Corneal infections can lead to corneal scarring and blindness if not diagnosed quickly and managed appropriately. Injuries, lid malpositions, topical medications like steroids, contact lens wear, and autoimmune diseases like rheumatoid arthritis are the various factors responsible for corneal ulcers [1,2]. A corneal ulcer is the second most important cause of infective blindness throughout the world, after trachoma. Also, it is the main cause of visual impairment and ocular morbidity in developing countries. Monocular blindness due to corneal diseases is seen in 1.5-2 million new cases annually worldwide. In India, about 6.8 million are blind because of corneal diseases [3,4].

Farming is the main occupation in rural parts of India, where accidental vegetative trauma to the cornea is common. Persons involved in other occupations like factory work, construction work, carpentry, and stone cutting are also more prone to corneal injuries.

Majority patients of infectious keratitis present as a corneal ulcer with complaints of redness, pain, watering, photophobia, and diminution of vision. These cases pose a challenge to treating ophthalmologist as far as diagnosis and management are concerned. Thus optimal treatment in time can reduce serious complications like corneal perforation, endophthalmitis, or even panophthalmitis [5].p>

The prevalence of corneal ulcers varies according to the climatic conditions, occupations, and socioeconomic status of the people in different parts of the world [6].

The present study was conducted to know the demographic, clinical, and microbiological pattern of infective corneal ulcers in patients presented to our institute. This study highlights the importance of demographic risk factors, typical presenting features with diagnostics involved in infective corneal ulcer cases in western Maharashtra region.

It was a retrospective analytical study done at a tertiary care hospital. The study involved 68 eyes of 68 patients, presented with an infective corneal ulcer from May 2017 to April 2019(2 years). The medical records of patients with infective corneal ulcers were analyzed.

The corneal ulcer was diagnosed by slit-lamp examination showing greyish haze or loss of clarity in cornea and epithelial defect after staining with fluorescein strip. Slit-lamp photographs and color-coded diagrams were recorded for documentation and to assess the progress. It is also important in medicolegal cases with h/o trauma

Then after putting 0.5 % proparacaine eyedrop to anesthetize the eye, corneal scraping was taken by an ophthalmologist under a slit lamp view. By using a 15 no. surgical blade the edge of the ulcer was scrapped and the sample was collected on two glass slides. One slide was sent for Gram staining to detect bacterias and other for 10% KOH mount for the detection of fungal hyphae. The viral corneal ulcer was diagnosed clinically if characteristic dendritic or geographic pattern associated with loss of corneal sensations and the presence of skin lesions were seen. Acanthamoeba ulcer is diagnosed if ring-shaped stromal infiltrates with hypopyon are observed [7].

Statistical analysis: The data was arranged in an MS Excel sheet and statistical analysis was done. The number and percentage of patients according to age groups, gender and occupations were calculated. Also, the percentage of patients with different clinical features of corneal ulcer and microbiological etiology was calculated.

Sixty-eight eyes of 68 patients with infective corneal ulcers were included in this study. The age group of patients involved in the study ranged from 18 to 90 years. The majority (62 i.e. 88.23%) patients were in the age group of 26 to 70 years (Table 1), mean age was 50.81 years and male to female ratio was 1.61:1 (Table 2). Twenty-eight patients (41.17%) were farmers by occupation and 12 patients (17.64%) were construction workers (Table 3).

Thirty-two patients (47.05%) had to present best-corrected visual acuity (BCVA) of less than 6/60 and only 6 patients had BCVA of 6/9 to 6/6 (Table 4). Most of the patients 37 (54.41%) were presented with corneal ulcers of size less than 5 mm and hypopyon was seen in 19 (27.84%). Central and paracentral ulcers were seen in 57 patients (83.82%) (Table 5).

Out of 68 eyes, 41 eyes had conclusive scraping reports on Gram stain and 10% KOH mount. Fungal etiology was found in 21 (26.92%) compared to bacterial etiology in 16 (20.51%) and 4 cases

Infective corneal ulcer causes significant ocular morbidity and often blindness. A proper history and clinical examination in detail are very important for the diagnosis and management of corneal ulcers [7].

In the present study, male preponderance was seen for infective corneal ulcers. Male to female ratio of 1.61:1 was seen. The age group most affected for infective corneal ulcers was 26 to 70 years which is comparable with other similar studies by Katara RS et al, Ranjini CY et al and Gopinathan U et al. [4,7,8].

By occupation, the majority of patients in the present study were farmers (28 i.e. 41.17%) followed by construction workers ( 12 i.e. 17.64%) and factory workers (4 i.e. 5.88%). So occupational injuries were seen in the majority of the patients (44 i.e. 64.7%). In similar studies by Mohod et al and Srinivasan et al, farming was found to be the main occupation in the majority of patients with corneal ulcers [10,11]. Gopinathan U et al reported that agricultural workers have 1.33 times greater risk of developing infective Keratitis. Farmers are more prone to vegetative trauma, which is the leading predisposing factor of infective corneal ulcers in developing countries [12]. Also, construction workers, factory workers, and welders are prone to accidental superficial and stromal corneal foreign bodies leading to infective corneal ulcers.

Thirty-two patients (47.05%) at presentation had BCVA below 6/60. A similar study by Khadka S et al had 41% of patients with microbial keratitis BCVA of below 6/60 [18].

In the present study, 37 eyes (54.41 %) had corneal ulcers measuring less than 5 mm and 31 ( 30.88%) had more than 5 mm. Khare P et al and Puri LR et al in their study noted corneal ulcer of less than 5 mm size in 74.53 % and 78.3% respectively and more than 5mm seen in 20.37% and 21.60% respectively [13,14]. In the present study, the involvement of central and paracentral cornea was seen in 57 ( 83.83% ) patients, while peripheral corneal involvement was noted in

In western Maharashtra, as farming is the main occupation where vegetative injuries are more common, the prevalence of fungal corneal ulcers is more compared to other causative microorganisms. People working at construction sites and in factories are also prone to ocular injuries leading to an infective corneal ulcer. Gram stain and KOH mount of corneal scrapings are simple and quick OPD investigations helpful in the detection of the type of microorganisms.

Detailed history, clinical examination, and lab investigations of scrapings in cases of infective corneal ulcers are essential to know the clinical and microbiological pattern.

The people working in fields, factories, and construction should be educated regarding the protection of eyes and need of urgency to visit an ophthalmologist in case of any eye injury. In suspected infective corneal ulcer patients whenever possible anti-microbials should not be started before gram stain and KOH mount of corneal scraping to avoid masking of infection. Self-treatment and home remedies should be avoided in any eye complaint.

Dr. Rajesh B. Gotekar: Concept, design, the definition of intellectual content, literature search. Dr. Hanumant R. Mandlik: Statistical analysis, manuscript preparation. Dr. Rasika D. Konduskar: Data acquisition, Data analysis. Dr. Ajit K. Joshi: Manuscript editing and manuscript review

The authors would like to express their gratitude to the microbiology department and to patients who joined in this study willingly.