Definition

A corneal ulcer is open sores on the cornea, often visible as a white spot or area on the eye. This condition can impair vision and potentially lead to blindness if left untreated, as the cornea is essential for light transmission to the retina. This process is important in seeing. Damage to the cornea, therefore, significantly affects vision.

In Indonesia, the precise incidence of corneal ulcers is not well-documented, but it is known to be more prevalent in developing countries and densely populated areas. For instance, the incidence in India is approximately 113 per 100,000 people per year, which is about ten times higher than in the United States.

Causes

Corneal ulcers are generally caused by infections from bacteria, viruses, fungi, or parasites, leading to corneal inflammation (keratitis). Subsequently, inflammatory cells will accumulate and damage the corneal surface, resulting in an ulcer.

Here are explanations of some causes of corneal ulcers:

Bacterial Infection

Extended use of contact lenses or using dirty lenses increases the risk of bacterial infections. Bacteria can accumulate on dirty lenses, and lenses that are only replaced sparingly can rub against the corneal surface and damage it, leading to ulcers.

Virus Infection

Viral infections can also cause corneal ulcers, often triggered by stress, weakened immunity, and sunlight exposure. Common viruses that can cause this condition include varicella-zoster (chickenpox) and herpes zoster (shingles).

Fungal Infection

Though rare, fungal infections causing corneal ulcers can be more severe. These infections often result from eye injuries caused by plants, such as paddy or tree branches. Unhygienic contact lenses or steroid eye drops can also lead to fungal infections.

Parasitic Infection

Parasites, such as amoebas, can cause corneal ulcers, typically due to use of unhygienic contact lenses. These parasites are commonly found in contaminated soil and water.

Eye Injury

Eye injuries increase the risk of corneal ulcers, particularly among workers in high-risk occupations like welding or construction who do not use eye protection. Chemical exposure from substances like glass cleaners, detergents, or food vinegar can also injure the cornea.

Non-infectious causes of corneal ulcers include allergies, Peripheral Ulcerative Keratitis (PUK), autoimmune diseases (such as Mooren's ulcer), complications from dry eyes, vitamin A deficiency, and Bell's palsy.

Risk Factor

Some factors that increase the risk of developing corneal ulcers include:

1. Poor hygiene with contact lens use.
2. Eyelid diseases, such as eyelid infections.
3. History of corneal surgery.
4. Underlying conditions such as diabetes or HIV/AIDS.
5. Long-term use of steroid eye drops.
6. Use of contaminated eye drops.
7. History of skin diseases like herpes or chickenpox.

Symptoms

Corneal ulcers typically present as white spots on the cornea. These white spots are visible and indicate an open wound on the cornea. Other additional symptoms include:

• Eye redness 
• Eye pain
• Sensation of a foreign body in the eye
• Increased sensitivity to light
• Watery eyes
• Sharp decline in vision
• Swollen eyelids, potentially accompanied by discharge or dirt

Diagnosis

Diagnosing corneal ulcers involves a comprehensive review of symptoms, a physical examination of the eye, and further diagnostic tests if needed. During the interview process, the doctor may inquire about:

• Contact lens usage (type of contact lens used, storage habits, hygiene, prolonged use, and history of contact lens use while swimming or bathing)
• Prior history of eye surgeries
• History of eye injuries
• History of herpes infections
• Occupational risks for eye injury (injury caused by small objects penetrating the eyes in workplace)
• History of immunosuppressive medications use

The physical examination will assess the cornea's structure, the anterior chamber of the eye, and intraocular pressure. Diagnostic tests such as fluorescein eye-stain, where an orange dye on a thin paper strip is applied to the eye, may be conducted. Eye examination with a slit lamp, which uses purplish light to detect corneal damage (the cornea appearing greenish under the light), is also common.

If needed, the doctor might perform corneal scrapings to identify the cause of the ulcer. Additionally, tests for autoimmune conditions, such as rheumatoid factor, dsDNA, and hepatitis C, may be conducted based on the doctor's assessment.

Management

Management of corneal ulcers involves professional medical treatment. Upon experiencing symptoms related to the eyes, it is crucial to consult a doctor. Treatments typically involve prescribed antiviral, antibiotic, or antifungal medications based on the underlying cause of ulcers. Patients should adhere strictly to the prescribed medication regimen. In bacterial infections, keeping the eyes uncovered is recommended to avoid excessive moisture that could foster bacterial growth.

During treatment, patients should avoid using contact lenses, eye makeup, and touching or rubbing their eyes with dirty hands. Pain relievers such as paracetamol or acetaminophen may be taken if there are no allergies. Protective glasses are advised, and maintaining hand hygiene is crucial to prevent the spread of infection.

If medications are ineffective, surgical interventions like keratoplasty or corneal transplantation may be recommended. Post-surgical follow-up care is essential until the patient is fully recovered.

Complications

Prompt treatment of corneal ulcers is vital to prevent complications. Untreated infections can penetrate deeper ocular structures, leading to conditions such as scleritis, uveitis, endophthalmitis, and panophthalmitis. Larger corneal tears may result in severe vision loss and potential blindness.

Prevention

Corneal ulcers, primarily caused by infections, can largely be prevented through personal hygiene practices. Individuals at risk of eye injuries, such as those working with small objects, should consistently wear eye protection while on the job. For contact lens users, following these steps can help prevent infections leading to corneal ulcers:

• Always wash hands thoroughly before handling contact lenses.
• Clean contact lenses before and after each use using recommended cleaning solutions. Avoid using other liquids, including tap water, which may appear clean but not.
• Remove contact lenses before sleeping.
• Refrain from using contact lenses if experiencing eye irritation until symptoms resolve completely.

When to See a Doctor?

Corneal ulcers require prompt medical attention from an ophthalmologist. If symptoms suggestive of a corneal ulcer arise, it is essential to seek medical consultation immediately. Untreated corneal ulcers can progress to severe complications, potentially resulting in blindness.

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