Corneal ulcer

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

A corneal ulcer is an inflammatory or more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and the agrarian societies. In developing countries, as well as in Florida, corneal ulcer is frequently the cause of great morbidity as well as economic loss to the person and family. Children afflicted by Vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes, which may persist lifelong, causing tremendous & avoidable loss to the person and the society.

Corneal ulcers are a common human eye disease. They are caused by trauma, particularly with vegetable matter, chemical injury, contact lenses, and infections. Other eye conditions can cause corneal ulcers, such as entropion, distichiae, corneal dystrophy, and keratoconjunctivitis sicca (dry eye).

People with poor eye hygiene and contact lens abusers (e.g. those who wear contact lenses overnight) are at an increased risk of developing corneal ulcers. Corneal ulcers are a common condition in humans, particularly those living in the tropics and in agrarian societies. In developing countries, children afflicted by vitamin A deficiency are at a high risk for corneal ulcer and may become blind in both eyes, which may persist lifelong if not treated.

Corneal ulcers are painful due to nerve exposure, and can cause tearing, squinting, and vision loss of the eye. There may also be signs of anterior uveitis, such as miosis (small pupil), aqueous flare (protein in the aqueous humour), and redness of the eye. An axon reflex may be responsible for uveitis formation — stimulation of pain receptors in the cornea results in release inflammatory mediators such as prostaglandins, histamine, and acetylcholine.

Diagnosis is done by direct observation under magnified view of slit lamp revealing the ulcer on the cornea. The use of fluorescein stain, which is taken up by exposed corneal stroma and appears green, helps in defining the margins of the corneal ulcer, and can reveal additional details of the surrounding epithelium. Herpes simplex ulcers show a typical dendritic pattern of staining. Rose-Bengal dye is also used for supra-vital staining purposes, but it may be very irritating to the eyes. In descemetoceles, the Descemet’s membrane will bulge forward and after staining will appear as a dark circle with a green boundary, because it does not absorb the stain. Doing a corneal scraping and examining under the microscope with stains like Gram’s and KOH preparation may reveal the bacteria and fungi respectively. Microbiological culture tests may be necessary to isolate the causative organisms for some cases. Other tests that may be necessary include a Schirmer’s test for keratoconjunctivitis sicca and an analysis of facial nerve function for facial nerve paralysis.

Surgery in the form of corneal transplantation may be needed in few cases to save the eye.

Contact lens wearers must be sure to wash their hands and pay very close attention to cleanliness while handling their lenses to prevent corneal ulcers. Also, contact lenses should not be worn overnight or when swimming, and eye lubricants should be used prior to lens removal to avoid scratches due to dryness. Prompt, early attention by an ophthalmologist or optometrist for an eye infection may prevent ulcers from forming.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Refractory corneal ulcers are superficial ulcers that heal poorly and tend to recur. They are also known as indolent ulcers or boxer ulcers. They are believed to be caused by a defect in the basement membrane and a lack of hemidesmosomal attachments. They are recognized by undermined epithelium that surrounds the ulcer and easily peels back. Refractory corneal ulcers are most commonly seen in diabetics and often occur in the other eye later. They are similar to Cogan’s cystic dystrophy.

Melting ulcers are a type of corneal ulcer involving progressive loss of stroma in a dissolving fashion. This is most commonly seen in Pseudomonas infection, but it can be caused by other types of bacteria or fungi. These infectious agents produce proteases and collagenases which break down the corneal stroma. Complete loss of the stroma can occur within 24 hours. Treatment includes antibiotics and collagenase inhibitors such as acetylcysteine. Surgery in the form of corneal transplantation (penetrating keratoplasty) is usually necessary to save the eye.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The cornea is a transparent structure that is part of the outer layer of the eye. It refracts light and protects the contents of the eye. The corneal thickness ranges from 450 to 610 micrometres and on an average 550 µm. thick in caucasian eyes. In Indian eyes, the average thickness is slightly less at 510 µm. The trigeminal nerve supplies the cornea via the long ciliary nerves. There are pain receptors in the outer layers and pressure receptors are deeper.

Transparency is achieved through a lack of blood vessels, pigmentation, and keratin, and through tight layered organization of the collagen fibers. The collagen fibers cross the full diameter of the cornea in a strictly parallel fashion and allow 99 percent of the light to pass through without scattering.

