Corneal Ulcer - Causes And

Treatment
By Chris A. Knobbe, MD

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A corneal ulcer typically occurs as a painful, red eye, with mild to severe eye discharge and reduced
vision.
The condition results from a localized infection of the cornea, similar to an abscess.
Causes Of Corneal Ulcer
Most cases of corneal ulcer are due to a bacterial infection that invades the cornea often
following eye injury, trauma or other damage.

A corneal ulcer is a painful open sore on the clear front surface of the eye that can cause loss
of vision and even blindness.
Contact lens wearers particularly are susceptible to eye irritation that can lead to a corneal ulcer. A
contact lens may rub against the eye's surface, creating slight damage to the epithelium that may
enable bacteria to penetrate the eye.
If you are a contact lens wearer, you can increase your chances of avoiding a corneal ulcer by
practicing good hygiene such as washing your hands before handling lenses and following other
safety tips.
Besides bacterial infection, other causes of corneal ulcers are fungi and parasites, such as:

Fusarium. These fungi have been associated with fungal keratitis outbreaks among contact lens
wearers who used a certain type of contact lens solution. Now withdrawn from the market, this
contact lens solution previously failed to prevent this type of infection.
Acanthamoeba. These common parasites can enter the eye and cause Acanthamoeba keratitis, a
very serious eye infection that can result in permanent scarring of the cornea and vision loss.
Acanthamoeba microorganisms are commonly found in tap water, swimming pools, hot tubs and
other water sources.
Contact lens wearers who fail to remove their lenses before swimming significantly increase their
risk for a corneal ulcer from Acanthamoeba keratitis. (The article "Can You Swim with Contact
Lenses?" contains useful tips for contact lens wearers who spend a lot of time in the water.)
Another cause of corneal ulcer is herpes simplex virus infection (ocular herpes), which can damage
exterior and sometimes even deeper layers of the eye's surface.
Other underlying causes of corneal ulcers are severely dry eyes, eye allergies and widespread
general infection. Immune system disorders and inflammatory diseases such as multiple sclerosis
and psoriasis also can lead to corneal ulcers.

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Evaluation And Treatment Of Corneal Ulcers

Your most important step if you suspect you have a corneal ulcer is an immediate visit to your eye
doctor. Otherwise, untreated corneal ulcers can lead to severe vision loss and even loss of the eye.
If your doctor suspects that bacteria are the cause of your corneal ulcer, usually treatment includes
frequent application of topical antibiotics, with or without initial cultures.
The location and size of the ulceration will guide your eye doctor in determining the need for
cultures. Most eye doctors see patients with corneal ulcers every one to three days, depending on
the severity of the condition.

If the ulceration is in the central cornea, the condition usually takes longer to go away, and vision
may be reduced permanently due to scarring. Unfortunately, permanent damage and vision loss
may occur even if the condition is identified and treated early.

If you have experienced trauma to the eye, your doctor may suspect ulceration from fungal keratitis,
particularly when your eye has encountered organic matter such as from a tree branch.

In most cases of this type of corneal ulcer, the eye already is compromised by pre-existing
conditions, such as an immune disorder.
 Your doctor would diagnose fungal keratitis only with microscopic evaluation of specially stained
specimens or cultures. He or she would administer anti-fungal agents, sometimes both topically to
the eye and orally, depending on the severity of the ulceration. The prognosis for good vision
depends on the extent of infection.

Even if detected early and managed properly, some cases of corneal ulcers will require a cornea
transplant (penetrating keratoplasty)

Corneal ulcers and infections

The cornea is the clear tissue at the front of the eye. A corneal ulcer is an open sore in the outer layer of the
cornea. It is often caused by infection.

Causes
Corneal ulcers are most commonly caused by an infection with bacteria, viruses, fungi, or a
parasite.

Acanthamoeba keratitis occurs in contact lens users. It is more likely to happen in people who
make their own homemade cleaning solutions.

Fungal keratitis can occur after a corneal injury involving plant material. It may also occur in
people with a suppressed immune system.

Herpes simplex keratitis is a serious viral infection. It may cause repeated attacks that are
triggered by stress, exposure to sunlight, or any condition that lowers the immune response.

Corneal ulcers or infections may also be caused by:

Eyelids that do not close all the way, such as with Bell's palsy
Foreign bodies in the eye

Scratches (abrasions) on the eye surface

Severely dry eyes

Severe allergic eye disease

Various inflammatory disorders

Wearing contact lenses, especially soft contacts that are left in overnight, may cause a corneal
ulcer.
 Watch this video about:Corneal injury
Symptoms
Symptoms of infection or ulcers of the cornea include:

Blurry or hazy vision

Eye that appears red or bloodshot

Itching and discharge

Sensitivity to light (photophobia)
Very painful and watery eyes
White patch on the cornea

Exams and Tests

Your health care provider will do the following tests:

Exam of scrapings from the ulcer

Fluorescein stain of the cornea

Keratometry (measuring the curve of the cornea)

Pupillary reflex response

Refraction test
Slit-lamp examination
Tests for dry eye

Visual acuity
Blood tests to check for inflammatory disorders may also be needed.

Treatment
Treatment for corneal ulcers and infections depends on the cause. Treatment should be started as
soon as possible to prevent scarring of the cornea.

If the exact cause is not known, you may be given antibiotic drops that work against many kinds
of bacteria.

Once the exact cause is known, you may be given drops that treat bacteria, herpes, other viruses,
or a fungus. Severe ulcers sometimes require a corneal transplant.

Corticosteroid eye drops may be used to reduce swelling and inflammation in certain conditions.
 Your health care provider may also recommend that you:

Avoid eye makeup

Do not wear contact lenses at all, or do not wear them at night

Take pain medications

Wear an eye patch to keep out light and help with symptoms

Wear protective glasses

Outlook (Prognosis)
Many people recover completely and have only a minor change in vision. However, a corneal
ulcer or infection can cause long-term damage and affect vision.

Possible Complications
Untreated corneal ulcers and infections may lead to:

Loss of the eye (rare)

Severe vision loss

Scars on the cornea

When to Contact a Medical Professional

Call your health care provider if:

You have symptoms of corneal ulcers or an infection

You have been diagnosed with this condition and your symptoms become worse after treatment

Prevention
Things you can do to prevent the condition include:

Wash your hands well when handling your contact lenses.

Avoid wearing contact lenses overnight.

Get prompt treatment for an eye infection to prevent ulcers from forming.

Alternative Names
Bacterial keratitis; Fungal keratitis; Acanthamoeba keratitis; Herpes simplex keratitis
 Corneal ulcer facts

A corneal ulcer is an open sore on the cornea.

There are a wide variety of causes of corneal ulcers, including infection, physical and
chemical trauma, corneal drying and exposure, and contact lens overwear and misuse.
Corneal ulcers are a serious problem and may result in loss of vision or blindness.
Most corneal ulcers are preventable.
With appropriate and timely treatment, the majority of corneal ulcers will improve with
minimal adverse effect on vision.

What is a corneal ulcer?

A corneal ulcer is an open sore or epithelial defect with underlying inflammation on the
cornea, the clear structure in the front of the eye. The cornea overlies the iris, which is
the colored part of the eye.

What does a corneal ulcer look like?

A corneal ulcer will often appear as a gray to white opaque or translucent area on the
normally transparent cornea. Some corneal ulcers may be too small to see without
adequate magnification and illumination. See the first reference for pictures of a corneal
ulcer.

What are the causes of a corneal ulcer?

Share Your Story

Most corneal ulcers are caused by infections. Bacterial infections cause corneal ulcers
and are common in people who wear contact lenses. Bacteria can directly invade the
cornea if the corneal surface has been disrupted. Some bacteria produce toxins that
can cause ulceration of the cornea. Viruses that may cause corneal ulcers include
the herpes simplex virus (the virus that causes cold sores) and the Varicella virus (the
virus that causes chickenpox and shingles). Fungal infections can cause corneal ulcers
and may occur with improper care of contact lenses or overuse of eyedrops that contain
steroids. Parasites like Acanthamoeba may also cause corneal ulcers.
Tiny cuts or scratches in the corneal surface may become infected and lead to corneal
ulcers. For example, metal, wood, glass, or almost any type of particle that strikes the
cornea can cause minor trauma. Such injuries damage the corneal surface and make it
easier for bacteria to invade and cause a corneal ulcer. A corneal abrasion is a larger
loss of the corneal surface and may ulcerate if left untreated.

Disorders that cause dry eyes can leave the eye without the germ-fighting protection of
the tear film and cause or aggravate corneal ulcers.

Disorders that affect the eyelid and prevent the eye from closing completely, such as
Bell's palsy, can dry the cornea and make it more vulnerable to ulcers. In addition,
mechanical problems of the lid turning inward toward the eye or lashes growing inward
can cause corneal ulcers.

Any condition which causes loss of sensation of the corneal surface may increase the
risk of corneal ulceration.

Chemical burns or other caustic (damaging) solutions splashing into the eye can injure
the cornea and lead to corneal ulceration.

People who wear contact lenses are at an increased risk of corneal ulcers. The risk of
corneal ulcers and other complications are lowest with daily wear disposable lenses.
The risk of corneal ulceration increases at least tenfold when using extended-wear
lenses. Extended-wear contact lenses are those contact lenses that are worn for
several days without removing them at night.

Scratches on the edge of the contact lens can scrape the cornea's surface and make it
more open to bacterial infections. Similarly, tiny particles of dirt trapped underneath the
contact lens can scratch the cornea. Bacteria may be on the improperly cleaned lens
and get trapped on the undersurface of the lens. If lenses are left in eyes for long
periods of time, bacteria can multiply and cause damage to the cornea. Wearing lenses
for extended periods of time can also block oxygen to the cornea, making it more
susceptible to infections.
In addition, some patients with immunological disorders
(immunosuppressed, rheumatoid arthritis, lupus, and others) may develop corneal
ulcers as a complication of their disease

Corneal Ulcer Overview

A corneal ulcer is an open sore on the cornea, the thin clear
structure overlying the iris (the colored part of the eye).

Corneal Ulcer Causes

Most corneal ulcers are caused by infections.

o
o Bacterial infectionscause corneal ulcers and are
common in people who wear contact lenses.

o
o Viral infections are also possible causes of corneal
ulcers. Such viruses include the herpes simplex
virus(the virus that causes cold sores) or the
varicella virus (the virus that
causes chickenpox and shingles).

o Fungal infections are an unusual cause of corneal
ulcers and may happen after injury with organic
material such as branches or twigs. People who
contract this type of infection have been treated with
steroid eyedrops or are wearing contact lenseswhich
are not properly disinfected.
 Tiny tears to the cornea may also cause corneal ulcers.
These tears can come from direct trauma; scratches; or
particles, such as sand, glass, or small pieces of steel.
Such injuries damage the cornea and make it easier for
bacteria to invade and cause a serious ulcer.

Disorders that cause dry eyes can leave your eye without
the germ-fighting protection of tears and cause ulcers.

Disorders that affect the eyelid and prevent your eye from
closing completely, such as Bell's palsy, can dry your
cornea and make it more vulnerable to ulcers.

Chemical burns or other caustic (damaging) solution

splashes can injure the cornea.

People who wear contact lenses are at an increased risk of

corneal ulcers. In fact, your risk of corneal ulcerations
increases tenfold when using extended-wear (overnight)
soft contact lenses. Extended-wear contact lenses are
those contact lenses that are worn for several days
without removing them at night. Contact lenses can
damage your cornea in many ways.

o
o Scratches on the edge of your contact lens can
scrape the corneas surface and make it more open
to bacterial infections.

o Similarly, tiny particles of dirt trapped underneath

the contact lens can scratch the cornea.
 o Bacteria may be on the lens or in your cleaning
solutions and, thus, get trapped on the undersurface
of the lens. If your lenses are left in your eyes for
long periods of time, these bacteria can multiply and
cause damage to the cornea.

o Wearing lenses for extended periods of time can also

block oxygen to the cornea, making it more
susceptible to infections.

Corneal Ulcer Symptoms

Red eye
Severe pain
Feeling that something is in your eye
Tears
Pus or thick discharge draining from your eye
Blurry vision
Pain when looking at bright lights
Swollen eyelids
A white round spot on the cornea that is visible with the
naked eye if the ulcer is very large

When to Seek Medical Care

Change in vision

Severe pain
 Feeling that there is something in your eye

Obvious discharge draining from your eye

History of scratches to the eye or exposure to chemicals

or flying particles

Exams and Tests

Because corneal ulcers are a serious problem, you should see
your ophthalmologist (a medical doctor who specializes in eye
care and surgery).

Your ophthalmologist will be able to detect if you have an

ulcer by using a special eye microscope, known as a slit
lamp. To make the ulcer easier to see, he or she will put a
drop containing the dye fluorescein into your eye.
If your ophthalmologist thinks that an infection is
responsible for the ulcer, he or she may then get samples
of the ulcer to send to the laboratory for identification.

