What Is a Corneal Ulcer (Ulcerative Keratitis)?
A corneal ulcer is an open sore on the cornea, the clear structure overlying the iris, which is the colored part of your eye.
What Causes a Corneal Ulcer?
- In the U.S., most corneal ulcers are caused by contact lens-related infections.
- The majority of contact lens-related infections are caused by bacteria. Other causes include fungal and Acanthamoeba (parasite) infections.
- Improper use and poor contact lens hygiene are modifiable risk factors for most contact lens-related infections.
- Water exposure (for example, swimming, hot tubs, tap water) to contact lenses is a major risk factor for Acanthamoeba infection.
- Viral infections are also possible causes of corneal ulcers. Such viruses include the herpes simplex virus (the virus that causes cold sores) or the varicella virus (the virus that causes chickenpox and shingles).
- Fungal infections can cause corneal ulcers and may develop with improper care of contact lenses, trauma to the eyes (especially agricultural), use of eyedrops that contain steroids, and corneas with preexisting conditions and corneal transplants.
- Tiny tears to the corneal surface (corneal abrasions) may become infected and lead to corneal ulcers. These tears can come from direct trauma by fingernail scratches, mascara wand injury, or metallic or glass particles striking the cornea. Such injuries damage the corneal surface and make it easier for bacteria to invade and cause a corneal ulcer.
- Disorders that cause dry eye can leave your eye more vulnerable to ulcers because the top layer of the cornea (epithelium) may become rough (known as punctate epithelial keratitis) from poor tear film quality.
- Disorders that affect the eyelid and prevent your eye from closing completely, such as Bell's palsy, can dry your cornea and make it more vulnerable to ulcers.
- Any condition that causes loss of sensation of the corneal surface (such as herpes simplex and herpes zoster) may increase the risk of corneal ulceration.
- Chemical burns or other caustic (damaging) solution splashes can injure the cornea and lead to corneal ulceration.
- People who wear daily-wear contact lenses are at an increased risk of corneal ulcers. The risk of ulcerative keratitis is 10-15 times greater when using extended-wear soft contact lenses compared to daily-wear lenses. Extended-wear contact lenses refer to those contact lenses that are worn for several days without removing them at night.
- Overnight wear of contact lenses is a major risk factor for infection. Improper use of contact lenses may damage your cornea in many ways:
- Scratches on the edge of your contact lens can scrape the cornea's surface and make it more vulnerable to bacterial infections.
- Similarly, tiny particles of dirt trapped underneath the contact lens can scratch the cornea.
- Bacteria may be on the improperly cleaned lens and get trapped on the undersurface of the lens. If your lenses are left in your eyes for long periods of time, these bacteria can multiply and cause damage to the cornea.
- Wearing lenses for extended periods of time can also block oxygen to the cornea, making it more susceptible to infections.
- All contact lenses must be purchased with a doctor's prescription. Lenses bought without prescription (unregulated lenses) have been linked to a higher infection risk and more serious infections. Unregulated lenses have been purchased on international web sites, beauty supply stores, and Halloween stores.
- Regular medical supervision of contact lens wearers is important to identify early problems and reinforce proper use.
- Less commonly, corneal ulcers can be the result of an autoimmune disorder or immunodeficient state.
What Are Risk Factors for a Corneal Ulcer?
The following are risk factors for corneal ulcers.
- The number one risk factor for corneal ulcer in the U.S. is contact lens wear.
- Trauma to the eyes
- Eye surgery, including corneal transplants, cataract surgery, and other corneal surgery
- Corneal disorders such as dry eye, herpes keratitis, and atopic and vernal keratitis
- Immune-mediated diseases such as Staphylococcus marginal disease, rheumatoid arthritis, Sjögren's syndrome, and inflammatory bowel disease
- Immune-compromised conditions such as HIV, diabetes mellitus, and cancer
What Are Corneal Ulcer Symptoms and Signs?
- Red eye
- Pain in the eye
- Feeling that something is in your eye
- Pus or thick discharge draining from your eye
- Blurry vision
- Pain when looking at bright lights
- Inflammation of the eyelids (swelling, redness)
- A white or gray round spot on the cornea that is visible with the naked eye if the ulcer is large
- An associated uveitis (inflammation of the ciliary body) with or without hypopyon
- A hypopyon (collection of white blood cells and inflammatory debris) in the anterior chamber (area of the eye between the cornea and iris) may indicate a more severe infection.
- Less commonly, there may be an associated retinopathy (changes in the retina) if the keratitis has progressed to involve the entire eye (endophthalmitis).
- A white eye without pain (This is usually related to a disorder of the immune system.)
Pink Eye (Conjunctivitis) Symptoms, Causes, Treatments
When Should Someone Seek Medical Care for a Possible Corneal Ulcer?
Seek medical advice from a health care provider if you experience the following signs or symptoms:
- Red eye
- A change in vision
- Severe pain
- Feeling that there is something in your eye
- Obvious discharge draining from your eye
- If you have a recent history of scratches to the eye or exposure to chemicals or flying particles
What Health Care Specialists Diagnose and Treat a Corneal Ulcer?
People with a corneal ulcer should be seen by an ophthalmologist. Those with more serious disease may also need to see an ophthalmologist with cornea expertise. If the ulcer is related to an underlying systemic disorder, consultation with your primary care physician and/or a rheumatologist may be indicated.
What Tests Do Health Care Providers Use to Make a Diagnosis of Corneal Ulcer?
