History

Fact Explanation
History of trauma to the eye Because the cornea is the most anterior part of the eye, it is susceptible to injury and Injury to the cornea can give rise to a ulcer in the cornea. Trauma can be caused by mechanical trauma, due to foreign bodies, contact lens wear, chemical and flash burns or due to excessive eye rubbing. [2,4]
Foreign body sensation in the eye, tearing, sensitivity to light Irritation of the eye will give rise to this symptom.[1,3,4]
Moderate to severe pain in the eye Due to inflammation of the corneal nerves.[1]
History of usage of contact lenses Well recognized predisposing factor for the development of corneal ulcers as those lenses facilitate growth of the micro organisms.[1,2]
Impaired eye sight A corneal abrasion is a defect in the epithelial surface of the cornea. The functions of the cornea are vital for normal vision, and include barrier protection, light refraction, and ultraviolet (UV) light filtration. So corneal ulcer will impair the normal functions of the cornea and impair the eye sight.[4]
History of HIV infection Patients with HIV infection known to develop corneal ulcers.[2]
References
  1. PRASHANT GARG, Gullapalli N Rao. Corneal Ulcer: Diagnosis and Management. Community Eye Health.[online] 1999; 12(30): 21–23. [viewed 28.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1706003/
  2. Jeng BH et al. Epidemiology of Ulcerative Keratitis in Northern California. Arch Ophthalmol.[online] 2010;128(8):1022-1028. [viewed 06.05.2014] Available from: http://archopht.jamanetwork.com/article.aspx?articleid=426096 doi:10.1001/archophthalmol.2010.144.
  3. G AMCSEUA, D Miller, EC Alfonso. What is causing the corneal ulcer? Management strategies for unresponsive corneal ulceration. Eye.[online] 2012; 26: 228-236. [viewed 06.05.2014] Available from: http://www.readcube.com/articles/10.1038/eye.2011.316 doi:10.1038/eye.2011.316
  4. JENNIFER L. WIPPERMAN, and JOHN N. DORSCH. Evaluation and Management of Corneal Abrasions. Am Fam Physician.[online] 2013 Jan 15;87(2):114-120. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/2013/0115/p114.html

Examination

Fact Explanation
Slit lamp examination Corneal epithelium should examined properly to detect break/discontinuity. Additionally fluorescein staining can be used to detect corneal epithelial defects accurately. An abrasion may stain yellow in normal light and appear in green with cobalt blue light illumination.[1,2,3]
Lid oedema Prominant in gonococcal ulcer and minimal in fungal ulcers. [2,3]
Discharge from the eye Purulent discharge in gonococcal ulcer and bluish green discharge in pseudomonas corneal ulcer.[2,3]
Hypopyon or hyphema The anterior chamber should be inspected for blood (hyphema) or pus (hypopyon). Hypopyon may or may not be present in bacterial ulcers but most of the pneumococcal ulcers will show leveled hypopyon associated with Dacryocystitis. Unlevelled hypopyon aids in diagnosis of fungal ulcers. These findings indicate severe injury and require immediate referral.[2,3]
Penlight examination Should be done at the beginning to detect foreign bodies, penetrating trauma, corneal opacities, hazy cornea due to edema and pupillary changes (dilatation, reactivity and regularity of margins).[2]
Visual acuity It is important to document the visual acuity of both eyes. It can be deranged due to abrasion in the visual axis, corneal edema.[2]
Extraocular movements Movements of the extraocular muscles of the eye should be examined to identify weakness, tenderness and associated nerve injuries supplying those muscles.[2]
Red reflex Have to look for the red reflex using a ophthalmoscope. Positive red reflex help excluding severe global injury..[2]
References
  1. PRASHANT GARG, Gullapalli N Rao. Corneal Ulcer: Diagnosis and Management. Community Eye Health.[online] 1999; 12(30): 21–23. [viewed 28.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1706003/
  2. JENNIFER L. WIPPERMAN, and JOHN N. DORSCH. Evaluation and Management of Corneal Abrasions. Am Fam Physician.[online] 2013 Jan 15;87(2):114-120. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/2013/0115/p114.html
  3. Guidelines for the Management of at Corneal Ulcer. Primary, Secondary & Tertiary Care health facilities in the South-East Asia Region. [viewed 06.05.2014] Available from: http://whqlibdoc.who.int/searo/2004/SEA_Ophthal_126_eng.pdf