There are five layers in the human cornea, from outer to inner:

• Epithelium
• Bowman’s membrane
• Stroma
• Descemet’s membrane
• Endothelium

The outer layer is the epithelium, which is 25 to 40 µm micrometers and five to seven cell layers thick. The epithelium holds the tear film in place and also prevents water from invading the cornea and disrupting the collagen fibers. This prevents corneal edema, which gives it a cloudy appearance. It is also a barrier to infectious agents. The epithelium sticks to the basement membrane, which also separates the epithelium from the stroma. The corneal stroma comprises 90 percent of the thickness of the cornea. It contains the collagen fibers organized into lamellae. The lamellae are in sheets which separate easily. Posterior to the stroma is Descemet’s membrane, which is a basement membrane for the corneal endothelium. The endothelium is a single cell layer that separates the cornea from the aqueous humor.

An ulcer of the cornea heals by two methods, migration of surrounding epithelial cells followed by mitosis (dividing) of the cells, and introduction of blood vessels from the conjunctiva. Superficial small ulcers heal rapidly by the first method. However, larger or deeper ulcers often require the presence of blood vessels to supply inflammatory cells. White blood cells and fibroblasts produce granulation tissue and then scar tissue, effectively healing the cornea.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Corneal ulcers are a common human eye disease. They are caused by trauma, particularly with vegetable matter, chemical injury, contact lenses, and infections. Other eye conditions can cause corneal ulcers, such as entropion, distichiae, corneal dystrophy, and keratoconjunctivitis sicca (dry eye).

Corneal ulcers are caused by trauma, particularly with vegetable matter, chemical injury, contact lenses, and infections. Many micro-organisms cause infective corneal ulcer. Among them are bacteria, fungi, viruses, protozoa, and chlamydia.

Bacterial keratitis is caused by Staphylococcus aureus, Streptococcus viridans, Escherichia coli, Enterococci, Pseudomonas, Nocardia and many other bacteria.

Fungal keratitis causes deep and severe corneal ulcer. It is caused by Aspergillus sp., Fusarium sp., Candida sp., as also Rhizopus, Mucor, and other fungi. The typical feature of fungal keratitis is slow onset and gradual progression, where signs are much more than the symptoms. Small satellite lesions around the ulcer are a common feature of fungal keratitis and hypopyon is usually seen.

Viral keratitis causes corneal ulceration. It is caused most commonly by Herpes simplex, Herpes Zoster and Adenoviruses. Also it can be caused by coronaviruses and many other viruses. Herpes virus cause a dendritic ulcer, which can be recur and relapse over the lifetime of an individual. Protozoa infection like Acanthamoeba keratitis is characterized by severe pain and is associated with contact lens users swimming in pools. Chlamydia trachomatis can also contribute to development of corneal ulcer.

Superficial ulcers involve a loss of part of the epithelium. Deep ulcers extend into or through the stroma and can result in severe scarring and corneal perforation. Descemetoceles occur when the ulcer extends through the stroma. This type of ulcer is especially dangerous and can rapidly result in corneal perforation, if not treated in time.

The location of the ulcer depends somewhat on the cause. Central ulcers are typically caused by trauma, dry eye, or exposure from facial nerve paralysis or exophthalmos. Entropion, severe dry eye and distichiasis (inturning of eye lashes) may cause ulceration of the peripheral cornea. Immune-mediated eye disease can cause ulcers at the border of the cornea and sclera. These include rheumatoid arthritis, rosacea, systemic sclerosis which lead to a special type of corneal ulcer called Mooren’s ulcer. It has a circumferential crater like depression of the cornea, just inside the limbus, usually with an overhanging edge. Other eye conditions can also cause corneal ulcers, such as entropion, distichiae, corneal dystrophy, and keratoconjunctivitis sicca (dry eye).

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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People with poor eye hygiene and contact lens abusers (e.g. those who wear contact lenses overnight) are at an increased risk of developing corneal ulcers. Corneal ulcers are a common condition in humans, particularly those living in the tropics and in agrarian societies. In developing countries, children afflicted by vitamin A deficiency are at a high risk for corneal ulcer and may become blind in both eyes, which may persist lifelong if not treated.

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