RECENT TRENDS IN THE

MANAGEMENT OF
CORNEAL ULCER
Presenter - Or. JlIyant Ekka ~'Iodcrutor - Or. Arup I)euri
Jrd year PC Student Assistant Professor
OVERVIEW
- PRESENT SCENARIO
- CLI ICAL EVALUATION
- INVESTIGATIONAL DIAG OSTIC
MODALITIES
- OLDER TREATMENT MODALITIS
- CURRENT TREATM E T OPTIONS
- RECENT ADVANCES AND
FUTURE SCOPE
PRESENT SCENARIO

- Corneal ulcer is the second commonest cause of preventable bl indness

next to cataract among people in Asia, Africa & in the Middlc East.
- Corneal opacities due to infectious keratitis is the 41h leading cause of
blindness globally and arc responsible for 10% of avoidable visual
impairment in developing countries."
- An important cause of monocular vision loss worldwide but unfortunately
the clinical features do not always correlate to the classical textbook
description.
.. In developing countries, funga! kcrntitis following trauma by vegetative
matter still contributes the majority .
.. With the increase in contact lens use. contact lens associated corneal ulcer
is the most common type secn in developed countries .
.. lmprovcmcnt in diagnostic modalitics leads 10 the isolation of less
common organism bcenme morc frequent.
.. Also as the refractive surgeries are nowadays commonly performed. the
atypical mycobacteria causing ulcer following refractive surgeries nrc
isolated more Frequcntly.
CLINICAL EVALUATION
.. Based on history and clinical examination .
.. The classical symptoms of corneal ulceration include the presence of pain,
watering, discharge. photophobia. decrease in visual acuity and swelling of
lids .
.. There arc no pathognomonic sign fOI'specific type of bacterial keratitis .
.. Points in the favor of fungal keratitis dry looking ulcer with feathery
margins. satellite lesions. relatively less symptoms, thick immobile
hypopyon
.. These typical features not always present in fungal keratitis and Ihen it is
difficult to differentiate with the bacterial ulcer.
.. In viral keratitis - cas)' to diagnose
FALLACIES

- Pain will be more in curly acanthnmocba keratitis. less in herpetic

dendritic ulcer and may be absent in neurotrophic ulcer.
- Bacterial keratitis - Suddcn onset of symptoms with rapid progression.
- Cenain bacteria like Mornxella, coagulase negative Staphylococcus.
Nocardia species and atypical Mycobacteria cause corneal ulcers that
present with gradual onset and have an indolent course.
- Acanthamocba - variable.
- Clinical picture suggestive of common organism but not improving on
empirical treatment - always suspect ofutypicalmycobactcria I
acanthnmocba.
BACTERIAL CORNEAL ULCER
FUNGAL CORNEAL ULCER
VIRAL ULCERATVE KERATITIS
ACANTHAMEBA KERATITIS
PERIPHERAL ULCERATIVE KERATITIS
MOOREN'S ULCER
CORNEAL SCRAPPINGS FOR SMEAR
EXAMINATION AND CULTURE

SMEAR
EXAMINATIO~

KOII WET CALCOFI.UOR

OTIIERS
'IO)';NT WIIITE
COLLECTION OF THE SAMPLE
- From the edge and the base.
- Kimura' s spatula. 26-gaugc needle. Bard Parker blade, hypodermic
needle, surgical blade no 15 and calcium alginate swab.
- Platinum spatula has been traditionally used. It is rapidly sterilized with a
Bunsen burner and cools rapidly between scrapings.

