A SEMINAR PRESENTATION

ON

KERATITIS
 
 BY
DR. ADANIHUOMWAN .O. BLESSING

DEPARTMENT OF OPHTHALMOLOGY
UNIVERSITY OF CALABAR TEACHING HOSPITAL

JUNE 30, 2021.

 OUTLINE
 Anatomy.
 Functions.
 Introduction.
 Epidemiology.
 Causes and risk factors.
 Pathogenesis/pathophysiology.
 Diagnosis (Role of optometrist).
 Forms of keratitis.
 Differential diagnosis.
 Complications.
 Treatment.
 Prevention.
 Prognosis.
 Conclusion/take home.
 References.
 Anatomy…

 Cornea is a clear transparent and elliptical structure with a smooth shining surface.
The average diameter is 11-12mm ((horizontal=12 mm, vertical = 11 mm).
 The thickness of the central part is 0.52 mm and the peripheral part is 0.67 mm, the
central one-third is known as the optical zone.
 Refractive index of cornea is 1.37.
 The dioptric power of the cornea is approximately + 43 to + 45 D. Histologically,
the cornea consists of five layers namely
 Anatomy…

 1. The epithelium—Stratified squamous type of epithelium consists of three cell

types namely the basal columnar cells, two or three layers of wing cells and
surface cells. It is normally replaced within 7 days when damaged.
 2. Bowman’s membrane—it is made up of collagen fibrils. It does not regenerate
when damaged. This results in the formation of permanent corneal opacity
 3. Substantia propria or stroma—it forms 90% of corneal thickness. It consists
of keratocytes, regularly arranged collagen fibrils and ground substance.
 Anatomy…

 4. Descemet’s membrane—it is a thin but strong homogeneous

elastic membrane which can regenerate.
 5. The endothelium-It is a single layer of flattened hexagonal cells.
The cell density is about 3000 cells mm2 at birth which decreases with
advancing age. Corneal decompensation occurs only when more than
75% cells are damaged. It is measured by specular microscopy.
 Anatomy…

 Nutrition of the Cornea

 Cornea is an avascular structure. It derives nutrition from:
 1. Perilimbal blood vessels—anterior ciliary vessels invade the periphery of the cornea
(limbus) for about 1 mm.
 2. Aqueous humor—It supplies glucose and other nutrients by process of simple diffusion or
active transport.
 3. Oxygen from atmospheric air is derived directly through the tear film.
 Nerve Supply: The nerve supply is purely sensory. It is derived from the ophthalmic division of the 5th
cranial nerve through the nasociliary branch.
 Functions…
There are two primary functions of the cornea.
 1. It acts as a major refracting medium.
 2. It protects the intraocular contents. This is possible by maintaining corneal
transparency and replacement of its tissues. Transparency is maintained by:
 i. Regular arrangement of corneal lamellae (lattice theory of cornea)
 ii. A vascularity
 iii. Relative state of dehydration.
 Introduction…

 Inflammation is part of the body’s defense mechanism and plays a role in

the healing process.
 When the body detects an intruder, it launches a biological response to
try to remove it.
 The attacker could be a foreign body, such as a thorn, an irritant, or a
pathogen. Pathogens include bacteria, viruses, and other organisms,
which cause infections
 Introduction…

 Inflammation happens in everyone, whether you are aware of it or

not. Your immune system creates inflammation to protect the body
from infection, injury, or disease. There are many things you wouldn’t
be able to heal from without inflammation.
 Introduction…

 Keratitis (kerat- cornea, itis- inflammation) is an inflammation of the cornea

— the clear, dome-shaped tissue on the front of your eye that covers the pupil
and iris prolonged unresolved inflammation could result in corneal ulcers.
 Inflammation of the cornea (keratitis) is characterized by corneal oedema,
cellular infiltration and associated conjunctival reaction.
 Corneal ulcer is an inflammatory or, more seriously, infective condition of
the cornea involving disruption of its epithelial layer 
 Classification…

