1. INTERSTITIAL KERATITIS
&
MOOREN’S ULCER
GURJEET SINGH
VI TERM

2. INTERSTITIAL KERATITIS

3. DEFINITION
Interstitial keratitis denotes an inflammation of the corneal
stroma without primary involvement of epithelium or
endothelium.

4. CAUSES
 Congenital syphilis
 Tuberculosis
 Cogan's syndrome
 Acquired syphilis
 Trypanosomiasis
 Malaria
 Leprosy
 Sarcoidosis

5. SYPHILITIC (LEUTIC) INTERSTITIAL
KERATITIS
 Syphilitic interstitial keratitis is associated more frequently
(90%) with congenital syphilis.
 Disease is generally bilateral in inherited syphilis & unilateral
in acquired syphilis.
 Congenital syphilis manifestation develops between 5-15
years of age.

6. CLINICAL FEATURES
The clinical features of interstitial keratitis can be divided into
three stages:
 INTIAL PROGRESSIVE STAGE
 FLORID STAGE
 STAGE OF REGRESSION

7. INTIAL PROGRESSIVE STAGE
 The disease begins with oedema of endothelium & deeper
stroma,secondary to anterior uveitis .
 Associated with pain,photophobia,lacrimation
blepharospasm,diffuse corneal gaze giving it ground glass
appearance
 This stage last for 2 weeks.

9. FLORID STAGE
 Eye is acutely inflamed.
 Deep vascularization covered by hazy cornea appear dull
reddish pink- salmon patch appearance.
 Superficial vessels and conjunctiva heap at the limbus.
 This stage last for 2 months.

11. STAGE OF REGRESSION
 Acute inflammation resolves.
 Clearing of cornea from periphery to centre.
 Resolution with some opacities and ghost vessels- non
perfused vessels

13. DIAGNOSIS
 Diagnosis is confirmed with blood tests : FTA-ABS
or MHA- treponema pallidum.
 Follow up with VDRL.

14.  Local treatment .
 Systemic treatment.
TREATMENT

15. LOCAL TREATMENT
It includes:
 Topical corticosteroids drops eg: dexamethasone.
 Atropine eye ointment 1% 2-3 times in a day.
 Dark goggles to be used in photophobia.
 Keratoplasty is required where dense corneal opacities are
left.

16. SYSTEMIC TREATMENT
 Benzyl Penicillin for ten days in high doses should be started
to prevent development of further syphilitic lesions.
 Systemic steroids may be added in refractory cases of
keratitis

17. TUBERCULOUS INTERSTITIAL KERATITIS
 The features of tuberculous interstitial keratitis are similar to
syphilitic interstitial keratitis except that is more frequently
unilateral & sectorial.
(usually involving a lower sector of cornea )

18. TREATMENT
 It consists of :
Systemic Antitubercular drugs
Topical steroids.
Cycloplegics.

19. COGAN’S SYNDROME
 This syndrome compromise unknown etiology, acute
tinnitus,vertigo, deafness
 It typically occurs in middle aged adults & is often bilateral.

20. TREATMENT
 It consists of: topical & systemic corticosteroids.
 Early treatment usually prevents permanent deafness &
blindness

22. MOOREN’S ULCER

23. DEFINITION
 Mooren’s ulcer ( chronic serpiginious or rodent ulcer ) is a
severe inflammatory peripheral ulcerative keratitis.

24. ETIOLOGY
 The exact etiology of mooren’s ulcer is not known.
 Most probably it is an auto immune disease.
 ( antibodies against corneal epithelium have been
demonstrated in serum)

25. CLINICAL FEATURES
 Two clinical varities of mooren’s ulcer have been recognised .
 Benign or limited form which is usually unilateral affect the
elderly Caucasians & is characterised by a relative slow
progress.

26. Cont.
 virulent type also called the progressive form is bilateral the
ulcer is rapidly progressive risk of scleral involvement.

27. SYMPTOMS
 It includes :
 Severe pain
 Photophobia
 Lacrimation
 Defective vision

28. SIGNS
 It is a superficial ulcer which start at the corneal margin
patches of grey infiltrates which coalesce to form a shallow
furrow over the whole cornea.
 Peripheral ulcer is associated with undermining of the
epithelium & superficial stromal lamellae at the advancing
border which forms a whitish overhanging edge .
 Base of ulcer soon become vascularized .
 End stage cornea is thinned & conjuctivalised.
 Ulcer rarely perforates & the sclera remains uninvolved.