Corneal Ulcer Treatment - Self-Care at Home

If you wear contact lenses, remove them immediately.
Apply cool compresses to the affected eye.
Do not touch or rub your eye with your fingers.
Limit spread of infection by washing your hands often and
drying them with a clean towel.
Take over-the-counter pain medications, such
as acetaminophen(Tylenol) or ibuprofen (Motrin).
Medical Treatment
Your ophthalmologist will remove your contact lenses if
you are wearing them.

Your ophthalmologist will generally not place a patch over

your eye if he or she suspects that you have a bacterial
infection. Patching creates a warm dark environment that
allows bacterial growth.

Hospitalization may be required if the ulcer is severe.

Medications
Because infection is a common occurrence in corneal
ulcers, your ophthalmologist will prescribe antibiotic
eyedrops. If the infection appears very large, you may
need to use these drops as often as 1 drop an hour.
Oral pain medications will be prescribed to control the
pain. Pain can also be controlled with special eyedrops
that keep your pupil dilated.

Surgery
If the ulcer cannot be controlled with medications or if it
threatens to perforate the cornea, you may require an
emergency surgical procedure known as corneal transplant.

Next Steps - Follow-up

If you do not need hospitalization, your ophthalmologist will
prescribe eyedrops and pain medications for you to take
regularly at home. You will need to follow up with your
ophthalmologist daily until your ophthalmologist tells you
differently.
You should contact your ophthalmologist immediately if you
experience symptoms, such as worsening vision, pain, or
discharge.

Prevention
Seek medical attention from your ophthalmologist immediately
for any eye symptoms. Even seemingly minor injuries to your
cornea can lead to an ulcer and have devastating
consequences.

Wear eye protection when exposed to small particles that

can enter your eye.

If you have dry eyes or if your eyelids do not close

completely, use artificial teardrops to keep your eyes
lubricated.

If you wear contact lenses, be extremely careful about the

way you clean and wear your lenses.

o
o Always wash your hands before handling the lenses.
Never use saliva to lubricate your lenses because
your mouth contains bacteria that can harm your
cornea.

o
 o Remove your lenses from your eyes every evening
and carefully clean them. Never use tap water to
clean the lenses.

o
o Never sleep with your contact lenses in your eyes.

o
o Store the lenses in disinfecting solutions overnight.

o
o Remove your lenses whenever your eyes are irritated
and leave them out until your eyes feel better.

o
o Regularly clean your contact lens case.

o
o Discard and replace the contact lenses at the interval
specified by your doctor

Outlook
A corneal ulcer is a true emergency. Without treatment, the
ulcer can spread to the rest of your eyeball, and you can
become partially or completely blind in a very short period of
time. Your cornea may also perforate, or you could develop
scarring, cataracts, or glaucoma.

With the proper treatment, corneal ulcers should improve

within 2-3 weeks.
 If scars from previous corneal ulcers impair vision,
a corneal transplant may be needed to restore normal
vision.
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Part 2 of 7

Why Do Corneal Ulcers Develop?

The main cause of corneal ulcers is infection.

Acanthamoeba Keratitis
This infection most often occurs in contact lens wearers.

Herpes Simplex Keratitis

Herpes simplex keratitis is a viral infection that causes repeated flare-ups,
which involve lesions or sores in the eye. A number of things can trigger
flare-ups, including stress, prolonged exposure to sunlight, or anything that
weakens the immune system.

Fungal Keratitis
This is a fungal infection that develops after an injury to the cornea involving
a plant or plant material. Fungal keratitis can also develop in people with
weakened immune systems.
 Other Causes
Other causes of corneal ulcers include:

dry eye
eye injury
inflammatory disorders
wearing unsterilized contact lenses
vitamin A deficiency
People who wear expired soft contact lenses or wear disposable contact
lenses for an extended period (including overnight) are at an increased risk
for developing corneal ulcers.

Part 3 of 7

What Are the Symptoms of a Corneal

Ulcer?

You may notice signs of an infection before youre aware of the corneal
ulcer. Symptoms of an infection include:

itchy eye
watery eye
pus-like discharge from the eye
 burning or stinging sensation in the eye
red or pink eye
sensitivity to light
Symptoms and signs of the corneal ulcer itself include:

eye inflammation
sore eye
excessive tearing
blurred vision
white spot on your cornea
swollen eyelids
pus or eye discharge
sensitivity to light
feeling like something is in your eye (foreign body sensation)
All symptoms of corneal ulcers are severe and should be treated
immediately to prevent blindness. A corneal ulcer itself looks like a gray or
white area or spot on the usually transparent cornea. Some corneal ulcers will
be too small to see without magnification, although you will be able to feel
the symptoms.
Part 4 of 7

How Is a Corneal Ulcer Diagnosed?

An eye doctor can diagnose corneal ulcers during an eye exam.

One test used to check for a corneal ulcer is a fluorescein eye stain. This test
involves placing a drop of orange dye onto a thin piece of blotting paper. The
blotting paper then lightly touches the surface of your eye to transfer the dye
to your eye. The doctor will then shine a special violet light onto your eye to
look for any areas that appear green through a special microscope called a
slit-lamp. Corneal damage will show green when the violet light shines on it.

If your doctor spots an ulcer on your cornea, they will investigate to find out
its cause. Your doctor may determine the cause by numbing your eye with
eye drops, then gently scraping the ulcer to obtain a sample. He will test the
sample to find out if it contains bacteria, fungi, or a virus.

Part 5 of 7

What Is the Treatment for a Corneal

Ulcer?

Once your eye doctor discovers the cause of the corneal ulcer, they can
prescribe an antibacterial, antifungal, or antiviral eye medication to treat the
underlying problem. If the infection is bad, your doctor may put you on
antibacterial eye drops while they test the ulcer scrapings to find out the
cause of the infection. In addition, you may have to use corticosteroid eye
 drops. Doctors normally prescribe these drops in cases where the eye is
inflamed and swollen.

During treatment, your doctor will likely ask you to avoid the following:

wearing contact lenses

wearing makeup
taking other medications
touching your eye unnecessarily
Corneal Transplants
In severe cases, the corneal ulcer may warrant a corneal transplant. A corneal
transplant involves the surgical removal of the corneal tissue and its
replacement with donor tissue. According to the Mayo Clinic, a corneal
transplant is a fairly safe procedure. But like any surgical procedure, there are
risks. This surgery may cause future health complications such as:
rejection of the donor tissue
development of glaucoma (pressure within the eye)
eye infection
cataracts (clouding of the eyes lens)
swelling of the cornea
Part 6 of 7

How Do I Prevent a Corneal Ulcer?

