Case: Bacterial Keratitis
Ann Marie Tabucan-Isaga
´Ms. Maria Makiling
´35 / Female
´From Davao City
´CC: Sudden eye
pain with blurring
of vision, OS 1 day
PTC
How do you
extract the
history of the
present
illness?
History of Present Illness
• About 2 days PTC, patient noted to have eye redness on her
left eye associated with mucopurulent discharge and light
sensitivity.
• 1 day PTC, she noted
slight blurring of vision
on her left eye
associated with
eye pain. No medication taken/applied. Hence, consultation.
Past Medical History Family History
´Patient is… ´ Unremarkable
´ (-) HPN
´ (-) DM
´ (-) BA
´No history of any eye surgeries
´No Food and drug allergies
Social History
´ Patient is a contact lens wearer for 10-years
´ She is a….
´Non-smoker
´Occasional alcoholic beverage drinker
OCULAR OD OS
Examination VA
PH
IOP
Eyelid
Conjunctiva
Sclera
Cornea
Anterior
Chamber
Pupils
Lymphadenopathy (???) Lens
OCULAR OD OS
Examination VA 20/100 HM w/ GLP
PH 20/20 N.I.
IOP
Eyelid
Conjunctiva
Sclera
Cornea
Anterior
Chamber
Pupils
Lens
OCULAR OD OS
Examination VA 20/100 HM w/ GLP
PH 20/20 N.I.
IOP 12 soft globe
Eyelid
Conjunctiva
Sclera
Cornea
Anterior
Chamber
Pupils
Lens
OCULAR OD OS
Examination Eyelid normal
Slightly
hyperemic
Congestion w/
Conjunctiva normal mucopurulent
discharge
Sclera normal Non-icteric
Cornea
Anterior
Chamber
Pupils
Lens
OCULAR
Examination OD OS
• Central epithelial
defect w/
stromal
infiltrates
Cornea normal
• Stromal edema
and folds
• (+) fluorescein
dye uptake
Anterior • Hypopyon
normal
Chamber • AC cells & Flares
OCULAR
Examination OD OS
Normal Normal
Pupils ERTL ERTL
(-) RAPD (-) RAPD
Lens Clear Clear
Lymphadenopathy (-)
What are the PERTINENT FINDINGS ???
Specify them from the basic
information of the patient to
the chief complaint, histories
and pertinent ocular
findings…
PERTINENT • Ms. Maria Makiling
FINDINGS
• 35 / Female
• Davao City
• CC: Sudden eye pain with
blurring of vision, OS 1 day
PTC
• Associated Sx: eye redness,
mucopurulent discharge,
photophobia 2 days PTC
PERTINENT • Unremarkable Past Medical
FINDINGS and Family histories
• (+) contact lens wearer for 10
years now
OCULAR OD OS
Examination VA 20/100 HM w/ GLP
PH 20/20 N.I.
IOP 12 soft globe
Eyelid
Conjunctiva
Sclera
Cornea
Anterior
Chamber
Pupils
Lens
OCULAR OD OS
Examination
Slightly
Eyelid normal
hyperemic
Congestion w/
Conjunctiva normal mucopurulent
discharge
Sclera normal Non-icteric
OCULAR
Examination OD OS
• Central epithelial
defect w/
stromal
infiltrates
Cornea normal
• Stromal edema
and folds
• (+) fluorescein
dye uptake
Anterior • Hypopyon
normal
Chamber • AC cells & Flares
What are the Differential Diagnosis???
Give at least 2 differential
diagnosis…
DIAGNOSIS
Bacterial Keratitis, etiology to
consider Pseudomonas
aeruginosa, OS
Laboratory Work-Up ???
Do you think we
need to have
laboratory tests
done?
