Corneal ulcer

Definition
Defined as discontinuation in normal
epithelial surface of cornea
associated with mecrosis of the
surrounding corneal tissue
 Bacterial corneal ulcer
Etiology
• Damage to corneal epithelium
• Infection of eroded area
 Pathogenesis
The development corneal ulcer is in 4
stages
2. Stage of progressive infiltration
3. Stage of active ulceration
4. Stage of regression
5. Stage of cicatrization
 Clinical features
• Depends on virulence of organism, its
toxins and enzymes and the response of
host tissue
Symptoms
• Pain
• Foreign body sensation
• Watering
• Photophobia
• Redness of eyes
 Signs
• Edema of lids
• Marked blepharospasm
• Conjunctival chemosis
• Corneal Epithelial defect
• Yellowish white area of ulcer, oval or irregular in shape
• Margins are swollen & over hanging
• Floor covered with necrotic material
• Stromal edema
• Muddy iris
• Small pupil
• Increased IOP
 Causative bacteria
• Staphylococcal aerues and
steptococus pneumonia
• Pseudomonus
• Enterobacteria
 General examination
• Built
• Nourishment
• Anaemia
• Immunological status
 Ocular examination
• Diffused light examination
• Regurgitation test and syringing
• Biomicroscopic examination (staining
with 2% fluorescein dye)
 Laboratory investigation
1. TC, DC, ESR
2. Microbiological investigation (scrapping from
the margins of the ulcer under LA)
c. Gram and Giemsa stain (gram +ve )
d. 10% KOH (fungal hyphae)
e. Calcofluor white (CFW) (fungal filaments)
f. Blood agar medium culture (aerobic )
g. Sabourauds dextrose agar medium (fungi)
 .. contd
f. Blood agar medium (most bacteria and
fungi except neisseria, hemophilus and
moraxella (NHM))
g. Chocolate agar medium (for NHM)
h. Cooked meat broth (anerobic and
fastidious )
i. Brain heart infusion (for aerobic & fungi)
 Treatment
1. Specific treatment for the cause
2. Non specific supportive therapy
3. Physical and general measures
 Specific treatment

a. Topical antibiotics
Ciprofloxacin (0.3%)
Ofloxacin (0.3%)
b. Systemic antibiotics
Ciplox (750 mg)
 Non specific treatment

• Cycloplegic drugs
b. 1% atropine ointment
c. 2% homatropine eye drops
d. Systemic anagesics & NSAIDS
e. Vitamin A,B,C
 Physical & general measures

a. Hot fermentation (vasodilation)

b. Dark goggles
c. Rest, good diet and fresh air
 Non healing ulcer
Treatment :
1. Removal of known cause
– Local (IOP concretions , foreign body)
– Systemic causes (diabetes, anaemia, malnutrition,
steroids)
2. Mechanical debridgement
3. Cauterisation of the ulcer
4. Soft contact lens bandage
5. Peritomy (severing of perilimbal conjunctival
vessels)
Treatment of impending perforation
1. No stain
2. Pressure bandage
3. Lowering of IOP
4. Tissue adhesive glue (cynoacrylate)
5. Conjunctival flap
6. Soft contact lens Bandage
7. Penetrating keratoplasty
 Treatment of perforated corneal
ulcer

• Depends on the size of perforation

availability of glues
• Conjunctival flap
• Soft bandage
• Keratoplasty
 Mycotic corneal ulcer
Etiology
• Filamentous fungi (Aspergillus, fusarium)
• Yeast (Candida & cryptococcus )
Mode of infection
• Injury by vegetative material
• Injury by animal dye
• Secondary fungal ulcers
 Diagnosis of MCU
• Clinical manifestation
• Laboratory investigations with wet KOH,
CFU grams and giemsa stain
Treatment:
• Topical antifungal (Natamocin 5%,
fluconazol 2%, Nistatin 3.5 % ointment)
• Systemic tab fluconazol 2-3 wks
Non specific treatment : Same as bacterial
 Viral corneal ulcers

• Most of the viruses effect the

epithelium of both conjunctival
and corneal
• Hence typical viral lesions
constitute the viral kerato
conjunctivitis
 Common viral infections

• Herpes zoaster virus

• Herpes simplex virus
Mode of infection (HSV1 - By kissing,
HSV2 – infected genitalia of mothers
to the neonates )
 Healing of corneal ulcer
• When an ulcer has become
vascularised, cicatrization occurs
which is carried out by the
regeneration of collagen and the
formation of fibrous tissue
• Bowmans membrane is never
regenerated
 Complications
• Thinning of entire cornea
• Scarring if the ulcer is deep
• Keratectasia, keratocele or
descemetocele
• Anterior staphyloma
 Preparation of fortified antibiotics

• Gentamicin 1.5 mg / ml (1.5 %) + 2ml

of 40 mg gentamicin vial
• Cefazolin 50 mg/ml (5%) + 500 mg
parentral antibiotic diluted with 2.5 ml
sterile water added to 7.5 ml of
artificial tears (stable for 24 hrs )
 Acanthamoeba keratitis
Diagnosis
• Presenting symptom blurred vision and
pain
Signs
• Grayish irregular epithelial surface
• Pseudendrites
• Stromal infiltrates
 Investigation
• Culture with non nutrient agar
• Staining – using periodic acid
schiff or calcofluor white
Treatment of acanthamoeba
• Debrigement 1
• Debrigement 2
• Topical amoebicids
• Topical steroids
• Pain control
• Keratoblasty