A corneal ulcer is one of the most serious eye emergencies I encounter in clinical practice. In my years at Bangladesh Eye Hospital, I have seen patients arrive with corneas that were near-perforation — not because their condition was untreatable, but because they did not know the warning signs, did not seek care quickly enough, or received incorrect initial treatment at the primary level.
The World Health Organization (WHO) published guidelines specifically for the South-East Asia region on the management of corneal ulcers across primary, secondary, and tertiary care facilities. As a cornea-trained ophthalmologist who completed my fellowship at LV Prasad Eye Institute — one of Asia’s leading corneal centres — I want to translate these guidelines into clear, practical information that patients and healthcare workers in Bangladesh can actually use.
This article covers what a corneal ulcer is, why it is an emergency, how it should be managed at each level of care, and when urgent referral to a cornea specialist is essential.
What is a Corneal Ulcer?
The cornea is the clear, dome-shaped front surface of the eye — the transparent window through which light enters. It plays a critical role in focusing vision and acts as the eye’s primary physical barrier against infection and injury.
A corneal ulcer is an open wound or erosion of the corneal tissue, typically caused by infection. It is not a superficial scratch. A corneal ulcer penetrates into the layers of the cornea itself — and if left untreated or poorly treated, it can destroy the cornea, cause perforation of the eye, and result in permanent vision loss or loss of the eye entirely.
Infectious keratitis, often manifesting as a corneal ulcer, is a significant cause of ocular morbidity worldwide — ranking among the top five causes of blindness globally, and disproportionately impacting marginalized groups. Dr. Agarwals
In Bangladesh, corneal ulcers are particularly common due to agricultural work (plant matter and soil are major risk factors for fungal keratitis), widespread use of traditional eye remedies that delay medical care, and limited access to specialist ophthalmology outside Dhaka and major cities.
What Causes Corneal Ulcers?
Understanding the cause is essential — because the treatment differs significantly depending on the causative organism.
Bacterial Keratitis — Most Common
The most frequent cause in Bangladesh, particularly following eye injuries from plant material, dust, or contaminated water. Bacterial keratitis is the most common cause of infectious corneal ulcers and should be the top differential diagnosis in patients presenting acutely with corneal infiltrates. It is often rapid in onset and progression, with potential for corneal melting and perforation within days. Dr. Agarwals
Common organisms include Pseudomonas aeruginosa (particularly aggressive — can destroy the entire cornea within days), Staphylococcus aureus, and Streptococcus pneumoniae.
Fungal Keratitis
In Bangladesh, fungal keratitis is the second most common cause — and arguably more difficult to treat. It typically follows trauma with vegetable matter: a paddy stalk, tree branch, or soil particle. Fungal ulcers tend to have feathery borders, satellite lesions, and a dry-looking surface — quite different from bacterial ulcers. They do not respond to antibiotics and require specific antifungal treatment, which many primary-level facilities do not stock.
Viral Keratitis — Herpes Simplex
Herpes simplex virus (HSV) is a significant cause of recurrent corneal ulceration, particularly the classic dendritic (branching) ulcer visible on fluorescein staining. It requires antiviral treatment — not antibiotics — and misdiagnosis with inappropriate steroid use can be catastrophic, causing rapid corneal destruction.
Acanthamoeba Keratitis
Less common but devastating. Associated with contact lens use, particularly in users who swim with lenses in or use tap water for lens cleaning. Acanthamoeba keratitis is extremely painful — often disproportionate to clinical signs — and resistant to most standard treatments. It requires prolonged specific therapy and is frequently misdiagnosed.
Risk Factors in Bangladesh
- Agricultural work — plant matter injuries are the single biggest risk factor for fungal keratitis
- Contact lens use — particularly poor hygiene or tap water use
- Traditional eye remedies — a major cause of delayed presentation and worsened outcomes
- Diabetes — impairs corneal healing and immune response
- Previous eye surgery or chronic eye disease
- Malnutrition and Vitamin A deficiency — particularly in children
Warning Signs — When to Seek Urgent Care
This is the most important section for patients and their families. A corneal ulcer is an ophthalmic emergency. If you or a family member has any of the following symptoms — especially after an eye injury — do not wait, do not apply home remedies, and do not use steroid eye drops without a doctor’s prescription.
