February 15, 2007
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Paradigms changing for culturing corneal ulcers

This month’s Corneal Health column discusses treatment for corneal ulcers.

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Corneal Health

Eric D. Donnenfeld, MD: When do we culture a patient who presents with a corneal ulcer? Let’s discuss a patient I saw recently, a 37-year-old woman with a 1 mm paracentral infiltrate that stained with fluorescein. There was an acute onset corneal ulcer in the right eye. I won’t give you all the information about her yet. What is important to ask about in this type of patient?

Terrence P. O’Brien, MD: You want to know about contact lens wear. In this country we recently had an epidemic of cases of fungal keratitis in which a certain contact lens solution was associated with its occurrence.

Eric D. Donnenfeld, MD
Eric D. Donnenfeld

Normally with contact lenses we would worry about bacterial keratitis. Now, however, we also have to think about the possibility of a mycotic process in these patients. Therefore, you want to ask whether they are using contact lenses. Ask about their regimen, whether they have an extended wear schedule, which solutions they are using and how they disinfect their contact lenses. These factors are important to know before you manage this type of patient.

Dr. Donnenfeld: And indeed, the patient I referred to earlier was a contact lens wearer. She had 20/30 visual acuity and had worn contact lenses.

It can be difficult to get a correct history from contact lens patients. My experience is that many patients do not know which solutions they are using. Sometimes they borrow solutions from other people, which is what happened to this patient.

Terrence P. O'Brien, MD
Terrence P. O'Brien

Should we start this patient on antibiotics immediately, or would we put this patient on steroids on the initial visit? There has been a paradigm shift on this issue from 1 or 2 years ago because of the epidemic Dr. O’Brien referred to. Many of us would have given this patient steroids on the first visit 2 years ago because the incidence of fungus is so low in the Northeast region of the country. Perhaps in Florida, where Dr. O’Brien is located, there is a higher incidence of fungus, but in my area there is a low incidence. I have stopped using steroids on initial presentation of corneal ulcers in patients who wear contact lenses.

This patient had Fusarium keratitis. We cultured and diagnosed it, but despite our best efforts this patient perforated with a Fusarium corneal ulcer several weeks later.

The overall message here is that we have opened a new era in dealing with corneal ulcers, and we have to be more vigilant. Culturing is probably becoming more widely used. There has been a shift in the number of doctors doing cultures vs. starting steroids upon initial visit in patients who have contact-lens-related corneal ulcers.

Culturing is becoming more frequent because of recent incidents
When should a corneal ulcer be cultured? Culturing is becoming more frequent because of recent incidents.

1-mm paracentral infiltrate that stained with fluorescein
Case study: A 37-year-old woman presented with a 1-mm paracentral infiltrate that stained with fluorescein.

Images: Donnenfeld ED

For more information:
  • Eric D. Donnenfeld, MD, is a cornea specialist in private practice at Ophthalmic Consultants of Long Island and co-chairman of Cornea and External Disease at Manhattan Eye, Ear and Throat Hospital. He can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714. Dr. Donnenfeld is a consultant for Advanced Medical Optics.
  • Terrence P. O’Brien, MD, is professor of ophthalmology and director of refractive surgery at Bascom Palmer Eye Institute. He can be reached at Bascom Palmer, Palm Beach Gardens, 7101 Fairways Drive, Palm Beach Gardens, FL 33418; 561-515-1544.