What is the treatment for a corneal ulcer?

Treatment of Corneal Ulcers

The treatment of corneal ulcers requires prompt administration of broad-spectrum topical antibiotics, with fluoroquinolones being the first-line therapy for most bacterial corneal ulcers. 1

Initial Assessment and Treatment Algorithm

Step 1: Identify the Type of Ulcer

• Bacterial keratitis: Most common, presents with pain, photophobia, decreased vision, and a white/yellow infiltrate
• Viral keratitis: Often dendritic pattern (herpes simplex virus)
• Fungal keratitis: Slow progression, feathery borders
• Acanthamoeba: Associated with contact lens wear, extremely painful

Step 2: Immediate Management

For Bacterial Corneal Ulcers:

1. Initial antibiotic therapy:

   • Small, non-central ulcers: Single fluoroquinolone therapy (ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5%) 1
   • Large or central ulcers: Fourth-generation fluoroquinolones (moxifloxacin 0.5% or gatifloxacin 0.3%) for better gram-positive coverage 1
   • Severe/visually significant infiltrates: Fortified antibiotics (cefazolin 5% and tobramycin 1.3%) 1

2. Dosing frequency:

   • For central or severe keratitis: Initial loading dose every 5-15 minutes, then hourly application 1
   • For less severe cases: Every 1-4 hours based on severity 2

For Viral Corneal Ulcers (Herpetic Keratitis):

• Ganciclovir ophthalmic gel 0.15% - 1 drop 5 times per day until the ulcer heals, then 3 times daily for 7 days 3

Step 3: Adjunctive Therapy

• Pain management: Oral analgesics (NSAIDs or acetaminophen) 1
• Ciliary spasm relief: Cycloplegic agents when anterior chamber inflammation is present 1
• Comfort measures: Preservative-free ocular lubricants every 2 hours 1

Special Considerations

Corticosteroid Use

Corticosteroid therapy in bacterial keratitis is controversial:

• Do not use initially - wait until infection is responding to antibiotics (at least 2-3 days of improvement) 2, 1
• Contraindicated in: Nocardia, fungal, or Acanthamoeba infections 2, 1
• Potential benefit in: Pseudomonas keratitis and severe cases (ulcers covering central 4-mm pupil) 2
• Timing matters: Addition within 2-3 days of antibiotic therapy may result in better visual acuity than later addition 2
• Use minimum amount required to control inflammation 2

Contact Lens Considerations

• Remove contact lenses immediately 1
• Avoid bandage contact lenses during active infection due to increased risk of bacterial keratitis 1
• Do not resume contact lens wear until complete resolution 1

Impending Perforation Management

For thinning corneas or small perforations:

• Tissue adhesive (cyanoacrylate) applied to a clean, dry, compact base 2
• May remain in place for 6+ weeks 2
• Apply bandage contact lens over the adhesive for comfort 2
• Not for use with: Ballooning descemetoceles or large perforations 2

Follow-up and Monitoring

• Daily follow-up during acute phase to assess:
  • Reduction in infiltrate size
  • Re-epithelialization
  • Decrease in anterior chamber reaction
  • Resolution of pain and redness 1
• Consider antibiotic resistance if no improvement after 48 hours 1
• Monitor IOP when using topical corticosteroids 2

Common Pitfalls to Avoid

1. Never prescribe topical anesthetics for outpatient use - they delay healing 1
2. Avoid patching, especially in contact lens wearers - increases risk of bacterial keratitis 1
3. Don't use corticosteroids without adequate antibiotic coverage 2, 1
4. Don't use fibrin glue for corneal perforations - it biodegrades too rapidly 2
5. Don't delay treatment - early intervention is crucial to prevent permanent visual loss 1

Treatment Failure

If the ulcer worsens despite appropriate therapy:

• Obtain cultures before changing antibiotics 1
• Consider subconjunctival antibiotic injections 1
• Consider systemic antibiotics for scleral/intraocular extension 1
• Surgical intervention may be necessary for perforations or non-healing ulcers 4

Prompt diagnosis and aggressive treatment are essential to minimize scarring and preserve vision in patients with corneal ulcers.