Corneal ulcerMANAGEMENT

OPHTHALMOLOGIC PRESENTATIONS · 12 SECTIONS

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488 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Acute angle-closure glaucoma Central retinal artery occlusion Central Retinal Vein Occlusion Chemical eye injury Corneal abrasion Corneal ulcer Endophthalmitis Globe rupture Herpes zoster ophthalmicus Hyphema Iritis-Uveitis Ocular foreign body Optic Neuritis Orbital cellulitis Orbital Floor Fracture (Blowout)Posterior vitreous detachment Retinal detachment Retrobulbar hematoma and orbital compartment syndrome Vitreous Hemorrhage

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp46

Triage and time-critical risks

›Vision-threatening priorities

›Rapid ophthalmology involvement for suspected infectious keratitis

›If central ulcer

›If large infiltrate

›If hypopyon

›If marked vision reduction

›Immediate escalation for perforation risk

›If Seidel positive

›If stromal melt

›Immediate safety checks

›Contact lens removal

›Lens saved in sterile container for possible culture

›Topical anesthetic limited to exam only

›No outpatient topical anesthetic due to corneal toxicity risk

›Hemodynamic and systemic instability screen

›Sepsis concern

›If fever

›If immunocompromised with systemic symptoms

Key Concepts

›Core framing

›Corneal ulcer as stromal infiltrate with epithelial defect

›High risk of rapid scarring in visual axis

›Risk of corneal thinning and perforation

›Microbial keratitis as ophthalmic emergency

›Time-to-therapy linked to visual outcomes

›Working diagnosis labels for coding

›ICD-10 corneal ulcer

02History/hx54

Symptom pattern and timeline

›Presentation profile

›Eye pain

›Rapid onset over hours to days

›Foreign body sensation

›Photophobia

›Worse with consensual light

›Vision change

›Blurry vision

›Central haze

›Discharge

›Purulent

›Watery

›Progression and prior therapy

›Prior topical antibiotics

›Nonresponse after 24 to 48 hours

›Prior topical steroids

›Worsening after steroid exposure

Exposure and risk profile

›Contact lens risks

›Overnight wear

›Pseudomonas risk

›Water exposure with lenses

›Swimming

›Hot tub

›Showering

›Poor lens hygiene

›Old solution reuse

03Physical Exam/exam49

Vision and basic ocular exam

›Visual function baseline

›Visual acuity each eye

›Pinhole acuity when available

›Pupils

›Relative afferent pupillary defect

›External and motility

›Eyelids and lash line

›Blepharitis

›Trichiasis

›Extraocular movements

›Pain with movement

›Restriction pattern

›Intraocular pressure

›Avoid tonometry if open globe concern

›Defer to ophthalmology

Slit lamp and fluorescein findings

›Corneal findings

›Epithelial defect with fluorescein uptake

›Size in mm

›Location relative to visual axis

›Stromal infiltrate

›Border quality

›Depth

›Satellite lesions

›Corneal edema

›Haze level

›Anterior chamber

04Differential Diagnosis/ddx37

Infectious causes

›Bacterial keratitis

›Contact lens associated

›Pseudomonas aeruginosa

›Post-trauma

›Staphylococcus species

›Streptococcus species

›Herpes simplex keratitis

›Dendritic epithelial keratitis

›Reduced corneal sensation

›Varicella zoster keratitis

›Dermatomal rash history

›Pseudodendrites

›Fungal keratitis

›Vegetative matter trauma

›Filamentous fungi

›Chronic indolent course

›Feathery borders

›Acanthamoeba keratitis

›Water exposure with contact lenses

›Pain out of proportion

›Ring infiltrate

Noninfectious mimics

›Sterile contact lens infiltrate

›Minimal pain

›Peripheral infiltrate

›Corneal abrasion without ulcer

