Complications
Severe keratitis may lead to corneal perforation due to stromal necrosis and thinning. This is an ocular emergency. A small perforation may be temporarily closed using cyanoacrylate glue. A bandage contact lens should be used to minimize friction and pain.
Severe keratitis may lead to corneal perforation due to stromal necrosis and thinning. This is an ocular emergency. A larger perforation is an indication for a graft. The purpose of penetrating keratoplasty performed in the acute setting is to maintain the integrity of the globe and to prevent endophthalmitis.
The graft often fails and scarring ensues, but another transplant may be attempted later when the infection is under control.
Spread of the infection to the intraocular cavities is a rare and dreaded complication of infectious keratitis that requires emergency intravitreal antimicrobial injection and/or vitrectomy. Visual prognosis is poor.
Scarring occurs as a result of inflammation and necrosis of the corneal stroma and limits visual acuity. Topical corticosteroids should be used to minimize corneal scarring that occurs due to stromal inflammation once the infection is controlled.
In bacterial keratitis, topical corticosteroids should usually be added as soon as the epithelial defect closes and the infiltrate appears to be responding well to the antibiotic treatment. Adjunctive treatment with topical corticosteroids in bacterial corneal ulcers does not provide benefit to the majority of patients in terms of improved visual acuity, infiltrate or scar size, time to re-epithelialization, and corneal perforation.[34] However, a small subgroup of patients with vision of counting fingers or worse, and those with large, central corneal ulcers may benefit from topical corticosteroid use with improvement in visual acuity.
Fungal keratitis should prompt more caution and the use of a topical ophthalmic should be delayed until the inflammatory infiltrate appears inactive.
In Acanthamoeba keratitis, use of topical corticosteroids is controversial due to the ability of the pathogen to enter a cystic phase resistant to most medications. The cysts can survive for months and may be reactivated by corticosteroids.
Treatment is generally continued until no change in the scar appearance is observed. Topical corticosteroids inhibit keratocyte proliferation and limit scar formation but need to be used with caution if active infection is still present. Penetrating keratoplasty may be necessary if an unacceptable amount of scarring remains.
Intraocular inflammation, as well as prolonged corticosteroid use, promotes cataract formation. Cataract extraction may be necessary after an episode of keratitis.
Glaucoma often accompanies active herpetic disease, but may be a complication of any infection causing intraocular inflammation. Topical glaucoma agents are used to control intraocular pressure, but in particularly severe cases a trabeculectomy or shunt placements may be required.
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