This document discusses various viral and protozoal causes of corneal ulcers, including herpes simplex virus (HSV), herpes zoster virus, and acanthamoeba. It describes the etiology, clinical features, diagnosis, and treatment of these conditions. Primary and recurrent HSV keratitis present with punctate epithelial lesions and dendritic ulcers. Herpes zoster ophthalmicus causes vesicular skin lesions following reactivation of varicella zoster virus in the trigeminal ganglion. Acanthamoeba keratitis is an opportunistic infection associated with contact lens use that presents with epithelial lesions and stromal infiltrates. Treatment involves antiviral medications for viruses and anti-am

1. VIRAL CORNEAL ULCER
Dr.Shanmuga sundaram
Ref.A.K.Khurana of Ophthalmology

2. Common viral infections
Includes
• Herpes simplex virus (HSV)
• Herpes zoster ophthalmicus
• Adeno virus keratitis

3. HERPES SIMPLEX KERATITIS
• Extremely common
• Constitute herpetic keratoconjunctivitis and
iritis
ETIOLOGY:-
Herpes simplex virus-
- DNA virus

4. HSV types :-
 HSV - I – above waist
 HSV – II – below waist
Mode of infection:-
HSV – I – acquired by kissing or close contact
with herpes labialis patient
HSV – II – transmitted to eyes of neonate from
affected genitalia

5. 0ccular lesions of herpes simplex
A. Primary herpes
- skin lesions
- acute follicular conjunctivitis
- cornea
- fine epithelial punctate keratitis
- coarse epithelial punctate keratitis
-dendritic ulcer

6. B. Recurrent herpes
1.active epithelial keratitis
- punctate epithelial keratitis
- dendritic ulcer
- geographical ulcer
2.stromal keratitis
- disciform keratitis
- diffuse stromal necrotic keratitis
3.trophic keratitis
4.herpetic iridicyclitis

7. Primary occular herpes
• Non-immune person
• Typically occurs in children of age 6 months to
5 years and teenagers
CLINICAL FEATURES
1.systemic features
• Mild fever , malaise , non suppurative
lymphadenopathy

8. 2.Skin lesions
Vesicular lesions over face , lips , periorbital
region and lid margins
3.Occular lesions
- acute follicular conjunctivitis
- keratits (coarse punctate or diffuse
branching epithelial keratitis )

9. Recurrent occular herpes
occurs due to periodical reactivation and
replication of virus in trigeminal ganglion
Predisposing stimuli
- fever , malaria , flu
- exposure to UV rays
- general ill health , mild trauma
- steriod and immunosuppresent
administration

10. 1.Epithelial keratits
SYMPTOMS
redness , pain , photophobia , tearing and
decreased vision
SIGNS
three dinstinctive patterns
1. punctate epithelial keratitis
- initial epithelial lesion
- fine or coarse superficial punctate lesion

11. 2. dendritic ulcer
- typical lesion
- irregular , zig zag linear branching shape
- branches knobbed at ends

12. 3.Geographical ulcer
branches of dendritic ulcer enlarges and
coalesces to form ‘ amoeboid ‘ or
‘geographical’ configuration
steroid use in dendritic ulcer also lead to
geographical ulcer

13. TREATMENT
A. specific treatment
1.antiviral drugs
-Acycloguanosine (Acyclovir) 3% ointment
5 times a day for 14-15 days
-Ganciclovir(0.5% gel) 5 times a day untill
ulcer heals and then 3 times a day for 5
days
- Triflurothymidine
- Adenine arabinoside(vidarabine)

14. 2.mechanical debridement
removal of virus laden cells along with a
rim of surrounding healthy epithelium
3.systemic antiviral drugs
for a period of 10-21 days
- acyclovir 400mg p.o tid to bid
- famcyclovir 250mg
- valacyclovir 500mg p.o bid

15. 2.Stromal keratitis
a.disciform keratitis
pathogenesis:-
- delayed hypersensitivity reaction to HSV
antigen
- primarily endothelitis occurs
- endothelial damege leads to disciform
corneal stromal oedema

16. SYMPTOMS:-
- Photophobia , mild to moderate occular
discomfort , reduction in visual acuity
SIGNS:-
• focal disc shaped patch of stromal oedema
• folds in descemet’s membrane
• keratic precipitates
• ring of stromal infiltrate (wessely immune
ring)
• Dinminished corneal sensations
• IOP may be raised

17. TREATMENT:-
- diluted steroid eye drops instilled for 4-5
times a day with an antiviral cover twice a day
- non specific and supportive treatment
b. stromal necrotic keratitis :-
caused by active viral invasion and tissue
destruction
symptoms:-
pain , photophobia , redness

18. signs :-
1. corneal lesion include necrotic ,blotchy ,
cheesy white infiltrates
2. mild iritis & keratic precipitates
Treatment:-
- systemic antiviral drugs
- keratoplasty

19. 3.Metaherpatic keratitis
• Not an active viral disease
• Mechanical healing problem due to persistent
defect in basement membrane
• Occurs at a site of previous herpetic ulcer
Clinical features:-
indolent linear or ovoid epithelial defect
margins-grey and thickened
Treatment:-
aimed to promote healing by use of lubricants ,
bandage soft contact lens and lid closure

20. HERPES ZOSTER OPHTHALMICUS
acute infection of gasserian ganglion of fifth
nerve by varicella zoster virus
ETIOLOGY:-
- varicella zoster virus
PATHOGENESIS:-
infection manifest as chicken pox and the child
develops immunity
virus remains in sensory ganglion of trigeminal
nerve

