27-year-old woman has pain and blurry vision after not removing her contacts for days.
Cataract/Anterior Segment
What is your diagnosis?
The diagnosis is...
The image is consistent with a diagnosis of corneal ulcer.
- Corneal ulcers typically result from trauma associated with contact lens or injury.
- Corneal ulcers may be caused by bacteria, fungi, or parasites.
- Risk factors include extended-use contact lenses and diseases affecting proper closure of the eyelids (causing exposure), such as Bell palsy, Graves ophthalmopathy, and being a patient who is post stroke.
- Patients sedated for extended periods of time, such as those in the intensive care unit (ICU), are at a higher risk of developing a corneal ulcer.
What is the role of the primary care or emergency medicine physician?
Corneal ulcers may become an ophthalmic emergency due to the potential for permanent damage or vision loss resulting from a
perforated globe or scarring of the corneal surface.
- Because of the urgency of corneal ulcer treatment, primary care and emergency medicine doctors should obtain a focused history including symptom onset and promptly refer patients to ophthalmology for further management and evaluation.
- Emergency medicine doctors could be asked to perform an eye examination. If a small ulcer is seen, they could initiate antibiotics and then refer patients to ophthalmology.
What is the role of the ophthalmologist?
Managing corneal ulcers can be challenging.
- Begin empiric treatment with antibiotics, such as 4th-generation cephalosporins, or fluoroquinolones, to prevent expansion of the ulcer and corneal scarring.
- Gently swab the corneal surface to obtain a sample to send for speciation (bacterial, fungal, parasitic, viral keratitis) and susceptibility.
- Treatment with steroids may also be involved.
What is the treatment?
- If there is high suspicion for a bacterial ulcer, initiate broad-spectrum antibiotics.
- Steroids may be used to prevent inflammation and scarring of the corneal surface, but they should not be used if the ulcer is due to a fungal infection, or they should be used cautiously if the pathogen is unknown.
- Other causes of ulcers are fungi, parasites, and viruses.
- Supportive measures include frequent artificial lubrication and shielding the cornea.
- If the ulcer perforates, tissue glue can be used. Delay corneal scar revision therapies to allow resolution of infection.
- If the ulcer is severe enough, a corneal transplant may be recommended. During a corneal transplant, all or part of the damaged cornea is replaced with healthy tissue from a donor.
Learn more: Ophthalmology resources for medical students