- Difficliities in Coltection a/ Corneal Scrapings

I. Small corneal ulcers
2. Non suppurative kemtiti.
3. Advanced keratitis with severe thinning.
Chlorazol Black E Mounts

- s"nsitivity of 82% and a specificity of 98')(,"

·"""_'''\''~I.~C,'-Cl''Uw''~'''tl
~"""'~cnI"" A.,~..,.l'Ot",I~$('~'f7I.
...... oI~~''"""oI
CULTURE

Culture on the standard media is the gold standard for the diagnosis
of microbial keratitis,
 I Common isolates
Blood Agar Aerobic and facultadve, anaerobic bacteria,
including P. aeruginosa. S. aureus, S.
epidermidis. S. pneumoniae
Chocolate Agar Aerobic and facultative, anaerobic bacteria.
including H. inf7uenUle. N. gonorrhoeae.
and Bartonella species
Thyoglicollate broth Aerobic and facultative, anaerobic bacteria
Lowenstein-lensen medium Mycobacte.rium species
Thayer-Martin agar Pathologic Neisseria
Sabouraud's dextrose agar Fungi
JONE'S CRITRERIA
.. Cllnlcnl slgns of in fcc lion plus

I. Isolauon of'bacteria (10 or more colonies) on one solid medium and one
additional medium, or
2. Isolation of fungi/bacterin (any dctectnblc growlh) 011 any solid I\VO media
or
3. Isolation of bacreriarfung] in one medium in the presence ofa positive
smear

.. Aerobic cultures of the corneal specimens should be held for 7 days,

anaerobic cultures for 7 10 14 days and Mycobacterinl and fungal cultures
for 4 10 6 weeks before being reponed as no growth.
CORNEAL BIOPSY
• In case of deep mycolic keratitis/intrastromal abscess - staining &
culture comes Ileg(lli\'e.
• In such cases, a diagnoslic corneal biopsy is necessary,
• Performed under topical ancsrhesia under operating microscope/slit lamp.
• A micro-trephine or 2-3 mm demlalological punch is advanced imo the
anterior corneal stroma 10 incorporate both the infected & clinically
normal I mm rim.
• Avoid visual axis .
• A crescent blade or bard parker kni fc is used to undermine the tissue,
which mny then be CUI with micro-scissors & the tissue excised
with fine tooth forceps.
NEWER TECHNIQUES

- CO.'lFOCAL i\!lCROSCOPY
- POLYMERASE CBAIN REACTION
IN-VIVO CONFOCAL MICROSCOPY

figurC(~l~e)Representative
confocal photogr~,phs of
patients whh fungal keratitls
- appeal' as high
rerlecttve, double wetted,
5CphUC nlameDls Siu 3 - 8 fl~
uniform "'idtll, irregular
branching.
Baeterta] keratitis is
charaeterlzcd by aerlvnted
kcrnlOCYlcs, with lnflltrutlon or
leucocytes, and Langcrhuns cells.
Bacteria typically not ,"isuaUzed

Acanlhanlocb. CYSIS present as

highly reflective, double walled
round parucfes I~20 11111 In
diameter ,,'Ithin the eurneal
epithelium and stroma. The inner
"all has. hexagonal
oonngurulion
Viral keratilis is churncterized by ovoid dendritlc
cells at the level of sub CI)Uhelial cells which are
8.0 indicator of disease acti\'ity whlch ts orten

over looked 00 slit lamp examination.

POLYMERASE CHAIN REACTION

- Rapid diagnosis within hours.

- PCR amplification and sequencing of bacterial genes encoding the small
subunit of ribosomal RNA (16s rONA) without prior cultivation allow the
identification of fastidious 01' non-culturnble bacterin.
- 28s rRNA is the targeting molecule for fungal keratitis. which is present in
all fungus.
- For acamhamoeba targeting molecule is 18s rRNA.
- A reduced-sensitivity PCR can deicer IISV ONA in rears from paiierus
with clinically diagnosed HSV epithelinl keratitis.
CULTURE VS PCR

CULTURE ,
PCR
TECHNIQUE STANDARD NEWER
REPORT DAYS TO WEEK HOURS
BEST RESULT UNTREATED ALL
PR1MER NOT REQUIRED REQU1RED
COST LESS MORE
CONTAMJNATION POSSIBLE NOT
TEMP VAlUED CONSTANT

III f I I •• , ,.. " .. , ..... \11"'"' " ,.

