CORNEAL ULCERS

Diagnosis and Management

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 DVD Contents
1. Multilayered Amniotic Membrane Grafting in Neurotrophic Keratitis
2. Corneoscleral Graft for Corneoscleral Melting Following Pterygium Surgery
3. Therapeutic Keratoplasty in a Perfroated Corneal Ulcer Following Fungal Keratitis
4. Patch Graft for Perforated Corneal Ulcer
5. Therapeutic Penetrating Keratoplasty in a Case of Infection Following Deep Anterior Lamellar Keratoplasty
 CORNEAL ULCERS
Diagnosis and Management

Namrata Sharma
MD DNB MNAMS
Associate Professor of Ophthalmology
Cornea, Cataract and Refractive Surgery Services
Dr. Rajendra Prasad Centre for Ophthalmic Sciences
All India Institute of Medical Sciences, New Delhi
India

Rasik B Vajpayee
MS FRCSEd FRANZCO
Head, Corneal and Cataract Surgery
Centre for Eye Research Australia
Royal Victorian Eye and Ear Hospital
University of Melbourne
Australia

Forewords
Hugh R Taylor
Peter R Laibson

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Corneal Ulcers: Diagnosis and Management

© 2008, Namrata Sharma, Rasik B Vajpayee

All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any
form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor
and the publisher.

This book has been published in good faith that the materials provided by authors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of any
dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2008

ISBN 978-81-8448-217-1
Typeset at JPBMP typesetting unit
Printed at Ajanta
 Dedicated to

My parents Dr Ramesh C Sharma and Maitreyi Pushpa,

husband Subhash Chandra and daughter Vasavdatta
— Namrata Sharma

My wife Madhu and children Mihika and Shubhankar

— Rasik B Vajpayee
 Foreword
Corneal opacity and scarring is one of the leading causes of vision loss and blindness worldwide. Although cataract
may be the leading cause of bilateral blindness, corneal scarring accounts for a significant portion of unilateral and
bilateral vision loss. Corneal scarring may result from specific conditions such as trachoma, xerophthalmia or
onchocerciasis, or from less specific causes such as microbial keratitis following often relatively trivial trauma. In
some areas one quarter of blindness may be due to corneal scarring.
One hundred years ago, or even 50 years ago, our ability to treat microbial keratitis was extremely limited. The
development of a broad range of antimicrobial agents, anti-inflammatory drugs, and vastly improved and faster
diagnostic methods has revolutionized our ability to treat corneal ulcers. The successful outcome for the management
of corneal ulceration depends on the prompt use of the appropriate antimicrobials and the careful management of
the healing phase. This is easy to say, but is much more involved to achieve. It requires good clinical and diagnostic
skills and excellent laboratory services to make the correct diagnosis so as to be able to select the appropriate
antimicrobial. The careful management requires the early recognition and correct management of a host of possible
complications.
Professor Rasik Vajpayee is a corneal surgeon of international renown. He was the Head of the very busy
Cornea and Refractive Surgery Services at the RP Centre for Ophthalmic Sciences at the All India Institute of
Medical Sciences and recently has taken over as Head of Cornea and Cataract Surgery at Centre for Eye research
Australia, University of Melbourne. Both he and Dr Namrata Sharma have a profound knowledge and broad
experience in the management of the whole range of corneal diseases and especially corneal ulceration. They have
crystallized their experience into a beautiful set of clear and succinct guidelines.
This book builds on a systemic approach with a clear statement of the fundamental issues relating to corneal
ulceration and the details that are important in the initial assessment. It covers in detail the microbiologic laboratory
assessment and treatment options. The section on the surgical management is superb and sets out in a series of
simple steps the way to successfully manage the various complications.
Professor Vajpayee and Dr Sharma have done us all a real service in compiling so much insight and experience
into this easy to follow text. I highly recommend this book to all who have to manage patients with corneal
ulceration.

