..TREATMENT OF NON TREATMENT OF NON HEALING CORNEAL HEALING CORNEAL

ULCERULCER

..

Superficial abrasions on the Superficial abrasions on the surface of the surface of the eye that fail to heal after 7 eye that fail to heal after 7 to 10 days.to 10 days.

In humans, physicians have identified several etiologies. Two common ones are traumafrom a sharp superficial cut (paper or fingernail) that can lacerate the epithelium andexcise a piece of basement membrane. Some patients then do not replace this lost pieceof basement membrane and their lesion becomes indolent.

The second most common etiology is a basement membrane dystrophy of known orunknown etiology or secondary to aging where the basement membrane duplicates withcollagen packets in between resulting in abnormal epithelial adhesions.

Defense of Ocular Surface Defense of Ocular Surface Normal Defense mechanismsNormal Defense mechanisms::1.1. EyelidsEyelids2.2. Tear film proteins (Secretory Tear film proteins (Secretory

immunoglobulins, complement immunoglobulins, complement components, and various enzymes components, and various enzymes including lysozyme, lactoferrin, including lysozyme, lactoferrin, betalysins, orosomucoid and betalysins, orosomucoid and ceruloplasmin have antibacterial ceruloplasmin have antibacterial effect)effect)

3.3. Corneal epitheliumCorneal epithelium4.4. Normal ocular floraNormal ocular flora

Risk FactorsRisk Factors1.1. Compromised normal ocular Compromised normal ocular

surface(proptosis,bell`s surface(proptosis,bell`s palsy,ectropion,deep palsy,ectropion,deep coma,lagophthalmos)coma,lagophthalmos)

2.2. Chronic colonization and infection of Chronic colonization and infection of the eyelid margin and lacrimal outflow the eyelid margin and lacrimal outflow system can predispose cornea system can predispose cornea

3.3. Chronic epiphora by reducing Chronic epiphora by reducing concentration of certain antibacterial concentration of certain antibacterial substances.substances.

4.4. Dry eyeDry eye

Risk FactorsRisk Factors5. Presence of N Gonorrhoeae, C 5. Presence of N Gonorrhoeae, C

Diphtheriae, Hemophilus Aegyptius Diphtheriae, Hemophilus Aegyptius and Listeria Monocytogenes – they can and Listeria Monocytogenes – they can penetrate intact corneal epithelium. penetrate intact corneal epithelium.

6. Compromised corneal epithelium as 6. Compromised corneal epithelium as in cases of contact lenses users, in cases of contact lenses users, corneal trauma, corneal surgery corneal trauma, corneal surgery bullous keratopathy.bullous keratopathy.

7. Absence of normal conjunctival flora. 7. Absence of normal conjunctival flora.

Risk FactorsRisk Factors8 Biofilm- is a slimy layer composed of 8 Biofilm- is a slimy layer composed of

organic polymers produced by organic polymers produced by embedded bacteria on contact lens, it embedded bacteria on contact lens, it protects bacteria from antibacterial protects bacteria from antibacterial substances and provide a nidus for substances and provide a nidus for infection. infection.

9. Corneal anaesthesia(neuroparalytic 9. Corneal anaesthesia(neuroparalytic keratitis)keratitis)

10. Abuse of topical anaesthetic solution 10. Abuse of topical anaesthetic solution

Risk FactorsRisk Factors11. Local immune suppression as due 11. Local immune suppression as due

to topical corticosteroidsto topical corticosteroids12. Previous viral infection12. Previous viral infection

External Risk FactorsExternal Risk Factors1.1. Trauma (Nocardia)Trauma (Nocardia)2.2. Exposure to contaminated water or Exposure to contaminated water or

solutionssolutions3.3. Chronic abuse of topical anaesthetic Chronic abuse of topical anaesthetic

solutionsolution4.4. Crack Cocaine smoking (disrupting Crack Cocaine smoking (disrupting

corneal epithelium via associated corneal epithelium via associated cellular and neuronal toxicity.cellular and neuronal toxicity.

Predisposing Systemic Predisposing Systemic ConditionsConditions

1.1. MalnutritionMalnutrition2.2. DiabetesDiabetes3.3. Collagen vascular diseasesCollagen vascular diseases4.4. Chronic alcoholismChronic alcoholism

Symptoms of Corneal Ulcer Symptoms of Corneal Ulcer Symptoms are usually marked, they are:Symptoms are usually marked, they are:

1. Diminution of vision, depending on location 1. Diminution of vision, depending on location of corneal ulcer of corneal ulcer 2. Watering (lacrimation)2. Watering (lacrimation)3. Difficulty in opening eyes especially in 3. Difficulty in opening eyes especially in bright light (photophobia and blepharospasm) bright light (photophobia and blepharospasm) 4. Pain and foreign body/ gritty sensation 4. Pain and foreign body/ gritty sensation usually intermittentusually intermittent

5. There may be discharge 5. There may be discharge (Mucopurulent / purulent)(Mucopurulent / purulent)

PresentationPresentationClinical signs and symptoms are variable Clinical signs and symptoms are variable

dependent on the virulence of the dependent on the virulence of the organism, duration of infection, pre-organism, duration of infection, pre-existing corneal conditions, immune existing corneal conditions, immune status of host and previous use of status of host and previous use of antibiotics/ steroidantibiotics/ steroid

Acanthamoeba can cause masquerading Acanthamoeba can cause masquerading syndrome mimicking bacterial keratitis.syndrome mimicking bacterial keratitis.

