Introduction

Keratitis is a condition which the eyes cornea become

inflamed and clouded.

Anatomy
The cornea is the anterior, projecting, transparent part of the external tunic.

Histology
The cornea consists of five layers arranged anteroposteriorly as follows: corneal epithelium, which is continuous with the conjunctival epithelium; anterior limiting lamina; substantia propria; posterior limiting lamina; endothelium.

Physiology
The cornea functions as a protective membrane and a

"window" through which light rays pass to the retina. Its transparency is due to its uniform structure, avascularity, and deturgescence.

Keratitis
Keratitis is corneal inflamation. Usually classified by affected layer into superficial and deep keratitis. Keratitis can be caused by infection, dry eyes, drug intoxication, allergy or chronic conjunctivitis. Signs : red eyes / bloodshot eyes & clouded image in cornea. Symptoms : pain & photophobia. Treatment based on etiology and atropine or mydriatric eye drops.

Bacterial Keratitis
Corneal disease caused by bacterial organisms.
Bacterial keratitis is considered a leading cause of

monocular blindness in the developing world.

Clinical Features
The clinical signs and symptoms of bacterial keratitis

depend greatly on the virulence of the organism and the duration of infection. Key features : Cellular infiltration of the corneal epithelium or stroma, corneal inflammation, and necrosis. Associated features : lid edema, conjunctival inflammation, discharge, anterior chamber reaction, hypopyon.

Etiology
Many bacteria can cause bacterial keratitis.
Gram-Positive bacteria that infect cornea :

staphylococci, streptococci, Bacillus cereus, corynebacteria, Listeria monocytogenes, clostridium, and Propionibacterium acnes. Gram-Negative bacteria that infect cornea : pseudomonas, serratia, escherichia, klebsiella, proteus, moraxella, haemophilus, neisseria, and Branhamella catarrhalis. Mycobacterium.

Streptococcal Bacterial Keratitis

Streptococcal bacterial keratitis with infiltration of the central cornea.

Pseudomonas Bacterial Keratitis

Intraepithelial infiltration of the cornea by Pseudomonas organisms in a hydrophilic contact lens wearer.

Diagnosis
The presumptive diagnosis of infectious keratitis is

based primarily on the clinical history and physical examination, but confirmation of infectious infiltration and definitive identification of the offending organism can be achieved only by examining stained smears of corneal scrapings and laboratory cultures of these scrapings.

Corneal Scarping
This procedure is performed at the slit lamp. The eye is anesthetized with topical anesthetic, and a heatsterilized platinum spatula or blade is used to firmly scrape. Scrapings should be placed on a slide for staining and directly applied to culture media to maximize the chance of recovery.

Staining
The most commonly applied stains are Gram's and

Giemsa stains. Ziehl-Neelsen stain : suspect mycobacterium infection.

Treatment
Gram-Negative
Gentamicin. Tobramycin. Polimiksin.

Gram-Positive
Cefazolin. Vancomycin. Basitracin.

Fungal Keratitis
Corneal disease caused by fungal organisms.
Fungal infections of the cornea are relatively

infrequent in the developed world but constitute a larger proportion of keratitis cases in many parts of the developing world.

Clinical Features
Fungal infection tends to arise in traumatized,

diseased, and immunocompromised corneas. Key features : Cellular infiltration of the corneal epithelium or stroma, corneal inflammation, and necrosis. Associated features : long-term steroid use, trauma involving vegetative matter, corneal infiltrate with feathery borders or satellite lesions.

Diagnosis
A high level of suspicion for nonbacterial keratitis

must be maintained at all times. Definite diagnosis : laboratory confirmation, by scraping for stains and cultures.

Treatment
Polyenes : amphotericin B, natamycin. 2. Imidazoles : ketoconazole, miconazole. 3. Triazoles : fluconazole. 4. Pyrimidines : flucytosine.
1.

Herpes Simplex Keratitis

Herpes simplex viral infection of the cornea.
Human herpesviruses have in common a state called

latency. Keratitis caused by HSV is the most common cause of cornea-derived blindness in developed nations.

Classification
Epithelial keratitis, 2. Stromal/endothelial keratitis,
1.

Epithelial Keratitis
Caused by actively replicating virus on the corneal surface. Initial episodes present with foreign body sensation but subsequent episodes are usually painless. Dendritic ulcer classic feature of epithelial disease.

Stromal/Endothelial Keratitis
This is usually an immunemediated response to nonreplicating viral particles, but more severe forms may be caused by live virus. Focal endotheliitis (disciform keratitis) classic feature of stromal disease.

Diagnosis
Diagnostic testing is seldom needed in epithelial

Herpes Simplex Virus Keratitis (HSVK) because of its classic clinical features and is not useful in stromal keratitis as there is usually no live virus present. Diagnostic testing that can be used : culture, DNA testing, fluorescent antibody testing, Tzanck smear,and serum antibody testing.

Treatment
Treatment of HSV is diametrically different from

epithelial and stromal keratitis. Antiviral : acyclovir, valacyclovir, famciclovir.

Noninfectious Keratitis
Noninfectious keratitis is typically characterized by

persistent corneal epithelial defects, stromal inflammation, and enzymatic degradation of the corneal collagen.

Moorens Ulcer
Moorens ulcer is a rare, chronic, painful, peripheral

ulcerative keratitis. The pathogenesis of Moorens ulcer is unknown but appears to involve an autoimmune reaction against a specific target molecule in the corneal stroma, which may occur in genetically susceptible individuals.

Types
Limited Types
Unilateral, Occurs in older patients

Second Types
More resistant to systemic

(fourth decade and older), More responsive to local surgical and medical therapy.

immunosuppression Involves a bilateral, painful, relentless, progressive destruction of the cornea, Usually in younger individuals (third decade), Many of whom are of African descent.

Ocular Manifestation
Moorens ulcer is characterized by a progressive, crescentic, peripheral corneal ulceration that is slightly central to the corneoscleral limbus.

Keratoconjunctivitis Sicca
Happened due to dryness on the corneal surface.
Patient may complain itch, foreign body sensation,

and blurred vision.

Treatment
Artificial tears,
Contact lens, Lacrimal puncta block.