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Corneal Ulcers: for the General Practitioner

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Corneal Ulcers: for the General Practitioner Corneal ulcers: For the general practitioner A corneal ulcer is a defect in the epithelial layer of the cornea. e general practitioner may play an important role in early management and appropriate referral. Incidence varies and depends on aetiology. S Ballim, MB ChB, Dip Ophth (SA), FC Ophth (SA) Department of Ophthalmology, University of KwaZulu-Natal, Durban, South Africa Correspondence to: S Ballim ([email protected]) Basic clinical assessment of the cornea clue as to the health of the posterior segment of the eye. Compare History ndings with the fellow eye. Presenting complaints include pain, irritation, decreased vision or foreign-body sensation. Ask about any history of trauma, including Fluorescein dye should be instilled. Any epithelial defects will stain nature of injury, the timing and the relationship to drop in vision. green. e stain shows up best under blue light (present on some Specic enquiry as to instillation of medication (e.g. steroid drops) ophthalmoscopes). is can, however, be adequately demonstrated or home remedies (e.g. breast milk or urine) is important, as these with a standard torch. e tear lm will become apparent and the may be important predisposing factors and give clues as to the lacus lacrimalis can be assessed. Dry eye is a very signicant factor aetiology. Contact lens use is a very common cause of corneal ulcers. in many corneal epithelial disorders. Tools for examination In general practice it is presumed that a slit-lamp and other specialised equipment is unavailable. It would be reasonable to have Topical antibiotics have been the following ophthalmic tools at one’s disposal: shown to have action against both • visual acuity chart bacterial and fungal pathogens • uorescein strips • topical anaesthetic eye drops and are suitable for preventing • direct ophthalmoscope. both possible superimposed infections. Examination Assessing vision with a Snellen visual acuity chart gives a clue as to the extent of the problem (e.g. a corneal abrasion with good vision is unlikely to require specialist intervention). Each eye should be tested individually, Corneal sensation may be tested with a wisp of cotton wool and unaided and then with pinhole, with the fellow eye occluded. compared with the other eye. Sensation may be decreased in trigeminal nerve palsies, chronic contact lens wear, chronic ocular As a corneal epithelial defect is, in most cases, a painful condition, surface disorders and systemic neuropathic disorders, e.g. diabetes. topical anaesthetic drops will assist in making the patient comfortable Note that the use of topical anaesthetic drops will nullify sensation enough to open his/her eyes. Use a torch or direct ophthalmoscope testing. to examine the cornea and note any haziness of the cornea, foreign bodies, or abnormalities of the pupil shape. e anterior chamber Examine the eyelids. Clues to aetiology may be present on should be well formed. A at anterior chamber or protrusion of the the skin, e.g. herpes zoster scars, lid lacerations, burns. Lid iris usually signies a perforated ulcer thus warranting emergency malposition should be excluded. Facial nerve function must referral.[1] e red reex should be observed. is helps to highlight be assessed as dysfunction could affect eyelid closure (e.g. subtle corneal opacities, allows assessment of the pupil, and gives a lagophthalmos). Eversion of the upper lid is important to exclude a foreign body abrading the cornea. Corneal exposure from eyelid defects, ectropion or lagophthalmos may result in exposure keratitis. Fig. 2. Corneal abrasion. Note the epithelial defect, with clear Fig. 1. Perforated corneal ulcer. Note the iris prolapse and the distorted underlying stroma. The defect stains after instillation with pupil. fluorescein dye. 153 CME April 2013 Vol. 31 No. 4 Corneal ulcers Classification of corneal epithelial defects Moraxella species, Pseudomonas aeruginosa, Proteus species, Corneal epithelial defects may be classied aetiologically into Klebsiella pneumoniae, Yersina species and Escherichia coli.[5] Fungal traumatic (including corneal abrasions), mechanical, infective, causes include Candida albicans, Aspergillus avus, Fusarium soloni, autoimmune and neurotrophic. Penicillium species, and Aspergillus fumigatus.[5] Corneal abrasions Acanthamoeba is the commonest protozoal infection of the cornea Direct trauma to the cornea may abrade the epithelium, leaving a and together with Pseudomonas species is commonly associated clear epithelial defect. Non-penetrating corneal foreign bodies may with keratitis from contact lens wear.[6] Ocular injury with muddy leave behind an epithelial defect when removed. implements is associated with Acanthamoeba keratitis.