebih luas dari
ulcusnya sendiri, begitu juga pada lapisan bowman
• Epitel dengan cepat tumbuh ke arah ulcus, tumbuh pada
pinggir bahkan diatas infiltrat. Dasar ulcus menonjol
karena adanya inhibisi cairan sekret ulcus.
• Batas antara ulcus dengan jaringan sehat, sama seperti
bagian tubuh yang lain, yaitu ada dinding PMN leukosit
membentuk lapisan kedua pertahanan sehingga lekosit
berfungsi sebagai :
- digestive : mencerna
- macerating : menghancurkan
- dissolving : melarutkan jaringan nekrose
Jaringan terlepas ulkus tambah lebar dan kekeruhan
berkurang
• Dasar dan pinggiran transparan Perbaikan mulai
terjadi, terbentuk pembuluh darah halus dari limbus
dekat ulcus untuk mensuplai bahan-bahan yang
rusak
• Antibodi untuk mengatasi infeksi (pannus)
• Meresap ke cornea di COA) merangsang
pembuluh darah iris dan corpus ciliare sehingga
terjadi hiperemi iris tanpa ciliary infection
• Iritasi/peradangan bisa terlalu hebat sehingga
leukosit dan PMN keluar dari pembuluh darah masuk
ke COA dan mengendap di bagian COA disebut
hypopion

SIMPTOM
• Ulcus cornea pada stadium akut/progresive ulcus
- blepharospasme
- lacrimation
- fotophobia dan pain
SIGN
• Visus menurun ulcus central
• Infiltrat dengan lesi epitel di atasnya
• Ciliary infection
• Iridocyclitis keratitis precipitate (bentuk segitiga
di epitel cornea), hypopion
• Pannus (pembuluh darah yang masuk ke cornea)

