Editing Keratitis

{{Short description|Inflammation of the cornea of the eye}}
{{More citations needed|date=September 2022}}
{{Infobox medical condition (new)
| name          = Keratitis
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| image         = Clare-314.jpg
| caption       = An eye with non-ulcerative sterile keratitis.
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| field         = [[Ophthalmology]]
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'''Keratitis''' is a condition in which the [[human eye|eye]]'s [[cornea]], the clear dome on the front surface of the eye, becomes [[inflammation|inflamed]].<ref>{{Citation|last=Singh|first=Prabhakar|title=Keratitis|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK559014/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32644440|access-date=2021-11-02|last2=Gupta|first2=Abhishek|last3=Tripathy|first3=Koushik}}</ref> The condition is often marked by moderate to intense pain and usually involves any of the following symptoms: pain, impaired eyesight, [[photophobia]] (light sensitivity), [[Red eye (medicine)|red eye]] and a 'gritty' sensation.<ref>{{Cite news|url=http://www.uic.edu/com/eye/PatientCare/EyeConditions/Keratitis.shtml|title=Ophthalmology & Visual Sciences|work=Chicago Medicine|access-date=2018-04-29|language=en-US}}</ref> Diagnosis of infectious keratitis is usually made clinically based on the signs and symptoms as well as eye examination, but corneal scrapings may be obtained and evaluated using [[microbiological culture]] or other testing to identify the causative pathogen.<ref name="Durand 2023" />

==Classification (by chronicity)==
[[File:Filamentary Keratitis.jpg|thumb|right|Slit Lamp biomicroscopy of filamentary keratitis]]

===Acute===
* [[Acute epithelial keratitis]]
* [[Nummular keratitis]]
* [[Interstitial keratitis]]
* [[Disciform keratitis]]

===Chronic===
* [[Neurotrophic keratitis]]
* [[Mucous plaque keratitis]]

==Classification (infective)==
===Viral===
[[File:Dendritic corneal ulcer.jpg|thumb|right|Dendritic corneal ulcer after fluorescein staining under cobalt blue illumination]]
[[File:Adenoviral keratitis.jpg|thumb|Adenoviral keratitis of a 24-year-old woman]]

The most common causes of viral keratitis include [[herpes simplex virus]] (HSV) and [[varicella zoster virus]] (VZV), which cause [[herpes of the eye|herpes simplex keratitis]] and herpes zoster keratitis (a subtype of [[herpes zoster ophthalmicus]]) respectively.<ref name="Durand 2023" /> Herpes simplex keratitis occurs due to latent HSV reactivation in the [[ophthalmic nerve]] (the V1 branch of the [[trigeminal nerve]]).<ref name="Durand 2023" /> Herpes keratitis is classically associated with a branching (dendritic) infiltrate pattern of inflammation in the corneal epithelium and may cause clouding of the cornea.<ref name="Durand 2023" /> 

Approximately 8-20% of cases of [[shingles]] (due to VZV reactivation) involve the eyes as herpes zoster ophthalmicus.<ref name="Mohammed 2021">{{cite journal |last1=Mohammed |first1=Taariq K |last2=Cohen |first2=Elisabeth J |last3=Jeng |first3=Bennie H |title=A Review of Treatment for Herpes Zoster Keratitis |journal=US Ophthalmic Review |date=2021 |volume=15 |issue=2 |pages=43 |doi=10.17925/USOR.2021.15.2.43|doi-access=free }}</ref><ref name="Durand 2023" /> And VZV keratitis occurs in 13-76% of cases of herpes zoster ophthalmicus, usually 1 month after onset of symptoms.<ref name="Durand 2023" /> Herpes zoster ophthalmicus is also associated with reactivation of ZVZ in the V1 branch (the ophthalmic nerve) of the trigeminal nerve.<ref name="Mohammed 2021" /> VZV keratitis presents as a dendriform epithelial keratitis pattern early in the course of the infection.<ref name="Mohammed 2021" /> ZVZ keratitis may cause clouding of the cornea, with 50% of cases involving inflammatory infiltrates in the [[stroma of cornea|stromal layer of the cornea]], corneal scarring is a possible complication of VZV keratitis.<ref name="Durand 2023" /> Vaccination with the [[zoster vaccine]] is highly effective in preventing shingles, as well as herpes zoster ophthalmicus and herpes zoster keratitis.<ref name="Durand 2023" />