The common symptoms of corneal ulceration include redness of the eye, circumcorneal congestion, pain, blurring of vision, photophobia (sensitivity to light), and watering of the eye — all with varying degrees of severity. Drashrafulhuq
Go to an eye specialist immediately if you have:
- A white or grey spot on the cornea (the coloured part of the eye)
- Sudden pain in the eye, especially after an injury
- Significant sensitivity to light
- Rapidly worsening vision
- Discharge from the eye combined with corneal haziness
- A red, painful eye that is not improving after 24–48 hours of antibiotic drops
“In my experience, the most preventable causes of permanent vision loss from corneal ulcers are delayed presentation and the use of traditional remedies or over-the-counter steroid drops before seeking specialist care. A corneal ulcer that is caught early and treated correctly has an excellent prognosis. The same ulcer treated late or incorrectly can end in a blind eye. Time matters enormously.”
— Dr. Ashraful Huq
WHO Guidelines — Management at Each Level of Care
The WHO Regional Office for South-East Asia published guidelines for the management of corneal ulcers at primary, secondary, and tertiary care health facilities specifically for the South-East Asia region — which includes Bangladesh. Here is how those guidelines translate into practice: Alcon
Primary Level — First Contact Care
At the primary level — a community clinic, health centre, or general practitioner — the most important role is rapid recognition and immediate referral. A suppurative corneal ulcer is an ophthalmic emergency which should be referred to the nearest eye centre for proper management. Drashrafulhuq
Before referral, the primary provider should:
- Apply broad-spectrum antibiotic eye drops (e.g. ciprofloxacin 0.3% or moxifloxacin 0.5%) hourly
- Instruct the patient to continue drops frequently during transit to the referral centre
- Never apply steroid eye drops — this is absolutely contraindicated without specialist assessment
- Never pad or patch the eye tightly — this creates a warm, moist environment that accelerates bacterial growth
- Document the history of injury, contact lens use, and any prior treatment
What primary care should NOT do:
- Prescribe steroid eye drops — can turn a treatable ulcer into a perforating one
- Apply traditional eye remedies of any kind
- Delay referral to see if the condition improves over several days
- Prescribe oral antibiotics as the sole treatment for a corneal ulcer
Secondary Level — District Eye Hospital
At the secondary level, the ophthalmologist should perform a full slit-lamp examination and attempt to establish the causative organism through corneal scraping and microbiological culture where possible.
Current guidelines recommend immediate treatment with broad-spectrum topical antibiotics as the first-line approach, with emphasis on empiric therapy for small noncentral ulcers. For bacterial ulcers, fluoroquinolones such as moxifloxacin 0.5% or ciprofloxacin 0.3% should be administered every 15–30 minutes for the first few hours, then hourly while awake for 24–48 hours, followed by gradual tapering based on clinical response. American Academy of Ophthalmology
Key management principles at secondary level:
- Corneal scraping for Gram stain, KOH preparation (for fungi), and culture sensitivity
- Topical fluoroquinolone monotherapy as first-line for most bacterial ulcers
- Fortified antibiotic drops (tobramycin + cefazolin) for severe cases
- Natamycin 5% eye drops for suspected fungal keratitis — not fluoroquinolones
- Acyclovir ointment for suspected HSV dendritic ulcers — not antibiotics
- Cycloplegic drops (atropine) to reduce pain from ciliary spasm and prevent posterior synechiae
- Corticosteroids may be considered after 48 hours of antibiotic therapy when the causative organism is identified and the infection has responded to therapy — but should be avoided in cases of suspected Acanthamoeba, Nocardia, or fungal infection. American Academy of Ophthalmology
Tertiary Level — Specialist Cornea Centre
At the tertiary level — a specialist cornea unit such as at Bangladesh Eye Hospital — management becomes more complex, particularly for cases that have not responded to initial treatment, have unusual organisms, or present with advanced corneal destruction.
At BEH, I manage cases referred from across Bangladesh, many of whom arrive after days or weeks of inadequate treatment elsewhere. Tertiary-level management may include:
- Repeat corneal scraping with extended culture techniques including fungal and Acanthamoeba-specific media
- Confocal microscopy for Acanthamoeba and fungal diagnosis without scraping
- Intensive fortified antibiotic or antifungal regimens tailored to organism and sensitivity
- Therapeutic penetrating keratoplasty (corneal transplant) for cases with impending or actual perforation
- Tissue adhesive (cyanoacrylate glue) and bandage contact lens for small perforations
- Long-term management of corneal scarring, including optical and tectonic keratoplasty
Corneal Scarring — What Happens After a Corneal Ulcer Heals?
This is something many patients are not told at the time of treatment — and it is important.
