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Central Sterile Corneal Ulceration Treatment & Management

  • Author: Saadia Zohra Farooqui, MBBS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 27, 2016
 

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 as follows:

  • 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 include the following:
    • 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
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Surgical Care

See Medical Care for possible surgical treatments

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Consultations

See the list below:

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

Complications include corneal scarring, neovascularization, decreased vision, central corneal perforation, and endophthalmitis. Other possible complications include cataract, glaucoma, and blindness.

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Prevention

Patients should wear eye protection to prevent injury to the cornea, especially if the cornea is thin.

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Prognosis

Prognosis depends on the severity of the condition and the patient response to therapy, in addition to associated local and systemic factors.

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Contributor Information and Disclosures
Author

Saadia Zohra Farooqui, MBBS Senior Resident, Singapore National Eye Centre, Singapore General Hospital, Singapore

Disclosure: Nothing to disclose.

Coauthor(s)

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO 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, FARVO 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, Sigma Xi

Disclosure: Nothing to disclose.

Joseph JK Ma, MD Assistant Professor, Department of Ophthalmology, University of Toronto Faculty of Medicine, Canada

Joseph JK Ma, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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.

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