===Bacterial===
* [[Bacterial]] keratitis. Bacterial infection of the cornea can follow from an injury or from wearing contact lenses. The bacteria involved are ''[[Staphylococcus aureus]]'' and for contact lens wearers, ''[[Pseudomonas aeruginosa]]''. ''Pseudomonas aeruginosa'' produces [[enzyme]]s that can digest the cornea.<ref>{{cite journal|journal=Invest Ophthalmol Vis Sci|year=2009|volume=50|issue=8|pages=3794–801|title=Properties of PASP: A Pseudomonas Protease Capable of Mediating Corneal Erosions|vauthors=Tang A, Marquart ME, Fratkin JD, McCormick CC, Caballero AR, Gatlin HP, O'Callaghan RJ |pmid=19255155|doi=10.1167/iovs.08-3107|pmc=2874894}}</ref>''
* In those who wear contact lenses, bacteria are the most common causative agent of keratitis, with 90% of cases being due to a bacterial pathogen. Of those 90% of cases, ''Pseudomonas aeruginosa'' is responsible for 40%.<ref name="Durand 2023">{{cite journal |last1=Durand |first1=Marlene L. |last2=Barshak |first2=Miriam B. |last3=Sobrin |first3=Lucia |title=Eye Infections |journal=New England Journal of Medicine |date=21 December 2023 |volume=389 |issue=25 |pages=2363–2375 |doi=10.1056/NEJMra2216081}}</ref> ''[[Staph aureus]]'' and ''[[streptococci]]'' are other common bacterial pathogens responsible for infectious keratitis in contact lens wearers.<ref name="Durand 2023" /> Lens cases, used to store contact lenses, may form a [[biofilm]] leading to colonization of the contact lenses by bacteria, this is especially common with poor contact lens hygiene or improper storage.<ref name="Durand 2023" />

===Fungal===
* [[Fungal keratitis]], caused by ''[[Aspergillus fumigatus]]'' and ''[[Candida albicans]]'' (cf. [[Fusarium]], causing an outbreak of keratitis in 2005–2006 through the possible [[Vector (epidemiology)|vector]] of [[Bausch & Lomb]] [[ReNu]] with MoistureLoc [[contact lens]] solution<ref>{{Cite journal|last=Epstein|first=Arthur B|date=December 2007|title=In the aftermath of the Fusarium keratitis outbreak: What have we learned?|journal=Clinical Ophthalmology|volume=1|issue=4|pages=355–366|issn=1177-5467|pmc=2704532|pmid=19668512}}</ref>)

===Amoebic===
* [[Acanthamoeba keratitis|Acanthamoebic keratitis]]
[[File:Parasite140120-fig1 Acanthamoeba keratitis Figure 1A.png|thumb|''Acanthamoeba'' keratitis]]

:* Amoebic infection of the cornea is a serious corneal infection, most often affecting [[contact lens]] wearers.<ref name="Lorenzo-MoralesKhan2015">{{cite journal|last1=Lorenzo-Morales|first1=Jacob|last2=Khan|first2=Naveed A.|last3=Walochnik|first3=Julia|title=An update on ''Acanthamoeba'' keratitis: diagnosis, pathogenesis and treatment|journal=Parasite|volume=22|year=2015|pages=10|issn=1776-1042|doi=10.1051/parasite/2015010|pmid=25687209|url= |pmc=4330640}} {{open access}}</ref><ref>{{Cite journal| last3 = Cabrera-Serra | first1 = M. | first2 = J.| last2 = Lorenzo-Morales | first3 = G. | first4 = F.| last5 = Coronado-Alvarez| last4 = Rancel| last7 = Valladares | first5 = M. | first6 = E.| last1 = Martín-Navarro | first7 = B. | title = The potential pathogenicity of chlorhexidine-sensitive Acanthamoeba strains isolated from contact lens cases from asymptomatic individuals in Tenerife, Canary Islands, Spain| last6 = Piñero| journal = Journal of Medical Microbiology | volume = 57 | issue = Pt 11 | pages = 1399–1404 | date=Nov 2008 | issn = 0022-2615 | pmid = 18927419 | doi = 10.1099/jmm.0.2008/003459-0| doi-access = free }}</ref> It is usually caused by ''[[Acanthamoeba]]''. On May 25, 2007, the U.S. [[Centers for Disease Control and Prevention|Center for Disease Control]] issued a health advisory due to increased risk of [[Acanthamoeba keratitis|''Acanthamoeba'' keratitis]] associated with use of [[Advanced Medical Optics]] Complete Moisture Plus Multi-Purpose eye solution.<ref>[http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00260 CDC Advisory] {{webarchive|url=https://web.archive.org/web/20070531084455/http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00260 |date=2007-05-31 }}</ref>

