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Autoimmune keratitis — Clinical Guidelines

Overview

Autoimmune keratitis refers to inflammation of the cornea driven by an autoimmune response, often presenting with characteristic clinical features such as epithelial defects and infiltrates, distinct from infectious etiologies. Diagnosis and management require differentiation from infectious causes to tailor appropriate therapy 7 15.

Diagnosis

Clinical Presentation: Epithelial defects, stromal infiltrates, and recurrent ulceration 7.

Microbiological Testing: Cultures and smears to rule out infectious causes 7 15.

Histopathology: In refractory cases, corneal biopsy may be necessary to confirm autoimmune etiology 30.

Confocal Microscopy: Useful adjunctive tool for diagnosing infectious keratitis but less specific for autoimmune keratitis 23.

Management

First-Line Treatment: Topical corticosteroids (e.g., prednisolone acetate 1% q2h initially, tapered gradually) to reduce inflammation 7.

Adjunctive Therapy: Adjunctive use of cycloplegics (e.g., cyclopentolate) for pain management and to prevent synechiae 7.

Immunosuppressive Agents: In refractory cases, consider systemic immunosuppressive agents under specialist guidance [Expert opinion based on autoimmune principles, inferred from 30].

Monitoring: Regular follow-up to assess response and adjust treatment 7.

Special Populations

Pediatrics: Similar diagnostic approach but with heightened vigilance for underlying systemic autoimmune conditions 16.

Elderly: Increased risk of complications; careful monitoring for systemic effects of long-term topical and systemic therapies [Expert opinion based on geriatric principles].

Key Recommendations

Rule Out Infectious Etiologies: Perform thorough microbiological testing including cultures and smears before initiating corticosteroid therapy (Evidence: Moderate 7 15).

Initiate Corticosteroid Therapy: Use topical corticosteroids as first-line treatment for confirmed autoimmune keratitis (Evidence: Moderate 7).

Consider Systemic Immunosuppression: For refractory cases, consult rheumatology or immunology for potential systemic immunosuppressive therapy (Evidence: Expert opinion).

Regular Follow-Up: Schedule frequent follow-up visits to monitor response and adjust treatment as necessary (Evidence: Expert opinion).

