Corneal ulcer, also called ulcerative keratitis, is a serious ocular condition involving a full-thickness breakdown of the corneal epithelium with associated inflammation and necrosis of underlying stroma.

This condition represents an ophthalmic emergency due to its potential to cause significant vision loss, scarring, or even globe perforation if not promptly diagnosed and adequately treated.

Understanding its complex pathophysiology, diverse etiologies, clinical presentation, and appropriate management is crucial for optimizing patient outcomes.

Causes and Pathogenesis

A corneal ulcer primarily results from infectious agents invading the corneal tissue, breaching its natural protective barriers. Bacteria, fungi, viruses, and protozoa (notably Acanthamoeba) constitute the most common causative organisms. Bacterial keratitis is primarily caused by Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pneumoniae, typically following corneal trauma or contact lens misuse.

Non-infectious factors such as dry eye disease, neurotrophic keratopathy, autoimmune disorders, and exposure keratopathy can predispose the cornea to ulcer formation by disrupting epithelial integrity and healing. Infections trigger an inflammatory cascade with neutrophil infiltration, proteolytic enzyme release, and collagen degradation, leading to tissue necrosis and ulceration.

Clinical Features and Diagnosis

Patients with corneal ulcers often present with acute onset of eye pain, photophobia, redness, tearing, blurred vision, and a sensation of a foreign body within the eye. On examination, slit-lamp biomicroscopy reveals an epithelial defect with underlying stromal infiltrate often accompanied by conjunctival injection and anterior chamber reaction, including hypopyon in severe cases.

Diagnostic evaluation involves corneal scraping for microbiological culture and staining, which is essential for identifying specific pathogens and guiding targeted antimicrobial therapy. Imaging tools like anterior segment optical coherence tomography may additionally assist in assessing ulcer depth and monitoring healing progression.

Treatment and Management Strategies

Timely and aggressive treatment is imperative to prevent complications. Management begins with empirical broad-spectrum topical antibiotics, such as fluoroquinolones (e.g., ciprofloxacin, ofloxacin), administered hourly initially. Culture-directed therapy follows once pathogen sensitivities are known.

Adjunctive therapies focus on controlling inflammation and promoting healing, though corticosteroids remain controversial due to risks of exacerbating infection and must only be used under strict specialist supervision. Pain management, avoidance of contact lens wear, and eyelid hygiene are essential supportive measures. Hospitalization may be warranted for severe infections or patients unable to comply with intensive treatment regimens.

Surgical intervention becomes necessary in cases with corneal thinning or perforation, employing techniques such as amniotic membrane transplantation or therapeutic keratoplasty to restore corneal integrity and prevent vision-threatening complications.

Dr. David E. Martinez, a board-certified ophthalmologist specializing in corneal and external eye diseases, "A corneal ulcer is an open sore on your cornea. It's often caused by an eye infection. It may also be caused by other eye disorders."

Corneal ulcer represents a potentially vision-threatening lesion resulting from infectious or non-infectious causes compromising corneal integrity. Its hallmark symptoms include pain, redness, tearing, and visual impairment, necessitating urgent medical evaluation.

Accurate diagnosis through corneal sampling and imaging underpins targeted antimicrobial and supportive therapies. Management demands vigilant monitoring and may extend to surgical measures in severe cases.