===Parasitic===
* [[Onchocerciasis|Onchocercal]] keratitis, which follows ''[[Onchocerca volvulus]]'' infection by infected [[Black fly#Role in human disease|blackfly bite]]. These [[Black fly|blackfly]], ''[[Simulium]]'', usually dwell near fast-flowing African streams, so the disease is also called "river blindness".<ref>{{cite web |url= https://www.cdc.gov/ncidod/dpd/parasites/onchocerciasis/factsht_onchocerciasis.htm#what |title= What is onchocerciasis? |publisher = CDC |access-date= 2010-06-28 |quote= transmission is most intense in remote African rural agricultural villages, located near rapidly flowing streams...(WHO) expert committee on onchocerciasis estimates the global prevalence is 17.7 million, of whom about 270,000 are blind. }}</ref>

Microbial keratitis (due to bacterial, fungal, or parasitic pathogens), as opposed to viral keratitis, is more commonly associated with the formation of [[corneal ulcers]]. Other risk factors for corneal ulcer formation include contact lens use, keratitis in the setting of eye trauma, underlying corneal disease or ocular surface diseases (such as severe [[dry eye syndrome|chronic dry eye]]).<ref name="Durand 2023" /> Infectious keratitis sometimes presents as corneal edema, or with a [[hypopyon]] (a collection of inflammatory cells in the [[anterior chamber]] of the eye).<ref name="Durand 2023" />

==Classification (by stage of disease)==
* [[Thygeson's superficial punctate keratopathy|Superficial punctate keratitis]]
* [[Corneal ulcer|Ulcerative keratitis]]

==Classification (by environmental aetiology)==
* [[Exposure keratitis]] (also known as exposure keratopathy) — due to dryness of the cornea caused by incomplete or inadequate eyelid closure ([[lagophthalmos]]).
* [[Photokeratitis]] — keratitis due to intense [[ultraviolet radiation]] exposure (e.g. snow blindness or [[welder]]'s arc eye.)
* Contact lens acute red eye (CLARE) — a non-ulcerative sterile keratitis associated with colonization of [[Gram-negative]] bacteria on [[contact lenses]].

==Treatment==
Treatment depends on the cause of the keratitis. Infectious keratitis can progress rapidly, and generally requires urgent antibacterial, antifungal, or antiviral therapy to eliminate the pathogen. Antibacterial solutions include [[levofloxacin]], [[gatifloxacin]], [[moxifloxacin]], [[ofloxacin]]. It is unclear if [[steroid]] eye drops are useful.<ref>{{cite journal|last1=Herretes|first1=S|last2=Wang|first2=X|last3=Reyes|first3=JM|title=Topical corticosteroids as adjunctive therapy for bacterial keratitis.|journal=The Cochrane Database of Systematic Reviews|date=Oct 16, 2014|volume=10|issue=10|pages=CD005430|pmid=25321340|doi=10.1002/14651858.CD005430.pub3|pmc=4269217}}</ref>

In addition, contact lens wearers are typically advised to discontinue contact lens wear and replace contaminated contact lenses and contact lens cases. (Contaminated lenses and cases should not be discarded as cultures from these can be used to identify the pathogen).

