Aetiology

Inflammatory response of the peripheral cornea to bacterial (e.g. Staphylococcal) exotoxins rather than direct inoculation.

Predisposing factors

Bacterial (e.g. Staphylococcal) blepharitis or meibomitis
Condition tends to be recurrent

Symptoms of marginal keratitis

Ocular discomfort (foreign body sensation, increasing to pain)
Lacrimation
Red eye
Photophobia

Signs of marginal keratitis

Stromal infiltrate, which may be round or arcuate, single or multiple, unilateral or bilateral. Infiltrates are typically adjacent to the limbus and separated by an interval of clear cornea.
Overlying epithelial loss may occur resulting in ulcer formation which stains with fluorescein
Ulcer stains with fluorescein
Hyperaemia of adjacent limbus
Hyperaemia and oedema of adjacent bulbar conjunctiva

Differential diagnosis

Other causes of ulceration of the peripheral cornea:

• microbial keratitis
• contact lens-associated corneal infiltrative keratitis
• contact lens associated peripheral ulcer
• rosacea keratitis
• peripheral ulcerative keratitis e.g. Mooren’s ulcer
• corneal phlyctenulosis
• Terrien’s marginal degeneration
• marginal herpes simplex keratitis

Management by optometrist

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

Initial management of marginal keratitis should focus on addressing predisposing factors

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)

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 and commonly used. However, the immunosuppressive effect of the steroid enhances the risk of infection
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

NB All patients on topical steroid drops or ointment should have their intraocular pressures monitored (see Clinical Management Guideline on Steroid Glaucoma)

Management category

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

Possible management by ophthalmologist

Microbiological cultures of lesion and lid margins if uncertainty of diagnosis.

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

Mondino BJ. Inflammatory diseases of the peripheral cornea. Ophthalmology. 1988;95(4):463-72

Keratitis (marginal)
Version 13
Date of search 02.10.23
Date of revision 27.11.23
Date of publication 23.01.24
Date for review 01.10.25
© College of Optometrists