Protocol for Treating Corneal Ulcers

Presentation: Sometimes sudden – pug ulcer. Sometimes O reports tearing/squinting/red eye/pawing at eye.

Hx: Trauma – cat scratch, abrasion. Sometimes hx of “eye problem”, hx of sulfonamides

CE: Blepharospasm, epiphora, injected sclera, discharge

Diagnosis:

- Thorough examination of eyelid and conjunctival function and anatomy (including 3 rd eyelid)
- Assessment of corneal and palpebral reflexes
- Microbiological tests of ulcer (C&S)
- Schirmer tear test
- Fluorescein staining

Simple vs Complicated ulcers:

- An ulcer should heal (fully re-epithelialised and no longer retaining fluorescein) within 7 days and without
progression to involve the stroma
- Failure of both of these events is abnormal
- Ulcers may be defined as simple or complicated on the basis of duration and depth
- An ulcer becomes complicated if it involves the stroma AND/OR persists for longer than 7 days

Non-healing ulcers:

- If an ulcer is not healing then it may be defined by one of the following categories:
● Underlying cause not diagnosed – thorough reexamination of the eye with special attention to
eyelids, aberrant hairs and tear production
● Ulcer has become infected – usually will have stromal involvement/loss
● Ulcer has become indolent – recurrent epithelial erosions and boxer ulcers

Treatment + follow up care:

- Antibiotics – indicated for all ulcers as disruption of the epithelium does predispose to the stroma to
infection.
● What we have – Chloramphenicol, Ofloxacin, Tobramycin
● We can prepare – fortified antibiotic solutions, stromal ulcers require these. (CEFAZOLIN 500mg
in 15ml artificial tears, 33mg/ml. Needs to be refrigerated. Shelf life 14 days)
- Mydriasis – very important to both relieve the pain of reflex uveitis and prevent adhesions. Atropine is
what we use. We have vials that can be opened and prepared for the client. Initially BID/TID and then
tapered as pupil dilates. (CARE with KCS + tear production)
 - Analgesics/Anti-inflammatory – oral NSAIDs (we have Rimadyl, Meloxicam and Previcox) are good
choices. Avoid both steroids + NSAID topically with ulceration as can delay wound healing.
- Serum (anti-collagenase) – should be used at least 4 times daily (hourly in severe cases) and kept in the
fridge.
- Lubricants – opsil tears need to be placed frequently
- Prevention of self trauma – very important for ocular conditions – buster collar at all times

NOTE: IF A SUPERFICIAL ULCER DOES NOT HEAL WITHIN 7 DAYS CHANGE THE DIAGNOSIS

- Surgery – often indicated in cases of stromal ulcers or descemetoceles. These ulcers need intensive
medical therapy as above AND surgical support to save the eye. Initiating cause should be found and
removed/controlled if possible. If the ulcer is deeper than half the corneal thickness then some form of
surgery is indicated. Conjunctival grafts are the mainstay of surgical procedures.
- Indolent ulcers – Very important to ensure that the inciting cause has been corrected (dry eye, ectopic
cilia etc).
● These occur due to the failed union between the epithelial basement membrane and the
anterior stroma.
● These ulcers are typically chronic, superficial, non-infected and minimally/moderately painful.
● Classically the ulcer bed will stain irregularly with a “halo” as the stain runs under the epithelium
● Diagnosed on signalment, chronicity, clinical appearance, staining pattern and ease with which
epithelium is debrided.
● Very frustrating to treat and owners MUST be informed of this from the outset
● Treatments include broad-spectrum eye drops, mydriatics (especially after any surgical
procedures) and grid keratectomy (+/- 3rd eyelid flap)
- Follow-up – depending on the severity of the ulcer, these patients will need regular follow ups to ensure
the treatment plan is working. Check-ups should always include restaining of the eye +/- STT. Remember
to always perform schirmer tear test BEFORE fluorescein staining.
Billing a corneal ulcer:

~5ml of blood should be drawn to ensure enough serum will be collected. O can wait while VA prepares (~10mins).
Serum should be drawn off and placed in red top blood tubes. O can be provided with plastic pipette to apply
drops. Remember to label the meds “KEEP IN FRIDGE!” and encourage the O to be as sterile as possible.