This document discusses the treatment of non-healing corneal ulcers. It begins by describing the signs and symptoms of a non-healing corneal ulcer. Risk factors include compromised ocular surfaces, dry eye, previous trauma or surgery, and systemic conditions like diabetes or malnutrition. Treatment involves topical antibiotics, debridement of necrotic tissue, bandage contact lenses, and in severe cases, therapeutic keratoplasty.

1. ..
TREATMENT OF NONTREATMENT OF NON
HEALING CORNEALHEALING CORNEAL
ULCERULCER
..

2. Superficial abrasions onSuperficial abrasions on
the surface of thethe surface of the
eye that faileye that fail
to heal after 7 to 10to heal after 7 to 10
days.days.

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

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

5. Defense of Ocular SurfaceDefense of Ocular Surface
Normal Defense mechanismsNormal Defense mechanisms ::
1.1. EyelidsEyelids
2.2. Tear film proteins (SecretoryTear film proteins (Secretory
immunoglobulins, complementimmunoglobulins, complement
components, and various enzymescomponents, and various enzymes
including lysozyme, lactoferrin,including lysozyme, lactoferrin,
betalysins, orosomucoid andbetalysins, orosomucoid and
ceruloplasmin have antibacterial effect)ceruloplasmin have antibacterial effect)
3.3. Corneal epitheliumCorneal epithelium
4.4. Normal ocular floraNormal ocular flora

6. Risk FactorsRisk Factors
1.1. Compromised normal ocularCompromised normal ocular
surface(proptosis,bell`ssurface(proptosis,bell`s
palsy,ectropion,deep coma,lagophthalmos)palsy,ectropion,deep coma,lagophthalmos)
2.2. Chronic colonization and infection of theChronic colonization and infection of the
eyelid margin and lacrimal outflow systemeyelid margin and lacrimal outflow system
can predispose corneacan predispose cornea
3.3. Chronic epiphora by reducing concentrationChronic epiphora by reducing concentration
of certain antibacterial substances.of certain antibacterial substances.
4.4. Dry eyeDry eye

7. Risk FactorsRisk Factors
5. Presence of N Gonorrhoeae, C5. Presence of N Gonorrhoeae, C
Diphtheriae, Hemophilus Aegyptius andDiphtheriae, Hemophilus Aegyptius and
Listeria Monocytogenes – they canListeria Monocytogenes – they can
penetrate intact corneal epithelium.penetrate intact corneal epithelium.
6. Compromised corneal epithelium as in6. Compromised corneal epithelium as in
cases of contact lenses users, cornealcases of contact lenses users, corneal
trauma, corneal surgery bulloustrauma, corneal surgery bullous
keratopathy.keratopathy.
7. Absence of normal conjunctival flora.7. Absence of normal conjunctival flora.

8. Risk FactorsRisk Factors
8 Biofilm- is a slimy layer composed of8 Biofilm- is a slimy layer composed of
organic polymers produced by embeddedorganic polymers produced by embedded
bacteria on contact lens, it protectsbacteria on contact lens, it protects
bacteria from antibacterial substances andbacteria from antibacterial substances and
provide a nidus for infection.provide a nidus for infection.
9. Corneal anaesthesia(neuroparalytic9. Corneal anaesthesia(neuroparalytic
keratitis)keratitis)
10. Abuse of topical anaesthetic solution10. Abuse of topical anaesthetic solution

9. Risk FactorsRisk Factors
11. Local immune suppression as due to11. Local immune suppression as due to
topical corticosteroidstopical corticosteroids
12. Previous viral infection12. Previous viral infection

10. External Risk FactorsExternal Risk Factors
1.1. Trauma (Nocardia)Trauma (Nocardia)
2.2. Exposure to contaminated water orExposure to contaminated water or
solutionssolutions
3.3. Chronic abuse of topical anaestheticChronic abuse of topical anaesthetic
solutionsolution
4.4. Crack Cocaine smoking (disruptingCrack Cocaine smoking (disrupting
corneal epithelium via associated cellularcorneal epithelium via associated cellular
and neuronal toxicity.and neuronal toxicity.

11. Predisposing Systemic ConditionsPredisposing Systemic Conditions
1.1. MalnutritionMalnutrition
2.2. DiabetesDiabetes
3.3. Collagen vascular diseasesCollagen vascular diseases
4.4. Chronic alcoholismChronic alcoholism

12. Symptoms of Corneal UlcerSymptoms of Corneal Ulcer
 Symptoms are usually marked, they are:Symptoms are usually marked, they are:
1. Diminution of vision, depending on location of1. Diminution of vision, depending on location of
corneal ulcercorneal ulcer
2. Watering (lacrimation)2. Watering (lacrimation)
3. Difficulty in opening eyes especially in bright3. Difficulty in opening eyes especially in bright
light (photophobia and blepharospasm)light (photophobia and blepharospasm)
4. Pain and foreign body/ gritty sensation usually4. Pain and foreign body/ gritty sensation usually
intermittentintermittent
 5. There may be discharge (Mucopurulent /5. There may be discharge (Mucopurulent /
purulent)purulent)

13. PresentationPresentation
Clinical signs and symptoms are variableClinical signs and symptoms are variable
dependent on the virulence of thedependent on the virulence of the
organism, duration of infection, pre-organism, duration of infection, pre-
existing corneal conditions, immune statusexisting corneal conditions, immune status
of host and previous use of antibiotics/of host and previous use of antibiotics/
steroidsteroid
Acanthamoeba can cause masqueradingAcanthamoeba can cause masquerading
syndrome mimicking bacterial keratitis.syndrome mimicking bacterial keratitis.