 The best way to prevent corneal ulcers is to seek treatment as soon as you
develop any symptom of an eye infection, or as soon as you receive an eye
injury.

Other helpful preventive measures include:

avoiding sleeping while wearing your contact lenses

cleaning and sterilizing your contacts before and after wearing them
rinsing your eyes to remove any foreign objects
washing your hands before touching your eyes
Part 7 of 7

What Is the Long-Term Outlook?

Some people may also develop a severe loss of vision along with visual
obstruction due to scarring over the retina. Corneal ulcers can also cause
permanent scarring on the eye. In rare cases, the entire eye may suffer
damage.

Although corneal ulcers are treatable, and most people recover quite well
after treatment, a reduction in eyesight may occur.

A corneal ulcer is an ocular emergency that raises high-stakes questions about diagnosis
and management. Four corneal experts provide a guide to diagnostic differentiators and
timely treatment, focusing on the types of ulcers most likely to appear in your waiting room.
When a large corneal ulcer is staring you in the face, time is not on your side. Despite
varying etiologies and presentations, as well as dramatically different treatment approaches
at times, corneal ulcers have one thing in common: the potential to cause devastating loss
of visionoften rapidly, said Sonal S. Tuli, MD, associate professor of ophthalmology,
director of the cornea and external diseases service, and residency program director at the
University of Florida, in Gainesville.
In the early 1990s, when broad-spectrum antibiotics became commercially available, there
was a sea change in the treatment of corneal ulcers, explained Elmer Y. Tu, MD, associate
professor of clinical ophthalmology and director of the cornea service at the University of
Illinois at Chicago. Before the introduction of fourth-generation fluoroquinolones, every
ulcer required referral to a tertiary-care center and the compounding of special antibiotics to
treat the lesion, said Dr. Tu. But since then, primary-care ophthalmologists can write
prescriptions to cure bacterial ulcers, often eliminating the need for referral to a tertiary-care
center.
That doesnt mean that diagnosing and treating corneal ulcers (ulcerative keratitis) is
simple. According to Natalie A. Afshari, MD, associate professor of ophthalmology and
director of the cornea and refractive surgery fellowship program at Duke University,
maximizing the chances of complete recovery requires first pinpointing the etiology and then
tailoring treatment, not just to the condition but to the individual as well.

Diagnostic Approach
Profiling the Ulcer
The number of ulcers seen in clinical practice depends largely on geography. In the
southern United States, corneal ulcers are significantly more common than in northern
states because its warm and humid, with lots of young people swimming and sleeping in
their contact lenses, said Dr. Tuli. Estimates of annual incidence in the United States range
from 30,000 to 75,000.1,2
Categories. Ulcers are primarily divided into infectious and noninfectious categories.
Bacterial infections (chiefly Pseudomonas and Staphylococcus) are by far the most
common, but other microbes include fungi (molds such as Fusarium and yeasts such
as Candida), parasites (Acanthamoeba), and viruses (herpes simplex). Noninfectious ulcers
include autoimmune, neurotrophic, toxic, and allergic keratitis, as well as chemical burns
and keratitis secondary to entropion, blepharitis, and a host of other conditions.
Talk to your patients. As clinicians, we sometimes get sucked into taking a quick look at
the eye to get the diagnostic process started without really talking to the patient, said
Francis R. Mah, MD, associate professor of ophthalmology and pathology and medical
director of the Charles T. Campbell Ophthalmic Microbiology Laboratory at the University of
Pittsburgh. Its imperative to take a detailed history to help identify the ulcers etiology.
Ask about pain. How does the patient describe the pain? If a patient says it feels like he
has a rock in his eye or got poked in the eye, that foreign-body sensation tells you theres
an epithelial defect, which is a symptom more typical of a bacterial ulcer, said Dr. Tuli. If
its more of a toothache in my eye or when the light hits my eye, it really hurts, thats more
likely a nonbacterial or noninfectious keratitis.
And how severe is the pain? If its Acanthamoeba keratitis, for example, patients typically
complain of far more pain than the physical findings would suggest; if its herpetic keratitis,
patients usually dont have pain complaints, even though the appearance would suggest the
presence of severe pain, said Dr. Mah.
Consider the context. The clinician should seek clues by asking the patient about
environmental or social factors that could be related to the infection. For example, Were you
wearing contact lenses when the problem started? Did you wear lenses while swimming or
wash them in tap water? Have you been gardening, or have you encountered vegetation or
dirt in another activity?
Its also important to talk about ocular history, in particular, such risk factors as previous
herpetic keratitis, ocular surgery, current or recent use of ocular medications, dry eye, or
trauma. Systemic diseases, such as diabetes or rheumatoid arthritis, also predispose
patients to corneal ulcers.3
If the patient wears contact lenses, thats obviously going to be a huge factor in swaying
your diagnosis toward infectious keratitis. However, the history and physical exam could
reveal a sterile contact lensassociated ulcer caused by the patient sleeping in contact
lenses, said Dr. Mah.
Examine the eye. The physical exam should include measurement of visual acuity,
external examination, and slit-lamp biomicroscopy. Bacterial ulcers are typically associated
with a large amount of necrotic material and an epithelial defect; other types are generally
less necrotic and may have intact overlying epithelium.3
Culture the site. With the advent of fluoroquinolone antibiotics, which can treat both gram-
negative and gram-positive species, many clinicians have dropped culturing as part of their
diagnostic practice.4,5Dr. Tuli said that its understandable if you dont culture small
peripheral ulcers. But, at the very least, you should always culture central ulcers and ulcers
2 mm or larger prior to initiating therapy. If you dont have access to all the culture media of
a lab (blood, chocolate, and Sabouraud agar), you can still get valuable information from a
Gram stain, she said.
The site should be cultured even in patients already on antibiotics; its still possible to get
positive results, Dr. Tuli added. If you dont get a positive culture, you have to start
considering nonbacterial causes.
When to Refer
Typically, when comprehensive ophthalmologists see a patient with a corneal ulcer, they
reflexively start fluoroquinolones. If the ulcer doesnt noticeably improve in a couple of days,
they refer the case to a cornea specialist or an academic institution.
But there are instances that require immediate referral to a cornea specialist to make sure
the patient doesnt go downhill quickly. For example, if an ulcer is larger than 2 mm,
especially if its located directly on the visual axis, or if theres stromal melting, anterior
chamber inflammation, or any scleral involvement at all, immediate referral is warranted,
said Dr. Mah. Any suspicious or atypical presentation should also be strongly considered for
referral.
Bacterial Ulcers
Sometimes the diagnosis is straightforward: A patient presents with a history of contact lens
wear and severe pain that started two days ago; there is purulent discharge and anepithelial
defect over a round, necrotic ulcer (Fig. 1). This type of presentation practically screams
bacterial keratitis, according to Dr. Tuli.