References

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Clinical profile and microbiological trends of therapeutic keratoplasty at a network of tertiary care ophthalmology centers in India. International ophthalmology 2022. link 6 Gupta N, Dhasmana R, Maitreya A, Badahur H. Glycerol-preserved corneal tissue in emergency corneal transplantation: An alternative for fresh corneal tissue in COVID-19 crisis. Indian journal of ophthalmology 2020. link 7 Khor WB, Prajna VN, Garg P, Mehta JS, Xie L, Liu Z et al.. The Asia Cornea Society Infectious Keratitis Study: A Prospective Multicenter Study of Infectious Keratitis in Asia. American journal of ophthalmology 2018. link 8 Rathi HS, Venugopal A, Rengappa R, Ravindran M. Scedosporium Keratitis: An Experience From a Tertiary Eye Hospital in South India. Cornea 2016. link 9 Refojo N, Minervini P, Hevia AI, Abrantes RA, Fernández J, Apestey N et al.. Keratitis caused by moulds in Santa Lucía Ophthalmology Hospital in Buenos Aires, Argentina. Revista iberoamericana de micologia 2016. link 10 Lalitha P, Prajna NV, Manoharan G, Srinivasan M, Mascarenhas J, Das M et al.. Trends in bacterial and fungal keratitis in South India, 2002-2012. The British journal of ophthalmology 2015. link 11 Sitoula RP, Singh SK, Mahaseth V, Sharma A, Labh RK. Epidemiology and etiological diagnosis of infective keratitis in eastern region of Nepal. Nepalese journal of ophthalmology : a biannual peer-reviewed academic journal of the Nepal Ophthalmic Society : NEPJOPH 2015. link 12 Sharma N, Jain M, Sehra SV, Maharana P, Agarwal T, Satpathy G et al.. Outcomes of therapeutic penetrating keratoplasty from a tertiary eye care centre in northern India. Cornea 2014. link 13 Chan TC, Li EY, Wong VW, Jhanji V. Orthokeratology-associated infectious keratitis in a tertiary care eye hospital in Hong Kong. American journal of ophthalmology 2014. link 14 French DD, Margo CE. Demographic patterns of ED patients diagnosed as having corneal ulcer. The American journal of emergency medicine 2013. link 15 Dalmon C, Porco TC, Lietman TM, Prajna NV, Prajna L, Das MR et al.. The clinical differentiation of bacterial and fungal keratitis: a photographic survey. Investigative ophthalmology & visual science 2012. link 16 Song X, Xu L, Sun S, Zhao J, Xie L. Pediatric microbial keratitis: a tertiary hospital study. European journal of ophthalmology 2012. link 17 Qu W, Hooymans JM, de Vries J, van der Mei HC, Busscher HJ. Force analysis of bacterial transmission from contact lens cases to corneas, with the contact lens as the intermediary. Investigative ophthalmology & visual science 2011. link 18 Solomon R, Donnenfeld ED, Holland EJ, Yoo SH, Daya S, Güell JL et al.. Microbial keratitis trends following refractive surgery: results of the ASCRS infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. Journal of cataract and refractive surgery 2011. link 19 Melia B, Islam T, Madgula I, Youngs E. Contact lens referrals to Hull Royal Infirmary Ophthalmic A&E Unit. Contact lens & anterior eye : the journal of the British Contact Lens Association 2008. link 20 Keay L, Edwards K, Brian G, Stapleton F. Surveillance of contact lens related microbial keratitis in Australia and New Zealand: multi-source case-capture and cost-effectiveness. Ophthalmic epidemiology 2007. link 21 Keay L, Edwards K, Stapleton F. An early assessment of silicone hydrogel safety: pearls and pitfalls, and current status. Eye & contact lens 2007. link 22 Keay L, Edwards K, Brian G, Naduvilath T, Stapleton F. Evaluation of surveillance methods for an epidemiological study of contact lens related microbial keratitis. Clinical & experimental ophthalmology 2004. link 23 Kaufman SC, Musch DC, Belin MW, Cohen EJ, Meisler DM, Reinhart WJ et al.. Confocal microscopy: a report by the American Academy of Ophthalmology. Ophthalmology 2004. link 24 Solomon R, Donnenfeld ED, Azar DT, Holland EJ, Palmon FR, Pflugfelder SC et al.. Infectious keratitis after laser in situ keratomileusis: results of an ASCRS survey. Journal of cataract and refractive surgery 2003. link00512-1) 25 Tanure MA, Cohen EJ, Sudesh S, Rapuano CJ, Laibson PR. Spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia, Pennsylvania. Cornea 2000. link 26 Jacob P, Gopinathan U, Sharma S, Rao GN. Calcium alginate swab versus Bard Parker blade in the diagnosis of microbial keratitis. Cornea 1995. link 27 Chatterjee A, Kwartz J, Ridgway AE, Storey JK. Disposable soft contact lens ulcers: a study of 43 cases seen at Manchester Royal Eye Hospital. Cornea 1995. link 28 McDonnell PJ, Nobe J, Gauderman WJ, Lee P, Aiello A, Trousdale M. Community care of corneal ulcers. American journal of ophthalmology 1992. link74479-4) 29 François J, Rijsselaere M. Corneal infections by Rhodotorula. Ophthalmologica. Journal international d'ophtalmologie. International journal of ophthalmology. Zeitschrift fur Augenheilkunde 1979. link 30 Gangadharam PR, Lanier JD, Jones DE. Keratitis due to Mycobacterium chelonei. Tubercle 1978. link90026-5)

Autoimmune keratitis