A 60 year old came with recurrent attacks of angle closure. Patient was diagnosed PACS and PI was done in both eyes elsewhere. Since iop was not under control with AGM (timolet plus, brimonidine) and chronic corneal oedema was present, combined surgery was planned. But eventually patient developed corneal ulcer with large epithelial defect and endothelial plaque. Patient had no pain or conjuctival hyperemia. He was started on antifungals after confirming sugar levels , and no response was seen. How do I proceed??

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As corneal ulcer has developed, it must also be attended to immediately. As there is plaque on endothelium, fungal etiology is more likely, but there could be mixed infection also. Glaucoma & corneal ulcer must be treated simultaneously &vigorously. Ulcer should be treated by Fluconazole e/drops, natamycin e/drops, Moxifloxacin eye drops, Tobramycin e /drops , chloramphenicol with polymyxin eye drops , atropine eye drops, tablet Fluconazole, tab. Paracetamol , tab. diamox & dorzolamide with timolol eye drops. Cauterisation of ulcer may be done. Atropine drops MUST be prescribed for infection even though intraocular pressure is raised. Daily eye check up must be done & treatment re decided every day. If there is no response to medical treatment & ulcer worsens, therapeutic k-plasty may have to be considered.

60 YEARS OLD PT WITH RECURRENT PACG NOT RESPONDING TO AGM PLANNED COMBINED PHACO TRAB DEVOLPED CORNEAL ODEMA WITH CORNEAL ULCER AND EPETHELIAL DEFECTS I DONT FEEL THAT THEIR IS ANY ROLE OF ANTIGUNGAL IT IS A CASE OF BULLOUS KERATAPATHY DUE TO UNCONTROLLED IOP FROM THE BENGINGING LASER IRIDOTOMY SHOULD HAVE BEEN DIONE WITH NEW AGM

Such a severe corneal decompensation after acute congestive glaucoma can happen only if it is ignored and untreated for a prolonged period over months and is very rare. The Eye may have become absolute before it. So either poor endothelial count which was present earlier on could be a possibility. It seems only filtration surgery nay not help. Patient may require keratoplasty ( DMEK) as well.

Sir everything was very acute. Infiltrate was seen in past 2-3 days... patient came 15 days back with closure attack vision was 3/60, which improved to 6/18..
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Rashmi look carefully if u are missing something in this case 15 days duration is too short How was the fundus during 6/18 vision Systemic history??? How is the other eye Any drugs the patient taking Profession?? And any other details

Other eye Pi was done and fundus was normal.. disc was normal wen the vision was 6/18. .patient came twice with attack and it was aborted. However iop was consistently high. initially it was just smal epithelial defect, no time it turned so bad.. Infact, patient was bout planned for combined .
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Ruptured bullae can cause persistent epithelial defect wid secondary infection as pic s nt clear nt seeing any infiltrate as such. Is der any NVI? Vision of eye?

Ya, sorry for the pic. Now the vision is HM+.. No NVI,..
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Now focus on ulcer. Switch to oral acetazolamide . Stop Topical agm (preservativess can cause more damage) Ulcer could b due to very old eye drops (contamination). Topical antibiotics/antifungal) every 15min including over night (round the clock) until infiltration decreased. Oral nsaids. Black glasses. Every day eye examination. No cycloplegics.

60 YEARS OLD PT WITH RECURRENT PACG

Ruptured bullae may cause eoi defect. Start medical line of treatment with hupersol 6, tear substitutes with preservative fre e antibiotic witj bandage contact lens.

Trab with amt must useful

Start medical treatment with hypersol 5, Tear drops and preservativefree antibiotic.

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