Medscape is available in 5 Language Editions – Choose your Edition here.


Corneal Ulceration and Ulcerative Keratitis in Emergency Medicine Clinical Presentation

  • Author: Trevor John Mills, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Nov 30, 2015


Numerous symptoms can help determine the diagnosis of keratitis.

Current symptoms

See the list below:

  • Erythema of eyelid and conjunctiva
  • Mucopurulent discharge from eye
  • Foreign body sensation
  • Blurred vision
  • Light sensitivity
  • Pain

Medication and contact lens use

See the list below:

  • Contact lens use [7]
  • Type of contact lens (soft, hard, extended wear)
  • Type of contact lens solution
  • Contact lens hygiene
  • Current ocular medications, especially steroids

Past medical history

See the list below:

  • History of ocular disease, eye surgery, or both
  • Diabetes mellitus
  • History of HIV or other immunodeficiency disorder
  • Exposure to sulphur mustard [8]
  • Collagen vascular disease ( rheumatoid arthritis [RA])

Social history

Smoking history is important.

Inquiry about the dietary habits of a patient with a corneal ulcer is important because vitamin A deficiency is associated with corneal ulcer formation. Inadequate vitamin A can occur in a patient with an intentional diet deprivation or unintentional deprivation found in young children and pregnant women from Africa and Southeast Asia. Secondary vitamin A deficiency may be found in a patient with celiac disease, sprue, cystic fibrosis, pancreatic disease, duodenal bypass, congenital partial obstruction of the jejunum, obstruction of the bile ducts, giardiasis, and cirrhosis.



The physical examination should be thorough, with additional focus on the eye examination.[9] Visual acuity, gross examination of the eyelids, surface of the eye, pupils, extraocular muscles, and fundi, should be performed and documented. A slit lamp examination and ocular pressure measurements should also be obtained.

Visual function is variably affected, depending on the location of the ulcer and whether associated corneal and uveal inflammation is present. Obtain visual acuities on all patients with ocular complaints.

Examination of the lids and the conjunctiva may reveal associated inflammation in these locations.

The eye is typically erythematous, and ciliary injection is often present. Pupillary constriction is usually present secondary to ciliary spasm and iritis.

Purulent exudate may be seen in the conjunctival sac and on the surface of the ulcer, and infiltration of the stroma may result in a creamy opacity of the cornea. The ulcer often is round or oval, and the border generally is demarcated sharply, with the base appearing ragged and gray.

Slit lamp examination may reveal findings of iritis, and hypopyon may be present. Hypopyon is an accumulation of inflammatory cells in the anterior chamber that produces a layered meniscus in the inferior anterior chamber.

Fluorescein staining may reveal the characteristic dendritic ulcer of herpes simplex virus infection.

A Wood lamp may be useful because the ulcer associated with P aeruginosa fluoresces in ultraviolet light.



Viral infections

Herpes simplex virus (HSV) infection is the most common cause of corneal ulcer in the United States. Although not always present, the classic finding in HSV infection is a branching dendritic ulcer.

Infection with HSV may interfere with corneal sensation, resulting in corneal anesthesia.

Varicella-zoster virus (VZV) can cause a corneal ulcer. Although corneal involvement can occur in varicella (chickenpox), it is uncommon and typically benign. The form of zoster (shingles) involving the ophthalmic branch of the trigeminal nerve is a more common corneal infection caused by VZV.

When herpetic eruption occurs along the nose, the nasociliary branch of the ophthalmic nerve is involved, indicating that corneal involvement is likely. This is known as the Hutchinson sign.

The dendritic pattern seen in HSV infection is not seen with zoster infection, although pseudodendrites, which only vaguely resemble true dendrites, may be present. Loss of corneal sensation is a prominent feature of zoster infection.

In contrast to the usual benign course in varicella and HSV, corneal complications in ophthalmic zoster can be severe and blinding.

Superficial punctate keratitis is characterized by destruction of pinpoint areas in the outer layer of the corneal epithelium is associated with adenoviruses.

Bacterial infections

Numerous bacteria have been reported to cause corneal ulcer, although staphylococcal species, P aeruginosa, Streptococcus pneumoniae, and Moraxella species are reportedly the most common causes in the United States.

