Patient will present as → a 34-year-old contact lens wearer with severe pain, redness, and photophobia. Eyes are injected with cloudy discharge unilaterally. A dense corneal infiltrate is visible with fluorescein staining.
A corneal ulcer is an eye infection that causes an open sore on the cornea (the clear layer in front of the iris and pupil)
- Corneal ulcers usually represent an infection deeper in the cornea by bacteria, viruses, or fungi as a result of a breakdown in the protective epithelial barrier
- Risk factor for contact lens wearers!
- Dendritic ulcer with fluorescein stain = Herpes Simplex Keratitis – common board review question
- Must be able to differentiate corneal ulcer from abrasion
All patients with corneal ulceration should be referred immediately to an ophthalmologist
Fluorescein stain is diagnostic (ulcers will often appear round “ulcerated”- like an "ulcer" vs. dendritic like herpes)
- Corneal cultures should be obtained before starting antibiotics
Immediate referral - if immediate referral is not possible, it is reasonable to start antibiotics without delay
- Ophthalmic antibiotics include ciprofloxacin 0.3%, ofloxacin 0.3%, gentamicin 0.3%, erythromycin 0.5%, polymyxin B/trimethoprim (Polytrim), and tobramycin 0.3%
- Most appropriately treated corneal ulcers should improve within two to three weeks. Treatment may continue for longer to reduce the amount of potential scarring
- Corneal ulceration is a serious condition, and with inadequate or no treatment, loss of vision and blindness may occur.
Fungal corneal ulcer
Fungal corneal ulcers have an indolent course with intraocular infection being common but fluorescein staining is negative for a dendritic pattern.
Acanthamoeba keratitis has a waxing and waning course over several months and has no fluorescein staining in a dendritic pattern.
Bacterial corneal ulcer
Bacterial corneal ulcers can progress aggressively resulting in corneal perforation. Fluorescein staining does not occur in a dendritic pattern.
References: Merck Manual · UpToDate