A corneal epithelial erosion that tends to A corneal epithelial erosion that tends to remain superficial and is not healing.remain superficial and is not healing.

The presence of a redundant or loose The presence of a redundant or loose undermined epithelial margin or bleb.undermined epithelial margin or bleb.

Fluorescein stain will undermine the Fluorescein stain will undermine the redundant border or pass through a fineredundant border or pass through a fine

epithelial break and be retained under the epithelial break and be retained under the epithelium beyond the edge of theepithelium beyond the edge of the

surface break.surface break.

The loose epithelial margin may even The loose epithelial margin may even be rolled or folded upon itself.be rolled or folded upon itself.

The eye may not be consistently painful The eye may not be consistently painful and it usually is intermittently painful.and it usually is intermittently painful.

Initially and even chronically there is Initially and even chronically there is usually a lack of an inflammatory usually a lack of an inflammatory response characterized by a lack or response characterized by a lack or scarcity of blood vessels.scarcity of blood vessels.

These lesions rarely become infected.These lesions rarely become infected.

SignsSigns6. Colour and pattern of iris may be disturbed 6. Colour and pattern of iris may be disturbed 7. Cornea: loss of transparency the ulcer 7. Cornea: loss of transparency the ulcer

appears yellowish/ grayish pale lesion of appears yellowish/ grayish pale lesion of varying shape /size, breach in continuity of varying shape /size, breach in continuity of corneal surface, ulcer with irregular floor corneal surface, ulcer with irregular floor and margins, floor appears grayish / and margins, floor appears grayish / grayish pale/ grayish yellow, zone of grayish pale/ grayish yellow, zone of infiltration with projecting swollen edges. infiltration with projecting swollen edges. The surrounding cornea may appear The surrounding cornea may appear ground glass like due to corneal edema ground glass like due to corneal edema

Corneal UlcerCorneal Ulcer

Peripheral Corneal UlcerCentral Corneal ulcer involving Lower periphery also

Clinical ExaminationClinical ExaminationEvaluation of predisposing and Evaluation of predisposing and

aggravating Factorsaggravating Factors1.1. A detailed historyA detailed history2.2. Prior ocular historyPrior ocular history3.3. Review of related medical Review of related medical

problems, current ocular problems, current ocular medications and history of medications and history of medication allergymedication allergy

ExaminationExamination1.1. Visual acuityVisual acuity2.2. An external ocular examination An external ocular examination

Facial appearance, eyelids, lid Facial appearance, eyelids, lid closureclosureConjunctiva, Nasolacrimal Conjunctiva, Nasolacrimal apparatus, corneal sensationapparatus, corneal sensation

ExaminationExamination3. Slit Lamp Biomicroscopy: For 3. Slit Lamp Biomicroscopy: For

Eyelid marginEyelid marginTear filmTear filmConjunctivaConjunctivaScleraScleraCornea (epithelial defects, punctate Cornea (epithelial defects, punctate keratopathy, edema, stromal keratopathy, edema, stromal infiltrates/ulceration, thinning or infiltrates/ulceration, thinning or perforation)perforation)

Slit Lamp Examination… Slit Lamp Examination… ContdContd

Location of lesionLocation of lesionDensity, Size , shape , depth, colour Density, Size , shape , depth, colour EndotheliumEndotheliumAnterior chamberAnterior chamberLoose or Broken suturesLoose or Broken suturesSigns of corneal dystrophySigns of corneal dystrophySigns of previous inflammation Signs of previous inflammation

Steroids must not be used in presence Steroids must not be used in presence of active infected corneal ulcerof active infected corneal ulcer

In cases of progressive corneal ulcer In cases of progressive corneal ulcer despite routine therapeutic treatment, despite routine therapeutic treatment, the following measures be considered: the following measures be considered: Scraping of ulcer floor followed by Scraping of ulcer floor followed by

cauterization with pure (100%) carbolic acid cauterization with pure (100%) carbolic acid or 10-20% trichloracetic acid. Povidone or 10-20% trichloracetic acid. Povidone Iodine can also be used for cauterization Iodine can also be used for cauterization

Systemic TreatmentSystemic Treatment1.1. Systemic Antibiotics: consider in Systemic Antibiotics: consider in

sever cases with scleral or intra-sever cases with scleral or intra-ocular extension of infection or with ocular extension of infection or with impending or frank perforation of the impending or frank perforation of the cornea cornea Systemic antibiotic therapy is Systemic antibiotic therapy is necessary in cases of Gonococcal necessary in cases of Gonococcal keratitis due to its fulminating keratitis due to its fulminating nature and systemic involvement nature and systemic involvement

