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Corneal Ulceration and Ulcerative Keratitis in Emergency Medicine Medication

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

Medication Summary

The first-line regimen in treating corneal ulceration usually consists of alternating an aminoglycoside with a first-generation cephalosporin every 15-30 minutes. Frequently used, ciprofloxacin 0.3%, offers a shorter average time to healing and a reduced duration of therapy than conventional therapy. Obviously, the concern with this type of monotherapy is resistance.

Antibiotics may be administered by subconjunctival injection if compliance is a concern. To reduce the inhibition of corneal regeneration caused by concentrated antimicrobial solutions, the intervals between antimicrobial instillation and/or frequency of instillation should be prolonged following a decrease in purulence and a reduction in ulcer size.[12]

If tests show that a viral infection is present, begin therapy with mechanical debridement of the infected rim along with a rim of the normal epithelium, followed by a topical instillation of the antiviral medications.

In fungal infections, a broad-spectrum antifungal drug usually is chosen. Some of the alternatives include natamycin, fluconazole, amphotericin B, miconazole, and ketoconazole. Natamycin is the first-line treatment in fungal infections of the cornea.[13]

An adjunctive therapy may be required for conditions secondary to the ulcer. Atropine 1% or scopolamine 0.25% drops can be used to prevent formation of adhesions between the iris and the lens or cornea.

Topical corticosteroid use is controversial because its use in viral infections is relatively contraindicated, but it may prevent corneal scarring and perforation.[14] Corticosteroids must be tapered to prevent rebound inflammation.

Hyperosmotics, carbonic anhydrase inhibitors, or beta-blockers can be administered if transient increases of intraocular pressure result from the keratitis.

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Anesthetics

Class Summary

Anesthetics are indicated for pain relief and for conjunctival and corneal scrapings. Local anesthetics stabilize the neuronal membrane and prevent the initiation and transmission of nerve impulses, thereby producing the local anesthetic action.

Proparacaine (Ophthetic, I-Paracaine)

 

Has a rapid onset of anesthesia that begins within 13-30 sec after instillation. Short duration of action (about 15-20 min). Since prolonged eye anesthesia can eliminate the patient's awareness of mechanical damage to the cornea, do not use outside of the ED. Frequent use of anesthetics may retard healing.

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Antibiotics

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Cefazolin (Ancef, Kefzol)

 

First-generation cephalosporin antibiotic for gram-positive bacterial coverage. Commonly used in combination with an aminoglycoside to achieve broad-spectrum coverage.

This 50-133 mg/mL solution must be compounded.

Gentamicin (Genoptic)

 

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with a first-generation cephalosporin.

Erythromycin (E-Mycin, E.E.S.)

 

Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Ciprofloxacin ophthalmic (Ciloxan)

 

Bactericidal antibiotic that inhibits bacterial DNA synthesis, and consequently growth, by inhibiting DNA gyrase in susceptible organisms.

Indicated for pseudomonal infections and those due to multidrug-resistant gram-negative organisms.

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Antirheumatic, disease-modifying agents

Class Summary

These agents are used in the treatment of rheumatoid arthritis associated corneal ulcer.

Infliximab (Remicade)

 

Chimeric anti-tumor necrosis factor alpha monoclonal antibody. Neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Mix in 250-mL normal saline for infusion over 2 h. Must use with low-protein-binding filter (1.2 micron or less). Indicated to reduce signs and symptoms of active ankylosing spondylitis.

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Cycloplegics

Class Summary

Instillation of a long-acting cycloplegic agent can relax any ciliary muscle spasm that can cause a deep aching pain and photophobia.

Scopolamine ophthalmic (Isopto Hyoscine)

 

Blocks the action of acetylcholine at parasympathetic sites in the smooth muscle, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).

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Antivirals

Class Summary

Therapy of viral infections begins with mechanical debridement of the involved rim along with a rim of normal epithelium. This is followed by the topical instillation of antiviral medications (eg, vidarabine, idoxuridine, trifluridine).

Vidarabine (Vira-A)

 

Indicated as a topical idoxuridine or when toxic or hypersensitivity reactions to idoxuridine occur. Appears to interfere with the early steps of viral DNA synthesis.

If no signs of improvement are evident after 7 d or if complete reepithelialization has not occurred in 21 d, consider other forms of therapy. Some severe cases may require longer treatment. After reepithelialization has occurred, treat for an additional 7 d at a reduced dosage (eg, twice daily) to prevent recurrence.

Idoxuridine (Herplex)

 

Used for epithelial infections (especially initial attacks). Infections characterized by the presence of a dendritic shape respond better to this medication than stromal infections.

Blocks the reproduction of HSV by producing incorrect DNA copies that prevent the virus from infecting or destroying the tissue.

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Antifungals

Class Summary

Broad-spectrum antifungal agents that cause minimal pain and corneal irritation are recommended. Natamycin is the first-line treatment in fungal infections of the cornea. Candidal infections refractory to natamycin may respond to amphotericin B, miconazole, fluconazole, and ketoconazole. Topical application of these drugs, however, is somewhat limited because most of them must be compounded.

Natamycin (Natacyn)

 

Predominantly fungicidal tetraene polyene antibiotic, derived from Streptomyces natalensis that possesses in vitro activity against a variety of yeast and filamentous fungi, including Candida, Aspergillus, Cephalosporium, Fusarium, and Penicillium species. Binds fungal cell membrane forming a polyene sterol complex that alters membrane permeability and depleting essential cellular constituents. Activity against fungi is dose related, but it is not effective in vitro against gram-negative or gram-positive bacteria. Generally, therapy should be continued for 14-21 d or until the fungal keratitis has resolved. In many cases, reducing the dosage gradually at 4-7 d intervals may help ensure that the organism has been eliminated.

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Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

Mechanism of action is believed to be through inhibition of the cyclooxygenase enzyme that is essential in the biosynthesis of prostaglandins. Inhibition of prostaglandin synthesis results in vasoconstriction and decreases in vascular permeability, leukocytosis, and intraocular pressure (IOP). These agents, however, have no significant effect on IOP.

Ibuprofen (Ibuprin, Motrin, Advil)

 

Usually the DOC for treatment of mild to moderate pain, if no contraindications exist.

Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.

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Analgesics

Class Summary

Pain control is essential to quality patient care, ensuring patient comfort, promoting pulmonary toilet, and containing sedating properties that benefit patients who experience mild or severe pain.

Oxycodone and acetaminophen (Percocet)

 

Drug combination indicated for the relief of moderate to severe pain.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Acknowledgements

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.

References
  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].

 
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Peripheral ulcerative keratitis in the right eye of a patient with rheumatoid arthritis. Glue has been placed.
 
 
 
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