## Risk factors
- Trauma/abrasion
- CL wear especially extended wear and with poor hygiene
- Iatrogenic: suture removal, LASIK, topical therapy especially steroid
- Ocular surface disease/exposure, blepharokeratoconjunctivitis
- Lid disease: entropion/trichiasis
- Nasolacrimal disease: chronic dacryocystitis
- Immunosuppression
- Nutritional: vitamin A deficiency

## Complications
- Limbal/scleral extension
- Perforation
- Endophthalmitis (eg. gonococcus, fungi or perforation)

## Management

See Microbiology section for stains/culture media.
- Admit if necessary
- Identify risk factors (as above)
- Perform corneal scrape

### Sterilization phase
- Admission and stop CLs
- Intensive topical antibiotics: typically combined therapy with cephalosporin (eg. cefuroxime 5%) and fluoroquinolone (eg. moxifloxacin 0.5% which has superior ocular penetration or ofloxacin 0.3%) or gentamicin forte (1.5%). Hourly day and night instillation for 24-48 hours
     - Quinolone monotherapy is inadequate against resistant species of Staph and Pseudomonas
     - Prolonged use of fortified aminoglycoside is toxic to the epithelium and can lead to necrosis

- Consider oral antibiotics (typically ciprofloxacin) if limbal disease, perforation or risk of endophthalmitis or bacterial scleritis
- Oral tetracyclines (and vitamin C) can promote healing (inhibit MMPs and inflammatory cytokines)
- Cycloplegia and oral analgesia for comfort

### Healing phase
- Taper therapy with improvement
- Add lubricant
- Add non-preserved topical steroid to reduce inflammation (typically only after re-epithelisation)
    - Steroids are contraindicated in fungal or mycobacterial cases (risk factors include previous refractive surgery and trauma involving vegetation)
    - Steroids can retard the eyes response to the microbes and retard epithelisation

<HotTopic>

**The Steroids for Clinical Ulcer Trial (SCUT)**: showed no effect on overall visual outcome but no apparent increased risk of perforation or safety issues 

</HotTopic>

- Where there are no positive microbiology results and initial treatment is ineffective, consider with-holding treatment and re-scraping (or corneal biopsy, PCR or confocal microscopy)
    - Restart intensive antibiotics
    - Consider alternative diagnoses eg sterile ulcer
    - Therapeutic penetrating keratoplasty
    - Gunderson flap for non-healing ulcers

## Sterile ulcers
- Post-infective eg. herpetic, fungal
- Nearby ocular surface inflammation
    - Lids/lashes
    - Skin: SJS, OCP, rosacea
    - Lacrimal gland: sicca

- Neurotrophic
    - Diabetes, herpetic

- Exposure
    - Facial palsy
    - Lagophthalmos
    - Proptosis

- Nutritional: vitamin A deficiency
- Neoplasia: acute leukaemia
- Immune-mediated
    - Connective tissues disease/PUK
    - Mooren’s
    - Marginal keratitis
    - Allergic keratitis

- Iatrogenic/self-inflicted

## Fungal keratitis
- Filamentous (septate eg. Fusarium and Aspergillus, and non-septate) vs yeasts
- Risk factors
    - Trauma with organic matter
    - Ocular surface disease
    - Systemic/local immunosuppression or steroids 

<HotTopic>
Always consider fungal keratitis in patients on long-term steroids
</HotTopic>

### Features
- Fluffy/feathery white ulcer
- Satellite lesions
- Ring infiltrate
- Endothelial plaque

### Management
- Antifungals interfere with ergosterol metabolism
- Amphoteracin B 0.015% is a polyene (yeasts)
- Natamycin 5% (filamentous)
- Azoles can be used systemically but are toxic
- Topical voriconazole 0.1%

## Persistent epithelial defect
- Remember that drug toxicity may cause symptoms even after the infection is eradicated
- Defined as a defect for >2 weeks
- Use non-preserved preparations
- Reduce frequency of therapy
- Add lubricant
- Ocular surface protection: tarsorrhaphy

