Corneal Ulcer (Keratitis)

introduction

What is Corneal Ulcer (Keratitis)?

A corneal ulcer (keratitis) is an erosion or an open sore on the cornea which is the thin clear structure of the eye that refracts light. If the cornea becomes inflamed due to infection or injury, an ulcer may develop.

Symptoms of Corneal Ulcer (Keratitis)

  • Redness
  • Pain
  • Watering
  • Gritty sensation
  • Blurry vision
  • Discharge
  • Burning
  • Itching
  • Light sensitivity

Causes of Corneal Ulcer (Keratitis)

The causes of a corneal ulcer (keratitis) are:

  • Contact lenses – contaminated solution, poor hygiene, over usage, sleeping with contact lenses on, using tap water or swimming with contact lens on. Wearing lenses for extended periods blocks the supply of oxygen to the cornea, making it susceptible to infections.
  • Trauma – chemical injury, thermal burn, bee sting, animal tail, makeup or vegetative matter like the branch of a tree, sugarcane
  • Post-surgery – delayed healing, loose sutures
  • Lid deformities – inward or outward turning of eyelid, misdirection of eyelashes constantly rubbing over the cornea, incomplete closure of eyes
  • Decreased nerve supply to the cornea – seen in diabetics and bell’s palsy patients
  • Allergic conjunctivitis
  • Vitamin A deficiency
  • Prolonged use of eye drops – corticosteroids
  • Severe dry eyes – caused by medical conditions like diabetes mellitus, thyroid disorder, vitamin A deficiency, rheumatoid arthritis, Sjogren syndrome, Stevens-Johnson syndrome

Risk factors of corneal ulcer (keratitis)

  • Injury or chemical burns
  • Eyelid disorders that prevent proper functioning of the eyelid
  • Dry eyes
  • Contact lens wearers
  • people who have or have had cold sores, chicken pox or shingles
  • Abuse of steroid eye drops
  • Diabetics
prevention

Corneal Ulcer (Keratitis) Prevention

  • Do not sleep with contact lenses on
  • Do not overuse contact lenses
  • Wash your hands before putting the lenses
  • Advised to use daily disposable lenses
  • Do not use tap water as lens solution
  • While riding a bike, wear eye protection or visor to prevent foreign bodies from entering the eye.
  • Do not rub your eye
  • Proper instillation of eyedrops. The nozzle of the eye drop bottle should not touch the eye or the finger
  • Use artificial tears in case of dry eyes
  • Wear protective eyewear when working with wood or metals, especially when using a grinding wheel, hammering on metal, or welding.
  • Do not use over-the-counter eye drops

Types of corneal ulcer (keratitis)

Multiple organisms are responsible for development of a corneal ulcer (keratitis).

The types of corneal ulcer (keratitis) are –

  • Bacterial – scratches or abrasion with fingernail, paper cuts, makeup brushes over the cornea when left untreated can lead to an ulcer. common in extended wear contact lens wearers
  • Fungal – injury to the cornea with any vegetative matter or improper use of steroid eye drops
  • Viral – the virus that causes chickenpox and shingles can cause ulcers too
  • Parasitic – infection caused by fresh water, soil or long standing contact lens used

Corneal ulcer (keratitis) Diagnosis 

The ulcer is carefully examined on the slit lamp microscopy for the analysis of size, shape, margins, sensation, depth, inflammatory reaction, hypopyon and presence of any foreign body. A fluorescein dye is used to stain the ulcera to enhance the features and check for any leak. 

Debridement of the ulcer is essential for microbiological evaluation to identify the causative organism. After putting an anaesthetic drop in the eye, the margins and the base of the ulcer is scraped with the help of a sterile disposable blade or needle. These samples are stained and cultured to identify and isolate the organism. Scraping the ulcer also helps in better absorption of the eyedrops.

If the patient is a contact lenses wearer, the lenses will be sent for microbiological evaluation. Random blood sugar levels are to be checked. If the sugars are not in control, a diabetologist opinion is taken as this affects corneal wound healing. A gentle ultrasonography of the affected eye is done to check for any posterior segment pathology.

Corneal Ulcer (Keratitis)Treatment:

Depending on the laboratory reports, treatment will be started. Antibiotics, antifungals or antivirals are started in the form of tablets and eye drops depending on the causative agent. In cases of large or severe corneal ulcer (keratitis), fortified eye drops are started which are prepared from available injectable preparations. This is accompanied by oral pain killers, cycloplegics eye drops which relieves pain, anti glaucoma eye drops to reduce the intraocular pressure and artificial tears. The frequency depends on the size of the ulcer. Corticosteroids are strictly prohibited in cases of fungal corneal ulcer (keratitis). However, they can be considered in other types of ulcers at a later stage under extreme caution and supervision.

In case of a small perforation, tissue adhesive glue is applied over the perforation under sterile conditions followed by a bandage contact lens to seal the perforation. Bandage contact lenses are also used in cases of recurrent epithelial erosions for better healing. Patients who have eyelid deformities, leading to an ulcer, need corrective surgeries. If the corneal ulcer (keratitis) is due to an eyelash growing inward, the offending lash should be removed together with its root. If it grows back in an abnormal manner, the root may have to be destroyed using a low-voltage electrical current. In cases of improper or an incomplete lid closure, a surgical fusion of the upper lid and lower lid is done. Small perforations are also treated with patch grafts which means taking a full thickness or partial thickness graft from the donor cornea and anchoring it over the perforated site.

For non healing ulcers surgical intervention is required. An amniotic membrane graft is placed on the cornea under sterile conditions to build thickness and establish healing. However, in cases of larger perforation or severe scarring, corneal transplant surgery is done which involves surgical removal of the diseased corneal tissue and replacing it with a healthy donor tissue.

Book appointment with an Ophthalmologist:

  • If noticing decrease in vision
  • Redness and foreign body sensation 
  • Discharge 
  • White spot forming in front of the eye

Written by: Dr. Preethi Naveen – Training Committee Chair – Dr. Agarwals Clinical Board

FAQ

What are the complications of a corneal ulcer (keratitis)?

  • Scarring
  • Perforation
  • Cataract
  • Glaucoma
  • Intraocular haemorrhage

The prognosis for a corneal ulcer (keratitis) depends on its cause, its size and location, and how rapidly it is treated together with the response to treatment. Depending on the degree of scarring, patients might have visual disturbances. If the ulcer is deep, dense, and central, scarring will cause some permanent changes in vision.

  • Contact lens should not be overused ( max of 8 hours).
  • Do not sleep with lenses on
  • Patient should not rub his/her eyes while the contact lens is on.
  • Hand should be thoroughly washed before using contact lens
  • Do not share contact lens case
  • Every month the case and the solution should be changed
  • Do not use tap water or saliva if solution not available
  • Do not wear contact lens if infection already present
  • Long standing contact lenses should not be reused

Depending on the cause of the ulcer and its size, location, and depth corneal ulcer (keratitis), it can take from 2 weeks to 2 months to heal.

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