Corneal Ulcer's

Basic Understanding

 A corneal ulcer is a defect in the surface of the cornea, the transparent front of the eye.  This defect is usually an infection caused by a bacteria, virus, or fungus or Amoeba.  Bacteria, Fungus and Virus often cause severe pain and redness. Amoeba infections can occur from swimming in fresh water rivers and lakes as well as hot tubs, while these can be very painful and while the eye may not look very infected.

Contact lens wearers are at increased risk of developing bacterial corneal ulcers.  Injuries from plants are associated with fungal infections. Herpes virus is a common cause of viral corneal ulcers.  Topical antibiotic, antiviral or antifungal eye drops are the mainstay of therapy.  

At Palm Beach Eye Center our physicians have the capability to prepare highly potent customized eye drops while you are in our office.  These states of the art treatments are often not readily available at commercial pharmacies and early treatment is essential to decrease the risk of vision loss.  Corneal ulcers may be due to conditions other than infections including autoimmune disease, chemical injuries, allergic reactions, and neurologic conditions. While standard treatment starts with lubricants and steroid eye drops, we can offer the most advanced therapy including amniotic membrane therapy and autologous serum eye drops.  These treatments are wonderfully safe and effective yet not available at many eyecare providers offices.

To Learn More on Autologous Serum

Cultures and Treatment Theory

There are a myriad of treatment for corneal ulcer's.  One dilemma we have in the treatment process is that to make sure we have the right antimicrobial therapy a culture is required. Culture's can take many days to get results.  Staining bacterial on a slide is very difficult and sometimes fruitless because you need a certain amount of exudate to put onto the slide.  The amount is so small on a cornea that many physicians can't get enough exudate such that the little we do get has more value if we can put it into a culture tube or Petri dish and grow the organism to determine what antimicrobial its sensitive to.

The goal of treatment when a ulcer is present is to try to determine the source of the infection and from that knowledge treat empirically with the antimicrobial that is most likely to work.  At Palm Beach Eye Center, we will try to take a culture and treat with multiple antibiotics or anti microbial drugs to kill anything that is growing on the eye.  In the picture seen here, the white spot just above the center of the cornea is the ulcer.  This ulcer is one of the worst one can have because it is central in the visual axis and the resulting scar after treatment will lead to a permanent loss of vision.  

Research and Layman's Interpretation

Contact lens related corneal ulcers: clinical, microbiological and therapeutic features

J Fr Ophtalmol. 2013 Sep;36(7):594-9. doi: 10.1016/j.jfo.2012.06.026. Epub 2013 Jun 20.
Benhmidoune L1, Bensemlali A, Bouazza M, Karami R, El Mansouri H, El Belhadji M, Rachid R, Chakib A, Amraoui A.

Purpose-Corneal ulcers in contact lens wearers are becoming more common, and can sometimes lead to severe complications. The purpose of this study is to define the epidemiological, clinical, microbiological and therapeutic considerations of these ulcers within the above context.

Conclusions-Cosmetic and therapeutic contact lens wear is a major cause of corneal ulcer. Delayed consultation results in severe sequelae with persistently decreased visual acuity.
Layman's Interpretation Contact lens wear can increase the risk of corneal infections.

Corneal cross-linking in the treatment of corneal ulcers.

Curr Opin Ophthalmol. 2016 May;27(3):250-5. doi: 10.1097/ICU.0000000000000248.

Price MO1, Price FW Jr.

Purpose-New treatments for corneal ulcers are needed to address challenges with antibiotic resistance, cost, and specificity requiring timely pathogen identification. This review assesses the evidence regarding safety and efficacy of corneal cross-linking (CXL) as an adjunct or stand-alone treatment.

Conclusion-Further work is needed to develop optimized CXL protocols for treatment of corneal ulcers, define the appropriate conditions for use, and determine the safety and efficacy relative to standard antibiotic treatments.
Layman's Interpretation- There are many new treatment options being researched.  You can rely on your ophthalmologist at Palm Beach Eye Center to always have access to the most up to date therapy for your eye condition.