## Perforation
- Causes
    - Infectious:
        - Diphtheria and gonococcus can cause extremely rapid onset perforation due to their virulence
        - Shigella, Listeria, and Haemophilus aegyptus also classical penetrate intact corneal epithelium

    - Surface related
    - Autoimmune: eg collagen vascular diseases like RA, SLE, GPA, sarcoid and IBD
    - Other: Moorens

### Management
- Therapeutic contact lenses: if no tissue loss or very small. Use with PF antibiotics
- Corneal glue: if less than 2mm. Used with polythene patches and hydrogel contact lenses to reduce discomfort.
- Amniotic membrane: for larger perforations. Provides biologically active anti-inflammatory and anti-scarring mediators
- Lamellar or full-thickness keratoplasty reconstructions for larger perforations

Risk factors Trauma/abrasion CL wear especially extended wear and with poor hygiene Iatrogenic: suture removal, LASIK, topical therapy especially steroid…

Cornea

Microbial Keratitis

Intro

FRCOphth Part 2 Study Notes

Tumours, masses and neoplasia

Tumours overview

Uveitis

Uveitis background

Anterior uveitis

Intermediate uveitis

Uveitis in JIA

Uveitis with JIA

Retinal vasculitis

Sarcoidosis

Behcet's disease

Toxoplasmosis

Viral uveitis

Strabismus

Overview

Esotropia

Fungal uveitis

Mycobacterial uveitis

Adnexal masses

Spirochaetal uveitis (including Syphilis)

Exotropia

Melanoma

Nematode uveitis

Retinoblastoma

Retinoblastoma (for Part 2)

Incomitent

Voyt-Koyanagi-Harada syndrome

Conjunctival intraepithelial neoplasia

Vertical deviations

Sympathetic ophthalmia

Orbit and ocular adnexae

Orbit

AV Malformations and hamartomas

Arteriovenous malformations and hamartomas

Restriction syndromes

Paediatrics

Leucocoria

Congenital Cataract

Paediatric Glaucoma

Retinopathy of prematurity

Retinopathy of Prematurity

ROP-like disorders

Congenital nasolacrimal duct obstruction

White dot syndromes

Aniridia: Short Arm 11 Deletion (11p13)

Choristomas

Management Of Amblyopia

Alphabet patterns

Scleritis

Iris Nodules

Meningioma

Strabismus surgery

Optic nerve glioma

Lymphoma

Extraocular Muscles

Rhabdomyosarcoma

Idiopathic orbital inflammation

Orbital neuroblastoma

Anterior Persistent Foetal Vasculature

Lacrimal system

Metastatic lesions

Surgical Retina

Retinal Detachment

Vitreoretinal Interface And Macular Hole

Epiretinal Membrane

Medical Retina

Diabetic Eye Disease

Orbital Blood Vessels

Retinal Vascular Disease

Macular Degeneration

Central Serous Chorioretinopathy (CSCR)

Sickle Cell Retinopathy

Retinitis Pigmentosa

Albinism

Retinal Telangiectasias

Miscellaneous Retinopathies

Atropine And Myopia Progression

Pharmacology

Side Effects Of Systemic Drugs

Foetal Alcohol Syndrome

Neuro-ophthalmology

Optic Neuropathy

Papilloedema

Idiopathic Intracranial Hypertension

Chiasmal Disorders

Retrochiasmal Disorders

Migraine

Paranasal Sinuses

Supranuclear Motility Disorders

Third Nerve Palsies

Fourth Nerve Palsies

Sixth Nerve Palsies

Seventh Nerve Palsies

Anisocoria

Myasthenia Gravis

Myopathies

Blepharospasm

Functional Visual Loss

Lacrimal Glands

Phakomatoses

Developmental diseases

Tear Film

Eyelids

Blinking

Lid Malpositions

Anterior segment - ocular surface

Conjunctiva

Conjunctivitis

Sclera

Pigmented Conjunctival Lesions

Squamous Cell Carcinoma Of The Conjunctiva

Ocular Cicatricial Pemphigoid

Corneal Structure And Development