Management of Corneal Ulcers

Diagnosis and Initial Assessment

Corneal scrapings should be obtained using a topical anesthetic and a sterile instrument to collect material from the base or periphery of the suspected infection, with samples inoculated directly onto appropriate culture media or placed in transport media and promptly taken to the laboratory 1
A simplified collection device using a nylon-tipped flocked swab has shown similar culture positivity rates compared to traditional methods 1
For deep stromal infections or poor response to treatment, corneal biopsy may be indicated 1

Topical antibiotic eye drops are the preferred method of treatment for bacterial keratitis, capable of achieving high tissue levels, with a loading dose every 5-15 minutes followed by hourly applications recommended for central or severe keratitis 2
Single-drug therapy using a fluoroquinolone has been shown to be as effective as combination therapy with fortified antibiotics 2
Fortified topical antibiotics should be considered for large and/or visually significant corneal infiltrates, especially if a hypopyon is present 2
Ciprofloxacin 0.3%, ofloxacin 0.3%, and levofloxacin 1.5% have FDA approval for treating bacterial keratitis 2

Patients should be followed daily initially until clinical improvement is confirmed 3
If cultures are negative and clinical response is poor, consider stopping antibiotic treatment for 12-24 hours and then reculturing 1

Cycloplegic agents may be used to decrease synechiae formation and pain from anterior segment inflammation 2
Topical corticosteroid therapy may be considered after at least 2-3 days of progressive improvement with antibiotics, typically after pathogen identification and ruling out fungal infection, with the minimum amount required to control inflammation 4, 3
Subgroup analysis showed potential benefit for corticosteroids in Pseudomonas keratitis and severe cases 4

Patients with pre-existing corticosteroid therapy should have their regimen reduced or eliminated until the infection is controlled 4
Chronic topical immunotherapy increases the risk of infectious crystalline keratopathy 4
For contact lens wearers with corneal abrasions, patching the eye or using therapeutic contact lenses is not advised due to increased risk of secondary bacterial keratitis 2

Patients with risk factors for bacterial keratitis should be educated about their increased risk and the signs and symptoms that warrant prompt ophthalmological consultation 2
Ocular surface diseases such as epithelial defects, tear deficiency, entropion, or lagophthalmos should be treated 2
Prophylactic antibiotics should be prescribed for contact lens wearers with corneal abrasions and for patients with trauma-related abrasions 2

Delaying appropriate culture and sensitivity testing can lead to ineffective treatment 1, 2
Using tetracaine as an anesthetic for corneal scraping can interfere with culture results due to its antimicrobial effect 1
Inappropriate use of corticosteroids, particularly in cases of Nocardia or fungal keratitis, can lead to poor outcomes 4
Failure to recognize and address underlying risk factors can lead to recurrent infections 2
Overuse of prophylactic antibiotics may promote growth of resistant organisms 2