Corneal ulcers in systemic autoimmunologic diseases

Klin Monbl Augenheilkd. 2011 Jan;228(1):66-9. doi: 10.1055/s-0029-1245122. Epub 2010 Aug 16.
Augsten R1, Dawczynski J, Voigt U, Oelzner P, Schulze E, Konigsdorffer E.
Purpose-Keratolysis is a rare severe complication following systemic autoimmunologic diseases. Despite of complex therapeutic treatments, the prognosis is very poor.
Conclusions-Despite of intensive local and systemic immunosuppressive as well as operative therapies, corneal ulcers associated with auto immunologic diseases (rheumatoid arthritis, Sjogren's syndrome) may cause a marked decrease of visual acuity or the loss of an eye. With regard to the healthy eye, an immunosuppressive therapy for life is most important.
Layman's Interpretation- Corneal Ulcers associated with underlying autoimmune disease are potentially extremely serious and require advanced therapy.

Transplantation of amniotic membrane in corneal ulcers and persistant epithelial defects.

Coll Antropol. 2011 Sep;35 Suppl 2:167-9.
Grzetic-Lenac R1, Merlak M, Balog T, Babic MB, Dekaris I.
Layman's Interpretation- Amniotic Membrane placement resulted in enhanced healing and less scarring for patients with corneal ulcers.

Advanced Level Treatment

When a patient has an ulcer, the doctors at Palm Beach Eye Center will determine how vision threatening the lesion is.  Then we will determine what the organism has to the eye to cause a perforation (hole in the eye).  A perforation is very serious and can lead to complete loss of the eye as now the organism will get inside.

Regularly, we will use antibiotics that are fortified.  This means that these antibiotic drops are much stronger in strength than ones you will get a pharmacy.  At Palm Beach Eye Center, we maintain a supply of these antibiotics for making fortified ones in the office on your visit to start treatment immediately.  

The next level of treatment is with Amniotic Membranes.  This tissue from a fetus and has proteins that stimulate healing and reduce inflammation (which can slow healing).  We are able to apply this tissue in all of our office locations.  While they are very expensive, we have found them indispensable in severe ulcers and very helpful in mild to moderate ones.  The healing time will be accelerated tremendously and this means less scaring and less pain and suffering for the patient.

Frequently Asked Questions (FAQ's)

1-Will I need a corneal transplant once I've had an ulcer?

If the infection is in the center of the cornea and after the infection is completely healed and the vision is still poor we can do a transplant to clear the vision.  At Palm Beach Eye Center, we can do partial transplants or complete ones.  We can tailor the transplant to your needs and visual requirements.

2-Is there anything else that can be done besides a transplant to help with the vision?

We will try various types of contact lenses prior to a transplant which very often help the patient see satisfactorily and reduce the need for a corneal transplant.

3-How often do we see ulcer's?

At Palm Beach Eye Center, we see them very often.  Sometimes, we will see 5-10 a week and sometimes just one ever few weeks.  Its really quite variable.  We have been treating them successfully for as long as the practice has been in business.

4-What if my eye perforates while be treated?

This is a very serious condition and we can temporarily glue the cornea closed until being able to take the patient to surgery for a transplant.

5-I think I have an ulcer, what should I do and should I treat myself?

Immediately, come to our offices after you've called.  Do not delay.  We have seen so many patients delay treatment and treat themselves such that the results are devastating.  Even if you think its mild, come in right away.  Let us diagnose and treat you.

6-What can happen to my eye if its not treated properly?

As the surgical and medical director, I have personally seen some of the worst outcomes from self treatment and improper treatment.  I have seen patients need their eye removed.  I have seen severe glaucoma, retinal detachments, severe vision loss, horrible cataracts and very poor outcomes from delay.  If you have pain in the eye for any reason, and especially if you wear contact lenses, have been in a freshwater lake or river, or been in a hot tub, call immediately and come in.  Its better to get it early than later.

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