Because corneal ulcers are a serious problem, you should see your ophthalmologist (a medical doctor who specializes in ocular care and surgery).
- Your ophthalmologist will be able to detect if you have an ulcer by using a special eye microscope, known as a slit lamp. To make the ulcer easier to see, he or she will put a drop containing the dye fluorescein into your eye.
- Your ophthalmologist may use a topical numbing eyedrop to examine and diagnose your ulcer, but this eyedrop cannot be used for pain control. Using this numbing eyedrop on a frequent basis can worsen the ulcer.
- If your health care provider thinks that an infection is responsible for the ulcer, he or she may then get samples of the ulcer to send to the laboratory for identification.
What Are Medical Treatments for a Corneal Ulcer?
- Your ophthalmologist will remove your contact lenses if you are wearing them.
- Your ophthalmologist will generally not place a patch over your eye if he or she suspects that you have a bacterial infection. Patching creates a warm dark environment that allows bacterial growth.
- You may need topical antibiotics or antifungal treatment, or combination treatment with subconjunctival injection and/or oral antibiotics/antifungal medications.
- Hospitalization may be required if the ulcer is severe.
- In some cases, your ophthalmologist may use a contact lens as a bandage to help in the healing process.
Are There Home Remedies for a Corneal Ulcer?
- If you wear contact lenses, remove them immediately.
- Apply cool compresses to the affected eye.
- Do not touch or rub your eye with your fingers.
- Limit worsening of infection by washing your hands often and drying them with a clean towel.
- Take over-the-counter pain medications, such as acetaminophen (Tylenol) or ibuprofen (Motrin).
- An early ophthalmologist assessment is necessary if a corneal ulcer is even suspected.
What Medications Treat a Corneal Ulcer?
- Because infection is a common occurrence in corneal ulcers, your ophthalmologist will prescribe antibiotic eyedrops. If the infection appears very large, you may need to use these antibiotic drops as often as one drop an hour, even throughout the night. Some patients require more than one type of treatment and some require eyedrops that are compounded at specialty pharmacies or in hospitals.
- Prescription pain medications are not usually required. Over-the-counter acetaminophen or ibuprofen may be used to help with pain. Some people may find pain relief with eyedrops that keep your pupil dilated (cycloplegic eyedrops).
- Steroid eyedrops may also be indicated.
Surgery for a Corneal Ulcer
- If the ulcer cannot be controlled with medications or if it threatens to perforate the cornea, a patient may require an emergency surgery -- a procedure known as corneal transplant.
When Can Patients Resume Wearing Contact Lenses After Treatment of a Corneal Ulcer?
Once an infection is resolved, patients should check with their ophthalmologist as to when they may resume contact lens use, since each patient scenario varies. A new contact lens should be worn, as well as the use of new care products (case, solutions). Typically, even after an infection is treated, it is prudent to let the corneal surface continue to heal before resuming contact lens wear. Often, once contact lens wear is resumed, it is on a modified schedule, gradually building up wear time.
Follow-up After Corneal Ulcer Treatment
If you do not need hospitalization, your ophthalmologist will prescribe eyedrops and pain medications for you to take regularly at home. You will need to follow up with your ophthalmologist even daily until your ophthalmologist tells you differently.
You should contact your ophthalmologist immediately if you experience symptoms such as worsening vision, pain, discharge, or fever.
Is It Possible to Prevent a Corneal Ulcer?
Seek medical attention from your ophthalmologist immediately for any ocular symptoms. Even seemingly minor injuries to your cornea can lead to an ulcer and have devastating consequences if left untreated, including blindness or loss of the eye.
- Wear eye protection when exposed to small particles that can enter your eye.
- If you have dry eye disease or if your eyelids do not close completely, use artificial teardrops to keep your eyes lubricated. In addition, your ophthalmologist may recommend other prescription dry eye medications and/or treatments such as warm compresses, punctal plugs, or eyelid surgery.
- If you wear contact lenses, be extremely careful about the way you clean and wear your lenses, and regularly see your optometrist or ophthalmologist for routine, preventative care.
- Always wash and dry your hands before handling the lenses. Never use saliva to lubricate your lenses because your mouth contains bacteria that can harm your cornea.
- Remove your lenses from your eyes every evening and carefully clean them or dispose of them if they are daily disposable lenses. Never use tap water to clean the lenses.
- Never sleep with your contact lenses in your eyes.
- Store the lenses in disinfecting solutions overnight. Always use fresh solution.
- Remove your lenses whenever your eyes are irritated, and leave them out until your eyes feel better.
- Regularly clean your contact lens case with disinfecting solution and air dry it upside down. Do not clean it with tap water. Dispose of your contact lens case at least every three months.
What Is the Prognosis of a Corneal Ulcer? How Long Does It Take a Corneal Ulcer to Heal?
A corneal ulcer is a true emergency. Without treatment, the ulcer can spread to the rest of the patient's eyeball. A patient can become partially or completely blind in a very short period of time. Your cornea may also perforate, or you could develop scarring, cataracts, or glaucoma.
- With proper treatment of most corneal ulcers, infection should improve within two to three weeks but may require even months of care depending on the severity of the infection.
- If scars from previous corneal ulcers impair vision, a corneal transplant may be needed to restore normal vision.
What causes dry eyes?
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. "Bacterial Keratitis." San Francisco, CA: American Academy of Ophthalmology, 2013. <https://www.aao.org/guidelines-browse?filter=preferredpracticepatternsguideline>.