Topical [[ganciclovir]] or oral [[valacyclovir]], [[famciclovir]] or [[acyclovir]] are used for HSV keratitis.<ref name="Durand 2023" /> Steroids should be avoided as application of steroids to a dendritic ulcer caused by HSV may result in rapid and significant worsening of the ulcer to form an 'amoeboid' or 'geographic' ulcer, so named because of the ulcer's map like shape.<ref>{{Cite book|last=John F.|first=Salmon|url=https://www.worldcat.org/oclc/1131846767|title=Kanski's clinical ophthalmology : a systematic approach|publisher=Elsevier|year=2020|isbn=978-0-7020-7713-5|edition=9th|location=Edinburgh|pages=219|chapter=Cornea|oclc=1131846767}}</ref>

==Prevention==
In those who wear contact lenses, good lens hygiene and storage practices reduce the risk of keratitis. Specific lens care practices which may lead to infectious keratitis include wearing contact lenses overnight or in the shower, not replacing contact lens cases, storing lenses in tap water rather than contact lens solution and topping off lens solution rather than replacing it regularly.<ref name="Durand 2023" /> Improper lens storage may lead to bacterial biofilm formation in the contact lens case and subsequent colonization of the lenses by bacteria.<ref name="Durand 2023" /> Exposure of the lens to tap water through improper storage or use may lead to [[acanthamoeba]] infection, as the amoeba is commonly found in tap water.<ref name="Durand 2023" />

Acyclovir prophylaxis has been found to reduce the risk of additional episodes of herpes simplex viral eye diseases (as well as oral or facial herpes) including a 50% reduction in the incidence of HSV keratitis. There was no rebound effect, or increased rate of HSV related eye disease upon stopping acyclovir prophylaxis.<ref name="Wilhelmus 1998">{{cite journal |last1=Wilhelmus |first1=Kirk R. |last2=Beck |first2=Roy W. |last3=Moke |first3=Pamela S. |last4=Dawson |first4=Chandler R. |last5=Barron |first5=Bruce A. |last6=Jones |first6=Dan B. |last7=Kaufman |first7=Herbert E. |last8=Kurinij |first8=Natalie |last9=Stulting |first9=R. Doyle |last10=Sugar |first10=Joel |last11=Cohen |first11=Elisabeth J. |last12=Hyndiuk |first12=Robert A. |last13=Asbell |first13=Penny A. |title=Acyclovir for the Prevention of Recurrent Herpes Simplex Virus Eye Disease |journal=New England Journal of Medicine |date=30 July 1998 |volume=339 |issue=5 |pages=300–306 |doi=10.1056/NEJM199807303390503}}</ref>

==Prognosis==
Some infections may scar the cornea, thereby limiting vision.  Others may result in perforation of the cornea, [[endophthalmitis]] (an infection inside the eye), or even loss of the eye.  With proper medical attention, infections can usually be successfully treated without long-term visual loss.{{Citation needed|date=January 2024}}

Acanthamoebic and fungal keratitis are difficult to treat and are associated with a poor prognosis.<ref name="Durand 2023" />

==In non-humans==
* Feline eosinophilic keratitis — affecting cats and horses; possibly initiated by [[feline herpesvirus 1]] or other viral infection.<ref>{{Cite web |url=http://www.vet.uga.edu/VPP/clerk/mackey/index.php |title=VET.uga.edu |access-date=2009-06-05 |archive-url=https://web.archive.org/web/20091119040542/http://www.vet.uga.edu/VPP/CLERK/mackey/index.php |archive-date=2009-11-19 |url-status=dead }}</ref>

==See also==
* [[Chronic superficial keratitis]], or pannus, for the disease in dogs
* [[Thygeson's superficial punctate keratopathy]]
* [[Keratoendotheliitis fugax hereditaria]]

==References==
{{reflist}}

== External links ==
{{Medical resources
| DiseasesDB      = 7150
| ICD10           = {{ICD10|H|16||h|15}}
| ICD9            = {{ICD9|370}}
| ICDO            =
| OMIM            = 148190
| MedlinePlus     =
| eMedicineSubj   =
| eMedicineTopic  =
| MeshID          = D007634
| SNOMED CT       = 5888003
}}
* [https://web.archive.org/web/20050327021720/http://www.nei.nih.gov/health/cornealdisease/index.asp Facts About the Cornea and Corneal Disease] The National Eye Institute (NEI)
* [https://web.archive.org/web/20071223103615/http://webeye.ophth.uiowa.edu/eyeforum/atlassearch1.htm?appSession=87915670818785&RecordID=1024&PageID=3&PrevPageID=2&cpipage=1&CPIsortType=&CPIorderBy= Filimentary keratitis]

{{Eye pathology}}
{{Authority control}}

[[Category:Inflammations]]
[[Category:Disorders of sclera and cornea]]