14. A corneal epithelial erosion that tends toA corneal epithelial erosion that tends to
remain superficial and is not healing.remain superficial and is not healing.
The presence of a redundant or looseThe presence of a redundant or loose
undermined epithelial margin or bleb.undermined epithelial margin or bleb.
Fluorescein stain will undermine theFluorescein stain will undermine the
redundant border or pass through a fineredundant border or pass through a fine
epithelial break and be retained under theepithelial break and be retained under the
epithelium beyond the edge of theepithelium beyond the edge of the
surface break.surface break.

15. The loose epithelial margin may even beThe loose epithelial margin may even be
rolled or folded upon itself.rolled or folded upon itself.
The eye may not be consistently painfulThe eye may not be consistently painful
and it usually is intermittently painful.and it usually is intermittently painful.
 Initially and even chronically there isInitially and even chronically there is
usually a lack of an inflammatory responseusually a lack of an inflammatory response
characterized by a lack or scarcity ofcharacterized by a lack or scarcity of
blood vessels.blood vessels.
These lesions rarely become infected.These lesions rarely become infected.

16. SignsSigns
6. Colour and pattern of iris may be disturbed6. Colour and pattern of iris may be disturbed
7. Cornea: loss of transparency the ulcer appears7. Cornea: loss of transparency the ulcer appears
yellowish/ grayish pale lesion of varying shapeyellowish/ grayish pale lesion of varying shape
/size, breach in continuity of corneal surface,/size, breach in continuity of corneal surface,
ulcer with irregular floor and margins, floorulcer with irregular floor and margins, floor
appears grayish / grayish pale/ grayish yellow,appears grayish / grayish pale/ grayish yellow,
zone of infiltration with projecting swollen edges.zone of infiltration with projecting swollen edges.
The surrounding cornea may appear groundThe surrounding cornea may appear ground
glass like due to corneal edemaglass like due to corneal edema

17. Corneal UlcerCorneal Ulcer
Peripheral Corneal Ulcer
Central Corneal ulcer involving
Lower periphery also

19. Clinical ExaminationClinical Examination
Evaluation of predisposing and aggravatingEvaluation of predisposing and aggravating
FactorsFactors
1.1. A detailed historyA detailed history
2.2. Prior ocular historyPrior ocular history
3.3. Review of related medical problems,Review of related medical problems,
current ocular medications and history ofcurrent ocular medications and history of
medication allergymedication allergy

20. ExaminationExamination
1.1. Visual acuityVisual acuity
2.2. An external ocular examinationAn external ocular examination
Facial appearance, eyelids, lid closureFacial appearance, eyelids, lid closure
Conjunctiva, Nasolacrimal apparatus,Conjunctiva, Nasolacrimal apparatus,
corneal sensationcorneal sensation

21. ExaminationExamination
3. Slit Lamp Biomicroscopy: For3. Slit Lamp Biomicroscopy: For
Eyelid marginEyelid margin
Tear filmTear film
ConjunctivaConjunctiva
ScleraSclera
Cornea (epithelial defects, punctateCornea (epithelial defects, punctate
keratopathy, edema, stromalkeratopathy, edema, stromal
infiltrates/ulceration, thinning orinfiltrates/ulceration, thinning or
perforation)perforation)

22. Slit Lamp Examination… ContdSlit Lamp Examination… Contd
Location of lesionLocation of lesion
Density, Size , shape , depth, colourDensity, Size , shape , depth, colour
EndotheliumEndothelium
Anterior chamberAnterior chamber
Loose or Broken suturesLoose or Broken sutures
Signs of corneal dystrophySigns of corneal dystrophy
Signs of previous inflammationSigns of previous inflammation

23. Steroids must not be used in presence ofSteroids must not be used in presence of
active infected corneal ulceractive infected corneal ulcer
In cases of progressive corneal ulcerIn cases of progressive corneal ulcer
despite routine therapeutic treatment, thedespite routine therapeutic treatment, the
following measures be considered:following measures be considered:
Scraping of ulcer floor followed byScraping of ulcer floor followed by
cauterization with pure (100%) carbolic acidcauterization with pure (100%) carbolic acid
or 10-20% trichloracetic acid. Povidone Iodineor 10-20% trichloracetic acid. Povidone Iodine
can also be used for cauterizationcan also be used for cauterization

