H Because of the risk of perforation, any type of corneal ulcer is an emergency requiring treatment by an ophthalmologist.

Conservative therapy. Treatment is initiated with topical antibiotics (such as ofloxacin and polymyxin) with a very broad spectrum of activity against most Gram-positive and Gram-negative organisms until the results of pathogen and resistance testing are known. Immobilization of the ciliary body and iris by therapeutic mydriasis is indicated in the presence of intraocular irritation (manifested by hypopyon). Bacterial keratitis can be treated initially on an outpatient basis with eyedrops and ointments.

An advanced ulcer, i.e., a protracted clinical course, suggests indolence and poor compliance on the part of the patient. Hospitalization is indicated in these cases. Subconjunctival application of antibiotics may be required to increase the effectiveness of the treatment.

Surgical treatment. Emergency keratoplasty is indicated to treat a desceme-tocele or a perforated corneal ulcer (see emergency keratoplasty, p. 152). Broad areas of superficial necrosis may require a conjunctival flap to accelerate healing. Stenosis or blockage of the lower lacrimal system that may impair healing of the ulcer should be surgically corrected.

H As soon as the results of bacteriologic and resistance testing are available, the physician should verify that the pathogens will respond to current therapy.

Failure of keratitis to respond to treatment may be due to one of the following causes, particularly if the pathogen has not been positively identified.

1. The patient is not applying the antibiotic (poor compliance).

2. The pathogen is resistant to the antibiotic.

3. The keratitis is not caused by bacteria but by one of the following pathogens:

Herpes simplex virus.

❖ Acanthamoeba.

❖ Rare specific pathogens such as Nocardia or mycobacteria (as these are very rare, they not discussed in further detail in this chapter).

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