Indolent Ulcer: The Ulcer That Won’t Go Away

The cornea is the clear, transparent part of eye that lets light into the globe, much like the aperture in a camera . The outer layer comprises several layers of epithelial cells which protects the rest of the cornea.

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WHAT IS A CORNEAL ULCER?

Corneal ulcers are painful defects to one or more layers of the cornea – like a scrape wound on your skin.

  • Superficial ulcers involve just the outer layer – epithelium. Uninfected ulcers heal rapidly (within 5 to 7 days) as the epithelial cells grow into the defect and new skin sticks to the underlying tissue.
  • Deep ulcers extend into the middle layer – stroma – and take longer to heal. With deep ulcers, vision may be severely compromised or even lost. Often, intensive antibiotic therapy and surgery is required.

Ref: vcahospital.com

SOME CAUSES OF CORNEAL ULCERS
  • ­Trauma: scratches, abrasions, puncture wounds
  • Entropion: eyelids rolling inwards
  • Keratoconjunctiva sicca: dry eyes
  • Ectopic cilia hairs: fine eye lashes that point inwards
  • Foreign body: an object sitting on the eye surface, e.g. a seed
SIGNS and SYMPTOMS
  • Squinting
  • Excessive blinking
  • Tearing
  • Eye discharge
  • Pawing at the eye
  • Redness of the conjunctiva
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Corneal ulcers are painful. Your dog will be squinting & tearing. There may also be eye discharge.

fluorescein stain test

Most ulcers can be diagnosed using a fluorescein stain. A green, non-toxic dye is applied to the surface of the cornea. On normal healthy eyes, the dye does not stain the corneal layer. If there is an ulcer, the dye adheres to the ulceration and illuminates bright green under a special light.

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Fluorescent dye sticks to the area of the eye that has a wound

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A slit lamp allows our vet to evaluate your pet’s cornea with a high degree of magnification & resolution. It helps determine the extent & depth of an ulcer.

what is an Indolent corneal ulcer?

Indolent ulcers are usually superficial and non-infected but take a very long time to heal. New skin tries to grow over the ulcer but fails to adhere to the underlying tissue. With careful examination, a thin layer of loose tissue can be seen surrounding the ulcerated area.

Because the epithelial cells do not stick down to the tissue underneath, it is not possible for indolent ulcers to heal with just the use of antibiotic eye medications and artificial tears. Without appropriate treatment, indolent ulcers persist for months and cause ongoing discomfort.

 

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Indolent ulcers are also known as chronic epithelial erosion, refractory superficial ulcer, Boxer ulcer & epithelial basement membrane dystrophy.

corneal debridement

In order for an indolent ulcer to heal, the loose tissue needs to be removed in a process called debridement. After local anaesthetic eye drops are applied, dry sterile cotton-­tipped swabs are used to gently remove the loose abnormal epithelium surrounding the ulcer. This procedure may have to be repeated several times.

For the indolent ulcer to heal, loose epithelium needs to be removed so that normal healthy epithelium can grow & spread across the defect to allow healing.

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Sometimes, a surgery is performed to suture the third eyelid across the defect to help the cornea heal faster.

grid or linear keratotomy

If needed, grid or linear keratotomy is performed after debridement. A hypodermic needle is used to make superficial parallel incisions in the underlying exposed stroma. Simply put, we scratch the cornea with a needle to provide a rough surface for new epithelial cells to anchor onto and allow for proper healing.

 

Grid keratotomy can be performed on calm & cooperative patients like Bonsi under topical anaesthesia. Otherwise, sedation or general anaesthesia is necessary.

Medications will be dispensed to prevent infection and control pain, and your dog will return for reviews until the ulcer is fully healed. Surgery for an indolent ulcer may have to be considered if it fails to heal after several attempts at debridement and keratotomy.