Suppurative Keratitis
Suppurative Keratitis
Suppurative Keratitis
June 2005
Authors: Dr. Edith Ackuaku, MB ChB, DO, MRCOphth, FWACS Senior Lecturer, Eye Unit, Department of Surgery University of Ghana Medical School, Korle Bu Teaching Hospital Dr. Maria Hagan, MB ChB, DOMS, DCEH, MRCOphth Head, Eye Care Unit, Ghana Health Service Former Head, Eye Unit, Korle Bu Teaching Hospital Professor Mercy Newman, MB ChB, MSc, FWACP Professor and Head, Department of Microbiology University of Ghana Medical School, Korle Bu Teaching Hospital
TABLE OF CONTENTS
Page 1. Acknowledgment 2. Foreword 3. Introduction 4. Aetiology 5. Epidemiology 6. Predisposing Factors 7. History Taking 8. Clinical Presentation 9. Examination 10. Microbiology Investigation 11. Treatment Guideline 12. Appendices Flow chart Treatment Guidelines Sample treatment Form Preparation of fortified antibiotics 13. References 3 4 5 6 7 8 9 10 14 21 24
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ACKNOWLEDGEMENT
This manual is based on the results of a Multi-centre Corneal Ulcer Project in Accra, coordinated from the International Centre for Eye Health (ICEH), London. The following Ophthalmologists actively participated in the study: Dr. Vera Essuman Dr. Oscar Debrah Dr. Ababio Danso Korle Bu Teaching Hospital, Accra Bawku Presbyterian Hospital Eye Clinic Agogo Presbyterian Hospital Eye Clinic
The study was initiated by Professor Gordon Johnson, and coordinated by Dr. Astrid Leck, both from ICEH, London. Treatment flow-chart was designed by Mr. George Anthony Kofi Bentum Hagan
Correspondence address Dr. Maria Hagan EYE CARE UNIT GHANA HEALTH SERVICE PRIVATE MAILBAG, MINISTRIES, ACCRA
E-mail [email protected]
Fax: 233-21-666850
FOREWORD
Suppurative Keratitis is an important cause of avoidable blindness in Ghana. The blindness results from corneal scarring. Corneal scarring may also represent the long term sequelae of trachoma or follow infections of eye injuries. An earlier study in Ghana on the causes of suppurative keratitis showed that one or more organisms were cultured from 114 out of 199 patient. Fungi alone or in combination were isolated in 56% of patients who had positive cultures. While 122 out of 199 had their treatment either determined or altered on the results of microbiological diagnosis, only 87 out of these had their treatment solely on the basis of direct microscopic examination. In Bangladesh a study by Williams and associates demonstrated that a simple miocrobiological laboratory made a substantial difference to accuracy of management of corneal suppuration. Of fifty-eight cases that were culture positive the results of forty-seven could have been anticipated on the basis of Gram stain alone. The Ghana study showed that both training in technique and experience in interpretation are necessary for microscopy based diagnosis by staff in the eye clinic to be of greatest value. This manual based on the results of a Multi-centre Corneal Ulcer Project in Accra and India and coordinated from the International Centre for Eye Health (ICEH), London, is to guide ophthalmologists in the management of suppurative keratitis. Early, accurate and effective management of this condition should help prevent blindness from suppurative keratitis. The manual is arranged under the following headings: 1. Introduction 2. Aetiology 3. Epidemiology 4. Predisposing Factors 5. History Taking 6. Clinical Presentation 7. Microbiology Investigation 8. Treatment Guidelines It is hoped that clinicians and medical technologists/technnicians will find the manual useful.
SIGNED Professor Agyeman Badu Akosa Director General, Ghana Health Service.
INTRODUCTION
Suppurative keratitis (infective corneal ulcer) is an important cause of preventable blindness especially in the developing world. Often it follows corneal trauma caused by airborne particles entering the eye and causing damage to the surface of the eye (the Cornea). These foreign bodies may be, vegetable matter such as rice husk, soil, sand, or metallic. These foreign bodies not only damage the corneal surface, but they also introduce infection. When left untreated or if inadequately treated, these ulcers progress and eventually lead to blindness. Prompt and adequate treatment may save the eye and salvage vision. Suppurative corneal ulcers may be caused by bacteria, fungi, or protozoa. For effective treatment it is crucial to identify promptly the causative organisms. Management is usually by intensive use of topical antimicrobials.
AETIOLOGY
From studies done in Ghana, the common causes of corneal ulcers include: 1. Bacteria (10.7%) mainly: Pseudomonas species Streptoccoccus species Staphyloccoccus aureus/epidermidis 2. Fungus (35.7%) commonly: Fusarium species Aspergillus species 3. 4. Mixed infections (both bacteria and fungi) = (1.7%) Unknown (51.7%)
Note: protozoa (e.g acanthoamoeba) and non-filamentous fungi (e.g Candida) may also cause corneal ulcer but are rare. In a recent study in Ghana one acanthoamoeba was isolated.
