Common infectious etiologies include
- bacteria (Staphylococcus, Streptococcus, Pseudomonas) and
- viruses (herpes simplex, adenovirus).
- Rare causes of corneal ulcers include fungal infections and Acanthamoeba, a ubiquitous protozoan associated with contaminated contact lens solutions.
- Bacterial corneal ulcers are commonly associated with extended-wear contact lenses.
- Fungal infections may also arise from trauma involving vegetable matter such as a tree branch. - - - -Acanthamoeba infections may also occur from swimming in lakes, especially while wearing contact lenses.
Clinical Features:Patients present with pain, photophobia, decreased vision, discharge, and a foreign body sensation.
Ocular findings include a corneal infiltrate, typically a round white spot, with conjunctival hyperemia, meiosis, and chemosis.
Slitlamp biomicroscopy may demonstrate an epithelial defect with fluorescein uptake. Anterior chamber findings can include cells and flare, keratic precipitates, and a hypopyon.
Management
- Corneal ulcers are an ophthalmologic emergency requiring emergent ophthalmology consultation.
- Stains and cultures should be obtained as expeditiously as possible.
- Intensive topical treatment using fortified antibiotics is the most effective treatment route, initially given every 30 to 60 minutes.
- For mild cases, a single fluoroquinolone agent may suffice.
- For more severe cases, dual therapy using a cephalosporin or vancomycin combined with an aminoglycoside is recommended.
- Clinical improvement is usually noted after 2 to 3 days.
- Systemic antibiotics are used in cases where the sclera is involved (Pseudomonas) or if there is a high risk of concurrent systemic disease (Neisseria, Haemophilus).
- Cycloplegics are recommended if there is an accompanying iritis.
- Steroids and eye patching are contraindicated.
- A contact lens wearer must discontinue contact lens wear.
Points To Remember
1. A corneal ulcer is an ophthalmologic emergency.
2. Extended-wear contact lens use is a risk factor for corneal ulcer.
3. Pseudomonas aeruginosa, associated with thick yellow green or blue-green mucopurulent tenacious exudate, is capable of destroying the cornea within 6 to 12 hours.
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