Laboratory Work-Up
ü CBC
ü Corneal scrapping for Gram stain, Geimsa stain, KOH
culture
* Corneal biopsy (if necessary)
DISCUSSION
Bacterial
Keratitis
Clinical Features:
´Most common form of corneal infection causing
central microbial keratitis
´3 most frequent etiologic organisms based on
local data:
1. Pseudomonas aeruginosa
2. Moraxella species
3. Streptococcus pneumoniae
Clinical Features:
´Other causes: Staphylococcus aureus and
epidermidis, Streptococcus viridans, Nocardia
asteroids, Haemophilus influenza, Nontuberculous
Mycobactrium, Alkaligenes faecalis, Klebsiella sp.,
Enterobacter sp., Proteus sp., and Escherichia coli
´Trauma is the most common predisposing factor in
the Philippines
Clinical Features:
´Non-traumatic related factors are ocular surface
disease, bullous keratopathy, exposure
keratopathy, soft contact lens wear, malnutrition
(Vitamin A deficiency) and corneal surgery
´In developing countries and in highly urbanized
cities, soft contact lens wear and pre-existing ocular
surface disease are the major risk factors
Clinical Features:
´Symptoms: acute onset of pain, redness, blurring of
vision, photophobia, mucopurulent discharge
´Signs: conjunctival congestion, corneal epithelial
defect with dense stromal infiltrates, stromal edema
and Descemet’s membrane folds, hypopyon,
anterior chamber cells and flares, chemosis, lid
swelling, immune ring of Wessely, corneal thinning,
melt and perforation, scleritis
Differential Diagnosis:
1. Fungal Keratitis
2. Acanthamoeba Keratitis
3. HSV Stromal Keratitis
4. Marginal Keratitis
5. Peripheral Ulcerative Keratitis
Evaluation:
• Complete history with attention to onset and
duration
Evaluation:
• Complete history with attention to onset and
duration
ü Corneal ulcer d/t Pseudomonas aeruginosa has the most rapid onset; can lead to
corneal melt and perforation in less than 5 to 7 days)
ü Trauma
ü Type of foreign body
ü Soft contact lens wear including cosmetic contact lens
ü Previous corneal surgeries (Keratoplasty, LASIK)
ü Pre-existing ocular surface disease (severe dry eye)
ü Corneal disease (Bullous keratopathy)
ü Lid problems (Blepharitis, Lagophthalmos)
ü NLDO and Dacryocystitis
ü Chronic glaucoma
ü Systemic illness (Vit.A deficiency, Measles)
ü Previous treatment and medications
Evaluation:
• Complete history with attention to onset and
duration
• Complete eye exam with attention to the
characteristic of the borders of the ulcer, size of the
ulcer and infiltrates, depth of infiltrates, stromal
edema, areas of thinning, height of hypopyon,
characteristic of discharge, and scleral involvement
Evaluation:
• Corneal scrapping should be done prior to starting
topical antibiotics.
• If on topical antibiotics, withhold antibiotic drops for 12
hours prior to scrapping
• Use sterile Kimura spatula or sterile disposable
surgical blade (#15) to scrape the margin and base
of the corneal ulcer. May use hypodermic needle
to access deepseated infiltrates
• Corneal scrappings should be stained with Gram.
Request for acid-fast stain if warranted.
Evaluation:
• Culture corneal scrapping specimens in blood agar,
brain heart infusion and chocolate agar. Request
for Lowenstein-Jensen if suspecting Mycobacteria.
• Submit contact lens, case and solution for culture.
Management:
• Discontinue contact lens use
• If empirical therapy, start with newer generation
topical fluoroquinolones like Moxifloxacin,
Levofloxacin, Gatifloxacin, 1 drop q/hourly for 24-48
hours then taper slowly according to clinical
response
• Always adjust antibiotics based on Gram stain and
culture results
Management:
• Newer generation fluoroquinolone has better
activity against Gram(+) bacteria like
Streptococcus and Staphylococcus
• For Pseudomonas aeruginosa, use newer
generation Fluoroquinolone combined with topical
Tobramycin
• Topical cycloplegic (Atropine sulfate 1%) 1 drop TID
Management:
• The use of topical steroid during the active phase is
controversial. Topical steroid should be used
judiciously and only after resolution of the corneal
epithelial defect.
• Consider subconjunctival antibiotic injection only if
there is poor compliance to topical treatment.
• Consider oral Doxycycline 100mg BID for anti-
collagenase effect.
Management:
• For corneal thinning, melt and perforation, consider
cyanoacrylate tissue glue application, conjunctival
flap, patch graft, lamellar or penetrating
keratoplasty.
• For sterile descemetocele, consider use of bandage
soft contact lens.
Follow Up:
• Every other day during the first week of treatment.
• Except signs of healing only after 2 to 3 days of
treatment.
• Monitor healing by measuring size of epithelial
defect and infiltrates.
• If improvement is noted, continue initial therapy.
• If no improvement is seen, check compliance to
treatment and culture results.
• Consider hospital admission to improve compliance
Follow Up:
• Consider drug toxicity if there is delayed epithelial
healing, increased irritation and redness.
• Do repeat corneal scraping or corneal biopsy to
consider nonbacterial causes if there is poor
response despite appropriate therapy
Prognosis:
• Highly dependent on etiology, severity of disease,
accuracy of diagnosis and timing of treatment.
• Resolution will leave a corneal scar (with or without
vascularization) and may need optical keratoplasty
to improve vision.
• May develop secondary angle closure glaucoma
and cataract.
Pearls:
üPseudomonas keratitis is almost always associated
with soft contact lens wear and hospital acquired
infection. It is characterized by rapid progression,
brush-like ulcer margins and muco-purulent
discharge.
üStreptococcal and Moraxella keratitis have distinct
ulcer margin and advancing infiltrates and can be
difficult to differentiate clinically.
Pearls:
üStreptococcus is usually associated with eye
trauma, bullous keratopathy, exposure keratopathy,
retained sutures or foreign body; nasolacrimal duct
obstruction and dacryocystitis.
üStaphycoccal and Moraxella keratitis are usually
associated with anterior blepharitis and angular
blepharitis, respectively.
Pearls:
üSecondary endophthalmitis due to bacterial
keratitis is very rare. Presence of hypopyon does
not always mean there is endophthalmitis
