eMedicine Specialties > Ophthalmology > Cornea
Ulcer, Corneal: Treatment & Medication
Updated: Apr 21, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Medical care is frequently ineffective.
- Systemic immunosuppressive agents (eg, azathioprine, cyclophosphamide, methotrexate, cyclosporine) are occasionally helpful. Start with 1 g/d of intravenous methylprednisolone in 4 divided doses; then, switch to 1 mg/d of oral prednisone, plus 1 of the chemotherapeutic agents outlined below. These medications must be prescribed by a rheumatologist or internist who is familiar with their dosages and adverse effects.
- Methotrexate 7.5-10 mg PO once a week administered with 1 mg/d folic acid
- Azathioprine 2 mg/kg/d
- Cyclophosphamide 2 mg/kg/d
- Cyclosporine A 3-5 mg/kg/d
- Topical agents
- Cycloplegic agents (eg, 0.5% scopolamine tid)
- Immunosuppressive agents (eg, topical cyclosporine 0.5% in alpha-cyclodextrin qid)
- Prophylactic broad-spectrum topical antibiotics (eg, 0.3% ciprofloxacin qid)
Surgical Care
Surgical care includes resection of adjacent conjunctival tissue. If there is perforation, lamellar or penetrating keratoplasties may be necessary.
Tectonic graft is a useful therapeutic option in selected cases of corneal thinning and perforations because it effectively restores the integrity of the eye and allows acceptable visual rehabilitation.
- Cyanoacrylate glue application is frequently inadequate.
- A vascularized, thinned, and scarred cornea is left after the inflammation, often with diminished visual acuity.
Consultations
These patients must be treated and monitored closely with a rheumatologist because the treatment is systemic and can have serious adverse effects and the systemic implications of these disorders often can be life threatening.
Medication
Immune corneal ulcers are rare ocular surface diseases with multiple etiologies. Immunosuppressive drugs and systemic or topical steroids occasionally may control the inflammatory process, but, in more severe cases, the ulcer may progress to melting or perforations.
No suitable treatment is currently available for these patients. The medical treatment of this ulcer is primarily systemic and needs to be coordinated with a rheumatologist. The ophthalmologic treatment is mainly supportive with broad-spectrum antibiotics to prevent superinfections and lubricating agents. Topically applied nerve growth factor (NGF) has been used in some patients with corneal neurotrophic ulcers and corneal melting with success.
Immunosuppressant agents
Inhibit key factors in the immune system responsible for inflammatory responses.
Methotrexate (Folex PFS)
Unknown mechanism of action in treatment of inflammatory reactions; may affect immune function. Adjust dose gradually to attain satisfactory response.
Adult
7.5 mg/wk or 2.5 mg PO/IM bid for 3 doses qwk
Pediatric
5-15 mg/m2/wk PO/IM single dose or 3 divided doses given 12 h apart
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX; probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, can increase MTX plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency
Pregnancy
D - Unsafe in pregnancy
Precautions
Monitor CBCs monthly; monitor liver and renal function q1-3mo during therapy (more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration); MTX has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occur; fatal reactions reported when administered concurrently with NSAIDs
Azathioprine (Imuran)
Antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. May decrease proliferation of immune cells, which results in lower autoimmune activity.
Adult
1 mg/kg/d PO for 6-8 wk; increase by 0.5 mg/kg q4wk until response or dose reaches 2.5 mg/kg/d
Pediatric
Not established
Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of MTX metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine
Documented hypersensitivity; low levels of serum TPMT
Pregnancy
D - Unsafe in pregnancy
Precautions
Increases risk of neoplasia; caution with liver disease and renal impairment; hematologic toxicities may occur; check TPMT level prior to therapy and follow liver, renal, and hematologic function; pancreatitis rarely associated
Cyclosporine A (Sandimmune, Neoral)
Cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions, such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft vs host disease for a variety of organs. For children and adults, base dosing on ideal body weight. A compounded ophthalmic solution of this medication has been used experimentally (1 gtt qid) but has not demonstrated efficacy in patients with corneal ulcers.
