In my years at Bangladesh Eye Hospital, few conditions concern me as much as a corneal ulcer that has been left untreated — or worse, treated incorrectly — before the patient reaches me.
A corneal ulcer is not a minor eye infection. It is an open wound on the most critical optical surface of the eye. Without the right treatment, started urgently, it can destroy the cornea within days and leave a patient permanently blind in that eye.
This article tells you what a corneal ulcer is, what causes it in Bangladesh specifically, how to recognise it early, and what the correct treatment pathway looks like — from a specialist who has managed these cases at both the secondary and tertiary level.
Cornea Services — Dr. Ashraful Huq
Corneal ulcers, keratoconus, corneal transplant (DALK/PK), and dry eye — specialist cornea care at BEH Dhaka.
What is a Corneal Ulcer?
The cornea is the clear dome at the front of the eye through which you see. It has five layers, and its transparency is critical to sharp vision. A corneal ulcer — also called infectious keratitis — is a break in the corneal epithelium (the outermost layer) that extends into deeper layers, caused by microbial infection.
Unlike a superficial scratch, which heals in 24–72 hours, a corneal ulcer involves active infection eating into corneal tissue. If untreated, it progresses from the outer layers inward, can perforate the eye entirely, and allows infection to enter the interior of the eye — a condition called endophthalmitis, which can be blinding or require removal of the eye.
What Causes Corneal Ulcers?
Bacterial Keratitis
The most common cause in Bangladesh. Follows eye injury — even a minor scratch from a plant, fingernail, or piece of dust. The most aggressive organisms are Pseudomonas aeruginosa (can destroy the entire cornea in 48 hours) and Staphylococcus aureus. Onset is rapid — redness, pain, and a white spot developing within hours to days.
Fungal Keratitis
The second most common cause in Bangladesh — and the one I see most often in patients referred from rural areas. Typically follows trauma with vegetable matter: a paddy stalk, tree branch, or soil. Fungal ulcers are slower to develop, have characteristic feathery edges and satellite lesions, and do not respond to antibiotic eye drops. Natamycin antifungal drops are required — which many primary-level facilities do not stock.
Herpes Simplex Viral Keratitis
Caused by HSV-1 — the same virus as cold sores. Produces a classic dendritic (branching) ulcer visible on fluorescein staining. Requires antiviral treatment (acyclovir). The critical danger: if steroids are applied to an HSV ulcer — a common mistake — the infection spreads rapidly and causes geographic ulceration, potentially destroying the entire corneal surface.
Acanthamoeba Keratitis
Linked to contact lens use — particularly swimming with lenses, using tap water to clean lenses, or poor lens hygiene. Excruciatingly painful — often out of proportion to what is visible on examination. Resistant to most standard treatments and frequently misdiagnosed as HSV or bacterial keratitis. Requires specific prolonged therapy with polyhexamethylene biguanide (PHMB) drops.
Risk Factors Specific to Bangladesh
- Agricultural work with plant material
- Traditional eye remedies — the single most damaging factor I see in referred patients
- Contact lens use with poor hygiene
- Diabetes — impairs corneal healing and immune response
- Vitamin A deficiency — particularly in malnourished children
- Delayed presentation due to cost, distance, or minimisation of symptoms
Warning Signs — Seek Urgent Eye Care Immediately
Do not wait if you or a family member has:
- A white or grey spot on the coloured part of the eye
- Eye pain — especially after an injury or foreign body sensation
- Rapid worsening of vision
- Significant sensitivity to bright light
- A red, watering eye that is not improving after 24 hours
- Any eye injury involving plant material, soil, or a foreign body
“A corneal ulcer caught in the first 24–48 hours and treated correctly has an excellent prognosis. The same ulcer after three days of the wrong treatment — or traditional remedies — is a surgical emergency. Time is cornea.”
— Dr. Ashraful Huq
Never apply these before seeing a doctor:
- Steroid eye drops — accelerates infection and can perforate the cornea
- Traditional remedies — breast milk, plant extracts, kohl, any non-prescribed substance
- Antibiotic drops alone for a fungal or viral ulcer — delays the right treatment
Diagnosis — What I Do at the First Visit
A thorough assessment is essential before any treatment is started. At BEH, my assessment includes:
- Slit-lamp examination — detailed visualisation of the ulcer’s size, depth, location, and characteristics
- Fluorescein staining — reveals the ulcer’s exact shape; a dendritic pattern indicates HSV
- Corneal scraping — material from the ulcer base is sent for Gram stain, KOH preparation (for fungi), and culture sensitivity
- Anterior segment OCT — assesses depth of stromal involvement without contact
- Intraocular pressure — elevated IOP can complicate management
- Full history — mechanism of injury, contact lens use, prior treatment, duration of symptoms, and — critically — whether any traditional remedies or steroid drops have been used
The culture result takes 48–72 hours, but treatment begins immediately based on clinical appearance while awaiting results.
Treatment — How Corneal Ulcers Are Managed
Bacterial Ulcer
Intensive topical fluoroquinolone antibiotics — moxifloxacin 0.5% or ciprofloxacin 0.3% — every 15–30 minutes for the first few hours, then hourly while awake. For severe or central ulcers: fortified antibiotic drops (tobramycin + cefazolin). Cycloplegic drops (atropine) reduce pain from ciliary spasm. Patching is not recommended — it creates a warm, moist environment ideal for bacterial growth.
