Approach Considerations
Appropriate care of a corneal ulcer depends on an assessment of risk of visual loss and perforation.
Emergency Department Care
Consulting with an ophthalmologist from the ED is the best practice whenever a corneal ulcer is identified. Because of its potential to permanently impair vision or progress to perforation and an open globe, a corneal ulcer is considered an ophthalmologic emergency.
Although most community-acquired cases of bacterial keratitis resolve with empiric therapy and are managed without cultures, cultures are indicated in cases that involve a corneal infiltrate that is central, large, and extends to the middle to deep stroma, cases that are unresponsive to antibiotic therapy, and cases that have atypical clinical features suggestive of fungal, amoebic, or mycobacterial keratitis. [8]
Antibiotic therapy
Low risk of vision loss
Small (< 1 mm), peripheral, nonstaining infiltrate. No epithelial defect. Shallow, minimal anterior chamber reaction, no discharge
Fluoroquinolone eyedrops every 1-2 hours [9]
In contact lens wearers, add tobramycin ointment or ciprofloxacin ointment every bedtime
Medium risk of vision loss
Medium (1-1.5 mm) peripheral infiltrate or any epithelial defect, discharge, or anterior chamber reaction regardless of ulcer size (including small [< 1 mm])
Fluoroquinolone eyedrops every 5 minutes in the ED for 5 doses, then every 1 hour. [9]
Vision threatening
Large (>1.5 mm) and/or central infiltrate, deep anterior chamber inflammation, and/or any scleral involvement
Consult with ophthalmologist immediately, and consider emergent ophthalmology consult in the ED; transfer may be appropriate in order to effect this evaluation.
Two fortified eyedrops every 5 minutes in the ED for 5 doses, tobramycin 15 mg/mL every 1 hour, alternating every 30 minutes with fortified vancomycin 25-50 mg/mL every 1 hour (alternative, cefazolin 50 mg/mL every 1 hour in place of vancomycin) [9]
Consider adding oral or intravenous ciprofloxacin
Cycloplegics
Cycloplegic drops (atropine 1% or cyclopentolate 1% [most common agent]) are applied to provide comfort and to prevent synechiae formation (adhesions between the iris and the lens capsule or cornea, posterior or anterior).
Avoidance of contact lens wear
Contact lens wear should be discontinued until cleared by an ophthalmologist.
Oral pain medications
Pain medication should be given as needed.
Viral infection
If tests results confirm viral infection, begin therapy with mechanical debridement of the infected rim along with a rim of the normal epithelium, followed by topical instillation of antiviral medications.
Fungal infection
A broad-spectrum antifungal drug usually is chosen for fungal infections. Common medications include natamycin, voriconazole, and amphotericin B. Other options include fluconazole, miconazole, and ketoconazole. Natamycin is the first-line treatment in fungal infections of the cornea. [10] Consult with an ophthalmologist.
Consultations
Consulting with an ophthalmologist from the ED is the best practice whenever corneal ulcer is identified. Because of its potential to permanently impair vision or progress to perforation and an open globe, a corneal ulcer is considered an ophthalmologic emergency.
Further Outpatient Care
Most corneal ulcers are managed on an outpatient basis. Consultation with an ophthalmologist from the ED is the best practice whenever a corneal ulcer is identified.
Further Inpatient Care
Inpatient care is occasionally required, most commonly when the ulcer is vision threatening. Inpatient care may also be required where there are significant issues of compliance with medications or follow-up.
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Peripheral ulcerative keratitis in the right eye of a patient with rheumatoid arthritis. Glue has been placed.
