Cornea

Question 1

How to manage a corneal ulcer <1mm (presumed bacterial)?

Answer 1

General points: stop CL wear
1. g.levofloxacin 0.5% or g.ofloxacin 0.3% hourly in day for 48hrs (D+N if severe)
2. g.cyclopentolate BD for 1 week
3. Review in 72 hours to reduce drops to 6x/day and start chloramphenicol ointment ON for 1 week
4. SOS advice

Question 2

How to manage more severe microbial keratitis (sterilisation phase - 48-72hrs)

Answer 2

General: scrapes/CL to lab for C/s and gram satin, stop CL wear

1. Consider admission
2. Limbal lesion, consider oral ciprofloxacin 750mg BD for 1 week (high limbal availability)
3. 1hr g.cipro 0.3%, g.levo 0.5% or g.oflox 0.3% (D+N) +/- g.cyclo 1% BD for 1 week
4. Review in 3 days to decreased to x6/day + chloramphenicol ON for 1 week

Question 3

How to manage more severe microbial keratitis (healing phase - post 72hrs) - if improving or non improving?

Answer 3

After second review, if worsening add g.cefuroxime 5% or g.gentamicin [0.3%, 1.5%, 3% - avoid last two if possible] and review in 2 days

If improving - decrease g.quinolone (1hrly D only, 2hrly or x6/day), add chloro ointment ON and review in 3-5 days.
- if improving after 1st week - decrease G.quinolone to x6 or x4/day, add lubricants and review in 1 week.
- After 1st week, check sensitivities and consider adding g.dex 0.1% (maxidex) or g.pred 0.5% (pred sol) if needed to decrease scarring and help inflammation (re-epilisation and sterile culture)

Question 4

What are the factors that may make you consider admission in a. Severe microbial keratitis

Answer 4

• only eye
• hypopyon
• > 1/5mm diameter infiltrate,
• poor compliannce

Question 5

Which patients should you avoid topical steroids in

Answer 5

• If fungal keratitis suspected
• if HSV or mycobacteria are present (beware if prior refractive surgery or trauma involving vegetation - best to avoid)

Question 6

If epithelial defect persists for > 2 weeks, what management steps could you take?

Answer 6

• Switch to preservative free
• Decrease no. of drops/frquency of drops
• add lubricates
• consider assisting lid closure (medically or surgically)

Question 7

How to treat corneal perforation secondary to microbial keratitis? (X4 methods)

Answer 7

• BCL , will need changing once AC reforms
• Tissue adhesive (<2mm perfs) - basically corneal glue
• Amniotic membrane
• Reconstruction

Question 8

In a CL patient with a dendritic ulcer, what is the diagnosis unless proven otherwise?

Answer 8

Acanthamoeba

Question 9

What sx/signs may suggest acanthamoeba keratitis?

Answer 9

Symptoms:
- pain out of proportion with what is being seen
- CL wear: wash in tap water, swimming, extended wear
- Trauma

Signs:
- perineural/perilimbal infiltrate
- dendritic or pseudo dendritic ulcer
- decreased corneal sensation
- ring infiltrates

Question 10

When would you consider whether a patient has fungal keratitis?

Answer 10

• if immunosuppressed or if trauma (with organic material)