DD MATA MERAH
1. conjunctivitis akut
2. Glaukoma akut
3. Keratitis
4. Uveitis
PENYEMBUHAN ULCUS
• Pannus (+) ada cicatrix pada bekas ulcus
• Serabut yang baru terbentuk tidak tersusun
teratur sebagaimana normalnya bias
cahaya tidak teratur
• Parut luas pembuluh darah besar
/menetap
• Membran bowman tidak tumbuh lagi
• Cornal focet’s cicatrix tidak keruh /
transparan dan permukaannya datar (mata
serangga)
• Nb : tidak terbentuk jaringan ikat, tapi cornea
masuk ke dalam.
 BERDASARKAN KETEBALAN
CICATRIX DIBAGI :
1. Nebula : kekeruhan ringan, dapat
dilihat dengan lup
2. Macula : kekeruhan lebih jelas
dapat dilihat dengan mata telanjang
3. Leucoma : kekeruhan jelas sekali
jika kekeruhan sangat menebal
(leukoma adherent) pelengketan ke
depan ke belakang cornea
dengan permukaan iris
KOMPLIKASI
• Cicatrix
Penyembuhan cicatrix yang tidak sempurna, cornea di bekas
ulcus menonjol/bulging disebut : ECTATIC CICATRIX =
KERAECTASIS
• Descematocele
Ulcus dalam seluruh stroma dikenai kecuali descement
membrane menonjol oleh karena tekanan intra oculi
sehingga terlihat gelembung yang transparant
• Hypopion
sebelum perforasi : steril (Ag-Ab reaction)
• Perforation
• Synechia Anterior
Kalau perforasi kecil, iris akan menutupnya sehingga ada
perlengketan iris ke kornea atau organisasi
• Leucoma Adherent
pada bagian cornea yang perforasi terbentuk parut tebal
dimana iris tetap melekat dibawahnya.
• Intra Oculer Haemorrhage
Perforasi tiba-tiba dilatasi tiba-tiba pada pembuluh darah
intra ocular ruptur pembuluh darah
KOMPLIKASI
• Cicatrix
Penyembuhan cicatrix yang tidak sempurna, cornea di
bekas ulcus menonjol/bulging disebut : ECTATIC CICATRIX
= KERAECTASIS
• Descematocele
Ulcus dalam seluruh stroma dikenai kecuali descement
membrane menonjol oleh karena tekanan intra oculi
sehingga terlihat gelembung yang transparant
• Hypopion
sebelum perforasi : steril (Ag-Ab reaction)
• Perforation
• Synechia Anterior
Kalau perforasi kecil, iris akan menutupnya sehingga
ada perlengketan iris ke kornea atau organisasi
• Leucoma Adherent
pada bagian cornea yang perforasi terbentuk parut tebal
dimana iris tetap melekat dibawahnya.
• Intra Oculer Haemorrhage
Perforasi tiba-tiba dilatasi tiba-tiba pada pembuluh
darah intra ocular ruptur pembuluh darah
2. Midriaticum
Sulfasatropin tetes mata 1% 3 guttae/hari untuk :
• Mengistirahatkan iris dan corpus ciliare
• Mencegah synechia
• Mencegah iridocyclitis
3. Kebersihan Ulcus
Bersihkan saccus conjunctiva 3 kali atau lebih
dengan antiseptik lotion hango
Fungsi :
• Antiseptik
• Menghilangkan sekret dan jaringan mati
• Menghilangkan mikroorganisme
Antiseptik :
• Acidum boricum 3% (2%)
• Amonium totrat normal 10%
• Mercuryl axicyanide 0.01%
4. Pemanasan (Heat)
• Moist heat kompres hangat dengan acidum boricum hangat beri 3 kali atau
lebih
• Dry heat penyembuhan lebih cepat
5. Perbaiki Keadaan Umum
6. Benda asing (corpus alineum)
- diangkat / ekstersi
7. Scrapping dan Cautherization
Scrapping mengatasi meluasnya ulcus, dinding dan dasar ulcus
Cautherization
- panas : electrocautery
actual cautery
- Chemical : yodium tinctur
puroliqueel carbonic acid 2 sampai 3 kali interval 1-2 hari
8. Tarsorrhapy
Menjahit kelopak mata atas dan bawah (agar obat dapat mencapai ulcus
melalui conjunctiva)
9. Conjunctival Flap
Ulcus ditutup dengan conjunctiva bulbi brigde ataupun total
10. Parasintesis
Tujuan
- mencegah erosi
- menghilangkan rasa sakit
- Nutrisi pada cornea yang sakit
- penambahan antibodi yang baru
Superficial punctate keratitis
Ulkus kornea
Ulkus kornea dgn hypopion
penangananan
• Antibiotika tetes / salep dapat diberi setiap
30 menit – 1 jam, tergantung keparahan
infeksinya
• Hindari pemakaian steroid
• Antibiotika fortified
pd kasus ulkus
kornea berat (dgn hypopion)
• Cycloplegic (atropin tetes)
• Injeksi antibiotika subconjunctiva
• Antibiotika oral
gol.fluoroquinolone
(mis. Ciprofloxacin 2 x 500mg),penetrasi
ke kornea baik
Injeksi subconjunctiva
Complicated Corneal Ulcer
Perforated Corneal Ulcer
Healed Keratocele
 Hypopyon Ulcer
Types
• 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)
 Introduction
• 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
Etiology
Predisposing Factors
1. High Virulence of infecting
organism
2. Resistance of the tissues, which is
low
3. Dacryocystitis
4. Ocular trauma
5. Old, debilitated or alcoholic
6. Measles or scarlet fever
Organisms
• 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
Symptoms
• Sever pain, photophobia, marked
diminution of vision, watering,
foreign body sensation (grittiness)
 Signs
• 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
Signs
• 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.
Complications
• 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
Treatment
• Routine treatment of Corneal Ulcer
• Tab Acetazolamide
• Local Betablocker
• Therapeutic keratoplasty
Control of infection results in
absorption of hypopyon
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
1. Trauma outdoor/ or the one which
involves plant matter (including
contact lenses)
2. 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
I. Yeast: Candida species (albicans),
Cryptococcus
II. Filamentous septated
A. Non-pigmented hyphae:
Fusarium species (solani),
Aspergillus species (fumigatus,
flavus, niger)
B. Pigmented hyphae
(dematiaceous): Alternaria,
Curularia , Cladosporium species
Causative fungi
III. Filamentous non-septated : Mucor
and Rhizopus species
IV. Diphasic forms: Histoplasma,
Coccidiodes, Blastomyces
Clinical Features
Symptoms

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

• Diminution of vision, depending on

location of ulcer
• Conjunctival and ciliary congestion
• Epithelial defect
• Stromal infiltrates
• Elevated areas, hypate (branching)
ulcers, irregular feathery margins
• Dry and rough texture
Fungal Keratitis with Hypopyon
Signs

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

• 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
Treatment

• Sub-conjunctival injection of
Miconazole 5 – 10 mgm of 10 mgm/ml
suspension (indicated in severe form
of keratitis, scleritis and
endophthalmitis)
• Systemic:
Fluconazole or Ketoconazole is
indicated in severe form of keratitis,
scleritis and endophthalmitis
Surgical Treatment

