Treatment of Corneal Ulcers
The treatment of corneal ulcers requires prompt administration of broad-spectrum topical antibiotics, with fluoroquinolones or fortified antibiotics as first-line therapy depending on ulcer severity, followed by appropriate adjunctive measures based on the underlying cause. 1
Initial Assessment and Management
Diagnosis and Classification
- Corneal ulcers should be examined by an ophthalmologist as part of the initial assessment
- Evaluate for:
- Size and depth of the ulcer
- Location (central vs. peripheral)
- Presence of hypopyon
- Extent of stromal involvement
- Underlying cause (bacterial, viral, fungal, or neurotrophic)
Bacterial Corneal Ulcers
Antibiotic Therapy
For small, non-central ulcers:
For central or severe keratitis (deep stromal involvement, infiltrate >2mm, or hypopyon):
- Initial loading dose: Apply drops every 5-15 minutes followed by hourly application 1
- Consider fortified antibiotics (cefazolin 5% and tobramycin 1.3%) for large/visually significant infiltrates 1, 3
- Studies show monotherapy with moxifloxacin is equivalent to combination therapy for moderate bacterial ulcers 3
Administration Protocol
- For severe ulcers: Start with loading dose (every 5-15 minutes) then hourly application
- For moderate ulcers: Hourly application for first 24-48 hours
- Taper frequency based on clinical response
- Continue until complete healing occurs
Viral Corneal Ulcers (Herpetic)
- For dendritic ulcers caused by herpes simplex virus:
- Ganciclovir ophthalmic gel 0.15% (Zirgan): 1 drop 5 times daily until ulcer heals, then 1 drop 3 times daily for 7 days 4
Adjunctive Therapy
- Cycloplegic agents to decrease pain from anterior segment inflammation and prevent synechiae formation 1
- Ocular lubricants (non-preserved hyaluronate or carmellose eye drops) every 2 hours 1
- Daily ocular hygiene to remove inflammatory debris 1
- For neurotrophic ulcers: Consider nerve growth factor treatment 5
Special Considerations
Prophylaxis
- For corneal abrasions: Broad-spectrum topical antibiotic to prevent ulceration (most effective when started within 24 hours) 1
- For contact lens wearers with abrasions: Avoid patching or therapeutic contact lens due to increased risk of bacterial keratitis 1
Monitoring and Follow-up
- Daily ophthalmological review during acute phase 1
- Assess for:
- Reduction in infiltrate size
- Re-epithelialization
- Decrease in anterior chamber reaction
- Resolution of pain and redness
Precautions
- Avoid topical corticosteroids in the presence of active infection without antibiotic coverage 1
- Patients should not wear contact lenses during treatment 1
- For suspected corneal infection, obtain cultures before initiating broad-spectrum therapy 1
- Be aware that Candida keratitis is common in patients with surface disease, so cultures for both bacteria and fungi are required 1
Treatment Failures
- If no improvement after 48 hours, consider:
- Antibiotic resistance (adjust based on culture results)
- Incorrect diagnosis (fungal, amoebic, or viral etiology)
- Non-infectious cause (neurotrophic, exposure keratopathy)
- For worsening ulcers, consider subconjunctival antibiotic injections or systemic therapy for scleral/intraocular extension 1
The evidence shows that early, aggressive treatment with appropriate antimicrobial therapy is crucial for preventing vision loss and preserving corneal integrity in patients with corneal ulcers.