Good Hope, Heartlands, and Solihull Eye Clinics

Peripheral Ulcerative Keratitis / Marginal Corneal Ulcers

David Kinshuck

 

 

What is peripheral ulcerative keratitis?

A 'marginal ulcer' is a shallow 
            ulcer on the surface of the cornea.

the cornea 

A small ulcer forms on the front part of the eye, the cornea. The cornea is the clear 'window' of the eye'.

An 'ulcer' is a shallow crater, a bit like a crater on the surface of the moon. A doctor or nurse can see the ulcer by using a slit lamp, a type of microscope, used in the eye clinic.

 

a marginal ulcer: the eye is red just near the ulcer

'peripheral ulcerative keratitis' is a shallow ulcer on the surface of the cornea, on the edge of the cornea.
The eye is red just near the ulcer.
The ulcer appears green when the doctor or nurse places a fluorescent dye drop in the eye.

marginal ulcer, side view

a side view

 

 

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What is happening?

The ulcer forms as part of the body's reaction to a mild bacterial infection. Some bacteria are trapped in the eyelids, and some are naturally present on the surface of everyone's eyes. The bacteria may invade the surface of the cornea, and your body's immune system reacts to the bacteria to make the ulcer. When the body 'overreacts' an ulcer forms.

Peripheral ulcerative keratitis in a contact lens wearer can be acanthomeoba..no topical steroids.

 

How does it feel?

At first the eye starts to feel a little sore, as though something may be in it, and a little bit achy. About 1-2 days later it may start to water and be painful and red. Bright lights become painful, and your eye may become sticky and difficult to open in the morning.  'Pain, discomfort, photophobia.'

 

Classification

First, without systemic disease: these are discussed on this page

  • marginal
  • Rosacea
  • Phlyctenulosis

Systemic/more serious, not discussed on this page

  • Type 1 older no systemic problems
  • Type 2 younger
    • helminthic infection
    • hepatitis C, CBC
    • Much more aggressive ..larger deeper
    • anca other antibodies
    • Rheumatoid with PUK

Treat these (which may be termed Moorens ulcers) with systemic steroids, or other immunosuppressive. Conjunctival recession may help. Some eyes are inflamed, others look quiet

 

Treatment

There are two parts to the treatment:

Treatment for the ulcer itself

  1. Steroid eyedrops: these stop the eye's immune system overreacting and so allows the ulcer to heal. The steroid drops, such as prednisolone or dexamethasone, generally have no side effects for the short time they are needed (1-3 weeks). The ulcer usually gets a little better in a day, and completely better in a week. Steroid drops have to be used withae due to sie effects.
  2. Usually an antibiotic drop is needed such as chloramphenicol to stop a more serious infection of the cornea.
  3. A typical treatment plan

First episode

  • dexamethasone and chloraphenicol each 3 times a day for 5 days, twice a day for 5 days, once a day for days

Recurrent episodes, add lid bathing and cleaning

  • Bacteria in the glands of the eyelids help to cause these ulcers. Some people develop marginal ulcers quite frequently, perhaps every few months. Cleaning the eyelids regularly may be stop more ulcers developing, or at least make them less frequent .
  • The cleaning helps to reduce the number of bacteria in the glands of the lid. This is the same treatment as for blepharitis and reduce all sorts of lid problems.
  • Gently clean with a cotton bud, looking in mirror

    Gently clean with Blepharaclean wipes ( or a cotton bud if unavailable), looking in mirror, pull the lower eyelid down with the index finger of one hand, and gently but firmly wipe the wipe or bud along the edge of the lid to scrape the debris off. With your chin up try the same on the upper lid, but this is harder.

  • Cleaning: clean lids with Blepharaclean wipes (these can be bought or obtained from a doctor's prescription, or if unavailable a cotton bud). Clean the edge of the eyelids (the eyelash edge) with the wipe or wet cotton bud. Gently scrape off the debris moving the wipe/bud side to side. If using a bud, warm tap water is usually quite safe. The Blepharaclean wipes are probably more effective.
  • Bathing: warm compresses with an 'Eyebag' hot compress: these can be bought or obtained on prescription, and one lasts a long time (or similar compress, there are may brands). If you don't have a compress or a microwave, use clean face cloth soaked in warm water, as hot as your eyelids can stand. Bath the eye (closed) for 5-10 minutes. Re-warm the cloth if it gets cold. This makes the debris easier to remove, as below.

    Frequent episodes, add

    1. Antibiotic cream occasionally helps (eg chloramphencial or fucithalmic)
    2. Antibiotic tablets if attacks frequent: doxycycline (long term; avoid lot of sunlight as it sensitises the skin to sunlight. 'photosensitivity'). Doxycycline 50-100mg a day is often effective, for 3 months. Generally you should have seen an ophthalmologist at least a couple of times with ulcers before considering tablets.
    3. or azithromycin (3 days)
    4. a healthy diet as for Blepharitis see NHS Direct

     

    What to expect etc

    A typical attack will last a week without treatment, sometimes getting better without drops. With drops the drops above your eye will feel a lot better the next day, nearly recovered in 3-4 days, and nearly back to normal after a week.

    If there is no improvement in 2 days, you may have a different type of ulcer. You should certainly seek advice from an ophthalmologist if your eye gets worse not better.

    1. Marginal ulcer in contact lens wearer can be acanthomeoba..no topical steroids.
    2. Occasionally herpes simplex present and this can be identified with a PCR scrape.
    3. If there is a lot of melting and infiltrate, a combination of antibiotics and steroids may be needed.

     

    Infected marginal ulcers

    • Corneal ulcers commoner in rheumatoid
    • Staph aureus..50% none carriers, 20% persistence
    • Topical fucithalimic, vanco, teicoplanin
    • Treat infection no steroid for first week
    • Mupiricin and chlorhexidine baths daily for a week and mupiricin..up nose, prontoderm body spray (same protocol as MRSA)