CLINICAL MANAGEMENT GUIDELINES

Microbial keratitis (bacterial, fungal)

Aetiology

Predisposing factors

Symptoms

Signs

Differential diagnosis

The commonest bacterial corneal pathogens are:

Pseudomonas sp. (Gram -ve)
Staphylococcus sp. (Gram +ve)
Streptococcus sp. (Gram +ve)
other Gram -ve organisms
Note: severe contact lens-related infections tend to be Gram -ve
Fungal keratitis is rare in the UK but common in some other parts of the
world. The commonest fungal corneal pathogens are:
Candida sp. (yeast-like)
Fusarium sp. (filamentous)
Bacterial keratitis is usually associated with one or more of the following:
contact lens wear, especially soft lenses worn overnight
ocular surface disease, including:
corneal exposure
corneal anaesthesia
corneal decompensation
chronic epithelial defect
neurotrophic keratopathy, e.g. secondary to HSK or
diabetes
tear deficiency
ocular trauma or surgery, including loose or broken sutures
immune compromise
topical steroid use
lid margin infection (usually Staphyloccocal)
Fungal keratitis (filamentous) is usually secondary to trauma involving
organic material; it can also be contact lens or solution related
Fungal keratitis (yeast-like) usually complicates ocular surface disease or
immune compromise
Pain, moderate to severe (acute onset, rapid progression)
Redness, photophobia (may be severe), discharge, blurred vision
(especially if lesion on visual axis)
Awareness of white or yellow spot on cornea
Usually unilateral
Lid oedema
Epiphora
Discharge (mucopurulent or purulent)
Conjunctival hyperaemia and infiltration
Corneal lesion usually single (central or mid-peripheral)
excavation of epithelium, Bowmans layer, stroma (tissue
necrosis)
stromal infiltration beneath lesion
stromal oedema with folds in Descemets membrane
endothelial fibrin plaque beneath lesion
Anterior chamber activity (flare, cells, hypopyon or coagulum if severe)
Fungal keratitis produces similar signs to bacterial keratitis, though the
infection may develop more slowly (however Fusarium infection can
progress rapidly and invasively)
Corneal infiltrative lesions (contact lens related or marginal keratitis; see
separate Clinical Management Guidelines)
peripheral, small (0.5-1.5 mm) with less anterior chamber
response

Microbial keratitis (bacterial, fungal)

Version 9 22.07.13
College of Optometrists

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CLINICAL MANAGEMENT GUIDELINES

Microbial keratitis (bacterial, fungal)

not a marker for increased risk of bacterial infection
Acanthamoeba keratitis (see Clinical Management Guideline)
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Warn contact lens wearers not to discard their lenses or lens cases, but
to retain them for culture
Pharmacological
None
Management Category A1: emergency referral to an Ophthalmologist; no intervention. Severe
sight-threatening condition. Telephone on-call Ophthalmologist.
Possible management by Ophthalmologist
Possible admission to hospital when good compliance is unlikely, or for
overnight treatment of severe infections (axial lesions, lesions 6mm or
more in diameter, or with 50% or more stromal thinning)
Identification of organism by corneal scrape, culture and determination of
antibiotic sensitivities
(Polymerase chain reaction [PCR] technique may be used to identify
fungal organisms)
Intensive (round the clock) topical antibiotics for bacterial infections
dual therapy: the recommended fortified agents (a cephalosporin
and an aminoglycoside) are not commercially available
monotherapy: fluoroquinolones (e.g. ofloxacin, levofloxacin) are
adequate for most cases but not for resistant species of
Staphylococcus aureus and Pseudomonas aeruginosa
Systemic antibiotics if lesion close to limbus
(Fungal infections usually require combined topical and systemic
therapy. Clinical strategies continue to evolve. The necessary drugs are
usually available from the Manufacturing Pharmacy of Moorfields Eye
Hospital, London (Moorfields Pharmaceuticals))
Cycloplegia
Hypotensive agents for secondary glaucoma
Topical steroids (only when infection controlled) see Evidence Base
Evidence base
The Ofloxacin Study Group. Ofloxacin monotherapy for the primary
treatment of microbial keratitis: a double-masked, randomised, controlled
trial with conventional dual therapy. Ophthalmology 1997;104:1902-9
Authors conclusions: The treatment outcomes with ofloxacin
monotherapy compared favourably with conventional therapy and were
associated with less toxicity
(The Oxford 2011 Levels of Evidence = 2)
Suwan-apichon O, Reyes JMG, Herretes S, Vedula SS, Chuck RS.
Topical corticosteroids as adjunctive therapy for bacterial keratitis.
Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.:
CD005430. DOI: 10.1002/14651858.CD005430.pub2
Authors conclusions: There are no good quality randomized trials
evaluating the effects of adjunct use of topical corticosteroids in bacterial
keratitis. The only randomized trial we identified in the literature suffered
from major methodological inadequacies.
(The Oxford 2011 Levels of Evidence = 2)
Microbial keratitis (bacterial, fungal)
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College of Optometrists

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