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Senior Lecturer, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Mr Massae (not his real name) is a forty-eight year old farmer who recently presented at a tertiary ophthalmology unit in Tanzania with a three-week long history of pain, purulent discharge, and loss of vision in the left eye. The burden of corneal blindness on the individual and the wider community can be huge, particularly as it tends to affect people at a younger age than other blinding conditions such as cataract and glaucoma. Corneal blindness often affects people at a young age, such as this twelve year old girl who is blind from vitamin A deficiency. There are many different conditions which can damage the structure and shape of the cornea leading to visual impairment and blindness. There are three important elements to addressing corneal blindness: prevention, treatment, and rehabilitation. Some blinding corneal conditions are very difficult to treat once established; however, they can be prevented by specific public health interventions (see page 36). Xerophthalmia, which is caused by vitamin A deficiency and sometimes precipitated by measles, accounts for more than half the new cases of childhood blindness each year. Onchocerciasis (river blindness) leads to blindness through an inflammatory response to the microfilaria of Onchocerca volvulus in the retina and the cornea. Traumatic corneal abrasion is a common event and is the major risk factor for microbial keratitis in low- and middleincome countries. In most low- and middle-income countries, microbial keratitis is the most common acute blinding corneal problem requiring treatment.
The treatment of microbial keratitis is discussed in detail in the articles on pages 39-41. Several problems make it difficult to deliver effective treatment for microbial keratitis in a low- and middle-income country setting. In many low- and middle-income countries, options for visual rehabilitation from corneal disease are limited as it usually requires the services of an ophthalmologist with sub-specialty training in corneal surgery, equipped to perform the surgery and with access to donated corneas from an eye bank.
In this issue, there is an article on corneal grafting (page 44) which discusses the indications for corneal grafting, the outcomes for different conditions, and some of the potential complications.
Without rehabilitation services, Mr Massae and several million people like him are destined to a life without sight.
A corneal infection is an infection of the cornea, the clear section in front of the eyeball that allows light into the eye (find out more about how the eye works). Corneal infections usually occur because of exposure to bacterial, viral or microbiological agents that cause the eyes to become red and swollen. Apart from contact lens related infections, infections can also occur due to existing abnormalities or disturbances of the eye surface or cornea or in cases of eye injury. Corneal infections after eye trauma can also be prevented in work site-related injuries with the appropriate use of safety googles. Surgery for corneal infections may be indicated in very severe infections or when the infection is not responding to medical treatment i.e. This is the most common type of corneal infection and is caused by a variety of bacteria with "pseudomonas" being the commonest. Various organisms producing keratitis include Acanthamoeba (most common), Microsporidia, Onchocerca, Leishmania Trypanosoma bruci and Echinococcus granulosus. Herpes Keratitis: The type 1 herpes simplex virus causes herpes keratitis, which is a viral corneal infection and the most common form of eye herpes. Stromal Keratitis: The type 1 herpes simplex virus also causes stromal keratitis, a rare infection that goes deep into the layers of the cornea.
Common or similar symptoms of a corneal infection (regardless of its type) may include eye pain, redness, burning, itching, watery eyes, discharge, sensitivity to light, a white patch on the cornea and impaired vision.
Although clinical signs may be insufficient to confirm infection, a break in the continuity of the epithelium associated with underlying stromal infiltrate should be considered infectious.
The antibiotics consist of an empirical therapy (based on previous clinical experience) with one or more commercially available broad spectrum antimicrobial agents. As for "viral" corneal infection such as herpes", early treatment of herpes keratitis can be effective in stopping the spread of the virus deeper into the cornea. Bacterial corneal infection: Because of its high incidence and potential complications, bacterial keratitis, is one of the most visually threatening ocular infectious pathologies. Viral corneal infection: The leading cause of corneal blindness in the United States is ocular herpes. Fungal corneal infection: Fungal keratitis is a major blinding eye disease especially in Asia. Parasitic keratitis: As the condition progresses, a ring-shaped ulceration may be visible around the cornea. The human eye is made up of several structures including the pupil, iris, cornea, and sclera. Can dry eyes cause sharp eye pain or can dry eyes cause glaucoma? I haven't been diagnosed as such but I have dry eye and I use artificial tears every day.
