Sterile Marginal Corneal Infiltrates (Corneal Ulcer)

Question 1

Sterile Marginal Corneal Infiltrates (Corneal Ulcer)

Answer 1

lid therapy
topical steroids 
corneal prophylaxis 
corneal ulcer 
indolent ulcer

Question 2

symptoms

Answer 2

burn, itch, red watery, tearing
scratchy, FB sens unilateral, bilateral
vision not reduced sometimes asymptomatic

Question 3

signs

Answer 3

lid erythema
collarettes (fibrin crust encircling an eyelash)
madarosis (missing lashes), trichiasis (an inturned lash) plugged meibomian glands
interpalpebral conjunctival injection
inspissated oil glands?
swollen eyelids?
mild mucus discharge
acne and/or ocular rosacea may be present midperipheral island(s) of infiltrate
clear zone between infiltrate and limbus
may have an overlying epithelial defect staining with NaFl often along 4:00 to 8:00 arc where lids cross limbus
an associated leash of conjunctival vessels
can present as a sterile marginal ulcer

Question 4

pathophysiology

Answer 4

• corneal hypersensitivity to sterile lid exotoxins (Staph)

Question 5

1. Must establish corneal health overlying the infiltrate

Answer 5

a. Cornea intact over infiltrate (no staining) and generally healthy
b. Cornea intact over infiltrate (no staining) with diffuse SPK
c. Cornea compromised over infiltrate (with staining) with diffuse SPK

Question 6

2. Cornea intact over infiltrate (no staining) and generally healthy

Answer 6

a. vigorous treatment of lid disease
i. hygiene as per previous recommendations (see Lids, Conjunctiva)
ii. antibiotics as per previous recommendations, eg AzaSite
b. low concentration steroid drops to quiet inflammatory reaction
i. prednisolone is 0.12% in Pred Mild (acetate), 0.125% in Inflamase Mild (phosphate), 0.20% in Blephamide (acetate)
ii. fluoromethalone is 0.1% in FML (alcohol)
iii. loteprednol (0.2% Alrex sol, 0.5% Lotemax sol/gel) iv. regimen TID to QID for 5-7 days

Question 7

3. Cornea intact over infiltrate (no staining) with diffuse SPK

Answer 7

a. risk exists for future corneal breakdown
b. a very conservative pro-active approach would begin considering the possibility of
bacterial infection and advise antibiotic drops for 7-10 days to protect cornea (corneal prophylaxis)
i. fluoroquinolone gtt or aminoglycoside gtt with Polysporin ung qhs 7-10d
ii. AzaSite 5 days (BID x 2d, qD x 3d)
c. vigorous lid hygiene approaches (see Lids, Conjunctiva)
d. low concentration steroid drop to quiet inflammation TID to QID
e. possible culture and sensitivity of lid pathogens if condition does not improve or
worsens within the first 2-3 days
f. modify antibiotic treatment as needed per sensitivity (if culture done)
g. artificial tears as much as possible to decrease risk of corneal breakdown
due to poor tear film; emphasize a full blink q 5-10 seconds, all day, all activities!

Question 8

4. Cornea compromised over infiltrate (with staining) with diffuse SPK

Answer 8

a. condition is of considerable urgency, much more so in a contact lens wearer than
in a non-wearer
b. a very conservative approach would advise antibiotic gtt/ung to protect cornea;
culture and sensitivity may be very important in CL wearer because it may yield a
definitive choice for antibiotic treatment
c. lid therapy for blepharitis and artificial tears for the cornea!
d. low concentration steroid drops to quiet inflammation QID

Question 9

Are scrapings and cultures of the infiltrates typically positive or negative?

Answer 9

negative!

Question 10

Where are sterile marginal corneal ulcers seen?

Answer 10

inferior limbus (4:00-8:00) with a clear zone b/w the peripheral corneal infiltration/ulceration and the limbus

Question 11

5. Infiltrated probably sterile (in your opinion) corneal ulcer

Answer 11

a. lid therapy for blepharitis and artificial tears for the cornea!
b. Combination steroid-antibiotic drop QID with F/up ≤1 day
i. Maxitrol susp (0.1% dexamethasone-neomycin/polymixin B), TobraDex susp (0.1% dexamethasone-tobramycin) TobraDex ST (0.05% dexamethasone-tobramycin), Pred-G susp (1% pred acetate-gentamicin)
ii. some other combination of a separate steroid and a separate antibiotic (two different Rx’s used together in combination); may consider either FML (0.1% fluorometholone), FML Forte (0.25% fluorometholone), or Lotemax (0.5% loteprednol) with a fluoroquinolone or aminoglycoside antibiotic; remember to not use the steroid more frequently than the antibiotic!
iii. notice that a sterile ulcer represents greater inflammatory damage to the cornea (in the absence of infectious keratitis) and requires a stronger steroid

Question 12

indolent ulcer

Answer 12

ulcer that wont go away

a. a shallow superficial ulcer unaccompanied by vascularization and infiltration, causing little reaction, few symptoms, showing little tendency to spread or heal
b. possible referral to corneal specialist (they love this stuff!)

Question 13

what is it an inflammation of?

Answer 13

the cornea secondary to lid disease that also affects conjunctival vessels

Question 14

is it an infection of the cornea?

Answer 14

not yet