Eyeworld

80 | EYEWORLD | APRIL 2023 C ORNEA Reference 1. Srinivasan M, et al. The Steroids for Corneal Ulcers Trial (SCUT): secondary 12-month clin- ical outcomes of a randomized controlled trial. Am J Ophthalmol. 2014;157:327–333. Relevant disclosures Beckman: None Majmudar: None Care and culturing Both Dr. Beckman and Dr. Majmudar said their corneal ulcer patients are generally referred from other eyecare providers. "As a corneal specialist who practices in a tertiary care environment, the majority of ulcer patients who I see have already seen one or more eyecare providers. More often than not, they have had multiple prior treatments and may not be improving," Dr. Majmudar said. He said his rule of thumb for referrals is "if you don't think that you can provide the most appropriate and efficacious care for that patient, send them to someone who can do so." Howev- er, he thinks most corneal ulcers can be effec- tively managed by non-cornea specialists with a basic understanding of common pathogens in the region and appropriate antibiotic therapy. "A pet peeve of mine is if a patient presents with a presumed contact lens-related infec- tion, treatment should generally be directed toward Pseudomonas," Dr. Majmudar said. "I've seen many patients be treated and ultimately referred to me for failed treatment, but they have been on antibiotics that have very little gram-negative coverage." Both physicians said that they culture almost all patients with a few exceptions. Dr. Majmudar said he might not culture if the lesion is not too peripheral or small. "My advice would be that any central ulcer should be cultured in order to provide the most effective and appropriate antibiotic treatment to the patient. If the clinical course is not going well, I would recommend reculturing and expanding the culture to include other atypical organisms." Dr. Beckman said he'll try to get a culture before antibiotic therapy begins because it can limit the yield of the culture. If that's not pos- sible, he'll still get a culture because there will sometimes still be a yield. He also mentioned that if the patient wears contacts and has them in the case, they can be used to culture, or he said that a corneal biopsy could get a specimen if initial cultures remain negative. continued on page 82 continued from page 79 Three tips for corneal ulcers from Dr. Beckman 1. Get a history. Always ask about inju- ry, foreign body, contact lens wear, and exposure. "If there is something unusu- al, then you have to think of unusual things." 2. Watch patients closely. Look for signs of improvement. Use caution with steroids. If there is secondary inflamma- tion that you have to treat, it's best to do so once you have the infection under control and know it's not fungal. 3. Get the epithelium to heal quickly. If a patient isn't healing, it doesn't neces- sarily mean they need more antibiotics. Sometimes it means you need less. Some fortified antibiotics are harsh and can result in a persistent epithelial toxicity. "My advice would be that any central ulcer should be cultured in order to provide the most effective and appropriate antibiotic treatment to the patient. If the clinical course is not going well, I would recommend reculturing and expanding the culture to include other atypical organisms." —Parag Majmudar, MD

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