Patient will present as → A 34 year old contact lense wearer who presents with severe pain, redness, worsened when eye is open (similar to corneal abrasion). The fluorescein stain demonstrates a white spot on surface of cornea.
Must be able to differentiate corneal ulcer from abrasion
- Corneal ulcers usually represent an infection deeper in the cornea by bacteria, viruses, or fungi as a result of breakdown in the protective epithelial barrier
- Risk factor for contact lense wearers!
- Dendritic ulcer with fluorescein stain = Herpes Simplex Keratitis – common board review question.
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%.
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.