OLDER MO.DALITIES IN TREATMENT

-- Research Article

-- Use of traditional eye medicines by patients

- -,,~,---CoIogo."""--.-
with corneal ulcer in India
Panka) Choodha.y, Charudan Chaisgaonl<a<, Neera Marathe, Su[ala l.ai<htal<ia

_,",P"*'I_e·"",,_"_
AeceM!d MaIdl29, 2015. AccepI!d Mard'l31. 2015
TREATMENT STRATEGIES OF NON-
VIRAL ULCER - EMPIRICAL
Smear No Gram Gram Fungal hyphae
not organism positj~e negative seen
possible seen on bacteria bacteria
smear seen seen
Cefazolin 5% and Natamycin 5%
Gentamycin 1.4% drops hourly drops hourly

or Amphotericin
THIRD OR FOURTH GENERATlON
FLUOROQUINOLONES MAY BE COMBINED WITH 0.15% drops
CEFAZOUN INSTEAD OF GENTAMYaN hourly

SOURCE: WHO GUIDEUNES

TREATMENT FREQUENCY, DURATION
AND FOLLOW-UP
BACTERIAL! NO ORGANISM FU GAL
ON SMEAR

Daily examination until the Examination every 2 days until

ulcer is improving the ulcer starts improving

Then gradually reduce frequency of Then continue drops at least 3

drops and follow up hourly for at least 2 weeks after
over 2 weeks healing of the ulcer
SOURCE: WHO GUIDEUNES
ADJUNCTIVE THERAPY

- CYClOPLEGICS
- ANALGESICS
- ANTI-GLAUCOMA MEDICATION
Decision making algorithrn in the management of
therapeutic failures in presumed bacterial
keratitis

No Slap onubsonc (ar 24-48hr

CuJture performed and n:'Cu.ture; eonrrscal biopsy in St.."Y('r~
progressive cases

No Cr()\vch

Org.lnl.sm.s
!tu~'p(lble
10 anlibiOCio. used
y.".
r •
Change Olncibiolic
coyer or&lnlsm
lnvnl\l(_'(1
1°1 Add spectne
"'cdIOl (or bOle;I(!rl._l,
fI,I''8i ~nd par.-.,he

I
!
Cn')\Ylh 01
Con~dt_"
Surgic.l'
In:.lln1t'nl
orga n is""' Opuou ..
 + +
72 hours o, No Walt (or Conside-r
Qowthof No Surgical
ther.>py 72 h" 0(
or&-lnlSm
t'te.,tmcnl Options
I~
lV""
Treat
I
I
SJX'Ofic~lIy

Non-<'C)mpliat'llC("
1 110>1
,mmuncx:umpromiSt."'Ci
I
1. Search for causative factor
• 2. Repeat culture
'11,,.-case to hourly
dosing 3. If not possible <om •• 1biopsy
4. Staining and cultur. on selective media
for uncommon organism
,~~,~,~~~ •.~L_ ~

SOURCE: WHO GUIDELINES

SHIFTING TRENDS TOWARDS FOURTH
GENERATION FLUOROQUINOLONES
MONOTHERAPY
- Good alternative to the converuional rherapy and has demonstrated
encouraging results, documented by meta-analysis and randomized
controlled trials where both forms of treatment have shown comparable
results in terms of efficacy and safety. *
- Fluoroquinoloncs demonstrate added advantages over fortified antibiotics
in terms of'beuer stability, longer shelf life and less epitheliotoxicity, with
the added advantage or not requiring refrigeration#

·'IAA(t: _\Is. JIU'lUIt I, Clu\~ "P. "to.Yoqll'~ ~ ron.flC!l_lb!obu tOt If'dI'flll ~ ~tndl'.:S)~1c tn\oc'w _.
~ofImI)"l\ o(~" iolllClfcj:,C.J~I*" 101l:4'h49J-9.
#00t.1'W1c: 1"s. ~kdQl~ "f'fXI*h lO ... rmiou, I::mllh"', .... n I 0pil1t.lll1111lt01:;S6:11S-lO.
co
- A more recent study in central lndia by TrIPPOet ul.(/lwIl"/r 2018) showed
that Besifloxncin 0.6% was effective in most of Gram positive and Gnu11
negative infections including pseudomonas to which ccfazolin was found
10 be resistant.'

