Keratitis (marginal)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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

  • Ocular discomfort increasing to pain
  • Lacrimation
  • Red eye
  • Photophobia

Signs

  • 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:

  • Microbial keratitis
  • Contact lens-associated corneal infiltrate
  • Rosacea keratitis
  • Mooren’s ulcer
  • Peripheral keratitis associated with rheumatoid arthritis or other systemic collagen vascular disease
  • 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

Non pharmacological

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)
  • Systemic analgesia if needed: paracetamol, aspirin or ibuprofen
  • Regular lid hygiene for associated blepharitis (with a view to limiting recurrence)

(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. 
  • The concurrent use of topical antibiotic (e.g. chloramphenicol) to reduce bacterial load, in addition to topical steroid (e.g. prednisolone) 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
  • Topical and/or systemic antibiotic treatment of blepharitis

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

Lay 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 10
Date of search 21.06.17
Date of revision 20.07.17
Date of publication 06.04.18
Date for review 20.06.19
© College of Optometrists 

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