21. diminished immmunity
reactivation and replication of dormant
virus
virus then travels down along the branches
of ophthalmic division of trigeminal nerve
causes cutaneous and occular lesions

22. CLINICAL FEATURES:-
- frontal nerve is more affected
- occular complications
- Hutchinson’s rule
occular involvement is frequent , if
vesicles where present over side or tip of the
nose
- lesions are strictly limited to one side of the
head

24. CLINICAL PHASES:-
1. Acute phase lesions
2. Chronic phase lesions
3. Relapsing phase lesions
1.ACUTE PHASE LESIONS
A. general features:-
fever , malaise , severe neurologic pain
B. cutaneous lesions:-
area of distribution is area where the affected nerve
distributed
- red and oedematous(mimicking erysipelas), followed
by vesicular formation
- pustules  crusted ulcers  permanent pitted scars
- last for 3 weeks
- severe neuralgic pain

25. C. Occular lesions:-
 conjunctivitis – mucopurulent with
petechial heamorrhages or acute follicular
with regional lymphadenopathy
 zoster keratitis
fine or coarse punctate epithelial
keratitis – followed by micro dentritic keratitis

26. Nummular keratitis
tiny multiple
granular deposits
surrounded by halo of
stromal haze
heal- nummular scar
Disciform keratitis
preceded by nummular
keratitis

27.  episcleritis and scleritis
 Iridocyclitis
 acute retinal necrosis
 secondary glaucoma
 anterior segment necrosis and phthisis
bulbi
D. associated neurological complications
- motor nerve palsies
- optic neuritis
- encephalitis

28. 2. CHRONIC PHASE LESIONS
 post-herpetic neuralgia
persistent pain even after subsidence
of eruptive phase of zoster
pain : mild to moderate , worsens at
night , aggrevated by touch and heat
aneasthesia dolorosa : aneasthesia of
skin associated with continued postherpetic
neuralgia
 lid lesions – ptosis , trichiasis , entropian
and notching

29.  conjunctival lesions – mucuos secreting
conjunctivitis
 corneal lesions
- neuroparalytic ulceration
- exposure keratitis
- mucous plaque keratitis
sudden development of elevated
mucous plaque stains brilliantly with rose
bengal
 scleritis and uveitis

30. 3.RELAPSING PHASE LESIONS
recurs even after 10 years of acute phase
include nummular keratitis , mucous plaque
keratitis , episcleritis , scleritis , secondary
glaucoma
TREATMENT
aimed at preventing severe devasting ocular
complications and promoting rapid healing of
skin lesions resulting in scarring of the nerves
and postherpetic neuralgia

31. 1.Systemic therapy
Oral antiviral drugs
started immediately after onset of rash
* Acyclovir 800 mg 5 times a day – 10 days
or
* valaciclovir 500 mg TDS
 Analgesics
combination of mephanic acid and
paracetamol or pentazocin or pethidine

32. Systemic steroids
apear to inhibit postherpetic neuralgia
when given in high doses
consider also the complications of high
dose steroids
Cimetidine – 300 mg QID for 2-3 wks starting
within 48-72 hrs of onset – to reduce pain
Amitriptyline – releive accompanying
depression

33. 2.Local theraphy
FOR SKIN LESIONS:-
 antibiotic-corticosteroid skin ointment or lotions
: 3 times a day till skin lesion heals
 No calamine lotion : as it promotes crust
formation
FOR OCCULAR LESIONS:-
 for zoster keratitis , iridocyclitis , scleritis
* topical steroid eye drops - 4 times
* cycloplegics – cyclopentaloate , atropine
* topical acyclovir

34. Topical antibiotics to prevent secondaary
infections
For secondary glaucoma
timolol, betaxolol,
accetazolamide 250 mg QID
For mucous plaques – topical mucolytics –
accetyl cysteine 3 times a day
 for persistent epithelial defects
* lubricating artificial tear drops
* bandage soft contact lens

35. 3.Surgical treatment
Lateral tarsorrhaphy
Amniotic membrane transplantation
 tissue adhesive with bandage contact lens
 keratoplasty

36. PROTOZOAL KERATITIS
ACANTHAMOEBA KERATITIS
Etiology:-
causative organism-acanthamoeba castellani
mode of infection
- contact lens wearers using home made saline
- mild trauma associated with contaminated
vegetables
- oppurtunistic infection

37. Clinical features
Symptoms
foreign body , mild to moderate pain ,
watering , photophobia , blepharospasm ,
blurred vision
Signs
- epithelial lesions
* epithelial roughening and ridges
* pseudodendritis
* epithelial and subepithelial curvilinear
opacities

38. - stromal lesions
* radial keratoneuritis
* patchy and satellite stromal infiltrates
* ring infiltrates
* ring abscess
- limbal and scleral lesions
* limbitis
* scleritis

39. Differential diagnosis
1.viral keratitis
2.fungal keratitis
3.suppurative keratitis
Diagnosis:-
difficult and usually made out by exclusion
with strong suspicion of non responsive
patients
 confocal microscopy – allows direct
visualisation of cyst

40. Laboratory diagnosis:-
- KOH mount – reliable for experienced hands
- calcofluor white stain – bright apple green
- lactophenol cotton blue stained film
- culture on non nutrient agar – show
trophozoites within 48 hours
- PCR – amoebic DNA
- corneal biopsy

41. treatment
• Topical anti amoebic agents
- diamidines
- biguanides
- aminoglycosides , imidazoles
- multiple drug theraphy
- propamidine or hexamidine + PHMB
- chlorhexidine + neomycin
- oral ketoconazole 200 mg BID
- long term prophylactic treatment with PHMB
twice a day for 1 year
- penetrating keratoplasty