DR K N Jha,MS
Professor of Ophthalmology
Email : firstname.lastname@example.org
What is corneal ulcer ?
Etiology, pathology, symptoms and signs
● Loss of corneal epithelium with inflammation
in the surrounding cornea is called corneal
● Corneal ulcer is one the common cause of blindness.
● It is an ocular emergency.
Infections are almost always exogenous
Causative organism: S.aureus, S.epidermidis, S.
pneumoniae, Pseudomonas aeruginosa,.
Uncommon: Neisseria gonorrhoeae, E. coli
Fungi : Aspergillus and Fusarium sp
• Trauma: e.g. Contact lenses, trichiasis, surgery
• Topical steroids
• Dry eye syndrome
• Lagophthalmos : e.g. Facial nerve palsy
• Neurotrophic keratitis resulting from viral infections and
lesions of ophthalmic division of Trigeminal nerve
• Deficiency states ( Vit. A ) and metabolic diseases ( DM)
• Poor local hygiene, and local infection ( chronic dacryocystitis)
Pathogenesis of Bacterial Ulcers
Bacterial adherence, proliferation, and invasion of corneal stromal lamellae
Corneal inflammation with local production of cytokines and chemokines
Diapedesis and migration of neutrophils into the peripheral cornea from
Release of bacterial proteases. Enzymes released by neutrophils and activation
of matrix metallopreoteinases exacerbate inflammatory necrosis.
Healing begins with control of microbial replication.
Pathology of Corneal Ulcer
• Localized necrosis of the anterior layers of the cornea
• Desquamation of the epithelium and damage to the
• Formation of the slough and purulent infiltration
• Regeneration of the epithelium
Clinical Features of Corneal ulcer
Symptoms : Painful red eye, diminution of vision,
Signs: Circumcorneal congestion, ulceration,
inflammation, and necrosis of corneal layers
Fungal Corneal ulcer
History of trauma with vegetable matter e.g., eye
trauma during harvesting of crops.
Ulcer appears dry; it has feathery edges.
Satellite lesions may be seen.
Endothelial plaque may be visible.
Hypopyon is common.
Complications of Corneal Ulcer
• Perforation and its complications
- Anterior synechia , Iris prolapse, expulsion of lens and
vitreous, Intraocular hemorrhage, Endophthalmitis /
• Secondary glaucoma
• Anterior capsular cataract
• Staphyloma formation
Assessment of Corneal ulcer
History, general, and systemic examination
- Visual acuity: may be low
- Eye and Ocular adnexa: Eye lid , lacrimal sac
Conjunctiva: circumcorneal congestion
Corneal ulcer: size, site ,surface, margin, slough, corneal
sensation, thinning , satellite lesions
Anterior chamber: Cells, flare, hypopyon
The majority are managed without smears or cultures.
Scraping from the ulcer margins and the base of the ulcer
Examination of Smear stained with Gram stain, Giemsa
stain, KOH mount for fungi
Culture on blood agar, chocolate agar, thioglycollate broth,
and Sabouraud’s dextrose agar
• Control of infection
• Symptomatic relief
• Prevention of complications
Control of Infection
• Fortified cephazolin eye drop 50 mg / ml 1/4/6 hourly
• Fortified tobramycin eye drop 14 mg/ ml 1/4/6 hourly
Fortified vancomycin eye drop 25-50 mg/ml drop
Fluoroquinolone eye drop ( Cipro/ oflo/ moxifloxacin/
gatifloxacin) 0.3 % drop
Dose: 1 drop every 5-15 min for 1 hour . ½ to 1 hourly
thereafter. Reduce the dose later.
Antimicrobials for Fungal corneal ulcer
Topical antifungal drops:
- Natamycin 5 % 1 hourly by day and 2 hourly by night
for 6 weeks to 6 mo
- Amphotericin B 0.15/ 0.3 % frequent instillation
Oral antifungal agents; Ketoconazole 200-600 mg/ day
Fluconazole 200-400mg/ day
Cycloplegics : Atropine 1 % eye drop t.i.d.
Debridement of the ulcer
Treatment of complications: perforation, secondary
Outcome of corneal ulcer
Healing with out opacity
Healing with opacity
Point to remember
Corneal ulcer causes painful red eye.
Trauma often is the predisposing event.
Community acquired infection often does not require
Fluoroquinolone 0.3 % eye drop 1-2 hourly, is adequate for
small, peripheral ulcers.
Atropine ointment 1% tds relieves pain, prevents synechia.
All cases must be referred to ophthalmologist.
Can you recall ?
Definition of a corneal ulcer
Symptoms and Signs
Treatment of corneal ulcer
Complications of corneal ulcer
Outcome of corneal ulcer