Corneal Ulcer

Prepared By: Renuka Shrestha

Roll no: 29
PBBN 3rd year
SMTC
Corneal ulcer
 Cornea
Cornea is the outermost transparent and
avascular structure of the eye that function in
vision. It most remains clear and smooth to
admit light to the retina. Epithelial layer of the
cornea repair rapidly but if they are penetrated,
infection can rapidly spread inward and vision
may be lost.
layer of cornea
 Corneal Ulcer
Definition
Corneal ulcer is defined as discontinuation in
normal epithelial surface of cornea associated
with necrosis of the surrounding corneal tissue.
 Classification
Classified on the basis of causative agents;
1) Bacterial
 Staphylococcus aureus
 Streptococcus pneumoniae
 E-coli
2) Viral
 HSV-I (Herpes simplex virus)
 HZV (Herpes zoster virus).
Cont…
3) Fungal
 Filamentous
 Candida albicans
 Aspergillus
4) Protozoal

 Acanthamoeba.
 Causes
 Ocular trauma
 Dry eye
 Entropion
 Trichiasis
 Xerophthalmia
 Contact lens wear
 Chronic dacryocystitis
 Prolong use of local steroids
 Pathology
Stages of corneal ulcer;
i. Stage of progressive infiltration
ii. Stage of active ulceration
iii. Stage of regression
iv. Stage of cicatrization
Cont…
1) Stage of progressive infiltration
 It is characterized by the infiltration of
polymorph nuclear or lymphocytes into the
epithelium from the peripheral circulation
supplemented but similar cells from the
underlying stroma if this tissue is also affected.
 Subsequently necrosis of the involved tissue
may occur.
Cont..
2) Stage of active ulceration
 Active ulceration results from necrosis and
sloughing of the epithelium, bowman's
membrane and the involved stroma.
 During this stage, accumulation of purulent
exudates on the cornea.
 There occurs vascular congestion of the iris
and ciliary body and some degree of iritis due
to absorption of toxins from the ulcer.
Cont…
3) Stage of regression
 Regression is induced by natural host defence
mechanism.
 A line of demarcation develops around the ulcer.
 The digestion of necrotic materials may result in
initial enlargement of the ulcer.
 This process may be accompanied by superficial
vascularization that increase the humoral and
cellular immune response.
 The ulcer now begins to heal and epithelium
starts growing over the edges.
Cont…
4) Stage of cicatrization:
 In this stage, healing continue by progressive
epithelization which forms a permanent covering.
 Beneath the epithelium, fibrous tissue is laid down partly
by the corneal fibroblasts and partly by the endothelial
cells of the new vessels.
 The degree of scarring from the healing varies.
 If the ulcer is very superficial and involves the epithelium
only it heals without leaving any opacity behind.
 When the ulcer involves bowman's layer and few
superficial stromal lamellae, the resultant scar id called a
‘nebulla’.
Pathological Stage of Corneal Ulcer
 Symptoms
 Pain and irritation
 Blurred vision
 Photophobia
 Redness
 Watering
 Discharge
 Eyelid swelling
 Discomfort and gritty feeling
 Sign of Corneal Ulcer
Bacterial Viral Fungal Protozoal