When a corneal ulcer heals, it leaves a scar. Unlike skin scars that can be hidden, a corneal scar sits directly in the visual axis — the path light travels to reach the retina. Depending on the size, depth, and location of the scar, this can cause:
- Permanent reduction in vision
- Irregular astigmatism — distorted, blurred vision that cannot be corrected by standard glasses
- Complete opacity — a white scar that blocks light entirely (leucoma)
For patients with corneal scarring that significantly affects vision, options at the tertiary level include:
- Rigid gas-permeable contact lenses — can mask irregular astigmatism in some patients
- Deep anterior lamellar keratoplasty (DALK) — replaces the scarred corneal layers while preserving the patient’s own endothelium
- Penetrating keratoplasty (PK) — full-thickness corneal transplant for severe cases
- Keratoprosthesis — in rare cases where standard transplantation has failed
The Role of Prevention — What Every Patient Can Do
Most corneal ulcers in Bangladesh are preventable. The following measures reduce risk significantly:
For agricultural workers:
- Wear protective eyewear when working with crops, particularly during harvesting
- Wash eyes immediately with clean water after any eye injury — then seek care
- Never rub soil or plant material into an injured eye
- Seek eye care within 24 hours of any penetrating eye injury — do not wait
For contact lens wearers:
- Never sleep in contact lenses
- Never use tap water to clean or store lenses
- Never swim with contact lenses in
- Replace lenses and cases on schedule
- Remove lenses immediately if the eye becomes red, painful, or uncomfortable
For everyone:
- Never use steroid eye drops without a prescription from an ophthalmologist
- Never apply traditional eye remedies — kohl, breast milk, plant extracts, or any substance not prescribed by a doctor
- Seek urgent care for any red, painful eye that does not improve within 24 hours
Dr. Ashraful Huq’s Clinical Perspective
I want to add something that the guidelines do not capture — what I see in clinic week after week.
The single most damaging thing that happens to corneal ulcer patients in Bangladesh is not the initial infection. It is what happens between the injury and the point they reach me. It is the three days of antibiotic drops that were not given frequently enough. It is the steroid drop prescribed by a well-meaning general practitioner who thought it would reduce the redness. It is the traditional remedy applied by a family member before the patient could be brought to Dhaka. It is the delay caused by cost, distance, or the belief that “it will get better on its own.”
By the time I see these patients, what began as a treatable ulcer has become a surgical emergency. Corneas that could have healed with drops now need transplants. Eyes that could have had normal vision now have permanent scars.
The WHO guidelines exist because this pattern is well recognised across South-East Asia. The pathway is clear: rapid recognition at the primary level, immediate topical antibiotic treatment, no steroids, prompt referral upward. When that pathway works, outcomes are excellent. When it breaks down at any point — through delay, misdiagnosis, or inappropriate treatment — patients pay the price with their vision.
If you have an eye injury or a red, painful eye that is not improving — please do not wait. Come and be assessed. Early treatment is always better, always safer, and always cheaper than treating the consequences of delay.
Frequently Asked Questions
What is a corneal ulcer?
A corneal ulcer is an open wound or erosion in the cornea — the clear front surface of the eye — usually caused by bacterial, fungal, viral, or amoebic infection. It is an ophthalmic emergency. Without prompt and correct treatment, it can cause permanent vision loss or loss of the eye.
What are the symptoms of a corneal ulcer?
Key symptoms include a white or grey spot on the cornea, eye pain, redness, photophobia (light sensitivity), watering, and blurred vision — especially after an eye injury. If you have these symptoms, seek urgent eye care immediately and do not apply any drops or remedies without medical advice.
Can a corneal ulcer heal on its own?
No. A corneal ulcer requires prompt medical treatment with appropriate eye drops — antibiotic, antifungal, or antiviral depending on the cause. Leaving a corneal ulcer untreated allows it to deepen, spread, and potentially perforate the eye. Do not wait for it to resolve on its own.
Are steroid eye drops safe for corneal ulcers?
No — not without specialist assessment. Steroid eye drops applied to an active bacterial, fungal, or viral corneal ulcer can cause rapid worsening, deeper penetration of infection, and perforation. Never use steroid drops for a red or painful eye without a confirmed diagnosis from an ophthalmologist.
What is the treatment for a corneal ulcer in Bangladesh?
Treatment depends on the cause. Bacterial ulcers are treated with intensive topical fluoroquinolone antibiotics. Fungal ulcers require natamycin antifungal drops. Viral (HSV) ulcers need antiviral therapy. Severe cases may need corneal transplantation. At Bangladesh Eye Hospital, Dr. Ashraful Huq manages complex corneal ulcer cases from across the country.
Can vision be restored after a corneal ulcer?
It depends on the size, depth, and location of the resulting scar. Small, peripheral scars may not affect vision significantly. Central or dense scars can permanently reduce vision. For significant corneal scarring, options include rigid contact lenses or corneal transplantation (keratoplasty) — both available at BEH with Dr. Ashraful Huq.
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