[4] Patients present with pain, mildly decreased visual acuity and a Clinical features include pain, decreased vision, foreign-body history of trauma. Examination reveals a staining defect with a clear sensation and red eye.[2] Duration of symptoms depends on underlying and surrounding cornea. ere may be other associated aetiology. Clinical examination commonly reveals decreased visual ocular, orbital or eyelid injuries. acuity. Corneal inltrate seen as haziness or whitening of the usually transparent cornea is universal to infective ulcers in varying degrees. Management involves exclusion of foreign bodies, prevention is signies the inammatory response to the pathogen. e of infection, promoting epithelial healing and pain relief. anterior chamber may have a collection of pus cells seen as a white Chloramphenicol ointment 6-hourly is a very cost-eective uid level, i.e. hypopyon. e conjunctiva is almost always injected treatment. Topical antibiotics have been shown to have action and discharge is frequent. Corneal ulcers may perforate, requiring against both bacterial and fungal pathogens and are suitable for emergency surgical intervention. preventing both possible superimposed infections.[2,3] Patching the aected eye assists with epithelial healing and pain relief. Indications for referral include a decrease in visual acuity, worsening pain, concomitant ocular injuries, delayed healing or haziness of the surrounding or underlying cornea. Resolution with full visual recovery can be expected within 24 - 72 hours and follow-up should be scheduled accordingly. Complications include infective keratitis, persistent epithelial defect and recurrent corneal erosions, all of which require specialist referral. Contact lens use is a very common Fig. 4. Dendritic ulcer stained with uorescein (courtesy Dr S M cause of corneal ulcers. Singh). Management involves hourly topical empiric antibiotic drops Infective corneal ulcers and urgent referral. Early commencement of eective treatment Infective corneal ulcers occur predominantly aer trauma or in improves visual prognosis.[2] Determining aetiology is important and eyes predisposed to infection, e.g. contact lens wearers, chronic can guide denitive treatment.[7] Topical steroids are to be avoided ocular surface disease, topical steroid use, previous ocular surgery, at primary care level. Topical fourth-generation uoroquinolones eyelid abnormalities and diabetes.[2,4] ey are a signicant cause of should be reserved for conrmed cases of microbial keratitis to limit ocular morbidity and visual loss. Incidence varies from 6.3 to 710 antibiotic resistance and maintain susceptibility of ocular pathogens per 100 000 per year and is 6-fold higher in contact lens wearers.[2] to this drug.[2] Aetiology may be bacterial, fungal, viral, spirochete or parasitic. Herpetic epithelial viral keratitis presents classically as a dendritic Bacterial causes include Staphylococcus aureus, Staphylococcus ulcer but may vary in severity from punctate corneal staining to a epidermis, Streptococcus pneumonia, Streptococcus pyogenes, large geographic ulcer. Associated conjunctivitis is common (Fig. 4). Acyclovir ointment 5 times daily is an eective treatment.[2] Fig. 3. Infective corneal ulcer. e staining epithelial defect with underlying stromal inltrate can be seen. A hypopyon is present. Fig. 5. Peripheral ulcerative keratitis. 154 CME April 2013 Vol. 31 No. 4 Corneal ulcers Peripheral ulcerative keratitis surgery are mandatory in severe cases. is depressed. Dry eye is common in this The causes for a corneal epithelial Entropion, trichiasis and dystichiaisis can setting. defect near the corneal limbus are cause abrasion of corneal epithelium. vast. Non-infective autoimmune causes Conclusions are a consideration in these cases. Other causes e general practitioner plays a vital role Rheumatoid arthritis, sarcoidosis, Wegener’s Corneal ulcers, known as shield ulcers, in the early detection and commencement granulomatosis and polyarteritis nodosa may also be seen in chronic allergic of treatment in many types of corneal are some of the possible causes. Local ocular conditions such as vernal kerato- epithelial defects. e use of the techniques autoimmune syndromes are also a conjunctivitis. The primary pathophysio- described is helpful in excluding or detecting possibility, e.g. Mooren’s ulcer. Intensive logy is the mechanical abrasion of the indications for referral and thus limiting the immunosuppression may be required in cornea by giant papillae on the tarsal possible visual consequences for the patient. these cases. Blepharitis is a common cause conjunctival surface. A plaque may of this condition (marginal keratitis). form on the ulcer, making it difficult to References Consequently adequate treatment and recognise the staining pattern. Control 1. Agrawal V.
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