EPIDEMIOLOGY
From studies done in Ghana AGE All age groups are affected, but average age is 35 years SEX Male : Female ratio is 1.4:1 SEASONALITY There are seasonal differences in geographical regions in Ghana, with peak infection coinciding with the harvesting season: June/July in the southern belt and November / December in the northern belt.
PREDISPOSING FACTORS
The normal cornea is protected from infection by its surface epithelium. Most organisms cannot penetrate the intact corneal epithelium. The following may predispose to suppurative corneal ulcers. Trauma: -e.g. from twigs, thorns, husk or seeds, finger pricks from a baby, broomsticks (in children during play). Abnormalities of eyelid: -e.g. trichiasis, lagophthalmos Malnutrition and Vitamin A deficiency and measles: - Usually in children. Harmful eye Practices -e.g. use of herbal preparations or steroid eye drops for treatment of eye infections
HISTORY TAKING
The history may suggest the causative organism in some patients but is not always useful. A history of injury on the farm or during gardening may suggest a fungal infection. Fungal infections are the commonest cause of corneal ulcers and would usually follow a slow chronic course. Bacterial infections are more acute and progress faster. Gram negative bacteria would usually progress very rapidly to involve the whole cornea in a few days. Record the severity of pain, photophobia and watering, as changes in these parameters will help you determine the progress of the ulcer.
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CLINICAL PRESENTATION
Common symptoms Sudden onset of pain Foreign body sensation Watering of eyes Photophobia Reduced vision Red eye
Signs Important signs include: Visual Acuity Reduced Swollen Eye lids Conjunctival injection (mainly circumcorneal) Corneal defect (the ulcer crater) with slough Corneal infiltrates surrounding the ulcer Other signs in severe cases include: Corneal endothelial plaque Corneal abscess Keratic precipitates Hypopyon Anterior chamber cells, flare, fibrin Some patients may present with any of the following Complications Descemetocoele Corneal perforation Corneal melting Endophthalmitis/Panophthalmitis Corneal scarring Staphyloma
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CLINICAL FEATURES
CornealUlcer
Fig. 2: Picture shows another eye with severe corneal ulcer. Patient had presented Late because he was on some treatment which did not improve the condition.
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COMPLICATIONS
Corneal Scar
Fig. 3: Following appropriate treatment corneal ulcer has healed leaving a feint scar. Patient presented early and eyesight has been saved
Corneal Perforation
Fig. 4: This picture shows an eye that had a severe corneal ulcer. The cornea perforated and iris prolapsed through the perforation. Ulcer is healed. There is a corneal scar with a tag of iris seen as brown spot in the corneal scar
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Corneal Staphyloma
Fig. 5: This picture shows an eye with a severe corneal ulcer. The entire cornea has thinned and iris is bulging out staphyloma. The vision in this eye cannot be restored. The eye is blind.
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EXAMINATION
The following examination scheme is suggested: Record the visual acuity in both eyes Measure the ulcer size in the greatest and smallest diameters Measure the surrounding infiltrate in the greatest and smallest diameters Determine the infiltrate depth and record (0-30%, >30- 60%, >60-100%) Note the presence or absence of hypopyon and measure the hypopyon height if any Note any anterior chamber cells and record as 0, 1, 2, 3 or 4 Note any anterior chamber flare and record as : 1+, 2+, 3+ 4+ Daily assessment of these parameters will help you determine the progress of the ulcer. Draw a diagram of the ulcer in the patients case notes showing both the front view and the cross sectional view (see pages 17 & 18 for guide) Examine patient daily to determine healing progress.
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Patient presents at eye clinic with suppurative keratitis Patients history is taken by ophthalmologist and a clinical examination is performed Laboratory personnel (or laboratory-trained ophthalmic nurse / technician) are requested to bring slides and media to outpatient clinic.
Do not stain the cornea with fluorescein until the ulcer has been scraped Prior to scrape only apply anaesthetic drops which do not contain preservative (Recommend Amethocaine hydrochloride 0.5% minims)
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Frontal View
Superficial vessel Scarring Epithelial edema Stromal edema Epithelial defect Epithelial bulla Infiltrate Spheroidal degeneration
Deep vessel
Edema Descemets folds Epithelial edema Pigment, iris, pupil, peripheral, iridectomy or iridotomy
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Slit View
Folds in Descemets membarane
Thinning 40%
K.P.
Hypopyon
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MICROBIOLOGY INVESTIGATION
To determine the causative organism, the ulcer is scraped for microscopy, culture and drug sensitivity. Scraping material should be inoculated directly onto culture media and slides. Steps in scraping a corneal ulcer: Sit the patient behind the slit lamp microscope Anaesthesize the affected eye with a topical anaesthetic drug which does not contain a preservative (minims). Insert an eye speculum Using a gauge 21 needle (or a spatula if available), gently but firmly scrape the base and edges of the ulcer.