29. “
”
Mooren's ulcers. (a) Peripheral corneal ulceration in a study patient; there is no involvement of the sclera (arrow).
(b) A clear corneal ulcer with a prowling edge in another study patient, showing the ulcer beginning at the
conjunction of the cornea and the sclera (arrow). (c) A rheumatoid arthritis-associated peripheral corneal ulcer. The
corneal ulceration is close to the central corneal area (arrow). There is a clear corneal area between the peripheral
corneal ulceration and corneal limbus. (d) Peripheral ulceration in a patient with Wegener's granuloma involving the
peripheral cornea and the sclera (arrow).

30. TREATMENT
 step-wise approach to the management of Mooren's ulcer, which is outlined as
follows:
1. Topical steroids
2. Conjunctival resection
3. Systemic immunosuppressives`
4. Additional surgical procedure
5. Rehabilitation
 The overall goals of therapy are to arrest the destructive process and to promote
healing and reepithelialization of the corneal surface

31. TOPICAL STEROIDS
 Initial therapy should include intensive topical steroids
 Prednisolone 1%, hourly in association with topical cycloplegics and prophylactic antibiotics.
 If epithelial healing does not occur within 2 to 3 days, the frequency of topical steroid application can
be increased to every half hour.
 Once healing occurs, the frequency can be reduced, and tapered slowly over a period of several
months.
 Such management, especially in unilateral, benign form gives good results.

32. Cont.
 Topical Oral therapy (60 to 100 mg daily of oral prednisone)
 tetracycline or medroxyprogesterone may be used for anticollagenolytic
properties of each.
 A therapeutic soft contact lens or patching

33. CONJUCTIVAL RESECTION
 Conjunctiva adjacent to the ulcer contains inflammatory cells that produce
antibodies against the cornea and cytokines which amplify the inflammation and
recruit additional inflammatory cell.
 conjunctival excision to bare sclera extending at least 2 clock hours to either side
of the peripheral ulcer, and approximately 4 mm posterior to the corneoscleral
limbus and parallel to the ulcer.

34. CONT.
 The overhanging lip of ulcerating cornea may also be removed.
 Tissue adhesive and a therapeutic soft contact lens may be beneficial.
 Cryotherapy of limbal conjunctiva may have a similar effect.

35. Systemic immunosuppressives
 The most commonly used agents are
 cyclophosphamide (2 mg/kg/day),
 methotrexate (7.5 to 15 mg once weekly) and
 azathioprine (2 mg/kg body weight/day).
 The degree of fall in white blood cell count is considered as the most reliable
indicator of immunosuppression produced by cyclophosphamide.

36. CONT.
 Agents such as cyclophosphamide may be effective by suppressing B
lymphocytes, which produce autoantibodies and promote immune complex
disease.
 oral cyclosporin A (10 mg/kg/day) has been successfully used to treat a case of
unresponsive bilateral Mooren's ulcer.
 It work by suppression of the helper T cell population and stimulation of the
depressed population of suppressor and cytotoxic T cells present in patients with
Mooren's ulcer.

37. CONT.
 Adverse effects of these, such as anaemia, alopecia, nausea, nephrotoxicity and
hepatotoxicity.

38. SURGICAL PROCEDURES
 Superficial lamellar keratectomy, has been shown to arrest the inflammatory
process and allow healing.
 Application of isobutyl cyanoacrylate, a tissue adhesive, forms a biological
barrier between host cornea and the reepithelializing conjunctiva and the
immune components it may carry.

39. CONT.
 When a perforation is too large for tissue adhesive to seal the leak, some type of patch
graft will be necessary.
 This may range from a small tapered plug of corneal tissue to a penetrating keratoplasty

40. Rehabilitation
 Rehabilitative surgical therapy in two stages, namely initial lamellar tectonic grafting followed by central
penetrating keratoplasty may be required in advanced cases.
 LKP is the most widely practiced surgery at present

41. CONT.
 For an ulcer smaller than half circle of the limbus and the central 7-8 mm of the
cornea uninvolved crescent shaped lamellar graft can be used.
 For an ulcer larger than 2/3 of a circle of the limbus where the central 7-8 mm of
cornea is intact, a doughnut shaped lamellar graft is recommended.

42. “
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