Ulcer, Corneal Treatment & Management

  • Author: Fernando H Murillo-Lopez, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Jan 28, 2010
 

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)
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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.[8]

  • Cyanoacrylate glue application is frequently inadequate.
  • A vascularized, thinned, and scarred cornea is left after the inflammation, often with diminished visual acuity.
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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.[9]

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Contributor Information and Disclosures
Author

Fernando H Murillo-Lopez, MD  Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Kilbourn Gordon III, MD, FACEP  Urgent Care Physician

Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

J James Rowsey, MD  Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Ralph Garzia, OD  Assistant Dean for Clinical and Academic Programs, Associate Professor, College of Optometry, University of Missouri at St Louis

Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Paroli MP, Pinca M, Speranza S, Marino M, Pivetti-Pezzi P. 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].

  2. 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].

  3. Flach AJ. Corneal melts associated with topically applied nonsteroidal anti-inflammatory drugs. Trans Am Ophthalmol Soc. 2001;99:205-10; discussion 210-2. [Medline].

  4. 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].

  5. 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].

  6. Schechter BA, Rand WJ, Nagler RS. Corneal melt after amniotic membrane transplant. Cornea. Jan 2005;24(1):106-7. [Medline].

  7. Wilson SE, Lee WM, Murakami C, Weng J, Moninger GA. Mooren-type hepatitis C virus-associated corneal ulceration. Ophthalmology. Apr 1994;101(4):736-45. [Medline].

  8. Vanathi M, Sharma N, Titiyal JS. Tectonic grafts for corneal thinning and perforations. Cornea. Nov 2002;21(8):792-7. [Medline].

  9. 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].

  10. Bullen CL, Liesegang TJ, McDonald TJ, DeRemee RA. Ocular complications of Wegener's granulomatosis. Ophthalmology. Mar 1983;90(3):279-90. [Medline].

  11. 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].

  12. 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].

  13. Jayson MI, Jones DE. Scleritis and rheumatoid arthritis. Ann Rheum Dis. Jul 1971;30(4):343-7. [Medline].

  14. Robin JB, Schanzlin DJ, Meisler DM, et al. Ocular involvement in the respiratory vasculitides. Surv Ophthalmol. Sep-Oct 1985;30(2):127-40. [Medline].

  15. West RH, Barnett AJ. Ocular involvement in scleroderma. Br J Ophthalmol. Dec 1979;63(12):845-7. [Medline].

 
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