Good Hope, Heartlands, and Solihull Eye Clinics


Corneal ulcers: microbial keratitis

David Kinshuck


Clinical history (after Prof Dua)

  • trauma..consider fungal
  • contact lens: pseudomonas or acanthomeoba
  • look for blocked tear duct, may syringe
  • ? cold sores, ? lasik or dsek, loose suture, take out
  • there is a cause for most ulcers..a healthy cornea in a healthy patients does not usually get infected
  • trauma, recent chest illness, connective tissue disease, radiotherapy,
  • handling lens issue, swim in lens, soil..microsporidia, steroid drops?
  • what is timeline of events, when the eye was last fine, 24h ...bacterial, pseudomonas
  • previous ocular surgery, previous bacterial infection, alcohol, lid malposition, trichiasis, misaligned punctum, nld blocked..?epiphora, dry eyes, incomplete lid closure
  • pain important....very painful: Pseudomonas... 11'12 pain score
  • people reuse lenses or share them, use out of date drops eg glaucoma
  • Marginal ulcer, gelatinous, ac activity ?pseudomonas
  • mixed organisms: Case..infiltrate, very red eye, clostridium & staph aureus, patient bowel problem, and thyroid eye disease, dry eye
  • 150 cases/year/1m people
  • Hsvk 33% recur
  • fungi in India are the most common BJO 16
  • Contact lenses and previous surface damage in Canada BJO 16
  • ulcers are much commoner in renal failure BJO18

blocked meibomian glands posterior blepharitis thickened in chronic blepharitis


Start anatomically, after Prof Dua

  • lids lashes, look for lashes  See
  • nasolacrimal obstruction....syringe
  • conjunctiva
  • follicles: viral, sore sticky, watery...viral, are lymphocytes
  • papillae: scarred in between fibrovascular
    tissue ?allergy, itch
  • follicles and papillae indicate chronic inflammation
  • ?posterior blepharitis
  • ?matted eye lashes clean:
    • ulcerative blepharitis may be under discharge,
    • if skin clear underneath, treat differently
  • discharge: sticky bacterial
  • Cornea limbus..........
    rolled up limbus..limbitis....usually hsv and A, not bacterial
  • Cornea go through layers
  • Hypopyon sterile, don't culture, just a response to toxins, dilated iris vessels...not rubeosis, just a response to infection
  • scleritis severe pain, intense redness
  • epithelial defect
  • Christmas tree infectious crystaline..bacterial infection with no host response..patients has had lots of steroids, or immunosuppressed, or no sensation, range of bacteria...just bacteria moving on their own
  • pressure: ICare best
  • Confocal signet ring, double wall cyst, white blob = acanthomoeba
  • corneal OCT...depth of infiltrate, is it regular oct?
  • acanthomeoba cysts / double wall cyst pathognomic acanthomeoba 
  • Hyphae are fungus filaments 80% specificity for fungus,
  • Rapd......should be normal, otherwise something else, if apd...bscan
  • Examine both eyes for clues, corneal sensation
  • tear film
  • Ac activity
  • Dilate fundal check
  • use slit beam and draw it to see how thin  cornea is, if then, very serious
  • acanthomoeba: epitheliopathy, punctate, branching lesions, subepithelial, raised, painful, profound limbitis, perineuritis, ring infiltrate. Confocal microscopy helpful, available at Moorfields.
  • Pseudomonas keratitis... Bactribam..mupiricin...useful antibiotic
  • Staph aureus infection ?up nose
  • staph resistance to quinolone BJO 17
  • Contact lens infection report to mhra
  • Corneal impression membrane, pcr,
  • fungus..naatamycin BJO 18

Examination in a child



  • speculum
  • proxymethocaine
  • sucrose to suck

For retina for baby

  • >6m age cyclopentolate 1% and 2.5% phenylephrine
  • <6m age cyclopentolate 0.5% and 2.5% phenylephrine
  • 28d lens to examine retina


Draw the ulcer accurately   (after Prof Kaye)

Drawing the ulcer helps you look for other problems, such as a hypopyon, as well. Photos are even better!

draw the conral ulcer accurately


Source of the infection

organism in relatin to site

organism in relation to site of ulcer

Contact lenses

Scraping and culturing the ulcer  





a typical treatment plan, a 0.5 mm contact lens ulcer

  1. a small contact lens ulcer left eye
  2. Exocin
    • hourly 36 hours
    • Then 4 times a day for 5 days, then stop
  3. Cyclopentolate
    1. 1% twice daily whilst painful (3 days)
    2. halves the pain but blurs sight and near vision: no driving with daytime use
    3. then reduce to night time only (3 days), then stop
  4. Occ ciprofloxacin (ointment) night to start day 2, use for 5 days.
  5. Bring drops each visit. Keep a diary as to the treatment given and what works and what does not help..keep at home in your medical records.
  6. See 2 days if worse.
  7. As the eye gets better lubricant drops are usually needed, e.g. Hyloforte, 
  8. and at night e.g. VitApos (best), (but no need whilst using antibiotic cream).
  9. See optometrist before restarting contact lens wear: daily disposable lens preferred.
  10. The causes of contact lens ulcers include:
    1. bad luck (unusual)
    2. not following the instructions carefully...for instance, over wearing the lens, reinserting the lens the next day, no optometrist supervision.
    3. dry eyes
    4. overnight wear (not recommended)
    5. monthly lenses are definitely not recommended
  11. If there is no response in 3 days, it is likely the infection is resistant to the antibiotics being used, so they will need to b changed
  12. Alternative treatment for a 'neuropathic ulcer' , or partly neuropathic, in the elderly, to avoid admission: ciprofloxacin ointment 4 time day and acyclovir cream 5 times day and see regularly (not for an aggressive infection like pseudomonas).




Prof Dua

Some old notes





Corneal signs of acanthomoeba

Epitheliopathy, punctate, branching lesions, subepithelial, raised, painful, profound limbitis, perineuritis, ring infiltrate, uveitis, cataract.


City Hosptial page


Fungal infection


Neurotrophic / persistent corneal ulcers

Sometimes there is an ulcer without pain: there is nerve supply to the eye is damaged. This happens in conditions such as bullous keratopathy as part of rubeotic glaucoma, or after damage to the 7th nerve such as an acoustic neuroma/surgery. see   see

Neurotrophins maintain the ocular surface. Treatment may include

Stem cell deficiency




Aetiology: "herpes simplex keratitis secondary to immune recovery disease post bone marrow transplantation, acanthamoeba keratitis, recessive dystrophic epidermolysis bullosa, and blepharokeratoconjunctivitis with acne rosacea."   Eye16