From the Guidelines
Corneal ulcers should be treated promptly with topical antibiotic eye drops, typically fluoroquinolones like ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5%, applied every 1-2 hours initially. The choice of antibiotic should be guided by the severity of the ulcer and the suspected causative organism, with fortified antibiotics considered for large and/or visually significant corneal infiltrates 1.
Key Considerations
- For central or severe keratitis, a loading dose such as every 5 to 15 minutes followed by frequent applications, such as every hour, is recommended 1.
- Cycloplegic agents may be used to decrease synechiae formation and decrease pain from anterior segment inflammation associated with bacterial keratitis 1.
- Single-drug therapy using a fluoroquinolone has been shown to be as effective as combination therapy utilizing antibiotics that are fortified by increasing their concentration over commercially available topical antibiotics 1.
Management and Follow-up
- Treatment should begin immediately after corneal scraping for culture, with drops gradually tapered as the ulcer improves, usually continuing for 7-10 days 1.
- Pain management with oral analgesics and cycloplegic drops like cyclopentolate 1% helps reduce discomfort and prevent complications.
- Antifungal medications (natamycin 5% or amphotericin B) are necessary for fungal ulcers, while acanthamoeba ulcers require polyhexamethylene biguanide or chlorhexidine.
- Patients should avoid contact lens wear during treatment and follow strict hygiene practices, with severe ulcers potentially requiring hospitalization 1.
- Follow-up within 24-48 hours is essential to assess treatment response and adjust therapy if needed, taking into account the potential for increased resistance to fluoroquinolones in certain pathogens 1.
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 treatment for corneal ulcer (keratitis) may include natamycin if the microorganism is susceptible to it. The treatment should be re-evaluated after 7-10 days if there is no improvement, and additional laboratory studies may be necessary 2.
From the Research
Treatment Options for Corneal Ulcers
- Infectious ulcers usually resolve with antimicrobial treatment 3, 4
- Noninfectious ulcers can often be resolved by eliminating toxic medications and providing surface support with lubrication and collagenase inhibitors 3
- Resistant ulcers may need more aggressive therapy with bandage contact lenses, tarsorrhaphy, or autologous serum 3
- Ulcers impending perforation require urgent surgical management, such as tissue glue, conjunctival flaps, or keratoplasty 3, 5
- Topical steroids are useful 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
Pharmacological Treatment
- Topical application with a broad-spectrum antimicrobial remains the preferred method for the pharmacological management of infectious corneal ulcers 4
- Gatifloxacin 0.3% ophthalmic solution has been shown to be effective in the treatment of acute bacterial keratitis 6
- Corneal cross-linking (CXL) has been used as an adjunct or stand-alone treatment for corneal ulcers, with approximately 200 clinical cases reported in the literature 7