Case: Corneal ulcer 서울성모병원 임상강사 황규연

2012.3.10 F/78 C/C tearing, redness, pain (OD) Onset 7일전, trauma Hx(-) Past Hx DM(+) CRVO(OD) NVG(OD) PDR(OU)  blindness(OD) 8년전 cat. Op(OD) 2-3년전 intravit. Avastin Inj(OD) x3 2달전 ppV d/t PDR c vit Hm(OS), phaco+PCL(OS) BCVA OD LP(-) OS 0.32(n-c) Ta OD 25 OS 20mmHg (O-COSTx2 O-BMDPx2 O-LTPxhs/(OU))

2012.3.10 Irregular epi-defect c infiltraion at center Melting(-) AC reaction (cell, hypopyon)

2012.3.10

생각할 점 각막 궤양의 원인균은 무엇인가? Infection의 방향 Bacterial (G+, G-(pseudomonas), ---) Fungal Infection의 방향 Corneal ulcer  endophthalmitis 서로 다른 경로로 발생

Classic presentation of corneal ulcer

Staphylococcus Staphylococcus

생각할 점 각막 궤양의 원인균은 무엇인가? Infection의 방향 Bacterial (G+, G-, pseudomonas, ---) Fungal Infection의 방향 Corneal ulcer  endophthalmitis 서로 다른 경로로 발생

Eye (2009) 23, 945–956

impression Corneal ulcer c endophthalmitis(OD) Cornea smear and culture Start broad spectrum antibiotics (vigamox + tobramycin x q1hr) Topical cycloplegics Paracentesis for culture Intravit. Vancomycin + fortum injection Systemic antibiotics (3rd cephalosporin)

2012.3.14 (HD #4)

검체: cornea smear 검체: anterior chamber

Eye (2009) 23, 945–956

S. Aureus Etiology rapidly progressive corneal infiltration More in compromised cornea Bullous keratopathy, chronic herpetic keratitis, keratoconjunctivitis sicca, ocular rosacea, atopic keratoconjunctivits rapidly progressive corneal infiltration moderate AC reactions with hypopyon Round or oval with dense infiltration and a distinct border Occasionally a stromal microabscess with an ill-defined border

2012.3.14 (HD #4) Vigamox x q1hr  q2hr tapering Tobramycin x4 Systemic antibiotics change (nafcillin)

2012.3.16~22 (HD #6~13) Cornea: decreased infiltration and microabscess (epi-defect enlarged d/t mechnical trauma) AC: decreased hypopyon

2012.3.31 (#21) Conjunctival injection : decreased Epi-defect(+), but infiltration(-) F-stain: late pooling vigamox x4 tapering, artificial eyedrops,

Review: How to approach to patients?

Culture-guided approach Corneal scrapings for staining and microbiological culture are performed in all cases of microbial keratitis before treatment is started. The initial therapy is based on the clinical and epidemiological information and may be modified according to microbiological results. Severe corneal ulcers or infections caused by atypical pathogens. Beneficial to monitor infectious trends through epidemiological surveys. The major disadvantage of this approach is the inconvenience and cost.

Empirical approach Pre-existing culture and sensitivity data without obtaining corneal specimens. Broad-spectrum antibiotics to cover potential causative organisms. The advantages of this approach are convenience and cost- effectiveness. The disadvantage Prolonged and nonelective use of fortified antibiotics may cause ocular discomfort and epithelial toxicity is no longer be collected for future reference and for monitoring of the potential emergence of resistant organisms.

Case-based approach Clinicians obtain corneal specimens before initial treatment only in selective cases with ulceration involving visual axis or with large, deep ulcers, trauma, or contamination by vegetation materials or unsanitized water.

Pathogenesis Gram-positive isolates Gram-positive cocci Class/organism Common isolates* Cases (%) Gram-positive isolates 29–53 Gram-positive cocci Staphylococcus aureus 4–19 Coagulase-negative staphylococci 1–45.5 Streptococcus pneumoniae 0–3 Streptococcus viridans group 1–6 Gram-positive bacilli Propionibacterium species 4–7 Mycobacterium species 3 Gram-negative isolates 47–50 Gram-negative bacilli Pseudomonas aeruginosa 3–33 Serratia marcescens 3–13.5 Proteus mirabilis 4 Enteric Gram-negative bacilli, other 1–10 Gram-negative Haemophilus influenzae, other Haemophilus species 2.5 Coccobacillary organisms Moraxella species and related species 1 Gram-negative cocci Neisseria species 2008 ophthalmology

Treatment Antibiotic therapy of bacterial keratitis Organism Topical concentration Subconjunctival dose No organism identified or multiple types of organisms Cefazolin with Tobramycin or gentamicin or Fluoroquinolones* 50 mg/mL 9–14 mg/mL Various 100 mg in 0.5 mL 20 mg in 0.5 mL Gram-positive cocci Cefazolin Vancomycin Bacitracin Fluoroquinolones* 15–50 mg/mL 10000 IU 25 mg in 0.5 mL Gram-negative rods Tobramycin or Gentamicin Ceftazidime Fluoroquinolones Gram-negative cocci Ceftriaxone Nontuberculous mycobacteria Amikacin Clarithromycin Azithromycin Fluoroquinolones 20–40 mg/mL 10 mg/mL Antibiotic therapy of bacterial keratitis

Evolution of the Quinolones Norfloxacin Lomefloxacin Ciprofloxacin Ofloxacin Sparfloxacin Grepafloxacin Levofloxacin Gatifloxacin Moxifloxacin Nalidixic Acid H3C N C2H5 O COOH H3C-N F CH3 N O COOH H HN N F O COOH O F COOH H HN N N OCH3 H Extended spectrum Enhanced activity against Gram-positives, streptococci, anaerobes, atypical mycobacteria Improved pharmacokinetic properties Extended spectrum Enhanced activity against Gram-negatives Limited spectrum of activity American Pharmaceutical Association; 2000.

Treatment * Initial management of microbial keratitis.

Clinical features suggestive of a positive response to antibiotic Tx 1) reduction in pain 2) reduced amount of discharge 3) less eyelid edema or conjunctival injection 4) consolidation and sharper demarcation of the perimeter of the stromal infiltrate 5) decreased density of the stromal infiltrate 6) reduced stromal edema and endothelial inflammatory plaque 7) reduced anterior chamber inflammation and reepithelialization.

Treatment * Reevaluation after 1 week of antimicrobial therapy.