Professor Hugh R Taylor

AC MD BS FRANZCO FRACS FAAO FACS
Ringland Anderson, Professor of Ophthalmology and Head
University of Melbourne, Department of Ophthalmology
Managing Director, Centre for Eye Research, Australia
 Foreword
Corneal Ulcers: Diagnosis and Management is a must-read reference and resource for every ophthalmologist interested
in anterior segment ocular pathology. It contains the most up-to-date information about the recognition and treatment
of this very severe and potentially blinding condition.
Dr. Rasik Vajpayee and Dr. Namrata Sharma have both published hundreds of papers and chapters in this area
and have a vast experience in diagnosing and treating corneal ulcers. They have put their combined knowledge to
excellent use by writing an outstanding textbook and guide to the management of these ulcers.
From the beginning chapters on the pathogenesis, microbiology and pharmacology of corneal ulcers, the writing
is clear, concise and readily absorbed. It is not encyclopedic, but very practical, with superb color photographs and
easily read box inserts highlighting the most significant material in the chapters.
Their chapter in Section 2 on the work up of a corneal ulcer is particularly illuminating, especially the many
color illustrations of microbiological organisms and the havoc they can bring to the cornea. There is an excellent
step by step approach to diagnosing and managing corneal ulcers, from the simple ones to the most complex.
Drs. Vajpayee and Sharma are particularly gifted in the field of microbiology, and their chapter on investigations
of corneal ulcers in Section 2 is extremely well designed, with inclusive but not overwhelming tables on how to
proceed with an ulcer work up. In Section 4, the chapters highlight specific types of microbial and immunologic
keratitis, including pediatric and peripheral ulcerative keratitis. The writing throughout is again very clear and the
photographs complement the text beautifully.
The surgical management section includes very high-quality illustrations on the use of glue and bandage contact
lenses, conjunctival flaps, therapeutic keratoplasty and phototherapeutic keratectomy, with which both authors
have extensive expertise, due to the severe and late-stage ulcerations treated in India.
I can strongly suggest, if not emphatically state, that this treatise will be a best-seller around the world and an
invaluable aid in addressing the problems of corneal ulceration.

Peter R. Laibson MD
Professor of Ophthalmology
Thomas Jefferson University School of Medicine
Director Emeritus
Cornea Department
Wills Eye Institute
Philadelphia, Pennsylvania
 Preface
Corneal ulcer is a major cause of blindness in the developing world. The condition requires early recognition and
prompt management to minimize the impact of disease process. There are many books available on the corneal
and external diseases and include details on various aspects of corneal ulcer. However, most of these books carry
enormous amount of information, some of which may not be required for the routine management of a case of
infectious keratitis. We felt that there is a need for a book on the specific aspect of corneal ulceration that carries
relevant, specific and practical information and can help general ophthalmologists in treating cases of corneal
ulceration effectively. Our book includes a chapter highlighting a practical approach on how to examine a case of
infectious keratitis and chapters on various types of keratitis. It also includes chapters on basic sciences relevant to
corneal ulcer and provides comprehensive information on various management issues including surgical options,
if required. We have tried to provide a precise format for our book and have written it in a user-friendly style. We
hope that this book will serve as a useful guide for the residents as well as the general ophthalmologists.

Namrata Sharma
Rasik B Vajpayee
 Acknowledgements
We would like to acknowledge Dr Tushar Agarwal, Dr M Vanathi, Dr Tishu Saxena and Dr Gunjan Prakash for
their useful inputs. We would also like to thank Departments of Microbiology of All India Institute of Medical
Sciences and St. Vincent Hospital for the photographs. Our heart felt to heartfelt gratitude to Ms Meena Verma,
Ms Sudha, and Ms Lata for helping us with clinical photography.
 Contents

SECTION 1: APPLIED BASIC SCIENCES

1. Anatomy and Physiology 3

2. Pathogenesis of Corneal Ulcer 8
3. Microbiology 13
4. Pharmacology 25

SECTION 2: WORK UP OF CORNEAL ULCER

5. Clinical Examination 35
6. Investigations 51

SECTION 3: TYPES OF MICROBIAL KERATITIS

7. Bacterial Keratitis 65
8. Fungal Keratitis 77
9. Viral Keratitis 91
10. Protozoal Keratitis 107

SECTION 4: SPECIFIC TYPES OF KERATITIS

11. Pediatric Keratitis 119

12. Contact Lens Related Keratitis 128
13. Infectious Crystalline Keratopathy 134
14. Post-surgical Microbial Keratitis 140
15. Keratitis and Endophthalmitis 150
16. Neurotrophic Keratitis 154
17. Peripheral Ulcerative Keratitis 162

SECTION 5: SURGICAL MANAGEMENT

18. Intracameral Antibiotics 177

19. Glue Application 180
20. Conjunctival Flaps 184
21. Therapeutic Keratoplasty 187
22. Phototherapeutic Keratectomy 197

Index 199