1. Daily debridement with spatula/

blade every 24 – 48 hours
2. Surgical treatment is required in
approximately 1/3rd cases of fungal
keratitis due to failure of medical
treatment or perforation
3. 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
VIRAL KERATITIS
Introduction
• Viruses are obligate intracellular parasites
that contain only one type of nucleic acid
within he infectious unit and are unable to
replicate by binary fission.
• Viruses that cause corneal disease are
• Herpes simplex ( HSV)
• Varicella zoster ( VZV)
• Epstein Barr ( EBV)
• Adenovirus
• Cytomegalovirus (CMV) can also cause
keratitis and is more commonly
associated with AIDS
Epidemiology and pathogenesis

• HSV, VZV, EBV, and CMV are all

members of the family Herpesviridae.
• DNA viruses
• There are two types of HSV
• HSV-1 is more commonly associated
with labial and ocular infection.
• HSV-2 is associated with genital
infection.
Ophthalmology 2004, (2), 475-481
 Epidemiology and pathogenesis

• Herpes simplex keratitis is a leading cause

of corneal blindness in the developing
world.
• Estimated prevalence is approx 150 per
100,000 population.
• Ocular HSV tends to be a unilateral
disease with only one eye affected by
primary disease in approx 80-90% of
cases.
• Atopy appears to be risk factor for
bilateral disease, & is associated with
gastric cancer, lumbar zoster, malaria and
pulmonary tuberculosis
HERPES SIMPLEX KERATITIS

Herpes Simplex Keratitis occurs in two

forms:

1. Primary

2. Recurrent
 Primary HSV-1 (HSV type 1) infections

Occurs most commonly in the mucocutaneous distribution of the

trigeminal nerve.
spread of
Primary virus Infected
Nearby
Infection epithelial cells sensory nerve
endings

Viral genome Cell body in transport

along
enters nucleus trigeminal ganglion
nerve axon
at neuron

(Persists indefinitely
in a latent state)
www.emedicine.com
PRIMARY HSV-1

• Primary infection of any of the 3 branches

(ophthalmic, maxillary, mandibular) of
cranial nerve V leads to latent infection of
nerve cells in trigeminal ganglion.
• Interneuronal spread of HSV within
ganglion allows patients to develop ocular
disease without ever having had primary
ocular HSV infection.

www.emedicine.com
RECURRENT HSV INFECTION

• Has been thought of as reactivation of

virus in the sensory ganglion.
• Virus migrates down nerve axon to
produce lytic infection in ocular disease.
• Recent evidence suggests, virus may
subsist latently within corneal tissue,
serving as a potential source of recurrent
disease.
www.emedicine.com
 CLINICAL FINDINGS

Primary Herpes Simplex Keratitis

• Infrequently seen
• Manifested as vesicular
blepharoconjunctivitis occasionally with
corneal involvement
• Usually occurs in young children
• Topical antiviral therapy may be used as
prophylaxis and as therapy
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136
 CLINICAL FINDINGS

• Recurrent type herpetic keratitis

Attacks triggered by
• Fever
• Overexposure to UV light
• Trauma
• Onset of menstruation
• Local/ systemic source of
immunosuppression
• Bilateral lesions develop in 4-6% of
patients and seen mostly in atopic
th Edition, 136
patients. Vaughan & Asbury’s General Ophthalmology 16
SYMPTOMS

• Irritation
• Photophobia
• Tearing
• Reduction in vision (when central
cornea is affected)
• Corneal anesthesia usually occurs
early in the course of infection and
thus symptoms may be minimal.
SYMPTOMS
• Corneal ulceration can occasionally
be the only sign of recurrent herpetic
infections

Recurrent herpes simplex virus

dendritic ulcer with an adjacent
stromal scar
 LESIONS: Dendritic ulcer

• Most characteristic lesion, occurs in corneal

epithelium
• Typical branching, linear pattern with
feathery edges and terminal bulbs at ends.
• Visualized by fluorescein staining

HSV dendritic ulcer stained

with fluorescein
 Dendritic keratitis

This patient suffers from herpetic keratitis. Fluorescein

staining reveals dendritic ulcer typical of herpes keratitis.
This is treated with topical 3% acyclovir
www.eyecasualty.co.uk/.../ cornealinfections.html
 Geographic ulceration

• Form of chronic dendritic disease.

• Delicate dendritic lesions take a
broader form.
• Corneal sensation is diminished

HSV geographic ulcer

 Other corneal lesions

• Other corneal epithelial lesions caused by

HSV are
• Blotchy epithelial keratitis
• Stellate epithelial keratitis
• Filamentary keratitis
• Usually transitory, often become typical
dendrites within a day or two.

