What is the treatment of choice for corneal ulceration?

From the Guidelines

The treatment of choice for corneal ulceration is broad-spectrum topical antibiotics, with fluoroquinolones such as ciprofloxacin 0.3% or levofloxacin 1.5% being effective options, as evidenced by the most recent study in 2024 1. The initial treatment approach should prioritize topical antibiotic eye drops, which can achieve high tissue levels and are the preferred method of treatment in most cases of bacterial keratitis.

• Key considerations include:
  • The use of fluoroquinolones, which have been shown to be as effective as combination therapy utilizing fortified antibiotics 1
  • The potential for variable susceptibility to fluoroquinolones among certain pathogens, such as Streptococci and anaerobes 1
  • The importance of frequent follow-up examinations to monitor healing progress and adjust treatment as needed In severe cases, fortified antibiotics like tobramycin 1.5% alternating with cefazolin 5% may be necessary, and cycloplegic agents such as cyclopentolate 1% or atropine 1% should be added to reduce pain and prevent synechiae formation.
• Additional treatment considerations include:
  • The use of ocular ointments at bedtime in less severe cases or as adjunctive therapy 1
  • The potential benefits and risks of topical corticosteroid therapy, which may be considered in certain cases of microbial keratitis, but should be used with caution and close monitoring 1 The treatment duration typically ranges from 1-3 weeks depending on severity, and pain management with oral analgesics is also important.
• Overall, the goal of treatment is to rapidly and effectively manage the corneal ulceration, prevent complications, and promote healing, while minimizing the risk of adverse events and optimizing patient outcomes.

From the FDA Drug Label

PRECAUTIONS: General. FOR TOPICAL OPHTHALMIC USE ONLY — NOT FOR INJECTION. Failure of improvement of keratitis following 7-10 days of administration of the drug suggests that the infection may be caused by a microorganism not susceptible to natamycin. The FDA drug label does not answer the question.

From the Research

Treatment Options for Corneal Ulceration

The treatment of choice for corneal ulceration depends on the underlying cause, with different approaches for infectious and non-infectious ulcers.

• For infectious corneal ulcers, topical application with a broad-spectrum antimicrobial remains the preferred method for pharmacological management 2.
• The use of topical steroids is beneficial when the ulceration is secondary to inflammatory mediators, but they are contraindicated in corneal melts with minimal inflammation 3.
• Systemic immunomodulation is required in addition to topical therapy in the presence of autoimmune disease 3.
• Quinolones are considered the first-line drug for bacterial keratitis, but treatment should be adjusted according to culture and drug sensitivity test results 4.
• Corneal cross-linking (CXL) has been explored as an adjunct or stand-alone treatment for corneal ulcers, with approximately 200 clinical cases reported in the literature 5.
• Initial therapy for suspected microbial corneal ulcers often involves broad antibiotic therapy based on the prevalence of organisms, with a combination of antibiotics such as cefazolin and tobramycin or gentamicin 6.

Specific Treatment Approaches

• For bacterial corneal ulcers, topical antibiotics such as quinolones are commonly used 4.
• For non-infectious ulcers, treatment may involve eliminating toxic medications, providing surface support with lubrication and collagenase inhibitors, and using bandage contact lenses or tarsorrhaphy 3.
• In cases of ulcers impending perforation, urgent surgical management such as tissue glue, conjunctival flaps, or keratoplasty may be necessary 3.
• The use of 0.66% nanoemulsion povidone-iodine has been reported as an effective treatment for corneal ulcers in a case report 4.