Infective keratitis { purulent}

 Bacterial
 Viral
 Fungal
 Chlamydia
 Protozoan
 Classification…

 Bacterial infections: 
 Bacterial keratitis is common in people who wear contact lenses and do not clean and store
them properly.
 The bacteria can also come from contaminated eye drops or contact lens solution. It is more
likely to occur if you wear extended-wear contact lenses (contact lenses that you sleep in).
 Pseudomonas aeruginosa and Staphylococcus aureus are the two most common types of
bacteria that cause bacterial keratitis. It mostly develops in people who use contacts
improperly
 Classification…

 Viral infections: Keratitis is usually due to the herpes simplex virus, the

chicken pox virus, or the common cold. If you’re sick, be careful about
touching your eyes and keeping your hands clean.
 If you have a cold sore (the herpes simplex virus), you can spread it by
touching your sore and then your eye.
 Viral keratitis is primarily caused by the herpes simplex virus, which
progresses from conjunctivitis to keratitis
 Classification…

 Fungal infections: 
 This type of keratitis infection is not common.
 It can be caused by scratching your eye with a branch or plant material. It can
also be caused by the improper use of contact lenses or steroid eye drops.
 Fungal keratitis is caused by Aspergillus, Candida, or Fusarium. As with
bacterial keratitis, fungal keratitis is most likely to affect those who wear contact
lenses. However, it’s also possible to be exposed to these fungi outdoors
 Classification…

 Parasitic (Acanthamoeba) infection: 

 Acanthamoeba are microscopic, single-celled organisms called amoeba.
 They are the most common amoebae found in fresh water and soil.
 The two biggest risk factors to get an Acanthamoeba infection are poor
contact lens hygiene and exposure to water (like swimming pools and
hot tubs) while wearing contact lenses.
EXTERNAL EXAM PRESENTATION
Signs present…

BACTERIAL FUNGAL
VIRAL KERATITIS
KERATITIS KERATITIS
 Classification…
Non infective {Non purulent}
Allergic keratitis
 Phylctenular keratitis

 Vernal keratitis

 Atopic keratitis

Trophic keratitis
 Exposure keratitis

 Neurotropic Keratopathy

 Keratomalacia

 Athermanous ulcer
 Classification…
 Keratitis associated with diseases of skin mucous membrane
 Keratitis associated with systemic collagen vascular disorders
 Traumatic keratitis, which may be due to mechanical trauma,
chemical trauma, thermal burns, radiations
 Idiopathic keratitis e.g.
 Mooren’s corneal ulcer
 Superior limbic keratoconjuctivitis
 Superficial punctate keratitis of thygeson
 Classification…

 Injury: Scratches, scrapes and cuts to your cornea can cause

noninfectious keratitis. These injuries can happen from a variety of
sources, such as fingernail scratches, paper cuts, makeup brushes, tree
branches, contact lenses, and chemical burns. The injury may also let in
bacterial or fungus to cause an infectious keratitis.
 Eyelid disorders that prevent proper eyelid function: If the eyelid
does not close properly, the cornea can dry out, and keratitis can develop.
 Classification…

 Dry eye syndrome: The eyes are not able to leave a protective layer of tears
(called the tear film) that washes, soothes and protects the eye every time you
blink. The eye then becomes dry and irritated which can lead to keratitis.
 Exposure to intense ultraviolet (UV) light (photo keratitis): Photo keratitis is
caused by damage to the cornea by UV light. It can be caused by the reflection of
UV light from the sun from sand, water, ice and snow; looking directly at a solar
eclipse without eye protection, tanning beds, and/or welding
 Epidemiology…
 Microbial keratitis - A review of epidemiology, pathogenesis, ocular
manifestations, and management. Chinyelu N Ezisi, Chimdia E
Ogbonnaya, Obiekwe Okoye et al. Federal Teaching Hospital,
Abakaliki, Ebonyi State, Nigeria
University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
 Concluded that Optimal outcome from management of Microbial
Keratitis will require an updated knowledge of its pathogenesis,
clinical features, and treatment protocols, especially in sub-Saharan
Africa where its prevalence is on the increase.
 Epidemiology…
 Corneal ulcers in a tertiary hospital in Northern Nigeria
Kehinde Oladigbolu, Abdulkadir Rafindadi, Emmanuel Abah et al. Department
of Ophthalmology, Ahmadu Bello University Teaching Hospital, Shika-Zaria,
Nigeria 5-Sep-2013
 Concluded that In this study most patients with corneal ulcer presented with poor
vision and excessive lacrimation. Trauma was the commonest predisposing
factor with bacterial organisms as the commonest isolate.
 Epidemiology…
 Suppurative Keratitis in a Nigerian Tertiary Hospital. Ulcerative Keratitis:
incidence, seasonal distribution and determinants in a tertiary eyecare facility
south east Nigeria.O.C Arinze Okoye,N.N Udeh,S.N Onwubiko et al.
 Concluded that The incidence rate of ulcerative keratitis is 0.6% occurring
highest in the month of June with more bacterial than fungal isolates. Many
participants were exposed to non- surgical trauma and use of TEM. Eye health
education (emphasizing the deleterious effects of TEMs) and protection
(especially for artisans) if instituted can reduce the visual morbidity associated
with corneal ulcers.
 Causes/risk factors

