ICO International Clinical Guidelines:

Bacterial Keratitis (Initial Evaluation)

On this page:

• Initial exam history
  
  
• Initial physical exam
  
  
• Diagnostic tests
  
  
• Care management
  
  
• Follow-up evaluation
  
  
• Patient education

(You can also download this Guideline as a PDF file - 100 KB)

Initial Exam History

• Ocular symptoms [A:III]
  
  
• Contact lens history [A:II]
  
  
• Review of other ocular history [A:III]
  
  
• Review of other medical problems and systemic medications [A:III]
  
  
• Current and recently used ocular medications [A:III]
  
  
• Medication allergies [A:III]

Initial Physical Exam

• Visual acuity [A:III]
  
  
• General appearance of patient [B:III]
  
  
• Facial examination [B:III]
  
  
• Eyelids and eyelid closure [A:III]
  
  
• Conjunctiva [A:III]
  
  
• Nasolacrimal apparatus [B:III]
  
  
• Corneal sensation [A:III]
  
  
• Slit-Lamp biomicroscopy
  
  
  • Eyelid margins [A:III]
    
    
  • Conjunctiva [A:III]
    
    
  • Sclera [A:III]
    
    
  • Cornea [A:III]
    
    
  • Anterior chamber [A:III]
    
    
  • Anterior vitreous [A:III]
    
    
• Contralateral eye [A:III]

Diagnostic Tests

• Manage majority of community-acquired cases with empiric therapy and without smears or cultures.
  
  
• Indications for smears and cultures:
  
  
  • Sight-threatening or severe keratitis of suspected microbial origin prior to initiating therapy [A:III]
    
    
  • A large corneal infiltrate that extends to the middle to deep stroma [A:III]
    
    
  • Chronic in nature [A:III]
    
    
  • Unresponsive to broad spectrum antibiotic therapy [A:III]
    
    
  • Clinical features suggestive of fungal, amœbic, or mycobacterial keratitis [A:III]
    
    
• The hypopyon that occurs in eyes with bacterial keratitis is usually sterile, and aqueous or vitreous taps should not be performed unless there is a high suspicion of microbial endophthalmitis. [A:III]
  
  
• Corneal scrapings for culture should be inoculated directly onto appropriate culture media to maximize culture yield. [A:III] If this is not feasible, place specimens in transport media. [A:III] In either case, immediately incubate cultures or take promptly to the laboratory. [A:III]

Care Management

• Topical antibiotic eye drops are preferred method in most cases. [A:III]
  
  
• Use topical broad-spectrum antibiotics initially in the empiric treatment of presumed bacterial keratitis. [A:III]
  
  
• For central or severe keratitis (e.g., deep stromal involvement or an infiltrate larger than 2 mm with extensive suppuration), use a loading dose (e.g., every 5 to 15 minutes for the first 1 to 3 hours), followed by frequent applications (e.g., every 30 minutes to 1 hour around the clock). [A:III] For less severe keratitis, a regimen with less frequent dosing is appropriate. [A:III]
  
  
• Use systemic therapy for gonococcal keratitis. [A:II]
  
  
• In general, modify initial therapy when there is a lack of improvement or stabilization within 48 hours. [A:III]
  
  
• For patients treated with ocular topical corticosteroids at time of presentation of suspected bacterial keratitis, reduce or eliminate steroids until infection has been controlled. [A:III]
  
  
• When the corneal infiltrate compromises the visual axis, may add topical corticosteroid therapy following at least 2 to 3 days of progressive improvement with treatment with topical antibiotics. [A:III] Continue topical antibiotics at high levels with gradual tapering. [A:III]
  
  
• Examine patients within 1 to 2 days after initiation of topical corticosteroid therapy. [A:III]

* Adapted from the American Academy of Ophthalmology Summary Benchmarks, November 2008 (www.aao.org)

(You can also download this Guideline as a PDF file - 100 KB)

Next: Bacterial Keratitis (Management recommendations)

Also see:

• International Clinical Guidelines (Preface)
  
  
• Introduction to the Guidelines
  
  
• List of Guidelines