- AT PRESENT FLUOROQUlNOLONE MONOTHERAPV IS

INDICATED:
I. < Jrnm in diameter,
2. pcripheralloeation not involving visual axis and,
3. not asscciered with thinning.
- S. pncumoniuc, which is the most common bacterial isolate in our country,
has variable susceptibility to f1uoroquinolones. and hence
Iluoroquincloncs may not be the ideal antibiotic for monotherapy for gram
posiriv e organisms in our country.
·f<'WOa.alC~.~oI"o(,"Cf~_~C __ Lb;""""'""",_C~ \CataI
~k \bMIrIr' I k_ J I \btdI MI.
TREATMENT OF FUNGAL KERATITIS

- For fllnmenteus fungi- Topical Natamyctn 5% suspension I hrly during

day and 2 hrly during night.
- For yensr - Topical "IIIp"olerici" B O.15% Ihrly during day and 2 hrly
during night. Nystatin 3.5% eye ointment 5 limes a day
- A new azole antifungal agent. Voriconazole. is deri, ed from Fluconnzole
and exhibits a wider spectrum of activity against Candida. Aspergillus and
Fusarium,
- Tapered according to response.
- Should be continued 2 weeks after the infection is resolved in all cases.
• The results of the MUTT 1(2013) show II benefit of natamycin over
vcriccnazole for tonical rrearrnem of fungal keratitis. and in particular for
Fusarium keratitis.·
• The MUTT II (2016) was a double masked, randomized, placebo-
controlled clinical trial investigating tile effect of adjuvant 01'81
voriconazolc vers us 01'81 placebo for smear-positive filamentous fungal
kcratitis··
• There was no difference in tile primary outcome, rate of perforation, or
need for therapeutic penetrating keratoplasty.
• There were signilicantly more adverse events in the oral voriconazole
group, including elevations in aspartate aminotransferase or alanine
aminotransferase .

• •~ NV. KtblIdIn T, RII,j_ It n.t. EIJ«1 Of (It'll \iJtI~ c- rvnpll:aMllU; In lilc M)'(VIIC Ukcr Tf\";ICtP(III
Trial n (MVIT
II!!. ~ dlnbftlW, lAMA <¥MhafIIIOl. 20I"';IJ4:IJ6$-IJ1l.
- Natamycin is currently the best drug against both molds and yeast.

- Contrary (0 popular belief. Voriccnazole was found to be inferior

espcclally against Fusarium.

- Oral Vcriconazole usc is associated with higher risk of adverse reactions.

- SYSTEr-IIC ANTIBACTERIAL

I. Gonococcal infections.
2. Young children with severe H. Influenzae or P. Aeruginosa keratitis.
3. Pcrforaticns and scleral involvement.
- Recommended io fungal ulcers. which are:

:;. Large and dec», or

:;.. Perforating. or
,. Have scleml involvement

- Systemic antifungal
I. Oml Fluconazole 200 mg 00
2. Oral Kctoconazole 200 mg TID
3. Oral Voriconazole 19 TID

- Continued for 2-3 weeks.

