Corneal Ulceration
- R. Scott Hoffman, M.D.
Basic Information
Definition
Corneal ulceration refers to the disruption of the corneal surface and/or deeper layers caused by trauma, contact lenses, infection, degeneration, or other means. Rather than simple epithelial abrasion, ulceration implies inflammation, such as with infection of the deeper corneal stroma.
Synonyms
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Infectious keratitis with ulceration
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Bacterial keratitis with ulceration
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Viral keratitis with ulceration
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Fungal keratitis with ulceration
| ICD-10CM CODES | |
| H16.009 | Unspecified corneal ulcer, unspecified eye |
| E50.3 | Vitamin A deficiency with corneal ulceration and xerosis |
Epidemiology & Demographics
Incidence (In U.S.)
Four to six cases per month seen by an average general ophthalmologist
Prevalence (In U.S.)
Common
Predominant Sex
Either
Predominant Age
All ages
Physical Findings & Clinical Presentation
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Localized, well-demarcated, infiltrative lesion with corresponding focal ulcer or oval, yellow-white stromal suppuration with thick mucopurulent exudate and edema. Usually red, angry-looking eye with infiltration in surrounding area of cornea.
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Eye possibly painful, with conjunctival edema and infection (pain is a helpful indicator of progression or improvement in infectious keratitis).
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Active keratitis is usually extremely painful, with photophobia and ciliary injection.
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Sterile neurotrophic ulcers with tissue breakdown and no pain.
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Fig. E1 illustrates various deep corneal lesions.
Etiology
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Complication of contact lens wear, trauma, or diseases such as herpes simplex keratitis or keratoconjunctivitis sicca. Often associated with collagen vascular disease and severe exophthalmos and thyroid disease.
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Viral causes often contagious.
Diagnosis
Differential Diagnosis
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Pseudomonas and pneumococcus and other bacterial infection—virulent
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Moraxella, Staphylococcus, α–Streptococcus infection—less virulent
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Herpes simplex infection or disease caused by other viruses
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Contact lens ulcers differ
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Autoimmune keratitis (e.g., peripheral ulceration with RA, SLE)
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Acute angle closure glaucoma
Workup
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Fluorescein staining, slit lamp
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Appearance often typical
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Differentiate carefully with contact lens wearers
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Note previous eye surgery or laser vision correction
Laboratory Tests
Microscopic examination and culture of scrapings are indicated for vision-threatening keratitis (lesions are large or central location in the cornea)
Treatment
Nonpharmacologic Therapy
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Warm compresses for blepharitis, eyelid hygiene
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Bandage contact lenses
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Stop contact lens wearing
Acute General Rx
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An ophthalmic emergency; refer to ophthalmologist same day.
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Intense antibiotic and antiviral therapy may be needed for infectious keratitis.
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Topical antibiotics (often broad-coverage, new-generation fluoroquinolones).
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Nonsteroidal antiinflammatory drugs and cycloplegic may help with comfort.
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Bacterial infection: subconjunctival cefazolin or gentamicin (e.g., topical Zymar, Vigamox).
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Fungal infection (rare): hospitalization and topical application of antifungal agents.
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Herpes: Viral keratitis can have similar symptoms; should avoid steroid drops unless diagnosis is near certain and showing improvement because viral keratitis can worsen with steroids.
Disposition
Ideally treated by an ophthalmologist if the patient does not rapidly respond to antibiotics (within 24 hr). Improvement in pain is often a good indication of improvement in the infection.
Pearls & Considerations
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Always stop contact lens wearing.
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Always refer ulcers to ophthalmologist.
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Never treat with topical anesthetics or steroids.
Comments
Do not use topical steroids because herpes, fungal, or other ulcers may be aggravated, leading to perforation of the cornea. Antibiotics may delay response and result in overgrowth of nonbacterial (fungal and amoebic) pathogens.
Related Content
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Approach to the patient with corneal disorders (Algorithm, Section III)