Diagnostic Differentiators
The characteristic presentation of bacterial keratitis
includes an acutely painful, injected eye, often
accompanied by profuse tearing and discharge and
decreased visual acuity. The patient will often
report feeling a large foreign body
in the eye with every blink, said Dr. Tuli.
Stromal invasion with an overlying area of epithelial
excavation is typical, and the lesion may produce
mucopurulent discharge. The cornea and/or the
eyelids may be swollen, and the conjunctival and
(1) Typical bacterial (Pseudomonas) ulcer with
episcleral vessels will be hyperemic and inflamed. a necrotic stroma, purulent discharge, and a
In severe cases, there may be a marked anterior hypopyon.
chamber reaction, often with pus.3
Treatment
Antibiotics: Frequent dosing required. The topical fluoroquinolones gatifloxacin and
moxifloxacin are excellent empiric antibiotics. Immediately after culturing, start putting the
antibiotic drops in every 5 minutes for at least half an hour to show the patient how
important it is to use the drops as often as possible, said Dr. Mah. By putting those drops
in yourself, you will, hopefully, impress upon the patient how imperative it is to dose
frequently. Compliance cannot be emphasized enough!
If the ulcer is larger than 2 mm, adding fortified antibiotics to fluoroquinolones ensures
eradication of all the gram-positive and gram-negative bacteria. Furthermore, if you have
the patient on two antibiotics, youre much less likely to miss resistant bacteria, said Dr. Tuli.
Tobramycin is a great and cheap medication, which we often use in conjunction with a
fluoroquinolone or vancomycin.
For the first 48 hours, we typically have the patient administer each antibiotic every hour,
alternating the antibiotics on the half hour, said Dr. Tuli. After 24 hours, well ease up a
little at night to maybe every two hours with the two medications five minutes apart, but you
have to make sure the patient understands the importance of antibiotics around the clock to
prevent a worsening infection by morning.
Noncompliance leads to failure. The most common reason for unsuccessful treatment of
bacterial ulcers is noncompliance, said Dr. Mah. If the ulcer is very serious or there was a
delay in accurate diagnosis and treatment, or if a patient has no support system to help with
compliance, consider admitting the patient to the hospital overnight.
Steroids: Use with care. Although using strong antibiotics will sterilize the ulcer, it wont
control the inflammatory reaction, which can be just as damaging to the cornea as the
infection itself, according to Dr. Afshari. As soon as there is evidence that the antibiotic is
working (e.g., the epithelial defect is starting to close, or the culture shows sensitivity to
antibiotics), using corticosteroids will inhibit the inflammatory response and reduce corneal
scarring.
Think carefully before starting the steroids because a steroid without antibiotic coverage
will make the infection much worse, said Dr. Afshari. For steroids to be most beneficial,
prescribe them while the ulcer bed is still open, usually within the first 48 hours after
initiating antibiotic therapy.
When to question the diagnosis. Day 1, you do a culture and start a fluoroquinolone.
Day 2, you expect the patient to feel at least no worse and, hopefully, a little better. Days 2,
3, and 4, the ulcer should start consolidating and the appearance of the eye should be
noticeably improved, said Dr. Mah. I have to reassure patients that vision is the last thing
to improve. But if you dont have signs of at least some overall improvement in four to seven
days, then start considering atypical causes of the keratitis. This is the time to refer the
patient to a cornea specialist.
Resistant Bacterial Ulcers
If a classic-looking bacterial ulcer isnt responding to fluoroquinolones,
when is it reasonable to suspect antibiotic resistance, in particular,
methicillin-resistant Staphylococcus aureus (MRSA)?
MRSA should be considered if a patient develops infectious keratitis in a
hospital or nursing home, is immunosuppressed or has previously been
on antibiotics without success, or works in a health care environment.
Also consider MRSA early in your differential diagnosis if the eye looks
especially toxic, said Dr. Mah.
The key thing with MRSA is that, even though you may not be able to
use some of the first-line agents we use today, you may be able to use
older agents that have regained some effectiveness, said Dr. Mah. You
have to culture the infection and look at sensitivities to various
antibiotics.
Bacitracin ointment and drops, sulfacetamide (Bleph-10) in patients who
arent allergic to sulfa drugs, gentamicin, and even cefazolin are
effective.
If older agents dont work, the medication to turn to is topical fortified
vancomycin, said Dr. Tu, which is the last-resort drug reserved for
MRSA or any gram-positive resistant bacteria.

Fungal Infections
Diagnostic Differentiators
Fungal keratitis is notoriously difficult to diagnose
and, according to Dr. Tu, needs to be cultured on
special media. With molds, the ulcer has a dull gray
infiltrate, and satellite lesions are often present.
Initially, molds produce lesions with characteristic
feathery, branching borders in the cornea (Fig. 2).
However, advanced fungal infection may resemble
advanced bacterial keratitis, which can lead to
misdiagnosis, said Dr. Tuli. (2) Fungal ulcer with feathery borders.
Ulcers caused by yeast have better defined
borders and may look similar to bacterial infections. Yeast infections remain localized,
causing a relatively small epithelial ulceration.6You can have both foreign-body sensation
and light sensitivity, but the eye wont produce a lot of discharge because the tissue isnt
being damaged, said Dr. Tuli.
Red flags. A major red flag for fungal infection is agricultural trauma with vegetable matter,
according to Dr. Mah. In addition, he suggested that clinicians maintain a high index of
suspicion in the setting of contact lens wear and in humid weather conditions.
Treatment
Only one medication is commercially available for fungal keratitis: natamycin, which is
usually applied hourly during the day. Natamycins best activity is against Fusarium mold. It
has less efficacy against Candida yeast, which we treat with a compounded medication
thats either amphotericin or voriconazole, said Dr. Tu.
Dosing regimen. Fungal keratitis requires medication for six weeks on average. The
dosing schedule doesnt have to be as aggressive as for bacterial ulcers because fungi
dont replicate as fast as bacteria. Patients will need to be on medication for so long that
you dont want to exhaust them early on with an intensive schedule, raising the risk of
noncompliance, said Dr. Tuli.
Management of complicated cases. A particularly worrisome risk in infection with fungi,
particularly molds, is deep penetration, not only into the cornea but also into the eye itself. If
the infection doesnt resolve, medical options are limited. Because the topical medications
do not penetrate deeply, Dr. Tu said that trying different delivery methods, like injecting the
antifungal directly into the stroma to achieve higher concentrations, is one well-documented
option. Corneal transplantation should be considered urgently if there is risk of the infection
moving into the eye or adjacent sclera.