 Keratitis usually happens because something has irritated the eye, for
example, an infection or injury.
  Certain risk factors make it more likely for keratitis to develop.
 Wearing contact lenses is a risk, especially if a person wears them
overnight
 Causes/risk factors

 Exposing the eyes to water parasite, caused by a tiny organism often

found in lakes and rivers or such as when swimming or in a hot tub —
is a high risk for keratitis. A person should always clean their contact
lenses with a contact lens solution, not wash them in water.
 Having systemic issues like simplex virus or herpes zoster virus
 Causes/risk factors

 Have reduced immunity: If your immune system has been weakened by

disease or medications, you are at a higher risk of developing keratitis.
 Use steroid eye drops: Use of steroid eye drops to treat an eye disorder
can increase your risk of developing infectious keratitis or worsen
existing keratitis.
 Have an eye injury: If one of your corneas has been damaged from an
injury, you may be more vulnerable to developing keratitis.
 Pathophysiology…

 The cornea is the most anterior part of the eyeball and is exposed to the
atmosphere and hence prone to get infected easily. At the same time the cornea
is protected from day to day minor infections by the normal defense mechanism
present in tears in form of lysozyme, betalysin and other protective proteins.
 Interruption of an intact corneal epithelium and/or abnormal tear film permits
entrance of microorganisms into the corneal stroma, where they may proliferate
and cause ulceration.
 Pathophysiology…

 In addition, some bacteria can penetrate an intact corneal epithelium to

cause infection:
 Neisseria gonorrhoeae.
 Corynebacterium diphtheriae.
 Neisseria meningitidis.
 Diagnosis…

 If you notice any of the signs or symptoms of keratitis, make an appointment to

see your eye doctor right away.
 If you wear contact lenses, do not wear them until you find out what is wrong.
Bring your contact lenses and contact lens case with you to the eye exam.
 Delays in diagnosis and treatment of keratitis can lead to serious complications,
including blindness. An eye doctor will examine the eye and ask questions about
what may have caused keratitis.
 Diagnosis (role of optometrist)…
 At your eye exam, the eye doctor will perform the following tests:
 History: The eye doctor will take a medical history, identify any illness, and
ask you about your symptoms before examining your eye.
 Visual acuity: This test will show how well you can see, or how much of your
vision has been affected.
 Penlight exam: The eye doctor may examine your eye using a penlight, to
check your pupil’s reaction, size, and other factors.
 Slit-lamp: The eye doctor uses a special microscope called a slit lamp. It shines
a light into one eye at a time so the doctor can look closely at the outside and
inside of the eye. Your eye doctor may apply a stain (fluorescein) to the surface
of your eye, to light up any damage to your cornea.
 Diagnosis…

 Laboratory analysis: The eye doctor may swab under your eyelid to

get a sample of tears or some cells from your cornea for laboratory
analysis. The doctor might also swab your contact lens case as a
separate sample for analysis. This will help to determine the cause of
keratitis and develop a treatment plan for your condition. A doctor may
diagnose bacterial or fungal keratitis by taking a small scraping from
the cornea to send to a laboratory to be tested.
 Diagnosis…

