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[Emergency] ATLAS OF CORNEAL ULCER

CORNEAL ULCER, ATLAS OF CORNEAL ULCER, The Atlas of Emergency Medicine, Fourth Edition, 2016, OPHTHALMIC CONDITIONS

CORNEAL ULCER 


Clinical Summary
A corneal ulcer is an inflammatory and ulcerative keratitis. Common infectious etiologies include bacteria (Staphylococcus, Streptococcus, Pseudomonas) and viruses (herpes simplex, adenovirus). Bacterial corneal ulcers are commonly associated with extended-wear contact lenses. Rare causes of corneal ulcers include fungal infections and Acanthamoeba, a ubiquitous protozoan associated with contaminated contact lens solutions. Fungal infections may also arise from trauma involving vegetable matter such as a tree branch. Acanthamoeba infections may also occur from swimming in lakes, especially while wearing contact lenses.

Patients present with pain, photophobia, decreased vision, discharge, and a foreign body sensation. Ocular findings include a corneal infiltrate, typically a round white spot, with conjunctival hyperemia, meiosis, and chemosis. Slitlamp biomicroscopy may demonstrate an epithelial defect with fluorescein uptake. Anterior chamber findings can include cells and flare, keratic precipitates, and a hypopyon.
Corneal Ulcer
FIGURE 2.48 ■ Corneal Ulcer. An elliptical ulcer at 5-o’clock
position near the limbus is seen. This location is atypical for a bacterial ulcer. 
The patient presented with painful red eyes and normal
uncorrected vision, but wore cosmetic soft contact lenses. Bilateral
corneal ulcers were diagnosed, which cleared after treatment with
topical ciprofloxacin. Note that the ciliary flush seen in the nasal portion of 
the limbus is not to be mistaken for conjunctivitis.  


Corneal Ulcer
FIGURE 2.49 ■ Corneal Ulcer. A faint white circular corneal infiltrate is 
seen in the central visual axis.

Corneal Ulcer
FIGURE 2.50 ■ Corneal Ulcer. A small circular corneal infiltrate is seen adjacent to the white flash photography reflection. Diffuse conjunctival hyperemia with a nasal ciliary flush is seen.  

Corneal Ulcer with Hypopyon
FIGURE 2.51 ■ Corneal Ulcer with Hypopyon. A hypopyon has developed 
from a corneal ulcer seen near the visual axis. The conjunctiva
is inflamed and a ciliary flush is present.

Corneal Ulcer
FIGURE 2.52 ■ Corneal Ulcer. Diminished visual acuity and pain
due to the corneal ulcer just superior to the visual axis contributed
to his MVC and airbag deployment, causing a large corneal abrasion
of the inferior third of the cornea.

Corneal Ulcer
FIGURE 2.53 ■ Corneal Ulcer. Fluorescein stain uptake of the
corneal ulcer just above the visual axis and the corneal abrasion of
the inferior third of the corneal surface due to airbag deployment.  


Corneal Ulcer
FIGURE 2.54 ■ Corneal Ulcer. A large oval opaque corneal ulcer
is seen at 8-o’clock position toward the limbus in a contact-lens
wearing patient.

Corneal Ulcer with Hypopyon

FIGURE 2.55 ■ Corneal Ulcer with Hypopyon. A middle-aged
female accidentally splashed dishwashing detergent in her eye one week
prior to ED visit. A large inferior corneal ulcer, with corneal edema and
hypopyon, is seen.


Management and Disposition
Corneal ulcers are an ophthalmologic emergency requiring emergent ophthalmology consultation. Stains and cultures should be obtained as expeditiously as possible. Intensive topical treatment using fortified antibiotics is the most effective treatment route, initially given every 30 to 60 minutes.
For mild cases, a single fluoroquinolone agent may suffice. For more severe cases, dual therapy using a cephalosporin or vancomycin combined with an aminoglycoside is recommended. Clinical improvement is usually noted after 2 to 3 days. Systemic antibiotics are used in cases where the sclera is involved (Pseudomonas) or if there is a high risk of concurrent systemic disease (Neisseria, Haemophilus). Cycloplegics are recommended if there is an accompanying iritis. Steroids and eye patching are contraindicated. A contact lens wearer must discontinue contact lens wear.

Pearls
1. A corneal ulcer is an ophthalmologic emergency.
2. Extended-wear contact lens use is a risk factor for corneal ulcer.
3. Pseudomonas aeruginosa, associated with thick yellowgreen or blue-green mucopurulent tenacious exudate, is capable of destroying the cornea within 6 to 12 hours. 

REFERENCES
The Atlas of Emergency Medicine, Fourth Edition, 2016. 

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CLINICAL ATLAS,118,DERMATOLOGY ATLAS,11,EMERGENCY ATLAS,44,HAEMATOLOGY ATLAS,23,HUMAN ANATOMY,1,MICROBIOLOGY ATLAS,66,PARASITOLOGY ATLAS,4,PATHOLOGY ATLAS,22,PEDIATRIC ATLAS,41,STDs,19,SUBCLINICAL ATLAS,116,
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Free Medical Atlas: [Emergency] ATLAS OF CORNEAL ULCER
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CORNEAL ULCER, ATLAS OF CORNEAL ULCER, The Atlas of Emergency Medicine, Fourth Edition, 2016, OPHTHALMIC CONDITIONS
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