Differential Diagnoses

Fact Explanation
Penetrating eye injury Important to suspect in every patient as it needs immediate referral.[1]
Acute angle-closure glaucoma Consider in a patient with a severe headache, reddish eye and a dilated pupil. Intraocular pressure will be high and corneal examination will reveal no defects or opacities.[1]
Conjunctivitis Important to exclude as it is the most common cause of red eye. [2]
Dry eye (keratoconjunctivitis sicca) Suspect in elderly women who present with a history of long duration and also who got risk factors to develop dry eyes such as certain medicines (antihistamines, decongestants, blood pressure medications and antidepressants), medical conditions ( rheumatoid arthritis, diabetes, thyroid problems)[5]
Recurrent erosion syndrome Patients often present after awakening from sleep with severe eye pain and symptoms similar to those of an abrasion. However, they have no history of trauma and may report previous episodes.[1]
Entropion Examine the eye lid margins properly, as in a eye with entropion, eye lid margins turn inwards against the globe.[3,4]
Blepharitis Important to exclude as it is one of the most common condition causing similar symptoms of corneal abrasion. Examination will reveal inflammed eye lid margins and debris in the eye lashes.[4]
Foreign Body in eye Examination will demonstrate foreign body particles in the eye causing irritation and producing symptoms such as red eye, itching and tearing.[5]
References
  1. JENNIFER L. WIPPERMAN, and JOHN N. DORSCH. Evaluation and Management of Corneal Abrasions. Am Fam Physician.[online] 2013 Jan 15;87(2):114-120. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/2013/0115/p114.html
  2. GARY L. MORROW, RICHARD L. ABBOTT. Conjunctivitis. Am Fam Physician.[online] 1998 Feb 15;57(4):735-746. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/1998/0215/p735.html
  3. RAIMONDA PISKINIENE. Eyelid malposition: lower lid entropion and ectropion. Medicina (Kaunas)[online] 2006;42(11):881-4. [viewed 10.05.2014] Available from: http://medicina.kmu.lt/0611/0611-03e.pdf
  4. SUSAN R. CARTER. Eyelid Disorders: Diagnosis and Management. Am Fam Physician. [online]. 1998 Jun 1;57(11):2695-2702. [viewed 10.05.2014] Available from: http://www.aafp.org/afp/1998/0601/p2695.html
  5. HOLLY CRONAU, RAMANA REDDY KANKANALA,THOMAS MAUGER. Diagnosis and Management of Red Eye in Primary Care. Am Fam Physician.[online]. 2010 Jan 15;81(2):137-144. [viewed 10.05.2014] Available from: http://www.aafp.org/afp/2010/0115/p137.html

Investigations - for Diagnosis

Fact Explanation
Gram stain, culture and ABST (Antibiotic Sensitivity Testing) of corneal scrapings To visualize the causative organism directly and to identify the appropriate antibiotics in suppurative keratitis.[1]
References
  1. PRASHANT GARG, Gullapalli N Rao. Corneal Ulcer: Diagnosis and Management. Community Eye Health.[online] 1999; 12(30): 21–23. [viewed 28.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1706003/

Investigations - Followup

Fact Explanation
Indications for referral & follow up Reccomended indications for referral and follow up are chemical burns, evidence of corneal ulcer or infiltrate, failure to heal after three to four days, worsening symptoms or no improvement after24 hours, inability to remove a foreign body, increased size of abrasion after 24 hours, penetrating injury, presence of hyphema (blood) or hypopyon (pus), rust ring, vision loss of more than 20/40.[2]
gram stain, culture and sensitivity results If the ulcer does not respond to treatment have to review with gram stain, culture and sensitivity results Also have to use appropriate culture media for viral and uncommon pathogens (anaerobes, acanthamoeba, mycobacteria).[1]
corneal biopsy If the organism is unknown and the patient is not responding to the treatment clinically consider taking a corneal biopsy.[1]
References
  1. Guidelines for the Management of at Corneal Ulcer. Primary, Secondary & Tertiary Care health facilities in the South-East Asia Region. [viewed 06.05.2014] Available from: http://whqlibdoc.who.int/searo/2004/SEA_Ophthal_126_eng.pdf
  2. JENNIFER L. WIPPERMAN, and JOHN N. DORSCH. Evaluation and Management of Corneal Abrasions. Am Fam Physician.[online] 2013 Jan 15;87(2):114-120. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/2013/0115/p114.html