INTRACAMERAL ANTIBIOTICS

• Deep keratitis particularly those due to fungal ctiology with

retrocorneal ;III'OII'('m('1I/or anterior chamber involvement,
• Wilh the advent of thc newer generation antibiotics such as
fluoroquinolones, which have excellent ocular penetration. the
intracameral mode of anti-bacteria Is is not used for corneal ulcer.
• Amphotericin B - constituted in 5% dextorse IOjlg in 0.1 mi.
• Repeat injections - based on the clinical response.
• Non-responding cases - a repeat injection may be considered after a
time interval of I to 5 days.
[NTRASTROMALAMPHOTERICIN B
.. For non healing fungal ulcer .
.. 5· 7.S Ilg in 0.1 ml dosage. given in the vicinity of the stromal she of fungal
growth •
.. Can be repeated after a period of 48 to 72 hours.
ROLE OF TOPICAL CORTICOSTEROIDS
.. Controversial in bacterial keratitis. Double aged sword .
.. The rationale for using steroids - to decrease tissue destruction in bacterial
keratitis .
.. Should be started after 48 hours of commencement of antibiotic therapy if
there is evidence of response to antibiotic .
.. Patient should be monitored at 24 & 48 hrs afler initiation and response to
steroid is evaluated .
.. Not recommended for fung:11 and acanthamoeba keratitis .
.. The Steroids for Corneal Ulcers Trial (SCUT 2012)' - "Topical
steroids. when used as an adjunctive treatment under antibiotic cover, do
not provide any added benefit for bacterial keratitis."

'SI,~ tot, \~ J. ~n.n R~~~ M. LAlIClu. r. GIl~ DV,rt,,1. <:"";tfI..\I~1'fII4'1fN'''Nti", kltUtili.,. TAli
Siffli#tt"JM(:.,.,.'IUm td'.lrSctJtJ.AI\:~Op'"MlmoI1tI1:IJO;I.u&
TREATMENT OF ULCERATIVE VIRAL
KERATITIS
.. TOPICALANTIVIItAL
I. TriOuridine 1% drops - 2 hourly until ulcer heals then 4 hourly for 5
days.
low bioavailability and causes ocular surface toxicity
2. Acictovtr 3% ointment - 5 times a day x 3 weeks.
as effective as trifluridine with less ocular surface
toxicity
3. Ganclclovlr 0.15% gel- 5 limes a day until ulcer
heals and then 3 limes a day for 5 days.
broad spectrum, active against HSV. IIZV.CMV, As effective as
acyclovir, less ocular surface toxicity and less development of resistance.
- SYSTEMIC ANTIVIRAL
• Used in herpes zoster ophthalmicus
• Acyclovir 800 mg 5 times a day x 10·14 days or
• Valuciclovir 500 mg thrice a day x 10·14 days

• Recurrent cases of herpes simplex keratitis and necrotizing stromal

keratitis
• Acyclovir 400 mg 5 times II day x 10·14 days or
• Valacielovir 500 mg twice a day x 10·14 days
HEDS

Do topical steroid treat stromal keratitis?? Yes. also decrease duration of

keratitis

Is oral acyclovir (steroid+trifluridine) helpful in No

stormal keratitis??
Is oral acyclovir helpful in HSV iritis?? Favoring use of oral acyclovir

Does oral acyclovir prevent epithelial to stormal No

keratitis?'!
Does oral acyclovir decrease HSV recurrencc?? Yes
TREATMENT OF ACANTHAMOEBA
KERATITIS
- Topica! antiamoebic agents include:
I. Diamidine»: Propamidine isethionate (0.1 %0). and hex amid inc (0.1 %).
2. Biguanides: Polyhcxamethylene bigunnide (PHMB). 0.02% anel
chlorhcx idinc, 0.02%.
3. Alllillog/Jocosides: Ncomycin and Paromycin
.J. Imidazoles: Clotrimazolc and rniconnzole.

- MUltip/e drllg d,eTl'p), is needed for a long time (3-4 months) for early
epithelial lesions and & 12 months for stromal lesions.
• Any or the followinl: eombination rnlly be chosen

I. Propamidine or hexamidine + PHMB or

2. Chlorhcxidinc + Ncomycin or
3. Paromycin + clotrimazole or miconazotc or
itraconazole .

• Frequency of instillation: hourly for a wcek, then taper slowly over 3-4
months for epithelial lesions and 6-12 months for stromal lesions.
TREATMENT OF METAHERPETTC
CORNEAL ULCER

- Elimination of toxic medications.