Take samples in the following order: Smears on 2 slides: 1 for Gram staining, 1 for lactophenol blue staining (for fungal hyphae) Blood agar plate Sabouraud glucose agar slope
Note:
Use a new needle for each scrape or re-sterilize in a spirit lamp flame before each subsequent scrape. For details of microscopy refer: Suppurative Keratitis: A laboratory manual and guide of microbial ketatitis. By A. K Leck, M. M. Matheson, J. Heritage
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2x clean microscope slides 21-gauge needles 1x Blood or chocolate agar plate (1x Non-nutrient agar plate) 1x Sabouraud glucose agar slope 1x Cooked meat broth 1xThioglycollate broth 1x Nutrient broth (for anaerobic culture)
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* If patient is using antimicrobial eye drops at presentation, stop treatment for 24hours and then scrape.
Label slides with name of patient and hospital identification number. Inoculate media and label agar plates and broth cultures as for slides. Patient name
Draw a circle on each slide to indicate area of slide in which corneal material should be smeared
The results from microscopy are reported to the clinician and a decision is made on treatment.
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TREATMENT GUIDELINE
Admit patient for intensive topical antimicrobial treatment Instillation of eye drops is frequent initially and gradually tailed down as the ulcer improves Suggested treatment regime 1st one hour every 15 mins
Next two hours - every 30 mins Next 3-5 days every 1 hour
Subsequently every two hours and then every 3 hours till ulcer heals. Examine patient daily to determine progress and review treatment accordingly (see Appendix 1 for treatment flow chart guide) Keep a treatment chart to monitor regular instillation of eye drops (see sample of treatment chart in Appendix 2) Adjuvant treatment with a short acting mydriatic (1% cyclopentolate or homatropine) helps relieve pain and prevent posterior synechiae formation
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TREATMENT GUIDELINE
Microscopy result must be ready within 1 hour from the hospital laboratory. Upon receiving results, proceed as follows: Gram positive organisms Give Ciprofloxacin or Ofloxacin or Chloramphenicol eye drops Gram negative organism Give Ciprofloxacin or Ofloxacin or fortified Gentamicin eye drops Fungal hyphae Give Natamycin eye drops Mixed bacterial (Gm positive and Gm negative) Give Ciprofloxaxin Or combine fortified Gentamicin and Chloramphenicol eye drops Mixed bacteria and fungal Combine Ofloxacin with Natamycin eye drops Or Natamycin + fortified Gentamicin + Chlroamphenicol eye drops If there is no improvement on above regime within 48-72 hours, modify treatment according to culture and sensitivity results if available. If sensitivity result is not available, or culture results show no growth, assume mixed infection and use broad-spectrum antibiotic and antifungal drugs as suggested above. If ulcer still does not improve within 72 hours refer patient to tertiary centre. (Refer Appendixes 1 and 4)
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Yes
Yes
6 Fungal Hyphae?
13 Discharge
Yes
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14 NO IMPROVEMENT OR PROGRESSIVE
15 CULTURE AVAILABLE?
No
17 Ulcer Healed?
Yes
Yes No 18 Growth? No
20 Ulcer Healed?
No
Yes
21 Discharge
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Date 12th Oct / 01 5am 6am 7am 8am 9am 10am 11am 12noon 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12midnight 1am 2am 3am 4am 13th Oct / 01 14th Oct / 01
16th Oct / 01
17th Oct / 01
18th Oct / 01
The nurse administering the drug signs against the time the drug is administered.
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CEFUROXIME
AMIKACIN
PREPARATION CONCENTRATION 2 mls parenteral Gentamicin (40mg/ml) is added to 5 mls 14 mg/ml commercially available ophthalmic Gentamicin eye drop (0.3%) Add 2.5 mls sterile water to 1000mg of Cefuroxime powder. Remove 2.5 mls from 15 50 mg/ml mls bottle of artifical tears. Take 2.5 mls of Cefuroxime solution and add to rest of artificial tears. Add 4 mls parenteral Amikacin 20 mg/ml (100 mg/2 mls) to 6 ml bottle of artificial tears.
NOTE: Keep all reconstituted drugs refrigerated for not more than 96 hours
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SUGGESTED TREATMENT Ciprofloxacin, Ofloxacin, or Chloramphenicol eye drops Ciprofloxacin, Ofloxacin or fortified Gentamicin eye drops Natamycin or Econazole eye drops
NOTE: Combination of appropriate drugs may be used in mixed infection. Natamycin is the first choice of drug in the treatment of filamentous fungal infections. Econazole is an alternative drug of choice Systemic Ketoconazole or Itraconazole may be used in severe fungal infections especially those close to the limbus Fortified Cefuroxime may be used in resistant Gram positive cocci Pseudomonas infection may be resistant to Amikacin Subconjunctival injections are not necessary. See Appendix 3 for preparation of topical drugs from parental preparations
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REFERENCES
1. 2. 3. Corneal Ulcer Project Document, Ghana Clinical Ophthalmology 4th Edition, by Jack J. Kanski Companion Handbook to The Cornea, by H. E. Kaufman, B. A. Barron, M. B. McDonald, S. C. Kaufman Ocular Infection, Investigation and Treatment in Practice, by D. V. Seal, A. J. Bron, J. Hay Suppurative Keratitis: A laboratory manual and guide of microbial ketatitis. By A. K Leck, M. M. Matheson, J. Heritage
4.
5.
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