Clinical characteristics of corneal ulcers caused by various bacteria are not sufficiently distinct to determine the causal bacterial agent, although a corneal ulcer having a bluish or green mucopurulent discharge is almost pathognomonic for P aeruginosa.[10]

Most corneal ulcers are centered, but some occur at the periphery of the cornea (ie, marginal ulcers).

Although the location of the ulcer does not correlate well with the causative organism, a marginal ulcer is more likely to occur as a result of staphylococcal blepharoconjunctivitis. This ulcer is not due to direct bacterial infection but rather is an inflammatory reaction to staphylococcal bacterial antigens and toxins. The ulcer usually is self-limited and lasts from 7-10 days, but it is likely to recur unless the underlying blepharoconjunctivitis is treated.[11]

Fungal infections

Fungal ulcers are caused by Candida, Fusarium, Aspergillus, Penicillium,Cephalosporium, and mycosis fungoides species.

  • Acanthamoeba keratitis
  • Peripheral ulcerative keratitis, associated with rheumatoid arthritis, relapsing polychondritis, and Wegener granulomatosis
  • Photokeratitis (snowblindness) is caused by excess exposure to UV light. This can occur with sunlight, suntanning lamps, or a welding arc.
  • Sulphur mustard chemical keratitis
Contributor Information and Disclosures

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.


Lisa Diane Mills, MD Associate Professor of Emergency Medicine, University of California, Davis, School of Medicine

Lisa Diane Mills, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, Southern Medical Association

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.

Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, and Wesley S Grigsby, MD, to the development and writing of this article.

  1. Jeng BH, Gritz DC, Kumar AB, et al. Epidemiology of ulcerative keratitis in Northern California. Arch Ophthalmol. 2010 Aug. 128(8):1022-8. [Medline].

  2. Jeng BH, Gritz DC, Kumar AB, et al. Epidemiology of ulcerative keratitis in Northern California. Arch Ophthalmol. 2010 Aug. 128(8):1022-8. [Medline].

  3. Kosker M, Duman F, Suri K, Hammersmith KM, Nagra PK, Rapuano CJ. Long-term Results of Keratoplasty in Patients With Herpes Zoster Ophthalmicus. Cornea. 2013 Mar 27. [Medline].

  4. French DD, Margo CE. Demographic patterns of ED patients diagnosed as having corneal ulcer. Am J Emerg Med. 2013 May 17. [Medline].

  5. Morgan PB, Efron N, Brennan NA, et al. Risk factors for the development of corneal infiltrative events associated with contact lens wear. Invest Ophthalmol Vis Sci. 2005 Sep. 46(9):3136-43. [Medline]. [Full Text].

  6. Efron N, Morgan PB, Hill EA, et al. Incidence and morbidity of hospital-presenting corneal infiltrative events associated with contact lens wear. Clin Exp Optom. 2005 Jul. 88(4):232-9. [Medline].

  7. Rasoulinejad SA, Sadeghi M, Montazeri M, Hedayati Goudarzi H, Montazeri M, Akbarian N. Clinical Presentation and Microbial Analyses of Contact Lens Keratitis; an Epidemiologic Study. Emerg (Tehran). 2014 Fall. 2 (4):174-7. [Medline].

  8. Kehe K, Szinicz L. Medical aspects of sulphur mustard poisoning. Toxicology. 2005 Oct 30. 214(3):198-209. [Medline].

  9. [Guideline] American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee. Bacterial keratitis. San Francisco (CA): American Academy of Ophthalmology (AAO); 2008. [Full Text].

  10. Park J, Lee KM, Zhou H, Rabin M, Jwo K, Burton WB, et al. Community practice patterns for bacterial corneal ulcer evaluation and treatment. Eye Contact Lens. 2015 Jan. 41 (1):12-8. [Medline].

  11. Sharma N, Arora T, Jain V, Agarwal T, Jain R, Jain V, et al. Gatifloxacin 0.3% Versus Fortified Tobramycin-Cefazolin in Treating Nonperforated Bacterial Corneal Ulcers. Cornea. 2015 Oct 27. [Medline].

  12. Miller D. Pharmacological treatment for infectious corneal ulcers. Expert Opin Pharmacother. 2013 Apr. 14(5):543-60. [Medline].

  13. Loh AR, Hong K, Lee S, Mannis M, Acharya NR. Practice patterns in the management of fungal corneal ulcers. Cornea. 2009 Sep. 28(8):856-9. [Medline].

