Keratitis in children is an inflammatory process in the cornea of the eye. The disease occurs when infected with viral, bacterial and fungal pathogens, eye injuries, systemic allergic reactions. The main signs of the disease: redness, pain and sensation of a foreign object, photophobia and lacrimation. For diagnosis, a fluorescein test, biomicroscopy, keratopachimetry, as well as sowing of biomaterial for verification of the pathogen are prescribed. Treatment is selected taking into account the etiology of keratitis. Local remedies (drops, ointments, gels) and systemic drugs are used in therapy, if necessary, surgical correction is performed.
Keratitis is infrequent and accounts for about 5% of all inflammatory eye diseases in children, significantly inferior to conjunctivitis, which accounts for 65-70%. Pathology is diagnosed among children of all age groups. Boys get sick more often than girls. The disease poses a great danger to visual acuity, since in the presence of scarring processes, about 50% of patients face a persistent decrease in visual function.
Up to 70% of keratitis in children begin on the background of herpes infection caused by Herpes simplex, Herpes Zoster or cytomegalovirus (herpes virus type 5). The disease is more common with a decrease in immunity: hypothermia, prolonged somatic pathologies, vitamin deficiency. In pediatrics, adenoviruses and measles virus are also an etiological factor. More rare causes of keratitis in children include:
- Bacterial infections. Purulent inflammation occurs when the eye is infected with nonspecific microorganisms: staphylococci, pneumococci, Pseudomonas aeruginosa. Specific pathogens of bacterial keratitis include Koch’s bacillus, pale treponema, Diphtheria bacillus.
- Fungal infections. Keratomycosis is a severe variant of the disease, which usually ends with an irreversible decrease in vision. It mainly develops with candidiasis infection, less often in children, aspergilli, ascomycetes become pathogens.
- Corneal injuries. Micro-injuries of the epithelium are caused by the ingress of foreign bodies with sharp edges into the eye, the inept putting on and taking off of contact lenses. The situation is aggravated in the case of the addition of secondary bacterial flora.
- Wearing contact lenses. In adolescents who use this type of vision correction and often neglect the rules of lens care, acanthamoeba begins to actively multiply on the cornea. It destroys the tissues of the outer shell of the eye, causing ring-shaped infiltrates.
- Allergies. In children, keratitis is formed as a manifestation of an acute allergic reaction to the action of exogenous (food, animal hair, plant pollen) and endogenous triggers (helminthiasis, bacterial toxins).
At the initial stage of keratitis, an infiltrate forms in the cornea — a cluster of leukocyte cells that penetrate from the marginal vessels. There is a clouding of the outer ocular membrane and its puffiness. A large number of nerve endings are located in this zone, which are irritated by an inflammatory focus, as a result of which a typical corneal syndrome develops.
If the infiltrate captures only the upper epithelial layer, treatment quickly eliminates the phenomena of infiltration, and the turbidity disappears without a trace. In other cases, the disease progresses to the next stage — the disintegration of the infiltrate, ulceration and necrosis of the corneal tissues. At this stage, a secondary infection joins. In the future, ulcers are scarred with the formation of turbidity or dense impenetrable cataract.
According to the localization of inflammation, keratitis in children is divided into superficial — damage to the outer epithelial layer, and internal — pathology in the corneal stroma with intact epithelium. There are 4 variants downstream: acute, subacute, chronic and recurrent. In pediatric ophthalmology, a clinical classification is widely used, according to which 3 groups of keratitis are distinguished:
- Exogenous. This includes corneal inflammation as a result of eye injury, conjunctival diseases, eyelids or meibomian glands. Also included in this category are infectious keratitis — bacterial, viral and fungal.
- Endogenous. The main representatives are specific infectious (herpetic, tuberculous) and allergic keratitis. Neuroparalytic and vitamin deficiency forms of lesion are less common in pediatric practice.
- Unexplained etiology. Such keratitis is characterized by the absence of obvious causes of inflammation, however, with the improvement of ophthalmological examination methods, this diagnosis is rarely made.
Clinically, the pathology is manifested by the classic corneal syndrome. The child complains of lacrimation, involuntary closing of the eyelids (blepharospasm), soreness in the affected eye and photophobia. As a rule, the feeling of a foreign body, burning and itching are bothering, so the patient constantly rubs his eyes with his hand. Keratitis is characterized by redness of the eyes caused by pericorneal injection.
On examination, parents may notice the outline of an infiltrate in the cornea, which looks like a cloudy spot with indistinct borders, covering the pupil and iris. It can be dotted (several millimeters in diameter) or large, occupying the entire cornea. With purulent processes, the infiltrate has a yellow tint, with viral infections due to the accumulation of lymphocytes, it turns gray.