Filamentary keratitis
Subepithelial lesions

• Caused by HSV infection

• Ghost like image, larger than original
epithelial defect seen in the area
immediately underlying epithelial
lesion.
• Does not persist for more than a year
 Disciform keratitis

• Most common form of stromal disease in HSV

infection.
• Edematous stroma without significant infiltration
and usually without vascularization.
• Edema is most prominent sign.
• Keratic precipitates may lie directly under
disciform lesion but may also involve the
endothelial lesion.

Vaughan & Asbury’s General Ophthalmology 16th Edition, 136

Peripheral lesions of the cornea

• Caused by HSV
• Usually linear lesions, show loss of
epithelium
• Testing for corneal sensation is
unreliable.
• Patient is far less photophobic than
patients with nonherpetic corneal
infiltrates.
Treatment

• Should be directed at eliminating

viral replication within the cornea,
while minimizing damaging effects of
inflammatory response.

Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137

Treatment
• DEBRIDEMENT
• Epithelial debridement is an
effective way to treat dendritic
keratitis
• Infected epithelium is easy to
remove with tightly wound cotton tip
applicator.
• Adjunctive therapy with topical
antiviral accelerates epithelial
healing.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
TREATMENT : DRUGS
Antiviral medicines used in treatment of Herpes Simplex Virus
Treatment Ocular Disease
Antiviral Route Form Frequency Action
Idoxuridine Topical 0.1% Hourly while Inhibits viral thymidine
solution awake kinase, thymidylate
kinase and DNA
polymerase
Vidarabine Topical 3% 5 times daily Inhibits viral DNA
ointment polymerase
Trifluridine Topical 1% Every 2 Inhibits viral
solution hours while thymidylate synthetase
awake
Acyclovir Topical 3% 5 times daily Activated by viral
ointment thymidine kinase to
Oral 200/400/ 400 mg 5 inhibit DNA polymerase
800Ophthalmology
DT 2004, (2), 475-482
times daily
Ophthalmology 2004, 2; 475-482
 Treatment
• Trifluridine and acyclovir are much
more effective in stromal disease than
others.
• Idoxuridine and trifluridine are
frequently associated with toxic
reactions.
• Oral acyclovir may be useful in
treatment of severe herpetic eye
disease particularly in atopic
individuals.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
 Treatment
• Oral acyclovir : DOSAGE:
• For active treatment 400 mg five times daily in
nonimmunocompromised patients.
• 800 mg five times daily in compromised and atopic
patients.
• Prophylactic dosage in recurrent disease is 400
mg twice daily.

• Famciclovir or valacyclovir may also be used.

• Topical corticosteroids accelerate corneal
thinning, increasing risk of corneal perforation.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
 Surgical treatment
• Penetrating keratoplasty indicated for visual
rehabilitation in patients with sever corneal
scarring. Should not be undertaken until herpetic
disease has been inactive for many months.
• Systemic antiviral agents should be used for
several months after keratoplasty to cover use of
topical steroids.

• Lamellar keratoplasty has advantage over

penetrating keratoplasty of reduced potential for
corneal graft rejection.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
Varicella zoster viral keratitis
(VZV)
• Occurs in two forms:
• Primary ( varicella)
• Recurrent ( herpes zoster)