›Fluorescein uptake without stromal infiltrate

05Laboratory Tests/lt31

Ocular microbiology

›Corneal sampling indications

›Smear and culture when high risk features present

›Central location

›Large size

›Deep stromal involvement

›Stromal melting

›Atypical appearance

›Poor response to empiric therapy

›Bacterial studies

›Gram stain

›Rapid organism class guidance

›Aerobic culture and sensitivities

›Targeted therapy adjustment

›Fungal studies

›KOH wet mount

›Filament detection

›Fungal culture

›Prolonged incubation needs

›Acanthamoeba studies

›Culture on non-nutrient agar with E coli overlay

›Specialty lab coordination

›Confocal microscopy access pathways

›Ophthalmology-directed

Systemic tests when indicated

›Immunocompromise evaluation

›Glucose for diabetes concern

›Poor healing risk context

06Diagnostic Tests/dt46

Scoring Systems

›Severity stratification for escalation

›Location risk tiering

›Central or paracentral as high risk

›Peripheral as lower risk

›Size tiering

›Greater than 2 mm as high risk

›2 mm or less as lower risk

›Depth tiering

›Deep stromal involvement as high risk

›Superficial as lower risk

›Anterior chamber reaction tiering

›Hypopyon as high risk

›None as lower risk

MRI

›Indications

›Suspected cavernous sinus complication

›Cranial neuropathies

›Severe headache with ocular findings

›Orbital apex syndrome concern

›Vision loss with ophthalmoplegia

›Limitations

›Low yield for isolated corneal ulcer

›Not first-line for keratitis

›Indications

›Orbital cellulitis concern

›Proptosis

07Disposition/dispo32

Ophthalmology coordination

›Same-day ophthalmology evaluation triggers

›Central ulcer

›Visual axis involvement

›Infiltrate size greater than 2 mm

›Culture consideration

›Hypopyon

›Severe infection marker

›Stromal thinning or melt

›Perforation risk

›Contact lens related ulcer

›Pseudomonas coverage priority

›Transfer criteria

›No local ophthalmology availability

›Vision-threatening features present

›Need for fortified antibiotics compounding access

›Severe ulcer pathway

Admission versus outpatient

›Admission criteria

›Impending perforation

›Seidel positive

›Rapid stromal melt

›Severe pain with inability to self-administer drops

›Hourly therapy requirement

›Immunocompromised with severe ulcer

›High complication risk

›Concern for endophthalmitis

›Emergent intravitreal therapy pathway

08Treatment/t86

Empiric antibacterial therapy

›Initial regimen selection by severity

›Mild to moderate suspected bacterial keratitis

›Fourth-generation fluoroquinolone monotherapy

›Moxifloxacin 0.5% ophthalmic

›Initiate 1 drop every 1 hour while awake

›If severe pain or high-risk features, initiate every 1 hour around the clock

›Gatifloxacin 0.5% ophthalmic

›Initiate 1 drop every 1 hour while awake

›If high risk, initiate every 1 hour around the clock

›Severe ulcer or sight-threatening features

›Fortified dual therapy

›Fortified tobramycin ophthalmic 14 mg/mL

›Initiate 1 drop every 1 hour alternating with second agent

›If fulminant, loading dose every 5 to 15 minutes for 1 hour then hourly

›Fortified cefazolin ophthalmic 50 mg/mL

›Initiate 1 drop every 1 hour alternating with aminoglycoside

›If gram negative concern, consider ceftazidime substitute per ophthalmology

›MRSA risk or poor response

›Fortified vancomycin ophthalmic per ophthalmology

›Dosing typically hourly initially

›Sensitivity-guided continuation

›Evidence notes for antibiotic choices

›Fluoroquinolone monotherapy and fortified combinations as common effective options

