PANCE Blueprint EENT (7%)

Corneal ulcer

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.

Corneal ulcer is perhaps the most serious risk of contact lens wear. Note the chemosis, subconjunctival hemorrhage, and corneal haze.

A corneal ulcer is perhaps the most serious risk of contact lens wear. Note the chemosis, subconjunctival hemorrhage, and corneal haze.

Question 1
A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis?
Viral keratitis
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
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.
Question 1 Explanation: 
Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining.
There is 1 question to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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