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Corneal ulcer
Last reviewed: 20.11.2021
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Corneal ulcer occurs when a pathogenic microflora (diplococcus, staphylococcus, streptococcus) gets on the erosion of the cornea or an infected infiltrate after any superficial keratitis. In this case, the irritation of the eye sharply increases, the eyelids become swollen. The bottom and edges of erosion take a gray-yellow color, the cornea around the ulcer greatly swells and becomes cloudy. Purulent Taurus joins the usual round cell infiltrate of the cornea. Very quickly, the iris is involved in the inflammatory process. The moisture of the anterior chamber becomes turbid, and almost always pus appears in it, which, due to gravity, accumulates in the lower part of the anterior chamber, confining itself from above with a horizontal line and assuming the shape of a crescent moon. The accumulation of pus in the anterior chamber is called the ginopion. It consists of leukocytes, enclosed in a fibrin mesh. Ginopion at the integrity of the cornea is sterile.
[Symptoms of a corneal ulcer
The course of purulent ulcers is more severe than simple. They have a tendency to spread both over the surface and into the depths of the cornea, causing it to perforate. The length of prevention of purulent ulceration is necessary for burial of the cornea to instill solutions of antibiotics into the conjunctival cavity.
A special place in the keratitis clinic with defects in the surface of the cornea is taken by the creeping ulcer of the cornea.
Creeping corneal ulcer begins with the appearance in the cornea, almost always in its centrally located area opposite the pupil, of an infiltrate with a yellowish tinge, which consists of purulent bodies. In the decay of purulent bodies, a histological enzyme is released, which melts the tissues; the infiltrate is disintegrated, and an ulcer is formed in its place, one edge of which is slightly elevated, undercut and surrounded by a strip of purulent infiltrate. This edge of the ulcer is called progressive. Pneumococci are not only in the tissue of the infiltrated margin, but also in the surrounding healthy corneal tissue.
The opposite edge of the ulcer is clean, the bottom is covered with a gray-yellow infiltrate.
The iris is involved very early in the process. This changes its color, the pattern changes, the pupil narrows, the iris pupil edge fuses with the anterior capsule of the lens (posterior synechiae), pus appears in the anterior chamber, pronounced effects of eye irritation, severe pain, eyelid edema, periconeal injection of violet. Creeping ulcer of the cornea is a serious disease, but often under the influence of timely correct treatment it is cleared and the resulting defect is epithelialized. At the site of the ulcer remains a recess (facet), In the future, the facet is filled with a connective tissue and a persistent intense clouding (thorns) is formed.
Sometimes the creeping ulcer of the cornea spreads both on the surface and deep into the cornea, leading to its perforation. After perforation, healing of the ulcer occurs followed by scarring and the formation of a thorn, fused with the iris. In very severe cases, the cornea rapidly melts, the infection penetrates the eye, causes a purulent inflammation of all the membranes of the eye (panophthalmitis). The tissues of the eye are destroyed, mixed with a connective tissue, the eyeball is atrophied.
Creeping ulcers of the cornea develops usually when pneumococcus, staphylococcus, streptococcus, or Pseudomonas enter the erosion surface. Superficial damage to the cornea can be caused by small foreign bodies, leaves and branches of trees, sharp cereal awns and grains. Cases of cervical ulcer disease are especially frequent in summer and early autumn during the period of agricultural work.
Infection is carried by a wounding body. Usually, the pathogens are in the normal flora of the conjunctival cavity as saprophyte. Especially often it is found in the pus of the lacrimal sac with chronic purulent dacryocystitis. Approximately in 50% of all cases creeping ulcer develops in persons suffering from chronic dacryocystitis or narrowing of the tear-nasal canal.
The forecast is always very serious. As a result of the central location of ulcers, their scarring leads to a sharp decrease in visual acuity, a corneal thorn is formed, fused with the iris.
If the causative agent of the Morax-Axenfeld rod (diplococcus), the corneal ulcer spreads very quickly in depth, both edges are infiltrated, the hypopion is of a viscous consistency.
Corneal ulcer with gonoblenoree has a whitish color, rapidly spreads over the surface and into the interior, the perforation and panophthalmitis rapidly occur. Exodus is a vast thorn, staphyloma of the cornea.
With Pseudomonas aeruginosa, lesion by the type of abscess quickly captures the entire cornea, the anterior layers of the cornea exfoliate and dangle. Melting of the cornea occurs in 24-48 hours, the ulcers are quickly perforated. The eye is dying.
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Treatment of corneal ulcer
Prevention of corneal ulcers should be carried out with any, even minor, trauma to the cornea: whether a mote, eyelashes, or an accidental slight scratch has fallen. In order to erosion of the cornea is not a herd entrance gate for infection, it is enough to instill in the eye any antibacterial eye drops 2-3 times a day, and put an eye ointment with antibiotics for a night.
The same is done by providing first aid to a patient who has a superficial keratitis. Instillations of antibacterial drops should be performed every hour until the patient has an appointment with a specialist, if a diagnosis of keratitis is made at a doctor's ophthalmic consultation, a smear of the contents of the conjunctival cavity or a scraping from the surface of the corneal ulcer is first taken to identify the causative agent of the disease and determine its sensitivity to antibacterial drugs, and then prescribed treatment aimed at suppressing infection and inflammatory infiltration, improving corneal trophism. Antibiotics are used to suppress infection: levomitsetin, neomycin, kanamycin (drops and ointments), tsipromed, okakcin. The choice of antimicrobials and their combination depends on the type of pathogen and its sensitivity to drugs. The drug of choice for gram-positive organisms is cerazoline, for gram-negative - tobramlinin or gentamicin. Assign cefazolin (50 mg / ml), tobramine and gentamicin (15 mg / ml) in instillations under the conjunctiva or parabulbarically systemically, depending on the severity of the process.
To enhance therapy, the installation is recommended to be performed every 30 minutes about the course of the day and every hour at night for 7-10 days. If there is no effect, the ulcer is extinguished with 10% iodine tincture, mechanical abrasion or diathermocoagulation. For the prevention of iridocyclitis, appoint installations of mydriatic. The frequency of their instillation is individual and depends on the severity of inflammatory infiltration and the reaction of the pupil.
Steroid drugs are prescribed topically during the resorption of inflammatory infiltrates after epithelializing the surface of the corneal ulcer. At this time, drugs containing a broad-spectrum antibiotic and a glucocorticoid (garazone) are effective. Along with these drugs, proteolysis inhibitors, immunocorrectors, antihistamines and vitamin preparations are changed locally and inward, as well as agents that improve trophic and corneal epithelialization (balarpan, taufon, sodoseril, actovegia, carpozin, etaden, etc.).
Indications for emergency surgical treatment are the progression of the corneal ulcer, 24-36 hours after the initiation of active treatment - an increase in the corneal ulcer, folding of membranes, the appearance of daughter infiltrates along the edge of the ulcer. To save the eye, layered therapeutic keratoplasty is performed. The first transplant can melt and fall off - the transplant is made deeper and wider, down to a through transplant of the cornea with a scleral rim.
The transplantation is done by a corpse corpse, dried on silica gel.