The cornea, the clear front part of the eye through which light passes, is subject to many infections and to
injury from exposure and from foreign objects. Infection and injury cause inflammation of the cornea—a condition called keratitis. Tissue loss because of inflammation produces an ulcer. The ulcer can either be centrally located, thus greatly affecting vision, or peripherally located. There are about 30,000 cases of bacterial corneal ulcers in the United States each year.
Description
The most common cause of corneal ulcers is germs, but most of them cannot invade a healthy cornea with adequate tears and a functioning eyelid. They gain access because injury has impaired these defense mechanisms. A direct injury from a foreign object inoculates germs directly through the outer layer of the cornea, just as it does to the skin. A caustic chemical can inflame the cornea by itself or so damage it that germs can invade. Improper use of contact lenses has become a common cause of corneal injury. Eyelid or tear function failure is the other way to make the eye vulnerable to infection. Tears and the eyelid together wash the eye and prevent foreign material from settling in. Tears contain enzymes and other substances to help protect against infection. Certain diseases dry up tear production, leaving the cornea dry and defenseless. Other diseases paralyze or weaken the eyelids so that they cannot effectively protect and cleanse the eyes.
Causes and symptoms
Viruses, bacteria, fungi, and a protozoan called Acanthamoeba can all invade the cornea and damage it under suitable conditions.
Bacteria from a common conjunctivitis (pink eye) rarely spread to the cornea, but can if untreated.
Fecal bacteria are more likely to be able to infect the cornea.
A bacterium called Pseudomonas aeruginosa, which can contaminate eyedrops, is particularly able to cause corneal infection.
Other sexually transmitted diseases—for example, syphilis—can affect the cornea.
The most common viruses to damage the cornea are adenoviruses and herpes viruses. Viral and fungal infections are often caused by improper use of topical corticosteroids. If topical corticosteroids are used in a patient with herpes simplex keratitis, the ulcer can get much worse and blindness could result.
Symptoms are obvious. The cornea is intensely sensitive, so corneal ulcers normally produce severe pain. If the corneal ulcer is centrally located, vision is impaired or completely absent. Tearing is present and the eye is red. It hurts to look at bright lights.
Diagnosis
The doctor will take a case history to try to determine the cause of the ulcer. This can include improper use of contact lenses; injury, such as a scratch from a twig; or severe dry eye. An instrument called a slit lamp will be used to examine the cornea. The slit lamp is a microscope with a light source that magnifies the cornea, allowing the extent of the ulcer to be seen. Fluorescein, a yellow dye, may be used to illuminate further detail. If a germ is responsible for the ulcer, identification may require scraping samples directly from the cornea, conjunctiva, and lids, and sending them to the laboratory.
Treatment
A corneal ulcer needs to be treated aggressively, as it can result in loss of vision. The first step is to eliminate infection. Broad spectrum antibiotics will be used before the lab results come back. Medications may then be changed to more specifically target the cause of the infection. A combination of medications may be necessary. Patients should return for their follow-up visits so that the doctor can monitor the healing process. The cornea can heal from many insults, but if it remains scarred, corneal transplantation may be necessary to restore vision. If the corneal ulcer is large, hospitalization may be necessary.
Prognosis
Treated early enough, corneal infections will usually resolve, perhaps even without the formation of an ulcer. However, left untreated, infections can lead to ulcers and the corneal ulcer can result in scarring or perforation of the cornea. Other problems may occur as well, including glaucoma. Patients with certain systemic diseases that impede healing (such as diabetes mellitus or rheumatoid arthritis) may need more aggressive treatment. The later the treatment, the more damage will be done and the more scarring will result. Corneal transplant is standard treatment with a high probability of success.
Prevention
Attentive care of contact lenses will greatly reduce the incidence of corneal damage and ulceration. Germs that cause no problems in the mouth or on the hands can damage the eye, so contact lens wearers must wash their hands before touching their lenses and must not use saliva to moisten them. Tap water should not be used to rinse the lenses. Contacts should be removed whenever there is irritation and left out until the eyes are back to normal. It is not advisable to wear contact lenses while swimming or in hot tubs. Daily wear contact lenses have been found to be less of a risk than contacts for overnight wear (extended wear). Organisms have been cultured from contact lens cases, so the cases should be rinsed in hot water and allowed to air dry. Cases should be replaced every three months. Patients should follow their doctors' schedules for replacement of the contacts.
Eye protection in the workplace, or wherever tiny particles are flying around, is essential. Ultraviolet (UV) coatings on glasses or sunglasses can help protect the eyes from the sun's rays. Goggles with UV protection should be worn when skiing or in suntanning salons to protect against UV rays. Prompt attention to any red eye should prevent progressive damage.
For people with inadequate tears, use of artificial tears eyedrops will prevent damage from drying. Eyelids that do not close adequately may temporarily have to be sewn shut to protect the eye until more lasting treatment can be instituted.
BOOKS
Newell, Frank W. "Ulcerative Keratitis." In Ophthalmology: Principles and Concepts. 8th ed. St. Louis: Mosby, 1996.
ORGANIZATIONS
American Academy of Ophthalmology. 655 Beach Street, P.O. Box 7424, San Francisco, CA 94120-7424. <http://www.eyenet.org>.
American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100. <http://www.aoanet.org>.
Prevent Blindness America. 500 East Remington Road, Schaumburg, IL 60173. (800) 331-2020. <http://www.preventblindness.org>.
J. Ricker Polsdorfer, MD
KEY TERMS
Fluorescein—A fluorescent chemical used to examine the cornea.