 A doctor may diagnose bacterial or fungal keratitis by taking a small

scraping from the cornea to send to a laboratory to be tested.
 Viral keratitis does not need laboratory testing, but a doctor will ask
for information about a person’s medical history.
 Parasitic keratitis may need a more detailed examination of the eye so
that the doctor can see the parasite causing the condition
 Forms of keratitis…
Keratitis
Etiology
Bacterial keratitis
Bacterial
Viral keratitis
Viruses
Fungal keratitis
Fungi
Eye injury from plant materials
Causative organisms Neisseria gonorrhoeae, Herpes simplex, Herpes zoster Aspergillus, Fusarium, Candida
Corynebacterium diphtheriae, and adenovirus
Neisseria meningitidis
Staphylococcus aureus,
pseudomonas pyocyanea e.t.c
Signs  Ulceration of the epithelium;  Eye redness Conjuctival injections
corneal infiltrate with no  Decreased vision Epithelial defects
significant tissue loss; dense, Suppuration
suppurative stromal Stromal infiltrates
inflammation with indistinct Anterior chamber reaction
edges; stromal tissue loss; and Hypopyon
surrounding stromal edema Endothelial plagues
 Anterior chamber reaction White rings and satellite lesions in the
(cells and flare) with or cornea
without hypopyon Fine or coarse granular infiltrates
 Folds in the Descemet within the epithelium and anterior
membrane stroma
 Upper eyelid edema Typical irregular feathery edged
 Posterior synechiae infiltrates
 Surrounding corneal  
inflammation that is either
 Forms of keratitis…
Symptoms 


Pain and foreign body
sensation
Watering from the eye



Eye pain
Photophobia
Foreign body sensation
Eyepain
Eye redness
Blurred vision
 Photophobia Sensitivity to light
 Blurred vision Excess tearing
 Redness of eyes Eye discharge
Risk factors  Contact lens wear •  weakened immune system  Trauma(contact lens, foreign body)
 Use of infected eye drops • Viral infections such as  Topical steroid use
 Foreign body herpes simplex  Corneal surgery
 Older patients
 Pre existing ocular disease
 Immunosuppressive disease
 Exposure keratitis
pathophysiology Interruption of an intact corneal  a weakened immune system or  Fungi gain access into the corneal stroma
epithelium and/or abnormal tear previous medical history of through a defect in the epithelium, then
film permits entrance of viral infections leave the body multiply and cause tissue necrosis and an
microorganisms into the corneal open to viral attacks which inflammatory reaction. The epithelial defect
stroma, where they may may invade the cornea and usually results from trauma (eg, contact
proliferate and cause ulceration. In proliferate till ulcerations lens wear, foreign material, prior corneal
addition, some bacteria can occur surgery). The organisms can penetrate an
penetrate an intact corneal intact Descemet membrane and gain access
epithelium to cause infection into the anterior chamber or the posterior
segment. Mycotoxins and proteolytic
enzymes augment the tissue damage.
Forms of keratitis…
vision Visual reduction due to corneal
haze
   

Differential diagnosis  Bacterial Endophthalmitis Bacterial keratitis

   Sarcoidosis Interstitial keratitis
 Corneal Ulcer Neurotrophic keratitis
 Scleritis
 
 Herpes Simplex Virus (HSV  Tuberculosis
) Keratitis
 
 Viral Conjunctivitis (Pink E
ye)
Treatment   systemic care Systemic care Systemic care
 Atopic Keratoconjunctivitis
ocular care Ocular care Ocular care
(AKC)
Complications  corneal ulcer  Chronic corneal Corneal perforation
 corneal scar inflammation and Corneal ulcer
 corneal perforation scarring. Corneal scar
 Chronic or recurrent viral Endophthalmitis
infections of your cornea.  
 Open sores on your  
cornea (corneal ulcers)
 Temporary or permanent
reduction in your vision.
 Blindness.
 Differential diagnosis…

 Bacterial Endophthalmitis
 Corneal Ulcer
 Viral Conjunctivitis (Pink Eye)
 Atopic Keratoconjunctivitis (AKC)
 Corneal scar
 Bacterial Conjunctivitis
 Complications…

 Corneal perforation

 Corneal ulcer

 Corneal scar

 Endophthalmitis
 Treatment…

 If a person has keratitis and wears contact lenses, they should take
them out as soon as they develop any symptoms of infection or
irritation. Contact lenses should not be used again until the condition
has gone away.
 Treatment…

