eMedicine Specialties > Ophthalmology > Cornea

Central Sterile Corneal Ulceration: Treatment & Medication

Author: Saadia Zohra Farooqui, MBBS, Aga Khan University Medical College, Pakistan
Coauthor(s): C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution; Joseph JK Ma, MD, Staff Physician, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
Contributor Information and Disclosures

Updated: Nov 6, 2008

Treatment

Medical Care

Individual treatment should be tailored toward the coconspirators that are identified by the history and physical examination. Again, the importance of first excluding infectious etiologies is paramount. Once identified, each contributing factor needs to be treated appropriately. All toxic drops should be eliminated if medicamentosa is suspected. Lagophthalmos should be treated with copious lubrication, with taping for variable amounts of time, beginning with sleeping hours. Tarsorrhaphy is indicated if previous method fails. Patients with sicca need copious lubrication and punctal plugs. Evaluate these patients for systemic rheumatologic disease if suspected by clinical history or examination. If immune disease is suspected, systemic immunomodulatory therapy may be necessary.

Treatment modalities are outlined below.

  • Antibiotics are used to treat the ulcer or as a prophylactic but do encourage resistant microbial strains. Long-term use with certain antibiotics may cause medicamentosa, epitheliopathy, and crystal deposits.
  • Immunomodulatory medications (eg, cyclophosphamide, cyclosporine, methotrexate, azathioprine) are indicated if necessary. Topical cyclosporine A drops are being evaluated in clinical trials.
  • Lubrication (eg, artificial tears) is recommended, but preservatives should be avoided.
  • For chemical burns, corticosteroids (ie, prednisone) are useful for reducing surface inflammation; however, after 10-14 days, collagen synthesis becomes important in the repair process. Prednisone may alter the balance of collagen synthesis versus degradation. Although they have weaker anti-inflammatory properties, progestational steroids (eg, medroxyprogesterone) demonstrate less suppression of collagen synthesis (wound repair).
  • Medroxyprogesterone (eg, Provera)
  • Oral tetracycline or minocycline can be combined with topical tetracycline preparations or with other therapeutic modalities, such as topical antibiotics, cycloplegics, ocular hypotensives, sodium citrate, ascorbic acid, and acetylcysteine.
  • Use of vitamin A is investigational. Initial trials demonstrated clinical efficacy that was not replicated subsequently.
  • Although investigational, fibronectin has been shown to improve epithelialization in vitro; however, clinical trials did not demonstrate efficacy.
  • Use of ascorbic acid/citrate for burns only is investigational.
  • Serum derived tears are under investigation.
  • Cell proliferation and trophic factors (eg, KGF, EGF, NGF) are investigational.
  • Recombinant human tumor necrosis factor receptor Fc fusion protein (etanercept) can be used in progressive disease or in cases that are unresponsive to traditional therapies.
  • PAF receptor antagonists are under investigation.
  • Topical administration of NGF is under investigation.
  • Topical application of lecithinated SOD analog (PC-SOD) has proven to be beneficial.
  • Metalloproteinase inhibitors
    • Synthetic thiols
    • N-acetylcysteine
    • Cysteine
    • Sodium and calcium EDTA
    • Penicillamine
    • Tetracyclines
    • TIMPs
  • Punctal occlusion includes plugs/cautery.
  • A primary barrier method (eg, therapeutic soft contact lenses, scleral lenses, glued on contact lens) should be created and used.
  • Tissue adhesives are best for impending or actual perforations that are 1 mm or smaller in size. They may be removed or allowed to extrude spontaneously after 6-8 weeks when a fibrovascular scar has formed and eliminated the risk of stromal ulceration.
  • Amniotic membrane transplantation (alone or with ex vivo expansion or limbal stem cell transplantation)
  • Conjunctival flap/graft or Tenon-plasty (for reestablishment of limbal vascularization in alkali burns)
  • Tarsorrhaphy (temporary vs permanent lateral)
  • Corneal transplant (lamellar or penetrating) or tectonic graft (temporizing measure until graft bed is vascularized and arrests further ulceration)
  • Mucous membrane grafting
  • Keratoprosthesis

Surgical Care

See Medical Care for possible surgical treatments.

Consultations

  • Corneal specialists
  • Neurologist or neuro-ophthalmologist for probable CNS neurotrophic etiology

Medication

As discussed in Medical Care, a number of medications for sterile corneal ulcers refractory to conventional treatment are currently being investigated with respect to their clinical efficacy (eg, fibronectin, vitamin A, ascorbic acid, serum-derived tears, metalloproteinase inhibitors, neurotrophic growth factor). Therefore, standard dosing, indications, treatment regimens, and contraindications with respect to these medications are not available. The authors recommend that interested physicians directly contact clinical investigators for specific treatment regimens currently used in treatment trials.

Antibiotics often are used prophylactically in treating patients with sterile corneal ulcerations. Specific dosing and medication information on topical antibiotics are not included in this article.

Immunomodulatory treatment regimens are complex, and elaborating on medication dosing and treatment regimens for specific rheumatologic diseases is beyond the scope of this article.

Ophthalmic corticosteroids

Minimize the activity of inflammatory cells and formation of granulomas. Used in symptomatic patients and commonly provides symptomatic improvement.


Prednisolone (AK-Pred, Pred Forte, Pred Mild, Inflamase Forte) Suspension 0.12%

Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.

Adult

1 gtt q1-12h, taper

Pediatric

Not established

Documented hypersensitivity; viral, fungal, or tubercular infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate); safety in lactation unknown

More on Central Sterile Corneal Ulceration

Overview: Central Sterile Corneal Ulceration
Differential Diagnoses & Workup: Central Sterile Corneal Ulceration
Treatment & Medication: Central Sterile Corneal Ulceration
Follow-up: Central Sterile Corneal Ulceration
References
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References

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Further Reading

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Keywords

central sterile corneal ulceration, neurotrophic ulcer, corneal ulcer, corneal stroma, corneal lesion, keratitis, corneal inflammation, stromal ulceration

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Contributor Information and Disclosures

Author

Saadia Zohra Farooqui, MBBS, Aga Khan University Medical College, Pakistan
Disclosure: Nothing to disclose.

Coauthor(s)

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Joseph JK Ma, MD, Staff Physician, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
Joseph JK Ma, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Ralph Garzia, OD, Assistant Dean for Clinical Programs, Associate Professor, School 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.

 
 
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