CASE REPORT: Corneal Ulcer
BARRY SCHECHTER, M.D.

A 51-year-old woman came into my office complaining of significant ocular burning, foreign body sensation and blurred vision in her left eye which had started 2 days prior. After questioning, she reported accidentally sleeping with her soft contact lenses in.

History

She claimed to be in excellent health and took no systemic medications. She had both puncta occluded previously to help wear her contact lenses more comfortably. She had not experienced a flare-up of Thygesons superficial punctate keratopathy in her fellow eye since the year before.

Examination

Visual acuity measured 20/20 with correction in the right eye and counting fingers in her left. Slit lamp examination of the right eye was unremarkable except for the presence of dilated limbal vessels. The left eye displayed 2+ eyelid edema, 1+ conjunctival chemosis and a central epithelial defect of 3.2 mm x 2.9 mm below and temporal to the center of the cornea. At the base of the defect, a dense, white stromal abscess obstructed the majority of the visual axis. There was no hypopyon, but an infiltration of white blood cells was seen in the anterior corneal stroma surrounding the abscess with a semi-lunar shaped retrocorneal plaque. A minimal anterior chamber reaction of cells and flare was noted.

Treatment

Cultures of the corneal infiltrate, the conjunctival cul-de-sac and the eyelid margins were taken. Due to the rapid intensity of the inflammation, the poor vision and the location of the lesion, a subtenons injection of vancomycin and gentamicin was administered. Fortified topical vancomycin 5% was formulated and would be utilized with topical gatifloxacin (Zymar, Allergan) every hour for the first 24 hours.

The patient was complaining of the inability to keep her left eye open, and a headache due to "straining" from her right eye. She was reluctant to take oral opiates since she had experienced significant gastro-intestinal side effects from these in the past. To control the ocular pain, topical ketorolac (Acular LS, Allergan) was started q.i.d. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac, primarily act as cyclooxygenase inhibitors and thus reduce the formation of endogenous prostaglandins.

Over the next several days, the ulcer only gradually responded, but the patient felt much more comfortable, and was able to return to work, avoiding systemic opiates.

Culture results disclosed a methicillin-resistant Staphylococcus aureus. Zymar was discontinued because the infection was also fluoroquinolone resistant. Bacitracin sensitivity was determined and the ointment was applied to the conjunctival cul-de-sac at bedtime.

No corneal thinning was ever noted and the epithelium continued to show progressive and steady healing. As the size of the epithelial defect decreased, the Acular LS was tapered. The patient remained comfortable throughout the treatment period.

Follow-up

The epithelium healed over the next 7 weeks with complete involution of the infiltrate. A paracentral corneal scar remains, but since the superior portion of the infiltrate had involuted first, the resultant uncorrected visual acuity measures 20/40+.

Discussion

It is well known that prepared fortified topical ophthalmic antibiotics might have an effect on epithelial wound healing, but 5% vancomycin was not shown to be particularly harmful.¹ Topical gentamicin is known to be epitheliotoxic and was avoided by using Zymar, which has excellent gram-negative coverage. Bacitracin ophthalmic ointment was utilized without side effect.²

One of the more controversial subjects related to corneal ulcers is limiting the inflammatory reaction so that tissue will be preserved while maintaining the ability of the immune system to fight the infection. A debate continues as to whether topical steroids should be added in these cases. In the presence of resistant organisms before cultures have returned, or in polymicrobial infections where a fungus is present, the infection may rapidly worsen in the presence of steroids.

Topical ophthalmic NSAIDs have had a reputation of causing corneal thinning and perforation after a rash of these occurred, associated with generic diclofenac, which was subsequently pulled off the market.³ However, these drugs reduce inflammation without suppressing the immune response. Their pain-suppressing qualities have been recognized, and as a result, topical NSAIDs have been widely used in refractive surgery or other cases of corneal trauma such as abrasions. Corneal wound healing has not been compromised when NSAIDs are used.⁴

A patient's ability to return to their normal function is paramount. Topical NSAIDs allow patients to return to work or school while their corneas are healing. It also reduces patient phone calls for prescription pain medications. NSAIDs primarily act as cyclooxygenase inhibitors and thus reduce the formation of endogenous prostaglandins.

I have personally treated over 100 corneal infiltrates with topical antibiotics (fortified and/or commercially available) and concurrent topical NSAIDs. In none of these cases did corneal melting or any other serious corneal side effect occur. Anecdotally, topical ketorolac (Acular LS) has caused less stinging, and less wound healing delay than topical diclofenac.

This case report typifies the clinical course of many of my patients that have been treated in the above mentioned manner. If any evidence of keratitis sicca, limbal stem cell depletion or autoimmune disease is present by either history or clinical examination, the NSAIDs are either discontinued or not utilized. Topical ketorolac has been used in conjunction with topical cyclosporine during the induction phase in treating patients with dry eye.⁵ The two drops worked synergistically in controlling discomfort and ensuring compliance without adverse corneal effects.

In summary, topical NSAIDs may be used with caution in cases of infectious corneal ulcers, in the absence of local and/or systemic autoimmune disease, which might predispose to cases of corneal thinning. Patients are more comfortable and anecdotally, wound healing has not been delayed.

References

1. Lin CP, Boehnke M. Effect of fortified antibiotic solutions on corneal epithelial wound healing. Cornea. 2000;19(2):204-206.

2. Baum JL. Initial therapy of suspected microbial corneal ulcers. Surv Ophthalmol. 1979; 24(2):97-105.

3. Hargrave SL, Jung JC, Fini ME, et al. Possible role of the vitamin E solubilizer in topical diclofenac on matrix metalloproteinase expression in corneal melting: an analysis of postoperative keratolysis. Ophthalmology. 2002;109(2):343-350.

4. Barba KR, Samy A, Lai C, Perlman JI, Bouchard CS. Effect of topical anti-inflammatory drugs on corneal and limbal wound healing. J Cataract Refract Surg. 2000;26(6):893-897.

5. Schechter BA, Wittpenn JR. Evaluation of Ketorolac (Acular LS®) During the Induction Phase of Cyclosporine A (Restasis®) Therapy to Improve Patient Comfort. Presented at ARVO; May 1-5, 2005; Fort Lauderdale, Fla.