Various refractive eye surgery techniques change the shape of the cornea in order to reduce the need for corrective lenses or otherwise improve the refractive state of the eye. Cohlmia Eye Center proudly serves patients speaking English, Spanish, and Arabic languages. Programme Development Adviser: Health Systems, Sightsavers International, 21 Nii Nortei Ababio Road, PO Box KIA 18190, Airport, Accra, Ghana. Preventing corneal blindness in the community involves action by the community itself, as well as actions by government and non-governmental organisations in the form of health and development services. Right up to the point when someone is seen by an eye care worker or admitted to hospital, the community will influence what happens. However, the community has the potential to influence most of these factors, either through change in the behaviour of individuals, or by lobbying for improvements at the community level. The eye care worker’s role, in particular when designing or participating in programmes to reduce corneal blindness, should be to inform and assist the community to address whichever of the above factors are relevant.
Traditional remedies, such as the one around this boy’s neck, contribute to delays in seeking medical treatment.
Whether you are planning to improve a prevention programme or designing a new one, it is helpful to learn as much as possible about what the community needs and how they may be able to support your programme. It is a good idea to do a situation analysis, which will help to clarify what you know about the community and identify any gaps in your knowledge (which you will then need to fill). What are the community’s knowledge and perceptions regarding the causes and treatment of corneal blindness? How will the community’s knowledge and perceptions influence the content of health messages and how they are presented? There are many social factors associated with corneal disease, such as poverty, inadequate water supply and sanitation, poor nutrition, and dangerous agricultural practices. To address the immediate medical causes and risk factors, the programme should provide health education about risk factors and how to avoid them, as well as information about what to do and where to go for help if an eye problem develops. Support for these activities may be possible by closely collaborating with the health promotion unit of the local or national health system. These early attempts at seeking care may be harmful, but also delay the process of obtaining correct treatment from the nearest medical facility. Understanding the health systems which already serve the community will help to ensure that new programmes make the best use of what is available and don’t overload existing services. Many health and community development programmes already in existence, such as measles immunisation, perinatal care, nutrition, water supply, and sanitation, make a significant contribution to reducing the most common causes of corneal blindness. Work with the community to identify individuals who can provide home-based care and training. Gather evidence about the effectiveness of community-focused intervention measures, such as water and sanitation programmes, immunisation campaigns, or free health care for children. Use your evidence to improve programme design and service delivery, and to lobby the authorities to maintain and strengthen these programmes. Work with the community to ensure that emergency eye care for corneal infections or trauma, particularly in children, is free and that cost does not restrict access to treatment.
Work with the decision-making bodies responsible for the local community’s development and health.
Encourage communities to take the lead on health matters, for example by working with community development groups. Support and encourage communication between the community and decision makers within the health system, as well as between different groups or specialties in the health system.

As an eye health worker designing or implementing a programme to prevent corneal blindness in the community, you should understand both the medical causes of corneal scarring, and the non-medical and social factors that lead to corneal blindness.
It is vital to understand the impact of development programmes led by other government departments (education, agriculture, water resources, community development, and justice) on the prevention of corneal blindness.
In order to do this well, you, as an eye health worker, should develop non-medical skills such as communication, negotiation, advocacy, and the ability to foster community engagement.
Several days after the onset, he had received treatment from his local health centre (chloroamphenicol drops), but his eye continued to get worse. It also disproportionately affects poor rural communities, because of the increased risk of eye injuries from contaminated objects such as plant material, limited access to treatment, and higher prevalence of communicable diseases such as trachoma and onchocerciasis. Improvement in water supply facilitates facial cleanliness, one of the four components of the SAFE strategy for trachoma control. These include infectious, nutritional, inflammatory, inherited, iatrogenic (doctor-caused), and degenerative conditions (see box opposite).
In this issue of the Community Eye Health Journal, you will find articles addressing aspects of each of these.
Once established, trachomatous corneal opacification is difficult to treat: the results of corneal grafting are often disappointing, in part due to a dry and damaged ocular surface.
Control programmes have been very effective in preventing blindness through the mass distribution of ivermectin and measures to control the Simulium fly. Simple topical antibiotic prophylaxis for a few days while the epithelium heals can protect the eye from developing potentially blinding infection.
There may be many days or even weeks between the onset of symptoms and the presentation of the patient at an appropriate health facility. This may sometimes be used by the patient before presentation and can make the problem more severe through the harmful effect of toxic compounds and infection with additional microorganisms.