Acanthamoeba Keratitis
Diagnostic Differentiators
If a patients history includes contact lens wear
and/or a recent trauma, especially agricultural
trauma, I would suspect Acanthamoeba, which is
on the rise, said Dr. Mah.The ulcer appears very
similar to herpes simplex keratitis, with epithelial
irregularity as well as ring-shaped and perineural
infiltrates (Fig. 3). But, in contrast to herpes
simplex, the pain level is out of proportion to the
physical exam findings.7
Patients with a parasite such as Acanthamoeba are
exquisitely light sensitive. I call it the jacket-over-
(3) Acanthamoeba keratitis showing typical
the-head signthey come in wearing two pairs of
perineuritis.
sunglasses with a jacket over their head because
they cant tolerate any light, said Dr. Tuli. This
overwhelms any foreign-body sensation they may have in the eye.
Among patients with Acanthamoeba keratitis, studies show that only about 33 to 45 percent
of cultured cases have a positive culture, said Dr. Tu. Alternative methods for diagnosis
include confocal microscopy, direct smears, and polymerase chain reaction.
Treatment
There are no FDA-approved medications for treating amoebic infections. We rely on
compounded antiseptics, most often biguanides, specifically topical chlorhexidine and
polyhexamethylene biguanide (PHMB), said Dr. Tu. Although good evidence supports the
use of these agents for Acanthamoeba,the organisms are difficult to eradicate, requiring
medication anywhere from three months to a year. Even after treatment, many patients go
on to need a corneal transplant, said Dr. Tu, either to control the infection or for visual
recovery.

Herpes Simplex Virus Keratitis

Diagnostic Differentiators
The characteristic slit-lamp finding in HSV keratitis
is a dendritic corneal ulcer (Fig. 4). Loss of corneal
sensation is also an important sign, so the clinician
should perform a cotton-wisp test. Although
patients dont report a foreign-body sensation or
much pain, they are usually photophobic. You turn
the light off, and the patient feels much more
comfortable; you put topical anesthetic in the eye,
and the patient doesnt feel a difference, said Dr.
(4) Herpes simplex virus keratitis.
Tuli.
Dr. Mah added that when there is far less discomfort than the physical findings would
indicate, you should suspect HSV, especially if the patient has a history of similar episodes.
Types of HSV keratitis. Primary HSV infection typically occurs in children, but the virus
persists in the body for a lifetime by becoming latent and hiding from the immune system in
neurons. Reactivation is sometimes triggered by fever, exposure to ultraviolet light, trauma,
stress, or immunosuppressive agents. In such a recurrence, the virus invades and
replicates in the corneal epithelium, causing epithelial keratitis.
HSV can also result in stromal keratitis, which isnot an infection but rather an inflammation
causedby the immune response to dead viral particles.
A third type of keratitis associated with HSV is what Dr. Tuli likes to call a diabetic foot in
the eye. Each time the virus replicates, it bursts out and kills off more nerves that supply
the eye, reducing sensation. The resultant hyposensitivity can lead to unrecognized trauma,
predisposing patients to neurotrophic keratitis (discussed below).
Treatment
Antivirals. For epithelial ulcers, the mainstay of treatment has been topical antivirals,
specifically trifluridine drops (nine times a day) or ganciclovir gel (five times a day). Topical
antivirals shouldnt be used for longer than 10 to 14 days because they kill both normal and
infected cells, leading to corneal toxicity.8
Gentle-wiping debridement with a cotton-tipped applicator may benefit epithelial ulcers, as
the infected cells come off easily, according to Dr. Tuli. In addition, oral antivirals like
acyclovir, valacyclovir, and famciclovir may shorten the course of the keratitis, said Dr. Tu.
Steroids: for stromal keratitis only. The treatment for stromal keratitis is topical steroids.
In addition, patients are usually given oral antivirals as prophylaxis to prevent spontaneous
recurrence of epithelial disease while the patient is on steroids. However, steroids are
contraindicated in epithelial keratitis because they would help the virus to replicate.
Conversely, the topical antivirals prescribed for epithelial ulcers are contraindicated in
stromal keratitis because they are ineffective (there is no live virus) and may cause toxicity.
Treatment is more complex in patients with herpetic necrotizing keratitis, in which both live
virus and an immune response are present. You have to walk a tightrope trying to figure
out which medication to increase and which to decrease, said Dr. Tuli. Many of these
patients end up with long-term problems, including glaucoma and corneal scarring.
Other measures. Because eyes with viral keratitis are prone to superinfections, Dr. Tuli
suggested using a daily drop of antibiotic to protect against bacterial infection. In addition,
for patients who are immunocompromised or have recurrent or vision-threatening disease,
chronic low-dose oral acyclovir or valacyclovir significantly reduces the risk of recurrence.

