Corneal Ulcer

A corneal ulcer is a serious infection involving multiple layers of the cornea. Corneal ulcers develop secondary to breaks in the epithelial barrier, allowing infectious agents to gain access to the underlying corneal stroma. The initial disruption of the epithelial layer can be due to desquamation, trauma, or direct microbial invasion. Exposure keratitis from incomplete lid closure secondary to Bell palsy can cause corneal desiccation and sloughing of the epithelium, allowing bacteria to gain access to the underlying stroma and create an ulcer. Trauma can also breach the epithelium and inoculate the cornea. Wearing of soft contact lenses is a very common cause of corneal ulcers, and the incidence increases dramatically in those who use extended-wear lenses and wearers who sleep with them in place.

Typically the patient will have a painful red eye, with tearing and occasionally photophobia. Examination reveals a staining epithelial defect and a white, hazy infiltrate underlying the defect and spreading into adjacent stroma. Occasionally a hypopyon is also present on slit-lamp examination (see Fig..230:7.), signifying an intraocular inflammatory response. Corneal ulcers need to be treated aggressively with topical antibiotics. A fluoroquinolone such as ciprofloxacin (Ciloxan) or ofloxacin (Ocuflox), one drop every hour in the affected eye, is the recommended treatment. A topical cycloplegic agent such as cyclopentolate 1% (Cyclogyl), one drop tid, can also help with pain control. The eye should not be patched because of risk of Pseudomonas infection, which can cause rapid, aggressive ulceration, with corneal melting and perforation. All corneal ulcers should be referred to an ophthalmologist to be seen within 12 to 24 h.

Treatment:

1. Ciloxan or Ocuflox, one drop every hour.

2. No patching.

3. Topical cycloplegic (1% cyclopentolate or 0.25% scopolamine tid).

4. Ophthalmology referral within 24 h.

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