It may not be possible to obtain a microbiological diagnosis or information about the sensitivity of the organism. It was several weeks before he reached an ophthalmology unit and received treatment, which contributed to the severity of the case.
However, his left eye has perception of light and has the potential to see better; to be rehabilitated. The following article focuses on eye banking (page 46) and addresses some of the specific challenges involved in running an eye bank service and finding donors. Without the implementation of the public health and treatment interventions outlined above, many more will be at risk of joining them. Unless otherwise stated, all content is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. The yearly incidence of infections related to contact lens wear varies between 1 in 10,000 hard contact lens users, 4 in 10,000 soft contact lens users to 22 in 10,000 extended wear contact lens wearers. In severe cases, it can cause changes to the corneal shape leading to astigmatism, opacification of the cornea from scarring or a combination of both. Avoiding contact lens wear completely in patients who have predisposing diseases of the cornea or surface of the eye may be necessary.
Acanthamoeba keratitis is a serious eye infection that most commonly occurs in individuals who wear contact lenses. Herpes keratitis generally affects only the top layer of the cornea and usually heals with no scarring. However, at times, there are certain common causes of infection such as severe dry eyes, an abrasion, and a foreign object in the eye, severe allergies and an inflammatory disorder. For example, herpes simplex virus infection is an important cause of corneal scarring and visual impairment. For further confirmation, depending on the type, your doctor can diagnose your corneal infection by running tests such as a visual acuity test, a tear test, a refraction test, a slit-lamp exam and by measuring and examining the cornea.
Depending on the specific type of infection, your doctor may also prescribe anti-viral or anti-fungal eye drops, as well as corticosteroid eye drops. Treatment with a commercially available antibiotic that has a broad spectrum of activity against gram-negative and gram-positive organisms, such as ciprofloxacin or ofloxacin, seems to be the least expensive first approach. Almost all of the corneal infection will require prompt treatment for the full recommended course (duration).
As is the case with all other medical treatments, medicines (especially antibiotics) used to treat various types of corneal infections can cause a number of side effects, depending on the type of antibiotic or medicine used. Something as simple as wiping the eye with a hard paper towel can scratch the eye and lead to sharp eye pain.
Ulcers on the cornea are a result of bacterial and viral infections, and are more common in those who wear contacts. Sometimes (especially when my eyes are very tired), I experience a sharp pain in one or both my eyes. The drugs they use can suddenly constrict and dilate blood vessels causing sharp pain in the eyes.
In order to be effective, eye health workers need to understand how all of the above can work together. This will allow the community to become an active partner in the prevention of corneal blindness.
Other contributing factors may include the high cost or unavailability of medicines or safety goggles. Use what you have learnt from the situation analysis to plan communication activities, for example by using existing and communityfriendly methods. As a result, patients with corneal disease or injuries are usually in pain and may suffer from photophobia; their eyes may water and they may have blurred vision. With careful thought, it may even be possible for a programme to contribute to the existing health systems, leaving them stronger and better able to serve the community in future. It is important to support these programmes by informing policy makers and funding agencies of their impact on the prevention of blindness, as this will increase the motivation of those involved and may improve the prospects for continued political and financial support. These could include retired professional people such as health workers or teachers who have returned to live in their communities.
For example, ensure that they are aware of the dangers of steroid eye drops and that they understand why it is important to instil antibiotic or antiseptic drops in newborn babies’ eyes. For example, ensure that ophthalmia neonatorum is a notifiable disease and record the number of children with measles or xerophthalmia.
Encourage them to allocate resources to measures such as latrine construction and home-based care.
Ordinary people can take responsibility for a range of interventions, from householdled health activities such as face washing to demanding better services. You should recognise the potential of the community to be involved and actively seek out ways to ensure their involvement. Mr Massae illustrates the burden from corneal disease: he is currently unable to farm his land and provide food for his family.
In Mr Massae’s case, we can see how all three elements are needed, as well as some of the challenges in their implementation. Prevention is key: vitamin A supplementation, measles vaccination, and nutritional advice have led to a marked reduction in this condition. Blinding trachoma can be prevented through the full implementation of the SAFE Strategy (Surgery for trichiasis, Antibiotics for infection, Facial cleanliness and Environmental improvement to control transmission).
