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Marginal InfiltrativeMarginal Infiltrative
KeratitisKeratitis
Dr. Victor MalinovskyDr. Victor Malinovsky
20062006
EtiologyEtiology
Staphylococci Staphylococci exotoxinexotoxin produces an produces an
antigen/antibiotic immune reactionantigen/antibiotic immune reaction
Sterile-infiltrate ulcer as opposed to liveSterile-infiltrate ulcer as opposed to live
bacteria in ulcerationbacteria in ulceration
Chronic Staphylococcal Chronic Staphylococcal blepharitisblepharitis: Mild to: Mild to
severesevere
Contact lens patients especially extended wearContact lens patients especially extended wear
more pronemore prone
More common in adult lifeMore common in adult life
SymptomsSymptoms
Acute or Acute or subacutesubacute onset with frequent onset with frequent
past history of prior attacks, most oftenpast history of prior attacks, most often
unilateral attacks, often worse in AMunilateral attacks, often worse in AM
Redness, foreign-body sensation, pain,Redness, foreign-body sensation, pain,
and photophobiaand photophobia
Visual acuity rarely affectedVisual acuity rarely affected
SignsSigns
BlepharoconjunctivitisBlepharoconjunctivitis: May be: May besubclinicalsubclinical, inferior , inferior punctatepunctate staining staining
Marginal intra-epithelial infiltrateMarginal intra-epithelial infiltrate: An: Aninitial gray-white, round or crescent,initial gray-white, round or crescent,raised raised subepithelialsubepithelial, anterior , anterior stromalstromalhaze seen near haze seen near limbuslimbus; circumferential; circumferentialwith with limbuslimbus, epithelium intact with, epithelium intact withsuperficial stainingsuperficial staining
Most vulnerable sites at 2,4,10 and 8:00Most vulnerable sites at 2,4,10 and 8:00of peripheral cornea, where lid marginof peripheral cornea, where lid margincrosses crosses limbuslimbus and more toxins present and more toxins present
SignsSignsLucidLucid (clear) interval between (clear) interval between limbuslimbus and andinfiltrateinfiltrate
Sector conjunctival injectionSector conjunctival injection
Size variable of 0.5 to 2 mm, single or multiple,Size variable of 0.5 to 2 mm, single or multiple,may coalesce into elongated chain lesionmay coalesce into elongated chain lesion
Anterior chamber is usually quietAnterior chamber is usually quiet
Marginal ulcerMarginal ulcer -Same lesion with an overlying -Same lesion with an overlyingepithelial defect. Infiltrate stains superficially andepithelial defect. Infiltrate stains superficially andclear within minutes and ulcers stain deeply andclear within minutes and ulcers stain deeply andtend to produce amorphous spreadingtend to produce amorphous spreading
Secondary corneal scars and Secondary corneal scars andneovascularizationneovascularization
Differential DiagnosisDifferential Diagnosis
Sterile culturesSterile cultures
Marginal herpetic keratitis (epithelialMarginal herpetic keratitis (epithelial
first then first then stromastroma))
PhylctenularPhylctenular ulcer, scleritis, vasculitis, ulcer, scleritis, vasculitis,
CT disease, CT disease, MoorenMooren’’ss ulcer are other ulcer are other
causes of marginal keratitiscauses of marginal keratitis
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TreatmentTreatment
Topical solutions of 0.3% Topical solutions of 0.3% TobrexTobrex or or CiloxanCiloxanor or OcufloxOcuflox 2 2 gttgtt every 2 to 4 hours, plus every 2 to 4 hours, plusbacitracinbacitracin, erythromycin, , erythromycin, polysporinpolysporin ointment ointmentat bedtimeat bedtime
Eyelid hygiene & warm compresses & D/C CLEyelid hygiene & warm compresses & D/C CLwearwear
CycloplegicCycloplegic if pain & A/C reaction: In office if pain & A/C reaction: In office
Antibiotic/steroid combination treatment; e.g.,Antibiotic/steroid combination treatment; e.g.,TobradexTobradex, , BlephamideBlephamide, , ZyletZylet or 1% or 1% PredPredForte q4-6h with rapid taper; if ulcerForte q4-6h with rapid taper; if ulcerformation, no steroids for 24 to 48 hoursformation, no steroids for 24 to 48 hours
•• New steroids: New steroids: VexolVexol, , LotemaxLotemax, , FlarexFlarex, or, orEfloneEflone
Chronic or RecurrentChronic or Recurrent
EpisodesEpisodes
Oral Oral doxycyclinedoxycycline, 100mg bid PO for 1, 100mg bid PO for 1
mo. then mo. then qdqd for 1mo. for 1mo.
Frequently Results in Nebula ScarFrequently Results in Nebula Scar
Formation and Formation and PannusPannus
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Lucid interval
Infiltrate
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