  14. Acharya NR, Srinivasan M, Mascarenhas J, et al. The steroid controversy in bacterial keratitis. Arch Ophthalmol. 2009 Sep. 127(9):1231. [Medline].

  15. Araki-Sasaki K, Nishi I, Yonemura N, et al. Characteristics of Pseudomonas corneal infection related to orthokeratology. Cornea. 2005 Oct. 24(7):861-3. [Medline].

  16. Clewes AR, Dawson JK, Kaye S, Bucknall RC. Peripheral ulcerative keratitis in rheumatoid arthritis: successful use of intravenous cyclophosphamide and comparison of clinical and serological characteristics. Ann Rheum Dis. 2005 Jun. 64(6):961-2. [Medline]. [Full Text].

  17. Frith P, Gray R, MacLennan S. The Eye in Clinical Practice. 1994. 77-95.

  18. Goldberg DF, Negvesky GJ, Butrus SI, et al. Ulcerative keratitis in mycosis fungoides. Eye Contact Lens. 2005 Sep. 31(5):219-20. [Medline].

  19. Höfling-Lima AL, de Freitas D, Sampaio JL, et al. In vitro activity of fluoroquinolones against Mycobacterium abscessus and Mycobacterium chelonae causing infectious keratitis after LASIK in Brazil. Cornea. 2005 Aug. 24(6):730-4. [Medline].

  20. Int Ophthalmol Clin. Contact lenses and external disease. Int Ophthalmol Clin. 1986. 26(1):1-166. [Medline].

  21. Khanal B, Deb M, Panda A, et al. Laboratory diagnosis in ulcerative keratitis. Ophthalmic Res. 2005 May-Jun. 37(3):123-7. [Medline].

  22. Krachmer JH, Mannis MJ, Holland EJ. Cornea: Fundamentals of Cornea and External Disease. 1997. 403-407.

  23. Leibowitz HM. Corneal Disorders: Clinical Diagnosis and Management. 1984. 353-372.

  24. Mirza SH. Fungal keratitis due to fusarium solani. J Coll Physicians Surg Pak. 2005 Sep. 15(9):576-7. [Medline].

  25. O'Donnell C, Efron N. Contact lens wear and diabetes mellitus. Cont Lens Anterior Eye. 1998. 21(1):19-26. [Medline].

  26. Pichare A, Patwardhan N, Damle AS, et al. Bacteriological and mycological study of corneal ulcers in and around Aurangabad. Indian J Pathol Microbiol. 2004 Apr. 47(2):284-6. [Medline].

  27. Pinna A, Sechi LA, Zanetti S, et al. Detection of virulence factors in a corneal isolate of Klebsiella pneumoniae. Ophthalmology. 2005 May. 112(5):883-7. [Medline].

  28. Seino JY, Anderson SF. Mooren's ulcer. Optom Vis Sci. 1998 Nov. 75(11):783-90. [Medline].

  29. Servat JJ, Ramos-Esteban JC, Tauber S, et al. Mycobacterium chelonae-Mycobacterium abscessus complex clear corneal wound infection with recurrent hypopyon and perforation after phacoemulsification and intraocular lens implantation. J Cataract Refract Surg. 2005 Jul. 31(7):1448-51. [Medline].

  30. Thomas JW, Pflugfelder SC. Therapy of progressive rheumatoid arthritis-associated corneal ulceration with infliximab. Cornea. 2005 Aug. 24(6):742-4. [Medline].

  31. Vaughan D, Asbury T, Riordan-Eva P. General Ophthalmology. 1995. 124-133.

  32. Velasco Cruz AA, Attie-Castro FA, Fernandes SL, et al. Adult blindness secondary to vitamin A deficiency associated with an eating disorder. Nutrition. 2005 May. 21(5):630-3. [Medline].

  33. Verhelst D, Koppen C, Van Looveren J, et al. Clinical, epidemiological and cost aspects of contact lens related infectious keratitis in Belgium: results of a seven-year retrospective study. Bull Soc Belge Ophtalmol. 2005. 7-15. [Medline].

  34. Zaher SS, Sandinha T, Roberts F, et al. Herpes simplex keratitis misdiagnosed as rheumatoid arthritis-related peripheral ulcerative keratitis. Cornea. 2005 Nov. 24(8):1015-7. [Medline].

Peripheral ulcerative keratitis in the right eye of a patient with rheumatoid arthritis. Glue has been placed.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.