Noninfectious Ulcers
The appearance of noninfectious ulcers is often quite different from infectious lesions. Most
notably, the underlying cornea is relatively clear, and you dont see a lot of haze or white
blood cells entering the area, said Dr. Tu.
Sterile infiltrates are typically smaller than 1 mm, gray-white circumlimbal lesions
separated from the limbus by about 1 mm of clear space, Dr. Mah said. Some patients are
asymptomatic, while others present with mild symptoms of conjunctival swelling, hyperemia,
and ocular irritation.
Sterile infiltrates are usually self-limiting and, left untreated, resolve within a week or two. If
an ulcer does develop but is less than 2 mm, fairly round, and peripheral, without much
stromal involvement or inflammation, it is most likely a sterile ulcer. These are very
responsive to steroids, said Dr. Mah. If youre concerned about a secondary bacterial
infection, I recommend giving a days worth of antibiotics before starting the steroids.
Comprehensive ophthalmologists should feel comfortable treating sterile ulcers related to
entropion, blepharitis, rosacea, incomplete lid closure, dry eye, and other problems that
damage the surface of the cornea as a result of constant friction or drying out. Fix the
underlying problem, and then all you have to do is manage the ulcer supportively with some
antibiotics and lubricating ointment, said Dr. Tuli.
Autoimmune-related keratitis (Fig. 5) is typically
associated with an underlying autoimmune disease
such as rheumatoid arthritis or Sjgren syndrome.
Its essential totag-team with the treating
rheumatologist to manage the condition, according
to Dr. Tu. Moderate to severe ulcers can progress
rapidly to melting and perforation. If a patient has
not yet received an underlying diagnosis, the
biggest hurdle initially is communicating to the
rheumatologist just how serious the ocular
condition is and getting him or her on board to treat
the patient systemically with potentially life-
threatening medications. (5) Autoimmune peripheral ulcerative keratitis.
Although systemic immunomodulation is required,
some topical measures, such as lubricating the surface, may be helpful, said Dr. Tu. The
clinician may also consider using topical cyclosporine to help heal the eye and
immunosuppressant drops such as ascorbate to reduce the risk of stromal melting.
Neurotrophic ulcers are associated with many underlying conditions, including diabetes,
HSV infection, chemical burns, and overuse of topical anesthetics. The common finding is a
decrease in corneal sensation.
A neurotrophic ulcer generally has smooth, thick, gray edges, with minimal inflammation;
and hypopyon may be present. Along with poor corneal sensation, there is a decrease in
the tearing that is needed to protect the ocular surface; moreover, the damaged corneal
nerves endings cant produce necessary growth factors to help heal the eye. Thus, patients
with neurotrophic ulcers have two problems, said Dr. Tuli: repeated minor traumas they
cant feel and impaired healing ability.
Minor neurotrophic ulcers can be managed supportively with preservative-free artificial tears
and ointments. Prophylactic antibiotic drops are generally added to the artificial tears.
Adjunctive medical and surgical approaches for
more serious ulcers are discussed below.
Topical anesthetic abuse (Fig. 6) is part of the
differential diagnosis when the ulcer appears as a
disciform, nonhealing epithelial defect. It shoots up
the list if the patient isa health care worker or has
been treated for everything but is still not
improving, said Dr. Mah. Its a diagnosis of
exclusion. The first step is to eliminate the
anesthetics. Dr. Tuli also recommends providing
surface support with lubrication, collagenase
inhibitors, and bandage contact lenses, as well as
treating the inflammation with topical steroids
cautiously. However, some patients will go to great
(6) Anesthetic abuse ulcer.
lengths to continue using topical anesthetics
despite the damage. Psychotherapy may be
indicated.
Allergic keratoconjunctivitis comes in two types: vernal (seen primarily in younger males,
typically when the weather is hot) and atopic (more typically seen in older women). These
can lead to ulcers with significant vascularization and scarring.
If the ulcer is recognized early, before theres significant corneal involvement, a
comprehensive ophthalmologist can treat it, said Dr. Mah. Medical management typically
includes antihistamines, steroids, and bandage contact lenses. Some reports say topical
cyclosporine is helpful, added Dr. Mah, who sometimes uses tacrolimus ointment (Protopic)
applied to the lids in especially resistant cases. Carefully monitor Protopic use because the
ointment can lead to some necrosis and skin color changes, he cautioned.
A patient with significant allergic keratoconjunctivitis usually has other allergic
manifestations (such as allergic rhinitis or contact dermatitis) and may already be under the
care of an allergist/immunologist. Its important to work in tandem. To fully treat such a
patient, immunotherapy may be necessary; and an allergist/immunologist is far more
experienced in administering immunotherapy shots than most ophthalmologists, said Dr.
Mah.

More at the Meeting

Dont miss the symposium on Non-bacterial Infectious Keratitis, a
combined meeting with the Cornea Society. It includes eight sessions
covering many of the topics in this feature, as well as the 2012
Castroviejo Lecture. (Monday, Nov. 12, 2 to 4 p.m.)
Several relevant instruction courses are also scheduled throughout the
Joint Meeting, including:

Herpes Simplex Keratitis: When Herpes Isnt a Dendrite, and

Vice Versa (Sunday, Nov. 11, 10:15 a.m. to 12:15 p.m.)

Diagnosis and Treatment Modalities in Cases of Moderate

and Recalcitrant Fungal Keratitis (Sunday, Nov. 11, 2 to 3
p.m.)

Atypical Keratitis (Monday, Nov. 12, 10:15 a.m. to 12:15 p.m.)

Help! A Corneal Ulcer Just Walked In! What Do I Do

Next? (Tuesday, Nov. 13, 2 to 3 p.m.)

Adjunctive Approaches
Supporting the surface. Most adjunctive medical and surgical interventions for corneal
ulcers focus on providing surface supportwith lubrication, collagenase inhibitors, and
growth factorsand shielding the cornea. Approaches include bandage contact lenses,
 punctal occlusion, autologous serum eyedrops, amniotic membrane, and tarsorrhaphy,
among others.
In cases of stromal melting, topical collagenase inhibitors such as N-acetylcysteine,
doxycycline, or medroxyprogesterone as well as oral vitamin C 1,000 mg per day may be
prescribed. Cyanoacrylate glue, a Gunderson (conjunctival) flap, or penetrating keratoplasty
may be indicated.
Ultimately, the treatment approach has to be individualized to each condition. Take
bandage contact lenses, for example. With an active infection, theyre contraindicated. You
dont want to hide dirt under the rug, so to speak said Dr. Afshari. But, in contrast, we do
use bandage contact lenses for neurotrophic ulcers, because those we want to cover to
promote healing.
Managing perforation. When an ulcer perforates the cornea, tissue glue is applied if the
defect is less than 2 mm. Otherwise, a partial or penetrating keratoplasty is needed. That
said, corneal transplants are not the best option for neurotrophic ulcers. If the patient cant
heal her own cornea, shell have the same problem with a transplanted cornea, said Dr.
Tuli.
Corneal scars can wait. For repairing the scarring caused by a bacterial infection that has
resolved, Time is on our side, unlike during the diagnostic phase, said Dr. Afshari. After
the infection has resolved and the ulcer has scarred over, we wait to see if the scarring will
improve over time. Then we try to improve vision without surgery, with either rigid gas-
permeable or scleral contact lenses that encompass the scar and give a new curvature. In
selected cases, we do phototherapeutic keratectomy to erase some of the superficial scar,
smoothing out the surface. If these dont work, lamellar or penetrating keratoplasty is the
final step

Corneal ulcer
A corneal ulcer is a painful sore on the clear thin covering of the eye.
These are more likely to affect people who wear contact lenses and are often caused by infections.
Having a corneal ulcer may feel like there's something in the eye and you may be more sensitive to bright
light.
Left untreated, a corneal ulcer can lead to permanent vision problems.
Corneal ulcer causes

Causes of corneal ulcers include:

Bacterial infections
Viral infections, including herpes zoster that causes shingles
Fungal infections
Eye injuries and small scratches on the eye's surface.