 Swelling of  Punctate/stellate  Dry greyish  Irregular and

lids pattern white stromal greyish epithelial
 Blepharospam  Linear branching infiltrate surface
 Ciliary ulcer with or  Satellite lesion  Focal anterior
without terminal  Elevated rolled stromal infiltrate
congestion buds out margins  Radial
 Greyish white  Reduced corneal  Hypopyon keratoneuritis
circumscribed sensation
infiltrate
 Yellowish
white irregular
area of eye
 Hypopyon
 Stromal
oedema
 Diagnosis
1) History taking: to elicit mode of onset,
duration of disease and severity of symptoms.
2) Corneal scraping;
a) Bacterial:
 Gram stain
 Culture and sensitivity
b) Fungal:
 10% KOH stain
 Culture and sensitivity
Cont…
c) Viral:
 PCR
d) Protozoal:
 Gram stain
 Culture and sensitivity.
3) Tomography measurements: assessing IOP
(normal 15-20 mmHg).
 Treatment
General management
i. Hospitalize the client.
ii. Discontinuation of the contact lens wear
iii. Advised to use dark glasses
iv. Encourage for nutritious diet (vit A, B-
complex and c).
v. Hot formentation; local application of heat
gives comfort, reduces pain and cause
vasodilatation.
 Medical Management
1) Bacterial corneal ulcer
a) Topical antibiotics
 Ciprofloxacin 0.3% (eye drop)
 Ofloxacin 0.3%
 Fluoroquinolone

b) Systemic antibiotics
 Ceftriaxone
 Cefotaxim
 Ciprofloxacin
Cont…
2) Viral corneal ulcer
a) Give antiviral drugs;
 Aciclovir 3% ointment- five times daily
 Ganciclovir 0.1% gel- five times daily.
b) Antibiotics prophylaxis
c) Oral antiviral drugs;
 Aciclovir (200-400 mg five times daily for 5-10
days.
 Famciclovir
 Valaciclovir.
Cont…
3) Fungal corneal ulcer
a) Topical antifungal;
 Amphoterician B
 Econazole
 Fluconazole
 Clotrimazole
 Natamycin
 Voriconazole.
Cont…
b) Oral antifungal
 Voriconazole 400mg twice a day for 1day
then, 200mg twice daily.
 Itraconazole 200mg once daily then, reduced
to 100mg once daily.
 Fluconazole 200mg twice daily.
c) Tetracycline/ doxicycline.
Cont..
4) Protozoal corneal ulcer
a) Topical amoebicides
 Polyhexamethylene
 Hexamidine
 Propamidine
b) Tropical antibiotics
c) Tropical steroids.
 Complication
1) Anterier uveitis
2) Hypopyon
3) Secondary glaucoma
4) Corneal scarring
5) Perforation of corneal ulcer
6) Descemetocele
Anterior uveitis
 Nursing Management
Assessment
 Assess pain; discomfort, onset, severity and
pressure in and around eyes.
 Neurosensory examination; blurred vision,
glare.
 Assess fear and anxiety.
Cont…
Nursing diagnosis
i. Acute pain related to trauma and increased
IOP.
ii. Risk for injury related to impaired vision.
iii. Anxiety related to damage to sensory and
lack of understanding of postoperative care.
iv. Risk for self deficit related to damage vision.
Cont…
Nursing Intervention
i) Acute pain related to trauma and increased
IOP.
 Give medication to control pain and IOP as
prescribed.
 Give cold compress on demand for blunt
trauma.
 Reduce lighting levels.
 Encourage the use of sunglasses in strong
light.
Cont..
ii) Risk for injury related to impaired vision
 Orient the patient in the room.
 Discuss the need for the use of googles when
necessary.
 Don’t put pressure on the affected eye.
 Use proper procedure when providing eye
drugs.
Cont..
iii) Anxiety related to damage to sensory and lack of
understanding of postoperative care.
 Assess the degree and duration of visual disturbance.
 Orient the patient to the new environment.
 Describe the perioperative routine.
 Suggest to run the day-to-day living habits when
able.
 Encourage participation of family or people who
mean to patient care.
 Visit frequently to determine the needs and
eliminate anxiety.
Cont…
iv) Risk for self deficit related to damage vision.
 Give instructions to the patient or the person
nearest the signs and symptoms, complications
should be immediately reported to the doctor.
 Give oral and written instructions for the
patient and the person who means the right
techniques in delivering drugs.
 Evaluation of the need for assistance after
discharge.
 Teach the patient and family guide vision
techniques.
Cont …
Evaluation
 Pain is reduced
 Verbalize of reduced anxiety.