A corneal ulcer is a loss of corneal epithelium with inflammation caused by bacterial or fungal infection that can lead to blindness if not treated properly. Common causes include infections from Staphylococcus or Pseudomonas bacteria. Treatment involves topical antibiotics like fortified cephazolin or tobramycin drops every few hours to control the infection along with cycloplegic drops for pain relief and prevention of complications like perforation or secondary glaucoma.

1. DR K N Jha,MS
Professor of Ophthalmology
Email : kirtinath.jha@gmail.com

2. Learning Aim
 What is corneal ulcer ?
 Etiology, pathology, symptoms and signs
 Differential diagnosis
 Laboratory diagnosis
 Treatment
 Complications

3. Corneal ulcer
● Loss of corneal epithelium with inflammation
in the surrounding cornea is called corneal
ulcer.
● Corneal ulcer is one the common cause of blindness.
● It is an ocular emergency.

4. Causative Organisms
 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

5. Predisposing factors
• 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)

6. 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
limbal vessels
 Release of bacterial proteases. Enzymes released by neutrophils and activation
of matrix metallopreoteinases exacerbate inflammatory necrosis.
 Healing begins with control of microbial replication.

7. Pathology of Corneal Ulcer
• Localized necrosis of the anterior layers of the cornea
• Desquamation of the epithelium and damage to the
Bowman’s membrane
• Formation of the slough and purulent infiltration
• Regeneration of the epithelium

8. Clinical Features of Corneal ulcer
 Symptoms : Painful red eye, diminution of vision,
photophobia
 Signs: Circumcorneal congestion, ulceration,
inflammation, and necrosis of corneal layers

10. 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.

11. Fungal corneal ulcer

12. Differential Diagnosis
- Acute conjunctivitis
- Acute iridocyclitis
- Acute congestive glaucoma

13. Complications of Corneal Ulcer
• Descematocele
• Perforation and its complications
- Anterior synechia , Iris prolapse, expulsion of lens and
vitreous, Intraocular hemorrhage, Endophthalmitis /
panophthalmitis
• Secondary glaucoma
• Anterior capsular cataract
• Staphyloma formation

14. 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
Pupil

16. Microbiological Investigations
 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

17. Management
Principles:
• Control of infection
• Symptomatic relief
• Prevention of complications

18. Control of Infection
Topical antibiotics
• Fortified cephazolin eye drop 50 mg / ml 1/4/6 hourly
• Fortified tobramycin eye drop 14 mg/ ml 1/4/6 hourly
Alternatives
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.

19. 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

20. Supportive Therapy
 Cycloplegics : Atropine 1 % eye drop t.i.d.
 Debridement of the ulcer
 Treatment of complications: perforation, secondary
glaucoma

21. Outcome of corneal ulcer
 Healing with out opacity
 Healing with opacity
 Staphyloma
 Secondary glaucoma
 Cataract
 Phthisis bulbi

22. Complete healing

23. Point to remember
 Corneal ulcer causes painful red eye.
 Trauma often is the predisposing event.
 Community acquired infection often does not require
microbiological work-up.
 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.

24. Can you recall ?
 Definition of a corneal ulcer
 Causative organisms
 Symptoms and Signs
 Microbiological investigation
 Treatment of corneal ulcer
 Complications of corneal ulcer
 Outcome of corneal ulcer