- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
Keratitis (marginal)
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Contents
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 work within their scope of practice, and where necessary seek further advice or refer the patient elsewhere
Non pharmacological
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)
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 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 in secondary care or local primary/community pathways where available
Additional guidance may be available
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
Summary
What is Marginal Keratitis?
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 may develop at the edge of the cornea (the clear window of the eye), which can resemble a number of other conditions including infection.
How is Marginal Keratitis managed?
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 typically the cause, this should be treated. Sunglasses will help with any light sensitivity.
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
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines