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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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