›Comparative effectiveness differences small across many regimens

›Time to healing varies by regimen in evidence synthesis

›AAO Preferred Practice Pattern support for culture in high-risk ulcers

Targeted pathogen pathways

›Herpes simplex keratitis suspicion

›Antiviral therapy

›Ganciclovir 0.15% gel

›Initiate 1 drop 5 times daily

›Taper per ophthalmology after epithelial healing

›Acyclovir PO 400 mg

›Initiate 5 times daily

›Duration per ophthalmology

›Steroid avoidance in epithelial HSV

›Ophthalmology-directed only

›Fungal keratitis suspicion

›Natamycin 5% ophthalmic

›Initiate 1 drop every 1 hour while awake

›Prolonged course expectation

›Voriconazole ophthalmic or PO per ophthalmology

›Escalation when natamycin nonresponse

›Acanthamoeba keratitis suspicion

›Biguanide therapy per ophthalmology

›PHMB 0.02%

›Initiate hourly initially

›Prolonged taper over months typical

›Chlorhexidine 0.02%

›Initiate hourly initially

›Combination strategy common

Adjunctive therapy and comfort

›Cycloplegia for pain and photophobia

›Cyclopentolate 1% ophthalmic

›Initiate 1 drop 2 to 3 times daily

›Atropine 1% ophthalmic

›Initiate 1 drop once to twice daily for severe spasm per ophthalmology

›Systemic analgesia

›Acetaminophen

›Dosing per age and weight

›NSAID oral if no contraindications

›Avoid topical NSAID when epithelial defect large

›Corneal melt mitigation adjuncts

›Doxycycline PO 100 mg

›Initiate twice daily when significant thinning or melt risk per ophthalmology

›Vitamin C supplementation per ophthalmology

›Collagen support rationale

Steroids and contraindications

›Topical corticosteroids

›Avoid initiation in ED without ophthalmology

›Risk of worsening undiagnosed fungal or HSV disease

›Adjunctive steroid evidence mixed

›Requires specialist selection and timing

›Contact lens precautions

›No contact lens wear until ophthalmology clearance

›Discard current lenses and case

Evidence levels and guideline framing

›Guideline alignment

›AAO Preferred Practice Pattern for bacterial keratitis as primary reference

›ACEP Level C style consensus mapping for ED actions

›Immediate topical antibiotic therapy for suspected microbial keratitis

›Urgent ophthalmology for high-risk features

›Class recommendation mapping

›Class I

›Immediate topical antimicrobial therapy when microbial keratitis suspected

›Same-day ophthalmology for central or severe ulcers

›Class IIa

›Corneal cultures for high-risk ulcers before antibiotics when feasible without delay

›Class IIb

›Adjunctive systemic agents for melt risk per specialist

09Special Populations/sp38

Pregnancy

›Maternal and fetal considerations

›Vision preservation priority

›Same urgency for therapy and ophthalmology evaluation

›Medication considerations

›Prefer topical therapy due to low systemic absorption

›Nasolacrimal occlusion technique to reduce systemic absorption

›Antimicrobial selection notes

›Fluoroquinolone ophthalmic typically acceptable when benefits outweigh risks

›Tetracycline avoidance in pregnancy

›Follow-up and monitoring

›Same-day ophthalmology when high-risk features

›Central ulcer

›Hypopyon

Geriatric

›Higher risk features

›Ocular surface disease prevalence

›Dry eye

›Blepharitis

›Immunosenescence

›More severe infection risk

›Medication safety

›Systemic NSAID caution

›Renal risk

›GI bleeding risk

›Polypharmacy review

›Anticoagulant considerations for trauma history

10Background/b33

Epidemiology

›Disease burden

›Infectious keratitis as leading cause of unilateral corneal blindness worldwide

›Regional variation by contact lens use and agricultural trauma

›Contact lens wear as major risk factor in high-income settings

›Pseudomonas prominence in lens-associated cases

Pathophysiology

›Mechanism

›Epithelial barrier disruption

›Microbial adherence and invasion

›Stromal inflammation

›Collagenolysis

›Thinning and perforation risk

›Organism-specific patterns

›Bacterial

›Rapid necrosis and suppuration

›Fungal

›Hyphal penetration

›Feathery infiltrate edges

›Acanthamoeba

›Perineural inflammation

›Pain out of proportion

Therapeutic Considerations

›Treatment principles

›Empiric broad coverage early

›High local drug concentrations with topical dosing

›Culture-directed narrowing when available

›Resistance and atypical pathogen detection

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Discharge instructions

›Diagnosis

›Corneal ulcer or suspected infectious keratitis

›Medications

›Use drops exactly as prescribed

›Do not stop early even if better

›Contact lenses

›No contact lens wear until cleared

›Discard current lenses and case

›Eye care

›No eye patch

›No rubbing

›Sunglasses for light sensitivity

›Follow-up

›Ophthalmology within 24 hours or same day as directed

›Return sooner if unable to obtain drops or worsening symptoms

›Return to ED now for

›Worse vision

›Increasing pain

›Increasing redness or swelling

›New headache with nausea or vomiting

›New fever

›Fluid leaking from the eye

›New severe light sensitivity

12References/r12

Clinical guidelines and high-quality sources

›Guideline sources

›American Academy of Ophthalmology Preferred Practice Pattern

›Bacterial Keratitis Preferred Practice Pattern 2024

›AAO education summary page for bacterial keratitis PPP 2023

›Evidence reviews

›Cochrane review on topical antibiotics for bacterial keratitis 2025

›Cochrane review on adjunctive topical corticosteroids for bacterial keratitis

›Systematic reviews comparing fluoroquinolones and fortified antibiotics

›Point-of-care references

›StatPearls Bacterial Keratitis chapter updates on hourly dosing and escalation

›EyeWiki Bacterial Keratitis overview and practice patterns

›Internal system formatting and structure rules

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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