Fungal Ulcer
Natamycin 5% eye drops — every hour initially. Voriconazole drops or oral voriconazole for severe cases or when natamycin fails. Antifungal treatment continues for weeks — fungal ulcers are slow to resolve and require prolonged therapy and close follow-up.
Herpes Simplex Ulcer
Topical acyclovir ointment 5 times daily. Oral acyclovir for severe or recurrent cases. Steroids are absolutely contraindicated in active HSV epithelial disease. Only once the epithelium has fully healed, under specialist supervision, may carefully titrated steroids be considered for stromal disease.
Acanthamoeba Keratitis
Polyhexamethylene biguanide (PHMB) 0.02% drops — initially every hour, round the clock for the first 48 hours, then tapered over weeks to months. Treatment typically continues for 6–12 months. Pain management is a major component of care — these patients are often in significant distress.
When Surgery is Needed
Patients referred late — with deep, central, or perforating ulcers — may require:
- Tissue adhesive (cyanoacrylate glue) for small perforations with bandage contact lens
- Therapeutic penetrating keratoplasty — emergency corneal transplant to save the eye in cases of impending or actual perforation
- Optical keratoplasty — elective corneal transplant after healing to restore vision lost to central scarring
Corneal Scarring — What Happens After the Ulcer Heals
Once an infectious corneal ulcer heals, it leaves a scar. Unlike a skin scar, a corneal scar sits directly in the visual axis. Outcomes range from mild haziness causing minimal vision impact, to a dense white leucoma that completely blocks light transmission.
For patients with visually significant corneal scarring, options include:
- Rigid gas-permeable contact lenses — masks irregular astigmatism in some patients
- Deep anterior lamellar keratoplasty (DALK) — replaces scarred corneal layers while preserving the patient’s own endothelium; lower rejection risk than full-thickness transplant
- Penetrating keratoplasty (PK) — full-thickness corneal transplant for deep or full-thickness scars
- Phototherapeutic keratectomy (PTK) — laser treatment to smooth superficial corneal scars
Both DALK and PK are performed at Bangladesh Eye Hospital by Dr. Ashraful Huq.
Prevention — What Every Patient Can Do
Agricultural workers:
- Wear protective eyewear during harvesting and fieldwork
- Wash any eye injury immediately with clean water — then seek eye care within 24 hours
- Do not rub plant material or soil into an injured eye
Contact lens wearers:
- Never sleep in lenses
- Never use tap water to clean, rinse, or store lenses
- Never swim with lenses
- Replace lenses and cases on schedule
- Remove lenses immediately if the eye becomes red, painful, or uncomfortable
Everyone:
- Never use steroid eye drops without an ophthalmologist’s prescription
- Never apply traditional remedies to an injured or infected eye
- Seek urgent care for any red, painful eye that does not clearly improve within 24 hours
Dr. Ashraful Huq’s Clinical Perspective
The pattern I see most in referred corneal ulcer patients follows a consistent and entirely preventable sequence: eye injury → traditional remedy applied → 2–3 days delay → steroid drops prescribed at a local pharmacy → rapid ulcer progression → referral to me with a near-perforating ulcer.
Each step in that chain is avoidable. The injury itself is often unavoidable. Everything that follows — the remedy, the delay, the steroid — is a choice, usually made out of habit, cost concern, or lack of awareness.
A corneal ulcer caught early costs a bottle of antibiotic drops and a few follow-up visits. Caught late, it may cost the cornea — and with it, functional vision in that eye for life.
If you have any concern about your eye after an injury, or a red painful eye that is not improving — come and be seen. Early assessment is always better, always safer, and always cheaper than managing the consequences of delay.
Frequently Asked Questions
What is a corneal ulcer?
A corneal ulcer is an open wound extending into the corneal layers, caused by bacterial, fungal, viral, or amoebic infection. It is an eye emergency. Without correct and prompt treatment it can permanently damage vision or cause loss of the eye.
How do I know if I have a corneal ulcer?
Key signs: a white or grey spot on the cornea, eye pain, redness, light sensitivity, watering, and blurred vision — particularly after an eye injury. Seek urgent specialist eye care immediately if you have these symptoms.
What is the treatment for a corneal ulcer in Bangladesh?
Treatment depends on the cause: intensive topical antibiotics for bacterial ulcers, natamycin antifungal drops for fungal ulcers, acyclovir for HSV. Severe cases may need corneal transplantation. Available at Bangladesh Eye Hospital, Dhaka under Dr. Ashraful Huq.
Are steroid eye drops safe for corneal ulcers?
No — not without specialist assessment and confirmed diagnosis. Steroids applied to an active bacterial, fungal, or HSV corneal ulcer cause rapid worsening and risk of perforation. This is the most common cause of preventable blindness from corneal ulcers in Bangladesh.
Can vision be restored after a corneal ulcer scar?
Yes — depending on scar size, depth, and location. Options include rigid contact lenses, DALK, or penetrating keratoplasty (corneal transplant). Both are performed at BEH Dhaka.
Can children get corneal ulcers?
Yes. Children with Vitamin A deficiency are at particularly high risk, and corneal ulcers in children can be rapidly blinding. Children with measles are especially vulnerable. Urgent treatment and Vitamin A supplementation are both required.
Related articles:
WHO Guidelines for Management of Corneal Ulcers →
LASIK vs SMILE vs ICL: Which Eye Surgery is Right for You? →
📞 Book a Cornea Consultation with Dr. Ashraful Huq
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