Corneal ulcer symptoms

Symptoms of corneal ulcers include:

 Grey-white area on the clear cornea
Eye pain
Eye redness
Eye discharge
Blurred vision
Eye discomfort
Light sensitivity.

Examinations and tests

Seek medical advice if you suspect you have a corneal ulcer.

An optometrist or ophthalmologist will diagnose the condition based on the symptoms and an examination
with a slit lamp after putting fluorescein drops in the eye.
A swab sample may be taken for laboratory testing to determine the cause of the ulcer.
Treatment

Treatment for a corneal ulcer will usually be with antibiotic or antiviral eye drops.
If contact lenses are usually worn, use glasses instead until the corneal ulcer heals.
A cool compress, like a damp cold flannel, may help with the symptoms.
Try not to touch, rub or irritate the eye.
Make sure hands are washed often to help stop spreading the infection to the other eye.
Painkillers, such as paracetamol or ibuprofen, may help with the pain from the corneal ulcer.
Hospital treatment may be needed if the problem is severe and a corneal transplant procedure may be
needed in severe cases.
With the correct treatment, corneal ulcers should improve within 2 to 3 weeks.
After seeing an eye specialist for the corneal ulcer, get back in touch or seek medical advice if symptoms
or pain worsen.
Prevention

Corneal ulcers cannot always be prevented, but taking good care of the eyes, looking after contact lenses
and cleaning and using them correctly and avoiding eye injuries can help reduce the chances of getting a
corneal ulcer.

What Is a Corneal Ulcer?

Written by: Kierstan Boyd
Reviewed by: Devin A Harrison MD
Mar. 01, 2015
A corneal ulcer is an open sore on the cornea the clear front window of the eye. The
cornea covers the iris (the colored portion of the eye) and the round pupil, much like a
watch crystal covers the face of a watch. A corneal ulcer usually results from an eye
infection, though it can be caused by severe dry eye or other eye disorders.

Corneal Ulcer Symptoms

Written by: Kierstan Boyd
Reviewed by: Devin A Harrison MD
Mar. 01, 2015
Symptoms of corneal ulcers include:

Redness of the eye;

Severe pain and soreness of the eye;
The feeling of having something in your eye;
Tearing;
Pus or other discharge;
Blurred vision;
Sensitivity to light;
Swelling of the eyelids;
A white spot on your cornea that you may or may not be able to see when looking in
the mirror.

If you think you have a corneal ulcer or have any eye symptoms that concern you, it is
important to see your ophthalmologist (Eye M.D.) immediately. If not treated, corneal ulcers
can severely and permanently damage your vision and even cause blindness.

Who Is At Risk for Corneal Ulcers?

Written by: Kierstan Boyd
Reviewed by: Devin A Harrison MD
Mar. 01, 2015
People at risk for corneal ulcers include:

Contact lens wearers

People who have or have had cold sores, chicken pox or shingles
People who use steroid eyedrops
People with dry eye
People with eyelid disorders that prevent proper functioning of the eyelid
People who suffer injury or burns to the cornea

If you wear contact lenses, safe handling, storage and cleaning of your lenses are key steps
to reduce your risk of a corneal ulcer. Learn how to safely take care of your contact lenses.

What Causes Corneal Ulcers?

Written by: Kierstan Boyd
Reviewed by: Devin A Harrison MD
Mar. 01, 2015
Many causes of corneal ulcers can be prevented. Use the correct protective eyewear when
doing any work or play that can lead to eye injury. And if you wear contact lenses, it is
important to care for your contact lensessafely and correctly.
Corneal ulcers are usually caused by the following types of infections:

Bacterial infections
These are common in contact lens wearers, especially in people using extended-
wear lenses.
Viral infections
The virus that causes cold sores (the herpes simplex virus) may cause recurring
attacks that are triggered by stress, an impaired immune system, or exposure to
sunlight. Also, the virus that causes chicken pox and shingles (the varicella virus)
can cause corneal ulcers.
Fungal infections
Improper use of contact lenses or steroid eyedrops can lead to fungal infections,
which in turn can cause corneal ulcers. Also, a corneal injury that results in plant
material getting into the eye can lead to fungal keratitis.
Parasitic (Acanthamoeba) infections
Acanthamoeba are microscopic, single-celled amoeba that can cause human
infection. They are the most common amoebae in fresh water and soil.
When Acanthamoeba enters the eye it can cause severe infection, particularly for
contact lens users.

Other causes of corneal ulcers include:

Abrasions or burns to the cornea caused by injury to the eye. Scratches, scrapes
and cuts from fingernails, paper cuts, makeup brushes and tree branches can
become infected by bacteria and lead to corneal ulcers. Burns caused by caustic
chemicals found in the workplace and at home can cause corneal ulcers.
Dry eye syndrome.
Bell's palsy and other eyelid disorders that prevent proper eyelid function. If the
eyelid does not function properly, the cornea can dry out, and an ulcer can develop.

Corneal Ulcer Diagnosis

Written by: Kierstan Boyd
Reviewed by: Devin A Harrison MD
Mar. 01, 2015
Your Eye M.D. will use a special dye called fluorescein (pronounced FLOR-uh-seen) to
illuminate any damage to your cornea then examine your cornea using a special
microscope called a slit lamp. The slit-lamp exam will allow your ophthalmologist to see the
damage to your cornea and determine if you have a corneal ulcer.
If your Eye M.D suspects that an infection is responsible for your corneal ulcer, a tiny tissue
sample may be taken so that the infection can be identified and properly treated.

Corneal Ulcer Treatment

Written by: Kierstan Boyd
Reviewed by: Devin A Harrison MD
Mar. 01, 2015
Antibiotics, antifungal or antiviral eyedrops are the mainstay of treatment. Sometimes
antifungal tablets will be prescribed, or an injection of medication is given near the eye for
treatment.
Once any infection has diminished or is gone, then steroid or anti-inflammatory eyedrops
may be used to reduce swelling and help prevent scarring. The use of steroid eyedrops is
controversial and should only be used under close supervision by your ophthalmology. It is
possible that steroid eyedrops may worsen an infection.

Abnormal cornea is removed.

Donor cornea is sutured in place.

Oral pain medication may be prescribed to reduce pain.
If symptoms of corneal ulcer continue after treatment including pain and redness of the
eye, tearing and discharge from the eye and blurry vision let your ophthalmologist know
right away so a different course of treatment can be started promptly.

Surgical treatment
If corneal ulcers cannot be treated with medication, surgery may be needed to keep your
vision. A corneal transplant can replace your damaged cornea with a healthy donor cornea
to restore vision.