What is the treatment for an ongoing corneal ulcer due to an over sensitivity immune reaction?

Treatment of Corneal Ulcers Due to Oversensitivity Immune Reaction

For corneal ulcers caused by immune hypersensitivity reactions, topical corticosteroids are the mainstay of treatment, but they must be used judiciously after ruling out active infection and with close monitoring for complications.

Initial Assessment and Management

Step 1: Rule Out Active Infection

• Obtain corneal cultures and smears before initiating corticosteroid therapy
• Ensure no fungal or Nocardia infection is present, as corticosteroids can worsen these infections 1
• Wait for the organism to be identified, epithelial defect to begin healing, and/or ulcer to consolidate before starting corticosteroids 1

Step 2: Initial Treatment

• Begin with broad-spectrum topical antibiotics to prevent or treat any secondary bacterial infection
• Options include:
  • Fluoroquinolones (ciprofloxacin 0.3%, ofloxacin 0.3%, levofloxacin 1.5%) 1
  • For severe cases, consider fortified antibiotics (cefazolin 5%, tobramycin 1.3%) 1

Step 3: Corticosteroid Therapy

• After 2-3 days of antibiotic therapy showing improvement, add topical corticosteroids 1
• Prednisolone acetate ophthalmic suspension is commonly used 2
• For central corneal infiltrates that compromise vision, corticosteroids are particularly beneficial 1
• Dosing should start more frequently (e.g., every 1-2 hours) and taper based on clinical response

Monitoring and Follow-up

Immediate Follow-up

• Examine patient within 1-2 days after initiating corticosteroid therapy 1
• Monitor for:
  • Intraocular pressure (IOP) elevation 2
  • Signs of worsening infection
  • Clinical improvement (reduced pain, decreased infiltrate density, reduced stromal edema) 1

Long-term Monitoring

• Regular follow-up to monitor for:
  • Posterior subcapsular cataract formation 2
  • Glaucoma development 2
  • Delayed wound healing 2
  • Secondary infections (bacterial, fungal, viral) 2

Special Considerations

For Severe or Progressive Cases

• If thinning progresses or small perforation develops:
  • Apply tissue adhesive (cyanoacrylate) over a clean, dry base 1
  • Avoid fibrin glue as it biodegrades too rapidly 1
  • Consider bandage contact lens to prevent dislocation of glue 1

For Non-healing Cases

• Consider amniotic membrane transplantation, which provides anti-inflammatory, anti-angiogenic, and prohealing mediators 1
• Available as membranes attached to scleral rings or as wafers placed under contact lenses 1

Cautions and Complications

Risks of Corticosteroid Therapy

• Potential complications include:
  • Elevation of IOP with possible glaucoma development 2
  • Posterior subcapsular cataract formation 2
  • Delayed wound healing 2
  • Secondary infections (particularly fungal) 2
  • Infectious crystalline keratopathy with chronic use 1

Warning Signs

• If signs and symptoms fail to improve after two days of treatment, reevaluate 2
• Suspect fungal invasion in persistent corneal ulceration where corticosteroids have been used 2
• If inflammation or pain persists longer than 48 hours or worsens, discontinue medication and reassess 2

Specific Immune-Mediated Corneal Ulcers

Autoimmune Corneal Ulcers

• For ulcers associated with rheumatoid arthritis or Sjögren's syndrome:
  • More aggressive immunosuppression may be needed 3
  • Consider systemic immunosuppressive therapy in addition to topical treatment 3
  • Prognosis may be poor despite treatment 3

Peripheral Immune-Mediated Ulcers

• Peripheral cornea has more immunologic activity than central cornea 4
• May respond better to corticosteroids due to underlying immune mechanism 4
• Monitor closely as these can progress to Mooren's ulcer in some cases 4

By following this structured approach, immune-mediated corneal ulcers can be effectively managed while minimizing the risks associated with corticosteroid therapy. The key is judicious use of corticosteroids after ruling out infection, with close monitoring for complications.