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Severity of corneal ulcer may drive treatment decision making
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KIAWAH ISLAND, S.C. — Treatment decisions for corneal ulcers may be best driven by the severity of the infiltrate.
 Raj K. Rajpal |
The virulence of an insulting pathogen will determine how aggressive the ulceration progresses as well as the degree of scarring. In turn, the severity of infection should signal how aggressively a pathogen should be managed, Raj K. Rajpal, MD, said at Kiawah Eye 2010.
"The more significant the infiltrate, the more significant its size, the more central its appearance, the more inflammation, the easier it is to justify culturing that infiltrate," Dr. Rajpal said.
Gram-positive organisms appear more frequently in peripheral ulcers, whereas gram-negative organisms are more commonly associated with contact lens wear or contact lens solution. Fungal infection leading to ulceration is more typically secondary to organic or vegetative matter coming in contact with the ocular surface, Dr. Rajpal said.
For smaller, less aggressive ulceration, "fluoroquinolones, generally, are the accepted mechanism of treatment initially because we don't know necessarily what type of pathogen we are dealing with," Dr. Rajpal said.
However, patients not doing well on initial therapy may require biopsy, especially if there is a high index of suspicion for an atypical organism; identification of the given insulting pathogen can lead to more directed therapy, Dr. Rajpal said.
Corneal biopsies are necessary when diagnosis of a corneal infection by traditional means does not yield positive results and the treatment is failing to acceptably improve the patients’ condition. For example, biopsy is an effective way to diagnose Acanthamoebia keratitis, which can be difficult to culture and can lead to prolonged keratitis that does not respond to anti-bacterial or anti-fungal agents.
– John A. Hovanesian, MD, FACS
OSN
Cornea/External Disease Board Member
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