Corneal Ulcer Surgical Management | PristynCare

Risk Factors

Risk factors for developing severe corneal ulcers requiring surgery include:

• Contact lens wear, especially extended or overnight use
• Prior corneal surgery or trauma compromising the epithelial barrier
• Diabetes and immunosuppression increasing infection susceptibility
• Severe dry eye or neurotrophic cornea
• Eyelid abnormalities causing incomplete closure
• Agricultural workers exposed to plant or soil trauma (fungal risk)

Who Needs Surgery

Surgery is indicated when corneal ulcers fail to respond to appropriate antimicrobial therapy after 48 to 72 hours, when perforation is imminent or has occurred, or when the ulcer involves more than 50% corneal thickness. Neurotrophic ulcers not responding to lubricants, amniotic membrane, or corneal neurotization also require surgical intervention.

Diagnosis

Diagnosis for surgical planning of corneal ulcers involves:

• Slit-lamp examination with fluorescein staining to assess ulcer size and depth
• Corneal scrapings for Gram stain, KOH mount, and cultures (bacterial, fungal, Acanthamoeba)
• Anterior segment OCT for precise assessment of stromal depth and Descemet membrane integrity
• Confocal microscopy to detect fungal filaments or Acanthamoeba cysts
• B-scan ultrasound if endophthalmitis is suspected

Treatment Approach

Medical management is continued during surgical planning. Surgical options depend on ulcer severity: tissue adhesive or bandage contact lens for small perforations, conjunctival flap for non-central ulcers with intact Descemet membrane, and therapeutic penetrating keratoplasty for severe or perforated ulcers. Post-operatively, antimicrobial therapy is continued and the graft is replaced with an optical graft once infection is controlled.

Corneal Ulcer Surgery Steps

Surgical management of corneal ulcers is performed as follows:

• Emergency assessment of ulcer severity and risk of perforation
• Pre-operative cultures and sensitivity testing if not already done
• Anesthesia: local or general depending on procedure type and patient cooperation
• Tissue adhesive application: cyanoacrylate glue is applied to seal small perforations (under 2 mm) with a bandage contact lens placed over it
• Conjunctival flap: conjunctival tissue is advanced over the peripheral or mid-peripheral ulcer and sutured in place
• Therapeutic keratoplasty: the infected corneal tissue is trephined out and replaced with donor corneal graft sutured with 10-0 nylon sutures
• Post-operative antimicrobial drops continued; optical keratoplasty planned after 6 to 12 months

Post-Surgery Recovery

Post-operative care for corneal ulcer surgery includes:

• Continue intensive antimicrobial drops as prescribed (antifungal, antibiotic, or antiviral)
• Topical steroids may be added cautiously once infection is controlled
• Protect the eye with a shield during sleep
• Attend follow-up examination every 3 to 5 days initially
• Report any worsening pain, increasing discharge, or vision deterioration immediately
• Optical corneal transplant may be planned 6 to 12 months after the therapeutic procedure

Risks and Complications of Corneal Ulcer Surgery

Complications associated with corneal ulcer surgical management include:

• Graft failure or rejection: Particularly in therapeutic keratoplasty performed in an infected eye
• Infection recurrence: Residual infection in graft or adjacent tissue
• Endophthalmitis: Spread of infection into the anterior or posterior segment
• Choroidal hemorrhage: Expulsive hemorrhage during open-globe surgery
• High astigmatism: After therapeutic keratoplasty, correctable with glasses or contact lenses
• Glaucoma: Secondary to inflammation, steroid use, or peripheral anterior synechiae