Corneal ulcer — red flags and referral priorities
Structured for Australian optometry practice. Source-cited clinical reference; not individually clinician-reviewed.
Clinical decision support only
OptoGuide™ supports professional judgement and does not diagnose or replace clinician responsibility.
Quick answer
- Corneal ulcer suspicion is driven by pain, photophobia, reduced vision, focal epithelial defect, infiltrate, or stromal haze.
- Contact lens wear, central location, rapid symptom progression, and anterior chamber reaction increase urgency.
- A corneal ulcer is sight-threatening and must not be observed — treat it as infective until an infective cause has been assessed and considered unlikely.
- A suspected corneal ulcer raises the same concern as suspected microbial keratitis — the two are one presentation, not two urgencies.
Common causes
- Microbial keratitis with focal corneal ulceration.
- Contact lens-related corneal ulcer.
- Herpetic corneal ulcer or neurotrophic epithelial breakdown.
- Peripheral ulcerative or inflammatory corneal lesion requiring differentiation.
Red flags (must not miss)
- Reduced vision or marked photophobia.
- Central ulcer, dense infiltrate, or stromal haze.
- Anterior chamber reaction, hypopyon, or rapid progression.
- Contact lens wear or overnight wear history.
- Corneal thinning or poor epithelial healing.
Use OptoGuide™ to guide this decision during consult.
What to check
- Visual acuity and pain severity.
- Ulcer size, depth, location, and edge characteristics.
- Fluorescein staining and surrounding infiltrate pattern.
- Anterior chamber reaction and corneal thinning risk.
- Contact lens history, trauma, and exposure history.
When to refer
- Suspected corneal ulcer or microbial keratitis: same-day ophthalmology assessment. Do not observe and do not treat empirically without specialist input.
- Escalate to emergency assessment if there is hypopyon, corneal thinning, perforation risk, or rapidly worsening pain and vision.
- A contact lens peripheral ulcer is a different, sterile lesion and is not this pathway — distinguish it before de-escalating.
- Urgent corneal review for central lesions, vision change, hypopyon, or thinning risk.
- Do not observe a likely ulcer without specialist input.
Initial management
- Frame the lesion as corneal ulceration first, then refine the differential.
- Record acuity, lesion location, stain pattern, and chamber findings clearly.
- Escalate early when the cornea is threatened or the lesion is not clearly superficial and low risk.
Clinical basis
This guidance reflects standard optometric clinical reasoning based on:
- Australian optometry clinical practice patterns
- Australian medicines regulation and PBS prescribing context
- Common ophthalmology referral standards
- Evidence-based clinical training and practice
Use OptoGuide™ during consult for structured clinical guidance.