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Corneal UlcerDR K N Jha,MS
Professor of OphthalmologyEmail : [email protected]
Learning AimWhat is corneal ulcer ?
Etiology, pathology, symptoms and signs
Differential diagnosis
Laboratory diagnosis
Treatment
Complications
Corneal ulcer●Loss of corneal epithelium with inflammation
in the surrounding cornea is called corneal
ulcer.
●Corneal ulcer is one the common cause of blindness.
●It is an ocular emergency.
Causative OrganismsInfections are almost always exogenous
Causative organism: S.aureus, S.epidermidis,
S. pneumoniae, Pseudomonas aeruginosa,.
Uncommon: Neisseria gonorrhoeae, E. coli
Fungi : Aspergillus and Fusarium sp
Predisposing factors • Trauma: e.g. Contact lenses, trichiasis, surgery
• Topical steroids
• Dry eye syndrome
• Lagophthalmos : e.g. Facial nerve palsy
• Neurotrophic keratitis resulting from viral infections and
lesions of ophthalmic division of Trigeminal nerve
• Deficiency states ( Vit. A ) and metabolic diseases ( DM)
• Poor local hygiene, and local infection ( chronic
dacryocystitis)
Pathogenesis of Bacterial Ulcers Bacterial adherence, proliferation, and invasion of corneal stromal lamellae
Corneal inflammation with local production of cytokines and chemokines
Diapedesis and migration of neutrophils into the peripheral cornea from limbal
vessels
Release of bacterial proteases. Enzymes released by neutrophils and activation
of matrix metallopreoteinases exacerbate inflammatory necrosis.
Healing begins with control of microbial replication.
Pathology of Corneal Ulcer• Localized necrosis of the anterior layers of the cornea
• Desquamation of the epithelium and damage to the
Bowman’s membrane
• Formation of the slough and purulent infiltration
• Regeneration of the epithelium
Clinical Features of Corneal ulcer
Symptoms : Painful red eye, diminution of
vision, photophobia
Signs: Circumcorneal congestion, ulceration,
inflammation, and necrosis of corneal layers
Fungal Corneal ulcerHistory of trauma with vegetable matter e.g.,
eye trauma during harvesting of crops.
Ulcer appears dry; it has feathery edges.
Satellite lesions may be seen.
Endothelial plaque may be visible.
Hypopyon is common.
Fungal corneal ulcer
Differential Diagnosis- Acute conjunctivitis
- Acute iridocyclitis
- Acute congestive glaucoma
Complications of Corneal Ulcer• Descematocele
• Perforation and its complications
- Anterior synechia , Iris prolapse, expulsion of lens and vitreous, Intraocular hemorrhage, Endophthalmitis / panophthalmitis
• Secondary glaucoma
• Anterior capsular cataract
• Staphyloma formation
Assessment of Corneal ulcer
History, general, and systemic examination
- Visual acuity: may be low
- Eye and Ocular adnexa: Eye lid , lacrimal sac
Conjunctiva: circumcorneal congestion
Corneal ulcer: size, site ,surface, margin, slough, corneal
sensation, thinning , satellite lesions
Anterior chamber: Cells, flare, hypopyon
Pupil
Microbiological Investigations The majority are managed without smears or
cultures.
Scraping from the ulcer margins and the base of
the ulcer
Examination of Smear stained with Gram stain,
Giemsa stain, KOH mount for fungi
Culture on blood agar, chocolate agar,
thioglycollate broth, and Sabouraud’s dextrose
agar
Management
Principles:
• Control of infection
• Symptomatic relief
• Prevention of complications
Control of InfectionTopical antibiotics
• Fortified cephazolin eye drop 50 mg / ml 1/4/6 hourly
• Fortified tobramycin eye drop 14 mg/ ml 1/4/6 hourly
Alternatives
Fortified vancomycin eye drop 25-50 mg/ml drop
Fluoroquinolone eye drop ( Cipro/ oflo/ moxifloxacin/
gatifloxacin) 0.3 % drop
Dose: 1 drop every 5-15 min for 1 hour . ½ to 1 hourly
thereafter. Reduce the dose later.
Antimicrobials for Fungal corneal ulcer
Topical antifungal drops:
- Natamycin 5 % 1 hourly by day and 2 hourly by night for 6 weeks to 6 mo
- Amphotericin B 0.15/ 0.3 % frequent instillation
Oral antifungal agents; Ketoconazole 200-600 mg/ day
Fluconazole 200-400mg/ day
Supportive TherapyCycloplegics : Atropine 1 % eye drop t.i.d.
Debridement of the ulcer
Treatment of complications: perforation,
secondary glaucoma
Outcome of corneal ulcerHealing with out
opacity
Healing with opacity
Staphyloma
Secondary glaucoma
Cataract
Phthisis bulbi
Complete healing
Point to rememberCorneal ulcer causes painful red eye.
Trauma often is the predisposing event.
Community acquired infection often does not require
microbiological work-up.
Fluoroquinolone 0.3 % eye drop 1-2 hourly, is adequate
for small, peripheral ulcers.
Atropine ointment 1% tds relieves pain, prevents
synechia.
All cases must be referred to ophthalmologist.
Can you recall ?Definition of a corneal ulcer
Causative organisms
Symptoms and Signs
Microbiological investigation
Treatment of corneal ulcer
Complications of corneal ulcer
Outcome of corneal ulcer