 Noninfectious keratitis
 A very mild case of noninfectious keratitis will usually heal on its
own. For mild cases, your eye doctor may recommend that you use
artificial tear drops. If your case is more severe and includes tearing
and pain, you may need to use antibiotic eye drops to help with
symptoms and prevent infection.
 Treatment…
 Infectious keratitis
 Treatment of infectious keratitis varies, depending on the cause of the
infection.
 Bacterial keratitis: Depending on the severity of your infection, antibiotic
eye drops may be used for mild cases. In moderate to severe cases, you may
also need to take oral antibiotics treat the infection.eg tobramycin,
cephazoline or vancomycin, fourth generation are increasingly used as
monotherapy e.g. floroquinolones.
 Fungal keratitis: You would need to take antifungal eye drops and oral
medication.eg Natamycin drops, imidazole and triazoles (ketoconazole,
miconazole, fluconazole etc), amphotericin B
 Treatment…
 Viral keratitis: You may need artificial tear drops, antiviral eye drops and/or
oral antiviral medications. e.g. oral and topical acyclovir, famcyclovir,
valacyclovir
 Acanthamoeba keratitis: This keratitis may be difficult to treat. You may be
prescribed antibiotic drops. If you have a severe case, a corneal transplant may
be needed.
 Your eye doctor may also prescribe steroid eye drops (never with fungal
keratitis) after your infection has improved or is gone. These drops help to
reduce swelling and help prevent scarring. You should only use steroid eye drops
under close supervision by your eye doctor because steroid eye drops can
sometimes make an infection worse.
 Treatment…

 Surgical Treatment
 A corneal transplant replaces a damaged cornea with a healthy donor
cornea. You may require a corneal transplant if you have the
following:
 Keratitis that does not respond to medication
 Corneal scarring that greatly impairs your vision
 Prevention…

 Apart from viral keratitis, most people can avoid other forms of the condition by
following good contact lens hygiene.
 People can help to prevent keratitis by:
 following the advice of their eye doctor about how to wear, replace, store, and clean
contact lenses
 washing and drying hands with soap and water before touching the eyes or contact
lenses
 avoiding sleeping in contact lenses
 Prevention…

 keeping water away from contact lenses, such as when showering or

swimming
 cleaning contact lenses with contact lens solution
 Do not swim or shower in your contact lenses
 visiting an eye doctor regularly, and contacting them with any
symptoms that give concern
 Prevention…
 Keratitis can affect people who do not wear contact lenses. It is
important to protect the eyes from damage that can cause the condition.
 Steps to protect the eyes include:
 wearing protective eyewear if working with plants or trees
 wearing sunglasses when exposed to bright sunlight
 being aware of anything that can cause an allergy, and avoiding them if
possible
 eating a diet that includes vitamin A, which can be found in milk and
eggs
 Prevention…

 It may also be possible to reduce the risk of viral keratitis. People

should take care not to touch the eyes or the area around them, and
only use eye drops that have been prescribed by a doctor.
 visiting an eye doctor regularly, and contacting them with any
symptoms that give concern
 Prognosis…

 Keratitis, if caught early, is usually easy to treat and clears up quickly.

Corneal scarring is the most common complication of keratitis, which
can lead to vision loss. If keratitis is not treated in a timely manner, the
infection could go through the cornea and spread to other areas of the
eye leading to possible blindness. It is important to see any eye doctor
as soon as symptoms of keratitis are noticed.
 Case presentation…

 CASE PRESENTATION.
 BIODATA
 NAME: A.I.S
 AGE: 27years
 SEX: Male
 ADDRESS: xx xxxxxx xxxxxxx Benin.
 D.O.B: 22ND SEPTEMBER 1994
 Case presentation…
 CASE HISTORY:
 PxCC: Patient complained of pain on the right eye.
 POVHx: pain began after removing his daily wear contact lenses that
he had worn overnight after mistakenly sleeping with them at the end
of a stressful day, patient feels vision on the right eye is blurry and
there has been frequent tearing from that eye. Also patient has the
sensation there is something in the eye, patient also reported
sensitivity to light and mucous discharge.
 P.Mhx: No medical history
 Case presentation…

 FOVHx: No history of eye conditions in the family

 FMHX: No history of medical conditions in the family
 ALLERGIES: No known Allergies
 MEDICATION: Not on any medication
 L.E.E: 6 months
 P.Shx: An Engineer.
 Case presentation…