Exogenous keratitis is often accompanied by conjunctivitis. The clinical picture is complemented by severe redness of the conjunctiva of the eyes, watery or purulent discharge. There may be small bubbles with transparent or cloudy contents on the conjunctival surface of the eyelids. Keratoconjunctivitis is complicated by scleritis, uveitis, and iridocyclitis. If the treatment is delayed or incorrect, children develop panophthalmitis, which is fraught with the development of blindness.
A dangerous complication is corneal ulcers, in which destructive processes occur in the thickness of the shell. The child has an epithelial defect in the eyeball with a cloudy gray bottom, which is covered with exudate. Ulcers are often accompanied by hypopion — an accumulation of pus in the anterior chamber. The healing of an ulcerative defect occurs with the formation of a scar (a cataract), which sharply reduces visual acuity.
During the examination, a pediatric ophthalmologist easily detects the symptoms of keratitis, since the cornea is the outer layer of the eyeball and is easily accessible to examination without special devices. According to the clinical symptoms, a preliminary diagnosis is made, after which the child is prescribed a full examination to clarify the etiology of the process. The standard diagnostic plan includes the following methods:
- Fluorescein test. A quick test is performed to assess the degree of corneal damage. The doctor instills a solution of fluorescein and carefully examines the eye surface — green colored areas indicate that the epithelium has been destroyed in this place.
- Biomicroscopy of the eye. With this method, an ophthalmologist examines all parts of the eyeball, determines the features of the infiltrate, studies the condition of the anterior chamber, lens and vitreous. For an accurate assessment of the depth and prevalence of the process, endothelial microscopy of the cornea is performed.
- Keratopachimetry. At the initial stage of keratitis, ultrasound measurement of the cornea shows its local or diffuse thickening, which confirms inflammatory edema. Ulcerative defects are characterized by thinning of the shell less than 450 microns. The safety of the corneal reflex is assessed by estesiometry.
- Bakposev smear. To determine the type of pathogen, a smear is taken from the conjunctiva or material from the surface of corneal ulcers. The biomaterial is sown on a nutrient medium to isolate colonies of microorganisms, and microscopy of stained smears is used as an express method. According to the indications, PCR, ELISA and other modern laboratory tests are used.
Treatment of superficial forms is carried out on an outpatient basis, and children with deep and complicated variants of keratitis receive therapy in ophthalmological hospitals. In the acute period, it is recommended to stop any visual load, the wearing of contact lenses also falls under the ban. The child is prescribed etiotropic therapy, which depends on the type of disease:
- Bacterial keratitis. Eye drops containing antibiotics are used. With a common process, systemic tablet or parenteral forms are shown. In some cases, parabulbar and subconjunctival administration of drugs is advisable.
- Viral keratitis caused by herpesviruses is successfully treated with local acyclovir preparations. If keratitis is provoked by other viruses, interferon-based medications and nonspecific immunomodulators are recommended.
- Fungal keratitis. Local treatment includes instillation of antimycotic solutions into the conjunctival sac. For systemic therapy, antifungal agents are selected in age-related dosages for 5-7 days.
- Allergic keratitis. For their relief, eye ointments and drops with corticosteroid hormones are used. Systemic antihistamines are also shown, which have a desensitizing effect and affect the pathogenetic mechanisms of the inflammatory process.
Regardless of the cause of the pathology, it is necessary to prescribe solutions of mydriatics for the prevention of secondary glaucoma, which may result from scarring processes. To accelerate the epithelialization of corneal surface defects, preparations with taurine, keratoprotectors in drops and gels are effective. Phonophoresis and electrophoresis with hyaluronidase are used to accelerate the resorption of the infiltrate.
If drug therapy is ineffective, laser methods are recommended: phototherapeutic keratectomy, corneal collagen crosslinking. The treatment eliminates the corneal syndrome, promotes the restoration of the epithelial layer in the area of the defect and resorption of the infiltrate. When forming dense scars, keratoplasty is indicated, and if keratitis is complicated by panophthalmitis, enucleation of the eyeball may be required.
Prognosis and prevention
With superficial keratitis, complete resorption of inflammatory foci and restoration of vision is noted. The prognosis of deep forms is less favorable, since the healing of infiltrates goes through the scarring stage and causes a decrease in visual acuity of varying degrees. To monitor the condition of the cornea and visual function, the child is recommended to be monitored by a pediatric ophthalmologist for six months or longer.
Prevention of keratitis includes timely treatment of conjunctivitis and other diseases of the eyeball, increasing the immune status. The child needs to be taught the rules of hygiene, explain that it is impossible to touch the eyes with dirty hands. For teenagers using lenses, the doctor should tell in detail the rules of care for them, especially if 1-3-6-month options for planned replacement are assumed.