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 such as moxifloxacin 0.5% being the first-line treatment for non-severe/peripheral ulcers, while severe or central ulcers require fortified antibiotics (cefazolin 5% + tobramycin 1.3%) with an initial loading dose applied every 5-15 minutes followed by hourly maintenance. 1

Initial Assessment and Management

Diagnosis

• Corneal ulcers present with:
  • Pain and discomfort
  • Reduced vision
  • Red eye
  • Visible epithelial defect with underlying stromal involvement

Immediate Management

1. For non-severe/peripheral keratitis:

   • Fluoroquinolone monotherapy: moxifloxacin 0.5% or gatifloxacin 0.3% every 1-2 hours
   • Alternatives: ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5% 1

2. For severe/central keratitis:

   • Loading dose of topical antibiotics every 5-15 minutes initially
   • Followed by hourly maintenance with fortified antibiotics (cefazolin 5% + tobramycin 1.3%) 1
   • Inappropriate initial treatment increases hospital charges and risk of requiring penetrating keratoplasty 2

3. For specific pathogens:

   • Vancomycin (fortified) for MRSA
   • Colistin 0.19% for multidrug-resistant Pseudomonas 1

Supportive Care

• Ocular hygiene: Daily cleaning to remove inflammatory debris and break down conjunctival adhesions 1
• Preservative-free lubricants: Apply every two hours to maintain corneal moisture and promote healing 1
• Pain management: Oral analgesics (acetaminophen, NSAIDs) and topical NSAIDs 1
• Cycloplegic agents: To decrease pain from anterior segment inflammation and prevent synechiae formation 1

Special Considerations

Herpetic Keratitis

• For dendritic ulcers caused by herpes simplex virus:
  • Ganciclovir ophthalmic gel 0.15% (ZIRGAN): 1 drop 5 times per day until ulcer heals, then 1 drop 3 times per day for 7 days 3

Contact Lens Wearers

• Patients should not wear contact lenses if they have signs or symptoms of corneal ulcers or during treatment 3
• Education on proper contact lens hygiene is essential for prevention 4

Monitoring and Follow-up

• If no improvement within 48 hours, obtain cultures to guide targeted antibiotic therapy 1
• Patients with large abrasions (>4mm) or worsening symptoms should return for follow-up within 24 hours 1
• Complete healing of small abrasions typically occurs within 24-72 hours 1

When to Refer to an Ophthalmologist

• Immediate referral (same day): Suspected bacterial keratitis or serious ocular infection
• Within 24 hours: Minor corneal abrasions without signs of infection 1
• Warning signs requiring urgent attention:
  • Worsening pain
  • Decreased or blurred vision
  • Increased redness or swelling
  • Yellow or green discharge
  • Lack of improvement within 48 hours 1

Advanced Treatments for Resistant Ulcers

• Collagen cross-linking: Can be used as an adjuvant for conventional treatment in resistant cases 5
• Surgical interventions: Reserved for deep corneal ulcers with significant stromal loss, persistent epithelial defects, descemetoceles, or impending perforation 1
  • Amniotic membrane transplantation
  • Lamellar keratoplasty
  • Tissue glue
  • Conjunctival flaps

Common Pitfalls to Avoid

1. Delayed treatment: Early and aggressive treatment is critical for preventing vision loss and complications
2. Inadequate antibiotic coverage: Use broad-spectrum antibiotics initially before culture results
3. Missing co-infections: Consider mixed infections (bacterial, fungal, acanthamoeba) in non-responsive cases 6
4. Inappropriate steroid use: Topical steroids are contraindicated in infectious ulcers until infection is controlled
5. Failure to refer: Timely ophthalmology referral is essential for severe or non-responsive ulcers