 VISUAL ACUITY: PIN HOLE

 OD: 6/24 OD: 6/12

 OS: 6/6 NEAR: N5 OS: 6/5

 Case presentation…

 INTERNAL AND EXTERNAL EXAMINATION

  RIGHT EYE LEFT EYE
CONJUCTIVA hyperemic clear
CORNEA Clear Clear
LIMBUS Encroaching blood vessels Normal
IRIS Normal Normal
A/C Deep Deep
PUPIL ERRLA ERRLA
LENS Clear Clear
VITREOUS. Clear Clear
RETINA Healthy Healthy
C/D RATIO 0.2 0.2
 Case presentation…

 SLIT LAMP EXAMINATION: With the use of flourescein and

under blue light examination showed slight epithelial defects were
noticed on the cornea
 LAB EXAMINATION: A smear of the discharge was swabbed and
sent to the lab for analysis and on return it was confirmed to be
Pseudomonas aeruginosa.
 Case presentation…

 DIAGNOSIS: After proper analysis it was termed BACTERIAL KERATITIS.

 ROLE OF OPTOMETRIST: The primary eye care practitioner prescribed

chloramphenicol as prophylaxis, also provided the patient with sun glasses for

the light sensitivity and referred to an ophthalmologist for further treatment.

 TAKE HOME…
 The cornea has the highest refractive property of the eye and as such
any issues concerning the cornea should be attended to immediately as
delay can cause severe complications and eventually blindness.
 Optometrists should also know when to make a referral because corneal
problem could lead to severe complications too.
 We should also take out time to buttress on the importance of contact
lens hygiene to contact lens wearers.
 Keratitis has various forms and as such proper and thorough case
history or clerking should be done to guide in treatment regimen and
also determine the next line of action.
 REFERENCES…
 "Ophthalmology & Visual Sciences". Chicago Medicine. Retrieved 2018-04-29.
 "Treat Keratoconus Guide". Tuesday, 26 January 2021
 "What is onchocerciasis?". CDC. Retrieved 2010-06-28. Transmission is most
intense in remote African rural agricultural villages, located near rapidly
flowing streams... (WHO) expert committee on onchocerciasis estimates the
global prevalence is 17.7 million, of whom about 270,000 are blind.
 CDC Advisory Archived 2007-05-31 at the Way back Machine
 Epstein, Arthur B (December 2007). 
"In the aftermath of the Fusarium keratitis outbreak: What have we learned?"
 Clinical Ophthalmology (Auckland, N.Z.). 1 (4): 355–366. ISSN 1177-5467. 
PMC 2704532. PMID 19668512.
 REFERENCES…
 Herretes, S; Wang, X; Reyes, JM (Oct 16, 2014). 
"Topical corticosteroids as adjunctive therapy for bacterial keratitis". The
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10.1002/14651858.CD005430.pub3. PMC 4269217. PMID 25321340.
  John F., Salmon (2020). "Cornea". 
Kanski's clinical ophthalmology: a systematic approach (9th Ed.). Edinburgh:
Elsevier. p. 219. ISBN 978-0-7020-7713-5. OCLC 1131846767.
 Lorenzo-Morales, Jacob; Khan, Naveed A.; Walochnik, Julia (2015). 
"An update on Acanthamoeba keratitis: diagnosis, pathogenesis and treatmen
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 REFERENCES…
 Martín-Navarro, M.; Lorenzo-Morales, J.; Cabrera-Serra, G.; Rancel,
F.; Coronado-Alvarez, M.; Piñero, E.; Valladares, B. (Nov 2008). 
"The potential pathogenicity of chlorhexidine-sensitive Acanthamoeba
strains isolated from contact lens cases from asymptomatic individuals
in Tenerife, Canary Islands, and Spain"
. Journal of Medical Microbiology. 57 (Pt. 11): 1399–1404. Doi:
10.1099/jmm.0.2008/003459-0. ISSN 0022-2615. PMID 18927419.
 Tang A, Marquart ME, Fratkin JD, McCormick CC, Caballero AR,
Gatlin HP, O'Callaghan RJ (2009). 
"Properties of PASP: A Pseudomonas Protease Capable of Mediating
Corneal Erosions"