Summary
Definition
History and exam
Key diagnostic factors
- corneal infiltrate
- corneal ulcer
- dendritic or geographic epithelial lesion
- periocular skin lesions
- multifocal corneal ulcer with feathery edges
- corneal perineuritis
- interstitial keratitis
Other diagnostic factors
- redness
- pain
- increased lacrimation
- lid edema
- discharge
- decreased visual acuity
- photophobia
- high intraocular pressure
- history of herpes simplex virus or varicella zoster virus infection
- multiple old stromal scars
- iris transillumination
- corneal hypoesthesia
Risk factors
- contact lens wear
- corneal trauma
- corneal abrasion/erosion
- recurrent corneal erosions
- immunocompromise
- history of autoimmune disease
- trichiasis
- blepharitis
- dry eye
- poor eyelid function
- previous herpetic disease
- exposure keratitis
- contaminated water exposure
- topical corticosteroid use
- topical anesthetic use
- previous eye surgery
Diagnostic tests
1st tests to order
- corneal scraping: microscope slide
- corneal scraping: cultures and sensitivity
Tests to consider
- CBC
- HIV test
- autoimmune testing
- corneal scraping: polymerase chain reaction (PCR) testing
Treatment algorithm
bacterial (presumed): high risk
bacterial
herpetic
fungal
protozoan (Acanthamoeba)
noninfectious keratitis
recurrent herpetic infection
corneal scarring impairing vision
Contributors
Authors
Kraig S. Bower, MD
Director of Refractive Surgery
The Wilmer Eye Institute
The Johns Hopkins Hospital
Baltimore
MD
Disclosures
KSB declares that he has no competing interests.
Frank S. Hwang, MD
Assistant Professor
Cornea, External Disease and Refractive Surgery
Loma Linda University Eye Institute
Loma Linda University
Loma Linda
CA
Disclosures
FSH declares that he has no competing interests.
Acknowledgements
Dr Kraig S. Bower and Dr Frank S. Hwang would like to gratefully acknowledge Dr Julie Freidlin Leigh, a previous contributor to this topic.
Disclosures
JFL declares that she has no competing interests.
Peer reviewers
Matilda Chan, MD, PhD
Proctor Fellow in Cornea and External Disease
Francis I. Proctor Foundation
University of California
San Francisco
CA
Disclosures
MC declares that she has no competing interests.
Parwez Hossain, MD, PhD, FRCOphth, FRCS (Ed)
Senior Lecturer & Consultant
Ophthalmic Surgeon
Division of Infection, Inflammation & Immunity
University of Southampton
Southampton General Hospital
Southampton
UK
Disclosures
PH declares that he has no competing interests.
References
Key articles
Rhee MK, Ahmad S, Amescua G, et al. Bacterial keratitis preferred practice pattern®. Ophthalmology. 2024 Apr;131(4):P87-133.Full text Abstract
Herretes S, Wang X, Reyes JM. Topical corticosteroids as adjunctive therapy for bacterial keratitis. Cochrane Database Syst Rev. 2014 Oct 16;(10):CD005430.Full text Abstract
Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev. 2015 Jan 9;(1):CD002898.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Corneal abrasion
- Vernal keratoconjunctivitis with shield ulcer
- Dry eye or exposure keratitis
More DifferentialsGuidelines
- Bacterial keratitis preferred practice pattern
- Cornea/external disease summary benchmarks - 2023
More GuidelinesPatient information
Herpes simplex eye infection
More Patient information
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