24. Systemic TreatmentSystemic Treatment
1.1. Systemic Antibiotics: consider in severSystemic Antibiotics: consider in sever
cases with scleral or intra-ocularcases with scleral or intra-ocular
extension of infection or with impendingextension of infection or with impending
or frank perforation of the corneaor frank perforation of the cornea
Systemic antibiotic therapy is necessarySystemic antibiotic therapy is necessary
in cases of Gonococcal keratitis due toin cases of Gonococcal keratitis due to
its fulminating nature and systemicits fulminating nature and systemic
involvementinvolvement

25. Systemic TreatmentSystemic Treatment
2. Analgesic anti-inflammatory2. Analgesic anti-inflammatory
3. Supportive treatment3. Supportive treatment
4. Acetazolamide Tab ,iv mannitol4. Acetazolamide Tab ,iv mannitol
BD,0.5%timolol BD is added in cases ofBD,0.5%timolol BD is added in cases of
impending perforation or perforatedimpending perforation or perforated
corneal ulcer and in cases where there iscorneal ulcer and in cases where there is
raised intra-ocular tension (in dosage ofraised intra-ocular tension (in dosage of
250 mgm upto four times a day)250 mgm upto four times a day)

26. Non-responsive / Progressive Corneal UlcerNon-responsive / Progressive Corneal Ulcer
TREATMENTTREATMENT
Re-evaluate forRe-evaluate for
Drug toxicityDrug toxicity
Non-infectious causes orNon-infectious causes or
Unusual organisms such as non-tubercularUnusual organisms such as non-tubercular
mycobacteria, Nocardia or acanthamoebamycobacteria, Nocardia or acanthamoeba
should be suspectedshould be suspected
Modification of anti-microbial therapyModification of anti-microbial therapy
Therapeutic keratoplasty may be undertakenTherapeutic keratoplasty may be undertaken

27. Indolent / Non-healing UlcerIndolent / Non-healing Ulcer
Consider debridement of necrotic cornealConsider debridement of necrotic corneal
stroma andstroma and
Frequent lubrication and/orFrequent lubrication and/or
Temporary tarsorrhaphyTemporary tarsorrhaphy

28. Mechanical Sterile Cotton TippedMechanical Sterile Cotton Tipped
Applicator (CAT's) debridement.Applicator (CAT's) debridement.
 Scraping with a corneal spatulaScraping with a corneal spatula
 Superficial Lamellar KeratectomYSuperficial Lamellar KeratectomY
Beaver blade under general anesthesiaBeaver blade under general anesthesia
Micropuncture with a 25 or 27 gaugeMicropuncture with a 25 or 27 gauge
hypodermic needle.hypodermic needle.

30. After the cornea has been debrided, softAfter the cornea has been debrided, soft
contact lens should be used. Be sure thecontact lens should be used. Be sure the
Schirmer values are greater than 15Schirmer values are greater than 15
mm/min.).mm/min.).
The contact lens will protect the corneaThe contact lens will protect the cornea
from the movements of the overlyingfrom the movements of the overlying
eyelids andeyelids and
splint the new epithelium tight up againstsplint the new epithelium tight up against
the anterior stroma.the anterior stroma.

31. when a contact lens is in placewhen a contact lens is in place
Topical ophthalmicTopical ophthalmic solutions ONLYsolutions ONLY
because ointments will clog poresbecause ointments will clog pores
of lens andof lens and
reduce or eliminate the passage ofreduce 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 lensCorneal edema will result when a lens
blocks respiration and seriousblocks respiration and serious
complications could occur rapidly.complications could occur rapidly.

32. FLUORESCEIN STAININGFLUORESCEIN STAINING
If a Contact lens is in place - fluoresceinIf a Contact lens is in place - fluorescein
will stain the lens and the lens will glowwill stain the lens and the lens will glow
fluoresceDo not leave a contact lens influoresceDo not leave a contact lens in
place longer than 14 days!(due to buildupplace longer than 14 days!(due to buildup
of protein and mucin material in the lensof protein and mucin material in the lens
pores leading to blockage of cornealpores leading to blockage of corneal
respiration)Remove lens using ciliarespiration)Remove lens using cilia
forcepsforceps

34. Cyanoacrylate ApplicationCyanoacrylate Application
In patients where a contact lens can notIn patients where a contact lens can not
be used because a lens does not fit or onebe used because a lens does not fit or one
isis
not available; a thin layer of Cyanoacrylatenot available; a thin layer of Cyanoacrylate
can be applied to act as a custom contactcan be applied to act as a custom contact
lenslens

35. 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 sulfatecycloplegic such as 1% atropine sulfate
should only be used in the face of ashould only be used in the face of a
uveitis.uveitis.

36. Surgical TreatmentSurgical Treatment
1.1. Conjunctival flap; In recalcitrant bacterialConjunctival flap; In recalcitrant bacterial
keratitiskeratitis
2.2. Penetrating Keratoplasty (PKP):Penetrating Keratoplasty (PKP):
Large central ulcer , presenting lateLarge central ulcer , presenting late
History of previous ocular surgeryHistory of previous ocular surgery
Injudicious use steroid treatmentInjudicious use steroid treatment
3.3. Peritomy when excessive vascularisationPeritomy when excessive vascularisation
hinders healinghinders healing