Doctors Revision

Ophthalmology (Eye Conditions)

Keratitis

Inflammation of the cornea (the clear front part of the eye), often involving infection (bacterial, viral, fungal, parasitic) or trauma, leading to potential corneal ulceration and vision loss.

Also known as: Corneal Inflammation, Corneal Ulcer

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Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL to Eye Specialist/Hospital (HC4/H/RR) for ALL suspected cases of keratitis. This is an ophthalmic emergency.

Red flags

  • Eye pain.
  • Reduced vision.
  • Photophobia.
  • Corneal opacity / white spot / infiltrate.
  • Purulent discharge.
  • History of contact lens wear or trauma with red eye.
  • Positive fluorescein staining showing epithelial defect.

Signs and symptoms

  • Eye pain (often severe).
  • Photophobia (sensitivity to light).
  • Blurred or decreased vision.
  • Redness (often circumcorneal injection - ciliary flush).
  • Foreign body sensation.
  • Tearing (epiphora).
  • Corneal opacity (haziness or white spot on cornea).
  • Purulent discharge (bacterial).
  • Corneal staining with fluorescein reveals epithelial defect/ulcer (pattern may suggest cause, e.g., dendritic ulcer in Herpes Simplex).

Risk factors

  • Contact lens wear (especially overnight wear, poor hygiene).
  • Corneal trauma (abrasion, foreign body).
  • Dry eye disease.
  • Topical steroid use (can worsen certain infections, esp. fungal/herpetic).
  • Previous ocular surgery.
  • Immunosuppression (HIV, diabetes).
  • Vitamin A deficiency (contributes to corneal dryness/ulceration).
  • Exposure keratopathy (incomplete lid closure).

Diagnosis

Clinical assessment

Suspect based on symptoms (pain, photophobia, decreased vision) and signs (red eye, corneal opacity/defect). Assess visual acuity. Evert eyelids to check for foreign body. Fluorescein staining is essential to identify epithelial defects/ulcers and characteristic patterns (e.g., dendritic for herpes).

Investigations

  • Visual Acuity measurement.
  • Slit Lamp Examination (detailed view of cornea, anterior chamber) - specialist level.
  • Fluorescein Staining: Essential to visualize epithelial defects.
  • Corneal Scraping: For Gram stain, KOH prep (fungi), Culture & Sensitivity (bacterial, fungal). Performed by specialist.
  • Consider testing corneal sensation (reduced in herpetic keratitis).

Diagnostic criteria

Clinical suspicion confirmed by presence of corneal inflammation/opacity and/or epithelial defect demonstrated by fluorescein staining.

Differential diagnosis

  • Conjunctivitis (vision normal, cornea clear, diffuse redness).
  • Acute Angle-Closure Glaucoma (severe pain, fixed pupil, hazy cornea, high IOP).
  • Anterior Uveitis (ciliary flush, small pupil, cells/flare in anterior chamber).
  • Corneal abrasion (history of trauma, linear stain).
  • Scleritis/Episcleritis (sectoral or diffuse redness, deeper pain).

Management

Non-pharmacological management

  • Immediate Referral to eye specialist is crucial for most cases.
  • Avoid eye patching if infection suspected (creates warm, moist environment).
  • Stop contact lens wear immediately.
  • Sunglasses for photophobia.

Pharmacological treatment

  • Treatment depends on the suspected cause (requires specialist diagnosis/guidance):
  • - Bacterial Keratitis: (LOC: HC4/H/RR - requires intensive treatment)
  • - Intensive Topical Antibiotics: Often combination therapy initially (e.g., fortified Gentamicin/Tobramycin + fortified Cefazolin/Vancomycin OR Fluoroquinolone monotherapy like Moxifloxacin/Gatifloxacin). Instilled frequently (e.g., hourly day & night initially). UCG mentions Gentamicin + Chloramphenicol drops 1-2 hourly.
  • - Cycloplegic drops (e.g., Atropine 1% or Homatropine) TID to reduce pain (ciliary spasm) and prevent posterior synechiae.
  • - Viral Keratitis (Herpes Simplex - HSV): (LOC: HC4/H/RR)
  • - Topical Antiviral: Acyclovir eye ointment 3% applied 5 times daily.
  • - Oral Antiviral (Acyclovir, Valacyclovir) may be added for stromal keratitis or recurrent disease.
  • - Cycloplegic drops (Atropine/Homatropine).
  • - Topical Steroids: Sometimes used very cautiously by specialists ONLY for stromal keratitis AFTER infection controlled by antivirals - NEVER use steroids alone in suspected HSV epithelial keratitis.
  • - Fungal Keratitis: (LOC: H/RR)
  • - Topical Antifungal: Natamycin 5% suspension (preferred for filamentous fungi) OR Amphotericin B drops OR Voriconazole drops. Requires prolonged, intensive treatment.
  • - Systemic antifungals may be needed.
  • - Acanthamoeba Keratitis (Contact lens related): (LOC: RR) Specialist treatment with agents like PHMB or Chlorhexidine.
  • Supportive Treatment:
  • - Cycloplegic drops (Atropine 1%) TID for pain relief. (LOC: HC4/H)
  • - Oral analgesics.
  • - Vitamin A supplement (if deficiency suspected). (LOC: HC2+)
  • DO NOT USE TOPICAL STEROIDS if infection suspected, unless under definite specialist guidance after confirming diagnosis (especially for HSV/Fungal).

Monitoring

Requires close monitoring by eye specialist (daily initially for severe ulcers). Assess visual acuity, ulcer size/depth, infiltrate, anterior chamber reaction. Adjust treatment based on response and culture results.

Complications

  • Corneal scarring and permanent vision loss.
  • Corneal perforation.
  • Endophthalmitis (spread of infection inside the eye).
  • Secondary glaucoma.
  • Cataract formation.
  • Blindness.

Prevention

  • Proper contact lens hygiene and care.
  • Prompt treatment of corneal abrasions/foreign bodies.
  • Use of eye protection in hazardous environments.
  • Avoidance of traditional eye remedies.
  • Appropriate use of topical steroids (only under supervision).

Patient education

  • Explanation of keratitis as a serious corneal inflammation/infection.
  • Need for urgent specialist care.
  • Importance of frequent eye drop instillation as prescribed.
  • DO NOT wear contact lenses.
  • Avoid rubbing the eye.
  • Symptoms of worsening to report immediately.
  • Potential impact on vision and need for follow-up.

Uganda-specific notes

Bacterial and fungal keratitis are significant causes of corneal blindness, often related to trauma (agricultural) or traditional eye medicine use. Herpes simplex keratitis also occurs. Access to corneal scraping, culture, and specialized antifungals/antivirals is limited to referral centres. Prompt referral is critical.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.1.5

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