If appropriate antibiotic prophylaxis is not started soon after the injury, infection can become established.
This delay is often catastrophic, allowing time for deep-seated infection to develop and extensive corneal damage to occur. This can lead to the use of ineffective treatment and is particularly a problem when fungal keratitis is missed. This can occur for several reasons: appropriate antibacterial or antifungal drops may not be available, the microorganism may be resistant to the medication, or the drops may not be given with sufficient intensity. It was very helpful in his management to have a microbiological diagnosis as it guided the choice and duration of treatment. The yearly incidence of vision loss from contact lens related infections has been estimated to be approximately 0.6 in 10,000 users in studies carried out in Australia and India.
In most cases, patients with severe corneal infections are admitted into hospital and samples from the infection are taken to identify the likely organism before the start of the treatment. Surgery may also be indicated later on if vision is reduced due to corneal scarring from the infection.

As for similarities in treatment, Cycloplegic agents such as atropine sulphate 1%, homatropine 1% or cyclopentolate 1% instilled three times a day reduce ciliary spasm and produce mydriasis, thereby relieving pain and preventing synechiae formation, irrespective of the infection type.
It is, therefore, essential to consult your doctor as soon as you notice any significant symptoms. Similarly, prolong and unnecessary use of antibiotics or self-medication can also lead to drug resistance and a high risk of recurring infections. The most common causes of sharp eye pain include corneal irritations and disorders, glaucoma, and scleritis.
Examples of foreign objects that can damage the cornea include metal shavings, wood splinters, and dust particles. Corneal ulcers can form because of improper eye care when using contacts, or from a scratch or abrasion on the surface of the cornea that becomes infected.
When this happens, pressure increases within the eye leading to sudden pain, headache, and blurred vision.
It only lasts for several seconds and then goes away. I think it might be because of dry eyes, but I'm worried that it might be something more serious like glaucoma. It was the worst eye pain I ever experienced in my life. I was lucky that my mom was a nurse and knew what to do. A good programme should support the community to obtain the health care and other services it needs, either by mobilising the community’s own resources or by lobbying government for help. If other conditions causing blindness through corneal pathology are included, such as trachoma, vitamin A deficiency, ophthalmia neonatorum, and onchocerciasis, the number would be significantly higher. Overall, in low- and middleincome countries, infectious keratitis tends to be the most common problem.
Timely presentation may be promoted through health education and training of staff at primary health facilities to recognise and refer patients with established microbial keratitis.
The development of a basic microbiological service with gram staining of slides can help to identify some cases of fungal infection.
Some of these problems can be overcome with the development of locally appropriate treatment protocols. In addition, as the left corneal scar does not involve the superior cornea, a rotational auto-graft, in which an eccentric corneal button is cut and rotated to bring the clear superior cornea into the centre, may help. Treatment with intensive eye drops is administered and adjusted until the infection improves. Surgery carried out in these situations aims to remove the diseased cornea (where scarring or severe infections is present) and replace the removed cornea with a corneal graft or transplant. Almost all types of bacterial corneal infections are sensitive to broad spectrum antibiotics. If left untreated, any corneal infection may lead to serious complications including complete vision loss (blindness).
Sharp eye pain can become worse when exposed to light, and should be looked at by an eye doctor. Lubricating eye drops and over-the-counter pain relievers can be used to relieve pain after an eye wash to ensure the eye is clean and free of debris. Treatment is aimed at the cause of the ulcer and often involves the use of eye drops and ointments. She couldn't find what was in my eye and we couldn't go to the hospital until the next morning so my mom put antibiotic, lubricant eye ointment in my eye and taped it shut with a cloth. He was treated with intensive topical antifungal (econazole) and anti-bacterial (ciprofloxacin) drops, a topical cycloplegic (atropine), and an oral antifungal medication (itraconazole). Moreover, there are probably many tens of millions more who are blind in one eye from corneal disease.
In contrast, in tropical regions, fungal keratitis is more frequent and may account for about half the cases.
Blindness control programmes need to know which organisms commonly cause microbial keratitis in their population as well as their pattern of antibiotic resistance so that appropriate drugs can be supplied to health facilities.
However, a penetrating corneal graft (transplant) would probably offer him the best quality of vision.
I slept that way and went to the hospital first thing in the morning. The eye doctor found the small rock particle stuck inside my upper eyelid.
The most superficial (or outer) layer of the cornea, the epithelium stops outside matter from entering the eye. The infection gradually responded to prolonged antifungal therapy, leaving a dense scar and small eccentric pupil (Figure 1). Four years earlier, Mr Massae had lost sight in his right eye due to severe suppurative keratitis following a minor corneal abrasion from a maize leaf; this caused dense scarring of his right cornea (Figure 2). The stroma is the middle and thickest layer of the cornea and is found behind the epithelium. It is made up mostly of water and proteins that give it an elastic, but solid, form.Endothelium. The endothelium works as a pump, expelling excess water back into the eye as it is absorbed into the stroma. Without this specialised function, the stroma would become waterlogged, creating a hazy and opaque cornea and reducing vision.The term ‘corneal disease’ refers to a variety of conditions that affect mainly the cornea. These include infections, degenerations and many other disorders of the cornea that may arise mostly as a result of heredity.What are symptoms of corneal problems?With its ability for quick repair, the cornea usually heals after most injuries or disease. Therefore, if you experience any of these symptoms, seek medical advice.What conditions can damage the cornea?KeratitisKeratitis is an inflammation of the cornea that sometimes occurs with infection after viruses, bacteria or fungi enter the cornea. These micro-organisms can enter the eye after deep injury, causing infection, inflammation and ulceration of the cornea. Sometimes, antiviral medications and steroid eye drops are necessary.Ocular herpes or herpes of the eyeOcular herpes is a viral infection of the eye that may recur.
The main cause of ocular herpes is herpes simplex virus I (HSV I), the same virus that most often causes cold sores, but it can also result from herpes simplex virus II (HSV II) that most often causes genital herpes.Ocular herpes produces sores on the surface of the cornea and, in time, the inflammation can spread deeper into the cornea and the eye.What conditions can damage the cornea?
After a bout of chickenpox, this virus usually remains inactive within the nerves of the body.
Corneal degenerationsThere are several types of corneal degenerations, diseases that can cause progressive structural problems with the cornea.KeratoconusKeratoconus is a progressive disease where the cornea thins and changes shape. Sometimes occurring as early as adolescence, this disease changes the curvature of the cornea, creating either mild or severe distortion, called astigmatism, and usually short-sightedness. In approximately 10% to 15% of patients with keratoconus, a corneal transplant may also be necessary.During a corneal transplant, the damaged cornea is replaced with a donated cornea.
Even after a transplant, you will still most likely need glasses or contact lenses to see clearly.Corneal dystrophiesThere are more than 20 corneal dystrophies, diseases that can cause structural problems with the cornea. Some of the most common are:Map-Dot-Fingerprint DystrophyMap-dot-fingerprint dystrophy is the abnormal appearance of the basement (or anchor) membrane of the epithelium of the cornea.
As this membrane, that separates the epithelium and stroma, grows irregularly (thicker in some places, thinner in others), irregularities in the cornea appear, resembling maps, dots and small fingerprints.Map-dot-fingerprint dystrophy usually affects adults between the ages of 40 and 70, or children as a result of heredity.
It is usually painless and causes no vision loss, and sometimes clears up without treatment. Epithelial erosion can expose the nerves lining the cornea, causing severe pain, particularly when waking in the morning. The cornea's normal curvature may be altered, causing astigmatism.What conditions can damage the cornea?
Occasionally, corneal scraping may be required to treat the problem.Fuchs' dystrophyFuchs' dystrophy is the gradual deterioration of endothelial cells for no apparent reason.
As these cells thin over time, the cornea is less capable of removing water from the stroma, causing it to swell and distort vision. Haze and small blisters may also appear on the corneal surface.As a slowly progressing disease, signs of Fuchs' dystrophy begin to appear in people 30 to 40 years of age, but it doesn't normally affect vision until about 20 years later. It is more common in women than in men.An early sign of Fuchs' dystrophy includes awakening with blurred vision that gradually clears up during the day. Although this condition can occur at any age, early changes can be seen in childhood.Lattice dystrophy gets its name from the clear overlapping lines of proteins in the stroma.
Avoid sharing eye makeup, contact lens solution, contact lens cases and eye drops with people – especially those with infection - and wash your hands thoroughly with soap and warm water for at least 15 seconds after contact with an infected person.

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