• Ocular manifestations are

uncommon in varicella but common
in ophthalmic zoster.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
Varicella zoster viral keratitis
(VZV)
Ocular manifestations
• Usual eye lesions are pocks on lids
and lid margins.
• Keratitis occurs rarely.
• Epithelial keratitis with or without
pseudodendrites occurs more rarely.
• Disciform keratitis with uveitis of
varying duration has been reported.
 Ophthalmic herpes zoster
• Is accompanied by keratouveitis that varies in
severity according to immune status of the
patient.
• Children with zoster keratouveitis usually have
benign disease, aged have severe and sometimes
blinding disease.
• Corneal complications in ophthalmic zoster often
occur if there is skin eruption in areas supplied by
branches of the nasociliary nerve.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
Distinguishing features of dendrites
associated with HSV versus VZV
Feature HSV VZV
Overall Fine, lacy Thick ropy
Epithelium Linear defect with Elevated, painted-on
bared stroma, appearance
surrounded by
edematous epithelial
cells
Staining Base stains with Minimal fluoroescein
fluorescein. Diseased staining
border epithelial cells
stain with rose
bengal
Terminal bulbs Frequent None
 Treatment
• Intravenous and oral acyclovir have been
used successfully for treatment of herpes
zoster ophthalmicus, particularly in
immunocompromised patients.
• Oral dosage is 800 mg five times daily for
10-14 days.
• Therapy needs to be started within 72
hours after appearance of the rash.
Vaughan & Asbury’s General Ophthalmology 16th Edition, 136-137
Traumatic Eye Injuries
• Corneal Foreign Bodies
– May be removed with fine needle tip, eye spud,
or eye burr after topical anesthetic applied
– Then treat as a corneal abrasion
– Deep corneal stoma FB or those in central
visual axis require ophtho consult for removal
– Rust rings can be removed with eye burr, but
not urgent
– Optho follow up in 24 hours for residual rust or
deep stromal involvement
UVEITIS
• ANTERIOR • POSTERIOR
• Autoimmune • Viruses
• Bacteria
• Infections
• Fungi
• Malignancy • Autoimmune
• Others • Malignancy
• Unknown
UVEITIS
• Inflammation of the uveal tract
• Symptoms
• blurred vision
• Photophobia
• Pain
 UVEITIS
• Inflammation of the uveal tract
• Signs
• Injection
• Flare
• Keratic precipitates
• Posterior synechias
• iris nodules
UVEITIS
• Complications
• Anterior synechias
• Posterior synechias
• Cataract
• Glaucoma
• Macular edema
UVEITIS
• Autoimmune
– JRA
– Ankylosing spondylitis
– Ulcerative colitis
– Crohn’s disease
– Reiter’s syndrome
– Lens induced
UVEITIS
• Infections
– Syphilis
– Tuberculosis
– Herpes zoster
– Herpes simplex
– Adenovirus
UVEITIS
• Malignancy
– Retinoblastoma
– Leukemia
– Lymphoma
– Malignant melanoma
UVEITIS
• Others
– Idiopathic
– Traumatic
– RD
– Fuch’s iridocyclitis
– Gout
UVEITIS
• Posterior
– CMV
– Toxoplasmosis
– Aids
– Herpes simplex
– Herpes zoster
– Candida
UVEITIS
• Autoimmune
– Behcet’s syndrome
– VKH syndrome
– Polyarteritis nodosa
– Sympathetic ophthalmia
UVEITIS
• Malignancy
– Malignant melanoma
– Leukemia
– Metastatic lesions

– Unknown
– Sarcoidosis
UVEITIS
• TREATMENT
– Steroids
• topical
• local
• systemic
– Cycloplegics
– Antimetabolites
– Analgesics
ENDOPHTHALMITIS
• Peradangan bola mata yg melibatkan
uvea dan retina, disertai dgn eksudat
di vitreous, camera okuli anterior dan
camera okuli posterior
Gejala
• Nyeri yg hebat
• Pandangan kabur
• Mata merah
Pemeriksaan
• Penurunan tajam penglihatan
• Injeksi konjungtiva
• Peradangan COA dan hypopion
• Funduskopi : nervus opticus dan
retina tidak dapat dilihat dgn jelas
krn adanya inflamasi vitreous
endophthalmitis
USG
Penanganan
• Antibiotik fortified topikal tiap jam :
cefazolin atau vancomycin,
gentamycin atau tobramycin
• Antibiotika injeksi subconjunctiva
• Vitrectomy dan antibiotika injeksi
intravitreal
• Vitrectomy diindikasikan pada pasien
yang tidak menunjukkan kemajuan
terapi dlm 48 – 72 jam atau pd pasien
dgn infeksi berat dmn tajam
penglihatan hanya persepsi cahaya.
• Vitrectomy bermanfaat utk
mengeluarkan organisme,toksin dan
enzim pada vitreous
PANOPHTHALMITIS
• Inflamasi purulenta pada seluruh
struktur bola mata termasuk kapsula
Tenon
Gejala
• Nyeri mata yg sgt berat dan nyeri kepala
• Hilangnya penglihatan
• Sangat berair
• Sekret purulen
• Mata sangat merah dan bengkak
• Demam
• malaise
Tanda
• Kelopak mata oedem dan hiperemis
• Bola mata sedikit proptosis, pergerakan
bola mata terbatas & nyeri
• Chemosis konjungtiva
• Kornea keruh
• COA
berisi pus seluruhnya
• Tajam penglihatan hilang (NLP)
• TIO menigkat
• perforasi
panophthalmitis
Penanganan
• Anti-inflamasi dan analgetik
• Antibiotika spektrum luas
• eviscerasi
eviscerasi