Management - General Measures

Fact Explanation
Topical non steroidal anti-inflammatory drugs (Diclofenac 0.1%) or oral analgesics (acetaminophen and NSAIDs) For pain relief. Prolonge use of topical NSAIDs may be associated with corneal toxicity and also they are more expensive than oral analgesics. Topical anesthetics are not recommended as they are known to cause epithelial toxicity, impaired healing, and masking of symptoms.[1,2]
Prevention 1) Should raise the community awareness of risk factors for suppurative keratitis such as minor trauma to the eye and the use of traditional eye solutions in the eye. 2) All workers who are at risk of getting eye trauma (working with metal, wood, machines, or chemicals, specially welders and those who participate in contact sports) should wear protective eye wear. Polycarbonate lenses can be provided as they protect from projectiles and blunt trauma. 4) Early recognition, diagnosis, referral to ophthalmologists (advanced patients) and treatment with appropriate antibiotics also important as this is a sight threatening condition.[1,2]
Tetanus prophylaxis Recommended if there is a penetrating injury into the eye, chemical burn, devitalized tissue, or trauma from contaminated material.[2]
Artificial tears Provide comfort to the eye.[2]
References
  1. PRASHANT GARG, Gullapalli N Rao. Corneal Ulcer: Diagnosis and Management. Community Eye Health.[online] 1999; 12(30): 21–23. [viewed 06.05.2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1706003/
  2. JENNIFER L. WIPPERMAN, and JOHN N. DORSCH. Evaluation and Management of Corneal Abrasions. Am Fam Physician.[online] 2013 Jan 15;87(2):114-120. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/2013/0115/p114.html

Management - Specific Treatments

Fact Explanation
Anti-microbial therapy Start empirically with a broad spectrum antibiotic (eg: ciprofloxacin or ofloxacin) and change according to the microbiological results. Topical antibiotics are preferred. Note: Combination preparations with a topical steroid are contraindicated because topical steroids increase susceptibility to infection and may delay healing.[1,2,4]
Supplementary therapy - Cycloplegic drugs, Anti glaucoma drugs 1) Cycloplegic drugs - Homatropine (1%) or cyclopentolate (1%) should be instilled to reduce ciliary spasm. Also beneficial as it relives pain and prevent synechiae formation by producing mydriasis. Note: Patients should be educated that blurry vision may occur, and should use care while driving. Scopolamine and atropine should be avoided because of their long duration of action.[1,4] 2) Anti glaucoma drugs - Used in patients with high intraocular pressure.[1]
Necrotic debridement Debridement of necrotic material will help facilitate drug penetration especially of anti-fungal agents.[1]
Foreign body removal If a corneal foreign body is found, it must be removed to prevent permanent scarring and vision loss. Measures that can be taken to remove a foreign body are saline irrigation, sweeping the cornea using a cotton swab and removal using an eye spud or 25-gauge needle. Latter should be done by a trained, experienced physician.[4]
Tissue adhesive using N-butyl cyanoacrylate with a bandage contact lens Useful in patients with marked thinning or perforation less than 2mm.[1]
Penetrating keratoplasty Indicated only in patients with advanced disease at presentation where there is no response to medical therapy or when a large perforation is present.[1] Maintains the integrity of the globe for future optical grafts and also promotes healing of corneal ulcer by total removal of pathology.[3]
Tarsorrhaphy Indicated in exposure keratitis due to Bells palsy and in neuroparalytic keratitis.[3]
Referral to a tertiary ophthalmic centre Indicated if the patient is a child, ulcer is in the only eye, when there is actual or impending perforation, suspecting a fungal ulcer and not improving after 3 days of treatment.[3,4]
Special considerations in management - Contact lens induced corneal ulcers 1) Should be treated with antipseudomonal topical antibiotics as In those patients' eyes are colonized with Pseudomonas aeruginosa and other gram-negative organisms. 2) Contact lenses should be discarded, and new ones should not be worn until the ulcer is healed and symptoms are resolved. 3) To avoid recurrences, lenses should fit properly, and patients should be instructed to practice proper lens hygiene and avoid extended-wear lenses. [4]
Special considerations in management - Chemical burns (exposure to strong chemicals) Need immediate, copious eye irrigation for 20 to 30 minutes. Then patients should be referred immediately to an ophthalmologist.[4]
References
  1. PRASHANT GARG, Gullapalli N Rao. Corneal Ulcer: Diagnosis and Management. Community Eye Health.[online] 1999; 12(30): 21–23. [viewed 06.05.2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1706003/
  2. R Maske, J C Hill, and S P Oliver. Management of bacterial corneal ulcers. Br J Ophthalmol.[online] Mar 1986; 70(3): 199–201. [viewed 06.05.2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1040966/
  3. Guidelines for the Management of at Corneal Ulcer. Primary, Secondary & Tertiary Care health facilities in the South-East Asia Region. [viewed 06.05.2014] Available from: http://whqlibdoc.who.int/searo/2004/SEA_Ophthal_126_eng.pdf
  4. JENNIFER L. WIPPERMAN, and JOHN N. DORSCH. Evaluation and Management of Corneal Abrasions. Am Fam Physician.[online] 2013 Jan 15;87(2):114-120. [viewed 07.05.2014] Available from: http://www.aafp.org/afp/2013/0115/p114.html