792 Viral Protozoal Corneal Ulcer
792 Viral Protozoal Corneal Ulcer
KERATITIS
Dr Sanjeev Kumar Mittal
Professor & Head, Ophthalmology
13-02-2018
HERPES VIRUS
Are ubiquitous human pathogen capable of causing both
asymptomatic infection and active disease
Humans are natural reservoir of HSV
2 types – HSV 1- oropharynx
HSV 2 – genital area
Ocular disease typically caused by type 1
Causes primary infection in children and neonates
MODE OF INFECTION:
IP – 3- 9 days
HSV 1 – close contact
HSV 2 – venereal – birth canal
MECHANISM OF ACTION
HSV (epitheliotropic & cytolytic) binds to one or
more cellular receptor – heparin sulphate
Virus fuses with cell membrane
Enters the cell and nucleus where the transcription
of viral DNA occurs – protein
•TG is the most common source of recurrent HSV infection.
•Primary infection may subsequently reactivate by travelling via
ophthalmic division of 5th CN to the eye.
PATHOGENESIS
Factors for reactivation –
UV rays
Trauma
Heat, abnormal body temperature
Other infectious disease
Emotional disease
Menstrual stress
Steroids, immunosuppresant, PGs
CLINICAL FEATURES
Suspicion of viral keratitis arises if there is
Associated skin lesions, recurrences of these lesions
Stress-induced recurrence
Immuno compromised status
History of contact
Symptomatic eye (Pain ,Photophobia ,Blurred vision,
Tearing ,Redness) with minimal conjunctival and
corneal signs
Superficial dendrites with loss of corneal sensation
CLASSIFICATION OF OCULAR DISEASE
1.Congenital & Neonatal
geographic
ulcer(amoeboid)
limbal ulcer
(marginal)
CLASSIFICATION OF HSV KERATITIS
The disease may present as 5. Stromal keratitis
any one or a combination of Necrotizing stromal keratitis
the following: Immune (interstitial)
1. Blepharoconjuctivitis keratitis
2. Episcleritis, scleritis Immune rings
3. Infectious epithelial Limbal vasculitis
Disciform keratitis
keratitis –(IEK)
4. Neurotrophic
6. Endothelitis
keratopathy
Disciform
Diffuse
Linear
7. Iridocyclitis
8. Trabeculitis
Herpes simplex epithelial keratitis
MC PRESENTATION
• Acanthamoeba keratitis
• Antiviral toxicity
Herpes simplex disciform keratitis
Signs Associations
Electron microscopy
INDICATIONS FOR ORAL ACYCLOVIR
Oral Acyclovir
Linear endothelitis
Diffuse endothelitis
Severe trabeculitis
Immunocompromised patients
Paediatric patients refractory to topical
Prophylaxis for post-PKP with h/o HSV
Prophylaxis against recurrent IEK
PROPHYLAXIS AGAINST RECURRENCE
•Hutchinson’s sign –
vesicles at the side & tip
of nose precedes HZO
1. Antivirals( treat for 7 days , starting within 72 hrs) Famcyciclovir 500mg PO TDS
Valacyclovir 1 g PO TDS
Acyclovir 800mg PO 5t/d
4. Pain prevention-
TCA’s( eg nortryptyline, desipramine) 25-75 mg PO * 3months
Nonnarcotic or short term narcotic analgesic .
OCULAR MANIFESTATIONS
1. Epidemic keratoconjunctivits
2. Pharyngoconjunctival fever
3. Nonspecific follicular conjunctivitis
4. Chronic adenoviral keratoconjunctivitis
EPIDEMIC KERATOCONJUCTIVIS
Serotype AD 8, 19, & 37.
Most serious adenoviral ocular illness
In young adults during the fall and winter months
U/L in 2/3rd pt
IP 8 days
Sign and symptoms:
Acute tearing, FBS, photophobia, followed by lid and
conjuctival edema and hyperemia, follicular and
papillary conjuctival response with or without hge or
membrane formation, & tender LN’s
PHARYNGOCONJUCTIVAL CHRONIC ADENOVIRAL
FEVER KERATOCONJUCTIVITIS
Serotype Ad 3 and 7 Serotype Ad 2,3,4 and 19.
CULTURE
Non-nutrient agar with
e.coli
Ulceration, ring abscess Stromal opacification
& small, satellite lesions
Treatment -Medical therapy given for 135 days
-Biguanides(chlorhexidine or polyhexamethylenebiguanide
(0.02%) effective against both forms
Source
Text-Kanski, Parson’s, Samar Basak, Pradeep
Sharma
Photographs- above , Archives & Website