- Preservative free lubricants.
- Punclalocclusion.
- Soft bandage contact lens.
- Autologus serum.
- Conjunctival nap.
- Amniotic membrane transplantation.
- Tarsorrhaphy.
TREATMENT OF MOOREN'S ULCER
AND OTHER STERILE PUK
• Topical corticosteroids for Mooren'5 ulcer,
• Used cautiously in patient with RA. Wegener's granulomatosis and
polyarterit is nodose.
• Conjunctival resection (peritomy).
• Severe thinning and small perforation cyanoacrylate glue
• Large perforation - full thickness keratoplasty
• Amniotic membrane unnsplamauon .
• Non responding ca.~emay require - systemic immunosuppression.
• Treatment of the associated collagen vascular disease.
TREATMENT OF NEUROTROPHIC!
NEUROPRALYTICIEXPOSURE KERATOPATHY

- Topical therapy - preservauve free lubricants, amibioties. eycloplcgics.

- Lid taping. -_
- Autologous serum drops. Oxervate' ... Ol102!loo"""""
(..._,.,,,_--
- Soft bandage COnlaCI lens.
- Amniotic membrane transplantation.
.. ... _--
-
- Conjunctival nap.
e-
- Lateral tnrsorrhaphy,
- Topicalnervegrowthfactor dropsfor neurotrophicII/Ur.
EVIDENCE OF HEALING ULCER

• The signs and symptoms decreases.

• Visual acuity continues to improve.
• Size of'thc epithelial defect and hypopyon decreases.
• The stromal infiltrates consolidate.
• Anterior chamber reaction decreases.
• Vascularization occurs and following complete healing the vessels regress
completely but sometimes leave "ghost vessels".
• Visible shrinking or the endothelial plaque.
• Epithcliali/.3tion is completed and necrotic stroma b replaced by scar.
SURGICAL TREATMENT MODALITIES

- Glue application.
- Conjunctival nap.
- Amniotic membrane transplantation.
- Therapeutic patch gran.
- Therapeutic lamellar keratoplasty.
- Therapeutic penetrating keratoplasty.
- Photothcrapeutic keratectomy.
- Corneal collagen cross-linking.
GLUE APPLICATION

• lndicarions:
I. Perforation < 2mrn
2. Mching and thinning
3. Oesccmutccclc
• Cyanoacrylate glue is used
• Followed by BCl
• II has significant bactcriostatlc activity againsr gram-positive organisms.
• Also decreases keratolysis by leukocytes.
• Helps in delaying surgery (PKlPalch gmfl) which can be performed as an
elective procedure later,
AMNIOTIC MEMBRANE TRANSPLANTATION
CONJUNCTIVAL FLAP APPLICATION

- Presently used only for recalcitrant sterile corneal ulcer.

- Provide a smooth ocular surface and also hclp in tectonic support
and nutrition to a chronic. non-healing corneal ulcer.
- Indications-
I. Neurotrophic corneal ulcers
2. Neuroparalytic keratitis
3. Exposure keratitis
4. Peripheral ulcerative keratitis
- TYPES·
I. Partial Conjunctival nops

A. Adv3nCCI1lCninaps
B. Single pedicle naps
C. Bi-pediclc naps
2.
Total Conjunctival nap (GUNDERSON flap)
THERAPEUTIC PENETRATING KERATOPLASTY

- Indications
I. Performion not amenable to glue application i.e <:: 3 mm
2. Non hCflling and non responsive fungal ulcer despite maximum medical
thempy.
3. Severe melting due 10 herpes necrotizing stromal keratitis.
4. Progressive non responsive bacterial ulcer despite maximum medical
therapy,
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n...1.1
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and "'"
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riMS
 TR~RAPEUTIC PATCH GRAFT

flpnt J ~ .,bn!p~ ~of.~(OfM.IIptriontJOfl_~I:rt. -'plItch,.,.ft.

