Keratitis (marginal)

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Contents

Aetiology

Toxic or hypersensitivity response to bacterial (e.g. Staphylococcal) exotoxins

Predisposing factors

Bacterial (e.g. Staphylococcal) blepharitis
Current or recent upper respiratory tract infection
Condition tends to be recurrent

Symptoms of marginal keratitis

Ocular discomfort increasing to pain
Lacrimation
Red eye
Photophobia

Signs of marginal keratitis

Ulcer (stromal infiltrate with overlying epithelial loss) which may be round or arcuate, single or multiple, unilateral or bilateral, adjacent to limbus, and separated from limbus by interval of clear cornea
Ulcer stains with fluorescein
Hyperaemia and oedema of adjacent bulbar conjunctiva

Differential diagnosis

Other causes of ulceration of the peripheral cornea:

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

Regular lid hygiene for associated blepharitis (see CMG on Blepharitis (Lid Margin Disease))
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Sunglasses to ease photophobia
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Pharmacological

Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Systemic analgesia if needed: paracetamol, aspirin or ibuprofen
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Marginal keratitis is a self-limiting condition. Nevertheless it is conventional to give pharmacological treatment with a view to relieving symptoms and shortening the clinical course. However, this practice is not supported by evidence from clinical trials

The concurrent use of topical antibiotic (e.g. gutt chloramphenicol 0.5%) to reduce bacterial load, in addition to topical steroid (e.g. gutt prednisolone sodium phosphate 0.5% or gutt loteprednol 0.5% for two weeks) to reduce inflammation, is theoretically justified. However, the immunosuppressive effect of the steroid enhances the risk of infection
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Management category

B3: management to resolution
If persistent or recurrent, refer to ophthalmologist

Possible management by ophthalmologist

Microbiological cultures of lesion and lid margins
Investigation of patient’s immune status

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Chignell AH, Easty DL, Chesterton JR, Thomsitt J. Marginal ulceration of the cornea. Brit J Ophthalmol 1970;54:433-40

Ficker L, Seal D, Wright P. Staphylococcal infection and the limbus: study of the cell-mediated immune response. Eye (Lond). 1989;3 ( Pt 2):190-3

Plain language summary

This is a slightly unusual condition caused by a reaction to the presence of bacteria (germs) near the eye, for example on the edges of the eyelids. It is an inflammation, not an infection. Patients experience redness, watering and pain in the eye. A shallow ulcer develops at the edge of the cornea (the clear window of the eye), which can resemble a number of other conditions including infection. The condition usually resolves by itself, but it may be dealt with more quickly if steroid and antibiotic drops are prescribed. If blepharitis (inflammation of the edges of the eyelids) is the cause, this should be treated.

Keratitis (marginal)
Version 12
Date of search 25.07.21
Date of revision 30.09.21
Date of publication 26.01.22
Date for review 24.07.23
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