Corneal ulcer: Difference between revisions
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''A corneal ulcer is also often referred to as [[bacterial keratitis]], although these terms are not directly interchangeable because a cornea may harbor a bacterial infection (i.e [[bacterial keratitis]]) without having a loss of tissue (an ulcer), and a cornea may have an ulcer without a bacterial infection.'' | ''A corneal ulcer is also often referred to as [[bacterial keratitis]], although these terms are not directly interchangeable because a cornea may harbor a bacterial infection (i.e [[bacterial keratitis]]) without having a loss of tissue (an ulcer), and a cornea may have an ulcer without a bacterial infection.'' | ||
==Background== | ==Background== | ||
[[File: | [[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]] | ||
*Major cause of impaired vision and blindness worldwide | *Major cause of impaired vision and blindness worldwide | ||
*Break in epithelial layer allows infectious agents to gain access to the underlying stroma | *Break in epithelial layer allows infectious agents to gain access to the underlying stroma | ||
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==Clinical Features== | ==Clinical Features== | ||
[[File:Corneal ulcer.jpg|thumb|Corneal ulcer without infection]] | |||
[[File:PMC3520035 TOOPHTJ-6-110 F3.png|thumb|Corneal ulcer infected with [[Pseudomonas]] spp.]] | [[File:PMC3520035 TOOPHTJ-6-110 F3.png|thumb|Corneal ulcer infected with [[Pseudomonas]] spp.]] | ||
*[[red eye|Redness]] and swelling of lids and conjunctiva | *[[red eye|Redness]] and swelling of lids and conjunctiva | ||
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*Requires careful physical exam as 40% of lesions < 5mm | *Requires careful physical exam as 40% of lesions < 5mm | ||
*[[Hypopyon]] may be present | *[[Hypopyon]] may be present | ||
*[[Iritis]] signs may be present (miotic pupil, consensual photophobia) | *[[Uveitis|Iritis]] signs may be present (miotic pupil, consensual photophobia) | ||
===Complications=== | ===Complications=== | ||
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==Evaluation== | ==Evaluation== | ||
*Clinical | *Clinical diagnosis | ||
*Grey white corneal lesion on gross vs slit lamp examination | |||
*Fluorescein uptake | |||
*Visual Acuity | |||
*Topical anesthetic (ie proparacaine or tetracaine) may assist in patient cooperation with exam once open globe excluded. | |||
**Repeated doses or Rx for topical anesthesia is contraindicated given concerns for impaired healing | |||
{{Corneal abrasion vs ulcer}} | |||
==Management== | ==Management== | ||
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*Topical antibiotics | *Topical antibiotics | ||
**Vigamox 1 drop qhour '''OR''' | **Vigamox 1 drop qhour '''OR''' | ||
**[[Ciprofloxacin]] | **[[Ciprofloxacin]] | ||
***2gtt q15 min x6 hours, then q30min x18h, then q1h x1 day, then q4h x12d | |||
*Consider [[antiviral]] or [[antifungal]] if high suspicion for viral or fungal cause (rare) | *Consider [[antiviral]] or [[antifungal]] if high suspicion for viral or fungal cause (rare) | ||
*[[Cycloplegic]] may help if iritis present | *[[Cycloplegic]] may help if iritis present | ||
Latest revision as of 12:26, 28 August 2021
A corneal ulcer is also often referred to as bacterial keratitis, although these terms are not directly interchangeable because a cornea may harbor a bacterial infection (i.e bacterial keratitis) without having a loss of tissue (an ulcer), and a cornea may have an ulcer without a bacterial infection.
Background
- Major cause of impaired vision and blindness worldwide
- Break in epithelial layer allows infectious agents to gain access to the underlying stroma
- Risk factors include: incomplete lid closure (e.g. secondary to Bell's palsy) and soft contact lens use (especially sleeping in contacts)
Causes
Clinical Features
Corneal ulcer infected with Pseudomonas spp.
- Redness and swelling of lids and conjunctiva
- Ocular pain or foreign body sensation
- Decreased visual acuity (if located in central visual axis or uveal tract is inflamed)
- Photophobia
- Gray/white corneal lesion (will have fluorescein uptake)
- Requires careful physical exam as 40% of lesions < 5mm
- Hypopyon may be present
- Iritis signs may be present (miotic pupil, consensual photophobia)
Complications
- Corneal scarring
- Corneal perforation
- Anterior/posterior synechiae
- Glaucoma
- Cataracts
Differential Diagnosis
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Hemorrhagic chemosis
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Evaluation
- Clinical diagnosis
- Grey white corneal lesion on gross vs slit lamp examination
- Fluorescein uptake
- Visual Acuity
- Topical anesthetic (ie proparacaine or tetracaine) may assist in patient cooperation with exam once open globe excluded.
- Repeated doses or Rx for topical anesthesia is contraindicated given concerns for impaired healing
Corneal abrasion vs. corneal ulcer
| Characteristic | Corneal abrasion | Corneal ulcer |
| History | *Acute pain immediately after injury | *Delayed pain frequently 2-3 days or more after initial event |
| Lesion viewable on fluorescein exam | *Yes | *Yes |
| Lesion viewable on white light exam | *No | *Yes |
| Lesion morphology | *Frequently linear, punctate, patterned, and/or irregular | *Commonly circular |
Management
- Emergent ophtho consultation
- Topical antibiotics
- Vigamox 1 drop qhour OR
- Ciprofloxacin
- 2gtt q15 min x6 hours, then q30min x18h, then q1h x1 day, then q4h x12d
- Consider antiviral or antifungal if high suspicion for viral or fungal cause (rare)
- Cycloplegic may help if iritis present
- Do not patch the eye
Disposition
- Discharge with ophtho followup within 24-48 hours