Adult
2.5-5 mg/kg/d PO in divided doses
Pediatric
Administer as in adults
Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin
Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UVB radiation in psoriasis since it may increase risk of cancer
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Evaluate renal and liver functions often by measuring BUN, serum creatinine, serum bilirubin, and liver enzymes; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO
Cyclophosphamide (Cytoxan, Neosar)
Used to control severe collagen vascular diseases. Chemically related to nitrogen mustards. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.
Adult
500-750 mg/m2 IV qmo
Pediatric
Administer as in adults
Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones; chloramphenicol may increase half-life while decreasing metabolite concentrations; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase rate of metabolism and leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia and neuromuscular blockade by inhibiting cholinesterase activity
Documented hypersensitivity; severely depressed bone marrow function
Pregnancy
D - Unsafe in pregnancy
Precautions
Regularly examine hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; regularly examine urine for RBCs, which may precede hemorrhagic cystitis
Antibiotics
Prevent superinfection in corneal ulcers with inadequate protection against bacterial keratitis.
Ciprofloxacin (Ciloxan)
Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to ciprofloxacin.
Adult
1-2 gtt in the eye(s) q4h while awake
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; coadministration with steroid combinations after uncomplicated removal of a foreign body from cornea
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
A white crystalline precipitate located in superficial portion of corneal defect may occur (onset starts in 1-7 d); precipitate usually is cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy
More on Ulcer, Corneal |
| Overview: Ulcer, Corneal |
| Differential Diagnoses & Workup: Ulcer, Corneal |
 Treatment & Medication: Ulcer, Corneal |
| Follow-up: Ulcer, Corneal |
| References |
| « Previous Page | Next Page » |
References
Asai T, Nakagami T, Mochizuki M. Three cases of corneal melting after instillation of a new nonsteroidal anti-inflammatory drug. Cornea. Feb 2006;25 (2):224-7. [Medline].
Bullen CL, Liesegang TJ, McDonald TJ, DeRemee RA. Ocular complications of Wegener''s granulomatosis. Ophthalmology. Mar 1983;90(3):279-90. [Medline].
Flach AJ. Corneal melts associated with topically applied nonsteroidal anti-inflammatory drugs. Trans Am Ophthalmol Soc. 2001;99:205-10; discussion 210-2. [Medline].
Foster CS, Forstot SL, Wilson LA. Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripheral ulcerative keratitis. Effects of systemic immunosuppression. Ophthalmology. Oct 1984;91(10):1253-63. [Medline].
Guidera AC, Luchs JI, Udell IJ. Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs. Ophthalmology. May 2001;108(5):936-44. [Medline].
Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. Sep 1997;40(9):1725. [Medline].
Jayson MI, Jones DE. Scleritis and rheumatoid arthritis. Ann Rheum Dis. Jul 1971;30(4):343-7. [Medline].
Lambiase A, Rama P, Bonini S, et al. Topical treatment with nerve growth factor for corneal neurotrophic ulcers. N Engl J Med. Apr 23 1998;338(17):1174-80. [Medline].
Lambiase A, Bonini S, Aloe L, et al. Anti-inflammatory and healing properties of nerve growth factor in immune corneal ulcers with stromal melting. Arch Ophthalmol. Oct 2000;118(10):1446-9. [Medline].
Paroli MP, Pinca M, Speranza S. Paracentral corneal melting in a patient with Vogt-Koyanagi-Harada's syndrome, psoriasis, and Hashimoto's thyroiditis. Ocul Immunol Inflamm. Dec 2003;11(4):309-13. [Medline].
Robin JB, Schanzlin DJ, Meisler DM, et al. Ocular involvement in the respiratory vasculitides. Surv Ophthalmol. Sep-Oct 1985;30(2):127-40. [Medline].
Schechter BA, Rand WJ, Nagler RS. Corneal melt after amniotic membrane transplant. Cornea. Jan 2005;24(1):106-7. [Medline].
Vanathi M, Sharma N, Titiyal JS. Tectonic grafts for corneal thinning and perforations. Cornea. Nov 2002;21(8):792-7. [Medline].
West RH, Barnett AJ. Ocular involvement in scleroderma. Br J Ophthalmol. Dec 1979;63(12):845-7. [Medline].
Further Reading
Keywords
corneal melt, chronic serpiginous ulcer of the cornea, ulcus rodens, corneoscleral melting
