Do not miss Peripheral ulcers!

1. Non-Infective (immune-
mediated) keratitis
Samhaa Mohammed Abd Elmoneim
Zagazig Ophthalmic Hospital
2021

2. Case
Patient? came to outpatient clinic with both
eyes pain, photophobia, red eye, decreased
vision
Examination shows peripheral corneal
epithelial defect, infiltrate, thinning.

3. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic
What are the main differences?
Life
saving

4. Keratitis
C/P:
• Pain, photophobia, blurred vision
• Epithelial defect
• Stromal infiltrate/ thinning
• Anterior chamber reaction (complicated cases,
associated anterior uveitis)
• Secondary infection, scar, odema, melting,
abscess, NV, descemetocele, perforation)
‫التشابه‬ ‫أوجه‬
How to differentiate despite
C/P similarities?

5. What discriminate non-infective keratitis?
History Exam. Investigation
(cause)
Treatment
(cause)

6. Infective keratitis
Unilateral
Central/ peripheral
Trauma/ CL
Topical Tx> systemic
Infection penetration/
scarring > perforation
Non infective
Bilateral
Peripheral
Auto-immune disease
Systemic Tx > topical
More progressive to
perforation

7. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

8. Case
Patient? came to outpatient clinic with both
eyes pain, photophobia, red eye, decreased
vision
Examination shows peripheral corneal
epithelial defect, infiltrate, thinning.
AGE GENDER,
OCULAR,
SYSTEMIC
help in Dx

9. How do you think about peripheral
cornea ulcer?
Exclude
infective
causes
Consider
autoimm
une
diseases
Consider
associate
d ocular
condition
If NO
More Common
For
Consultation
Blepharo-
conjunctivitis
Roscea
Mooren

10. Case
Patient? with Hx of recurrent chalazia came to
outpatient clinic with both eyes pain,
photophobia, red eye, decreased vision
Examination shows peripheral corneal
epithelial defect, infiltrate, thinning.
OCULAR

11. How do you think about peripheral
cornea ulcer?
Exclude
infective
causes
Consider
autoimm
une
diseases
Consider
associate
d ocular
condition
If NO
More Common
For
Consultation
Blepharo-
conjunctivitis
Roscea
Mooren

12. Marginal keratitis
Blepharo-conjunctivitis
hypersensitivity ③
immune-complex to
staph
Infiltrate → ukceration
Marginal keratitis
Topical steroid/ lid
hygeine/ oral
doxycycline
+ topical AB in
epithelial defect

13. Phlycten
hypersensitivity ④
delayed, T helper to
staph, TB (QFT), young
age, stool analysis
(Asthma….)
Phlycten
Topical steroid/ lid
hygeine/ oral
doxycycline/
Azithromycin
-TB Tx (Rifampicin)

14. Rosacea
-hypersensitivity ④
-papulo-pustular rash,
telangectasia,
rhinophyma
Rosacea
Lid blepharitis
telangectasia, chalazia
conjunctivitis, phlycten,
marginal keratitis,
vascularization,
thinning, dry eye
Hypersensitivity
types? Examples?

15. Rosacea
-Topical AB
(Erythromycin, Fusidic,
Azithromycin)
-lid hygeine/ hot
fomentation
-oral Doxycycline 2/d
for 4wk (↓ fatty acid
production in MG,
anticollagenase,
↓normal flora)
- Refer to
dermatologist

16. Case
Patient? with Hx of nasal bleeding came to
outpatient clinic with both eyes pain,
photophobia, red eye, decreased vision
Examination shows peripheral corneal
epithelial defect, infiltrate, thinning.
F 30y SYSTEMIC
(AUTOIMMUNE
DISEASE)

17. How do you think about peripheral
cornea ulcer?
Exclude
infective
causes
Consider
autoimm
une
diseases
Consider
associate
d ocular
condition
If NO
More Common
RA, SLE, PAN
For
Consultation
Blepharo-
conjunctivitis
Roscea
Mooren
Life
saving

18. PUK (peripheral
ulcerative keratitis)
RA, (ESR, CRP, RF),
Wegner
Granulomatosis
(ANCA-C), SLE, PAN
(ANCA-P)
PUK
Cresenteric ulcer →
CL ulcer
Limbitis, scleritis,
episcleritis
Vaso-occlusive
RA (skin, joints)
WG (ENT, renal)

19. PUK
Refer to
rheumatologist
Systemic steroid/
Doxycycline
Topical PF lubricant,
steroid?
PUK
Conjunctival resection
Perforation (AMT,
cyanoacrylate,
Tectonic lamellar KP)
PKP (recurrence,
rejection)
DD inferior
epithelial defect

20. PUK
Conjunctival resection
Perforation (AMT,
cyanoacrylate,
Tectonic lamellar KP)
PKP (recurrence,
rejection)
PUK
Refer to
rheumatologist
Systemic steroid/
Doxycycline
Topical PF lubricant,
steroid?
Tectonic
lamellar KP

21. Case
Patient? 60y came to outpatient clinic with RT
eyes pain, photophobia, red eye, decreased
vision.
Examination shows peripheral corneal
epithelial defect, infiltrate, thinning.
NO

22. How do you think about peripheral
cornea ulcer?
Exclude
infective
causes
Consider
autoimm
une
diseases
Consider
associate
d ocular
condition
If NO
More Common
RA, SLE, PAN
For
Consultation
Blepharo-
conjunctivitis
Roscea
Mooren

23. Mooren
Peripheral, circumferential
ulcer
Limbitis
Undermined, infiltrated
leading edge
Exclude autoimmune
disease
Mooren
Old age: unilateral
Young age: more
aggressive bilateral

24. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

25. Interstitial keratitis
• Non ulcerative stromal inflammation
• C/P: early stromal odema, infiltrate, NV,
ghost vessels, lipid keratopathy, scarring.
+ C/P of the cause (associated ocular, systemic
manifestation/ hx/ Tx)
Causes

26. Interstitial keratitis
Immune mediated
• Cogan syndrome
• Sarcoidosis
• CL associated
• RA, PAN, wegner
granulomatosis
Infectious
• Herbetic stromal
• Syphilis
• TB, lyme
• Fungal,
acanthamaeba (other
involved layers)

27. CL
(NV)
Cogan syndrome
(periphery)

28. Syphilis
Feathery? scarring
Syphilis
Stromal hge
Ocular
association
of Syphilis?

29. Interstitial keratitis
Immune mediated
• Cogan syndrome
(systemic steroid)
• Sarcoidosis
• CL associated (self
limiting)
• RA, PAN, wegner
granulomatosis
Infectious
• Herbetic stromal
• Syphilis
• TB, lyme
• Fungal,
acanthamaeba (other
involved layers)
Topical/ systemic
steroids
Topical/ systemic
microbial

30. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
BUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

31. Infective keratitis
Unilateral
Central/ peripheral
Trauma/ CL
Topical > systemic
Infection penetration/
scarring > perforation
Non infective
Bilateral
Peripheral
Auto-immune disease
Systemic Tx > topical
More progressive to
perforation

32. DD corneal thinning (ulcerative/ non
ulcerative)?

33. Thank you