Systemic TreatmentSystemic Treatment2. Analgesic anti-inflammatory2. Analgesic anti-inflammatory3. Supportive treatment3. Supportive treatment4. Acetazolamide Tab ,iv mannitol 4. Acetazolamide Tab ,iv mannitol

BD,0.5%timolol BD is added in cases of BD,0.5%timolol BD is added in cases of impending perforation or perforated impending perforation or perforated corneal ulcer and in cases where there corneal ulcer and in cases where there is raised intra-ocular tension (in is raised intra-ocular tension (in dosage of 250 mgm upto four times a dosage of 250 mgm upto four times a day)day)

Non-responsive / Progressive Corneal UlcerNon-responsive / Progressive Corneal Ulcer

TREATMENTTREATMENTRe-evaluate forRe-evaluate for

Drug toxicityDrug toxicityNon-infectious causes orNon-infectious causes orUnusual organisms such as non-tubercular Unusual organisms such as non-tubercular mycobacteria, Nocardia or acanthamoeba mycobacteria, Nocardia or acanthamoeba should be suspected should be suspected

Modification of anti-microbial therapyModification of anti-microbial therapy Therapeutic keratoplasty may be Therapeutic keratoplasty may be

undertaken undertaken

Indolent / Non-healing UlcerIndolent / Non-healing UlcerConsider debridement of necrotic Consider debridement of necrotic

corneal stroma andcorneal stroma andFrequent lubrication and/orFrequent lubrication and/orTemporary tarsorrhaphy Temporary tarsorrhaphy

Mechanical Sterile Cotton Tipped Mechanical Sterile Cotton Tipped Applicator (CAT's) debridement.Applicator (CAT's) debridement.

Scraping with a corneal spatulaScraping with a corneal spatula Superficial Lamellar KeratectomYSuperficial Lamellar KeratectomYBeaver blade under general anesthesiaBeaver blade under general anesthesiaMicropuncture with a 25 or 27 gaugeMicropuncture with a 25 or 27 gaugehypodermic needle.hypodermic needle.

After the cornea has been debrided, softAfter the cornea has been debrided, softcontact lens should be used. Be sure the contact lens should be used. Be sure the

Schirmer values are greater than 15 Schirmer values are greater than 15 mm/min.).mm/min.).

The contact lens will protect the cornea The contact lens will protect the cornea from the movements of the overlying from the movements of the overlying eyelids andeyelids and

splint the new epithelium tight up splint the new epithelium tight up against the anterior stroma.against the anterior stroma.

when a contact lens is in placewhen a contact lens is in placeTopical ophthalmic Topical ophthalmic solutions ONLY solutions ONLY

because ointments will clog pores of because ointments will clog pores of lens andlens and

reduce or eliminate the passage of reduce or eliminate the passage of respiratory gases, tear components, etc. respiratory gases, tear components, etc. through the lens.through the lens.

Corneal edema will result when a lens Corneal edema will result when a lens blocks respiration and serious complications blocks respiration and serious complications could occur rapidly.could occur rapidly.

FLUORESCEIN STAININGFLUORESCEIN STAINING If a Contact lens is in place - fluorescein If a Contact lens is in place - fluorescein

will stain the lens and the lens will glowwill stain the lens and the lens will glowfluoresceDo not leave a contact lens in fluoresceDo not leave a contact lens in

place longer than 14 days!(due to place longer than 14 days!(due to buildup of protein and mucin material buildup of protein and mucin material in the lens pores leading to blockage of in the lens pores leading to blockage of corneal respiration)Remove lens using corneal respiration)Remove lens using cilia forcepscilia forceps

Cyanoacrylate ApplicationCyanoacrylate Application In patients where a contact lens can In patients where a contact lens can

not be used because a lens does not not be used because a lens does not fit or one isfit or one is

not available; a thin layer of not available; a thin layer of Cyanoacrylate can be applied to act Cyanoacrylate can be applied to act as a custom contact lensas a custom contact lens

DrugsDrugs · Antibacterial: Either a triple antibiotic · Antibacterial: Either a triple antibiotic

such as neomycin, bacitracin, polymyxin;such as neomycin, bacitracin, polymyxin;gentamicin; or ciprofloxacin.gentamicin; or ciprofloxacin. · Mydriatic-cycloplegic: Mydriatic-· Mydriatic-cycloplegic: Mydriatic-

cycloplegic such as 1% atropine sulfate cycloplegic such as 1% atropine sulfate should only be used in the face of a should only be used in the face of a uveitis.uveitis.

Surgical TreatmentSurgical Treatment1.1. Conjunctival flap; In recalcitrant Conjunctival flap; In recalcitrant

bacterial keratitisbacterial keratitis2.2. Penetrating Keratoplasty (PKP): Penetrating Keratoplasty (PKP):

Large central ulcer , presenting lateLarge central ulcer , presenting lateHistory of previous ocular surgeryHistory of previous ocular surgeryInjudicious use steroid treatmentInjudicious use steroid treatment

3. 3. Peritomy when excessive Peritomy when excessive vascularisation hinders healingvascularisation hinders healing