No(,t: fA) M 8.)•.,...o'd I"QII WIdI. <omt.aIl"riora_ *UO<Ilud -" (:ItQI~ no.", ~ ~rrow). til. wlow ~.1I!d ","""on lbtlUJ*'Of
~ ~ltJd\)NlIHwft.~~tf<rsNOI!r(#ll*-","""""(td.~ncI"'~'9P>.~~.u,",byWltur.otu..~,,,,w~
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JIO'I~ ku<ot1'eCWd'ri1oUlla.cwt)' W.h W)OO

, u
Jolt-filltrlor. Ytllo:ojtawa II \"1al, Surc:icliJ tllt'rllilin pf'rrnnllJolu:
far CClf'tl(':81 10 ytaD.,r tlUO in • It'tlbry rer etral buspllili. 2014. J)u"C'
p .... ,
.. Helps by the following methods:

I. Debltlki"lI or removing the infectious organism.

2. II maintains the illlegl'ily of the globe integrity.

3. It may also help in diagllOlis of the infective pathology.

PHTOTHERAPEUTIC KERATECTOMY

- The ability of 193 nm excimcr laser to treat microbial keratitis was

demonstrmed initially by Serdaveric et al.

- It has been shown to be effective in curly localized Fusarium,

Mycobacterium and Pseudomonas keratitis in animal models.

- Due 10 the ultraviolet radiation. [issue sterilization occurs and this effect is
further enhanced due to ablution or elimination of organisms and the
surrounding necrotic tissue.

- It also provides debulking cffccr and improves drug penetration.

COLLAGEN CROSS-LNKING**
- Collagen cross linking (CXL) of the cornea has been developed recoruly as
a new treatment for muludrug-resistam infectious keratitis. as documented
by several recent case repons.
- This technique has showed promising results specially in patients with
corneal melting and impending perforation.
- Corneal melting has been arrested and complete epithelialization achieved
in several cases.
- The success rate was higher for bacterial infections than fungal infections
- Although randomized controlled trials are needed. the available evidence
supports the use of CXL in the treatment of infectious keratitis.
RECENT ADVANCES AND FUTURE
SCOPE
- NANO PARTICLES FOR SUSTAINED A:'IITI-FU)I(GAL DRUG
DELIVERY.
Cell-penetrating pcptides (CPPs) -10 transport molecules across Ihe ccII
membranes -10 enhance extracellular and intracellular internalization or
biomolccules. Eg; NTM wirh CPP carrier - TAT Dimer

- PHOTOACTIVATED CHROMOI'HORE FOR INFECTIOUS

KERATITIS (PACK)
direct amimicrobial effect and effect by halting the ongoing melting.

- ROSE BENGAL PHOTODYNAMIC THERAPY

SUMMARY

.. While characteristic clinical features have been described for ulcers caused
by different microorganisms. it is difficult to confirm these. especially
after the disease has become well established .
.. A very close clinical suspicion is required for the diagnosis of
acanrharnocba keratitis .
.. Microbiological examination (smear and cuJrurc) still remains the gold
standard for the diagnosis of bacterial and fungal corneal ulcer .
.. Viral ulccraiive keratitis diagnosed solely on clinical findings .
.. Newer diagnostic modalities like in-vivo confocal microscopy aid in
diagnosis of fungal and acanthamoeba keratitis.
- Fortified topical antibiotic combination therapy still remains the mninstay
of'treauncnr of bacterin I corneal ulcer however there is shining trends
towards the monothcrnpy with commercially available 4,h generation
fluoroquinolones.
- Emergence of resistance to Iluoroquinolones is a great concern in recent
decade.
- The most important problem with treating fungal corneal ulcer is less
penetmtion and bioavailabiliry of currently availablc anti fungal drugs.
- Recent development of sustained drug delivery system for the fungal ulcer
may revolutionize the management in near future.