Relevance of Intraocular Pressure Measurement in Ulcerative Microbial Keratitis

Acta Scientific Ophthalmology (ISSN: 2582-3191) Volume 4 Issue 4 April 2021 Research Article

Shikha Jain, Ashok Pathak*, Rahul Verma and Punam Kapoor Received: February 17, 2021 Department of Ophthalmology, ABVIMS & Dr. RML Hospital, New Delhi, India Published: March 06, 2021 *Corresponding Author: Ashok Pathak, Department of Ophthalmology, ABVIMS & © All rights are reserved by Shikha Jain., et Dr. RML Hospital, New Delhi, India. al.

Abstract Purpose: Intraocular pressure measurement in a case of ulcerative microbial keratitis is often neglected as treatment of ulcer takes precedence. However, prolonged rise in IOP can cause optic nerve damage and failure of visual recovery even after complete resolution of keratitis. This prospective longitudinal comparative study was done to evaluate the importance of IOP measurement in cases of ulcerative keratitis. Methods: 122 cases of ulcerative microbial keratitis were divided into three groups based on their etiology- bacterial (Group A), fungal (Group B) and indeterminate (Group C). Comparative evaluation of IOP between all the three groups was done and results recorded. Results: - sponded to treatment. In fungal keratitis, higher IOP was noted later in the follow up visits. The IOP was also related to the size of On presentation, IOP was significantly high in bacterial and indeterminate group (Group A and C) but subsequently re

ulcerConclusion: and depth of infiltrate with size more than 5 mm and midstromal level of infiltrate showing a significantly high IOP. - sion. IOP measurement and management although difficult in cases of keratitis if neglected can cause permanent loss of vi Keywords: Ulcerative Microbial Keratitis; Intraocular Pressure; Non Contact Tonometry

Introduction often missed as management of ulcer takes precedence. Increased In developing countries microbial keratitis is an important IOP even for one to two weeks can cause potential damage to the cause of preventable blindness. Infectious keratitis often causes optic nerve. anterior chamber reaction ranging from mild to severe uveitis. In- traocular pressure (IOP) elevation secondary to uveitis is a well- Very few studies are available highlighting the importance of el- [1]. evated IOP in cases of ulcerative keratitis [1-3]. A prospective longitudinal comparative study was done to evaluate the IOP in cases recognizedIncreased consequence IOP is a risk of factor anterior for chamberglaucoma inflammation which can result in blindness. Although IOP measurement is a part of routine oph- follow up. of ulcerative keratitis at the time of presentation and at subsequent thalmic examination, in cases of microbial ulcerative keratitis it is

Citation: Shikha Jain., et al. “Relevance of Intraocular Pressure Measurement in Ulcerative Microbial Keratitis". Acta Scientific Ophthalmology 4.4 (2021): 39-43. Relevance of Intraocular Pressure Measurement in Ulcerative Microbial Keratitis

40 Material and Methods Results 122 cases of ulcerative microbial keratitis presenting to the Cor- The age and sex distribution of cases in the study is shown in nea Services of our institute from June 2018-September2019 were table 1. enrolled for the study. Mean IOP in all the 3 groups at presentation, 2 weeks and 6 Patients with prior history of glaucoma or ocular hypertension weeks is given in table 2. in either eye, viral keratitis or corneal perforation at the time of presentation were excluded from the study. Group A Group B Group C Age Total Male Female Male Female Male Female <30 B) and indeterminate (Group C) on the basis of clinical examina- 2 3 1 2 1 1 10 The cases were classified as bacterial (Group A), fungal (Group years tion and microbiological assessment of the corneal scrapings by 9 6 11 4 3 38 years patients, Group B of 38 and Group C of 26 patients. 30-45 staining and culture methods in all cases. Group A consisted of 58 5 14 11 8 7 7 years History included pain, redness, discharge, decrease in vision and 45-60 >60 5 52 photophobia. Risk factors for systemic illness (like diabetes melli- 8 3 2 2 2 22 years tus, hypertension, tuberculosis), trauma, contact lens use, dry eyes, 5 use of corticosteroids and other medications were documented. Total 33 23 13 13 122 25 15 Ocular examination included visual acuity, corneal sensation, lid Table 1: Age and sex distribution. lamp biomicroscopy. Anterior chamber reaction was documented abnormalities, size of corneal ulcer and depth of infiltrate on slit Change in IOP from baseline to 2 weeks and 6 weeks was evalu- and posterior segment examination was done whenever possible. ated and compared as shown in table 3. This showed that IOP al-

All the patients underwent measurement of IOP with Non-con- Time in Group A Group B Group C tact tonometer (NCT) on the day of presentation and at every fol- weeks low up visit. When NCT was unable to measure IOP due to distorted 0 24.4+/- 7.99 22+/- 4.33 27.2+/- 6.403 mires, a bandage contact lens was temporarily used for recording 2 20.04+/- 3.48 22.74+/- 4.6 of IOP . 6 19.89+/- 3.23 18.6+/- 4.02 20.5 +/- 4.59

Due[4,5] to the limitation posed by hazy media to optic disc assess- 17.3+/- 5.18Table 2: Mean IOP. any of the visits was considered glaucomatous. ment and visual field analysis, an IOP greater than 21 mm Hg on was noted on treatment. The pain scoring was done in all cases at the time of presenta- though high in all the 3 groups at presentation, a significant drop tion and at 2 weeks and 6 weeks follow up. A comparison of mean IOP was also done between the 3 groups on the basis of etiology and the results were as shown in table 4. The patients were given appropriate antimicrobial therapy and cycloplegics. Anti-glaucoma therapy was added when IOP was greater than 21mm Hg. determinate group followed by bacterial. At the time of presentation, IOP was significantly higher in in- The IOP was correlated to etiology, size of corneal ulcer, depth of - rately. the infiltrate, visual acuity, pain score in all the three groups sepa

IOP 0-2 weeks IOP 0-6 weeks Size of Group A Group B Group C p ulcer G NG Total G NG Total G NG Total t test p value t test value 4 14 18 2 6 8 1 2 3 Bacterial 19 13 32 13 11 24 12 1 13 keratitis (Group 3.21 0.001 0.001 2-5 mm >8 mm 3 8 3 3 6 10 A) 5-8 mm 5.58 26 32 18 20 38 18 8 26 Fungal keratitis 5 5 5 2.2 0.02 2.4 0.01 (Group B) Table 5: Size58 of ulcer and IOP at presentation. Indeterminate G for glaucomatous and NG for non glaucomatous keratitis (Group 2.8 0.001 C) 0.005 5.6 Table 3: Change in IOP. 2 2 = 6.76, p < The IOP was significantly high in patients with ulcer size of 2 5-8mm in Group A (X = 6.33, p < 0.05) and Group C (X 0.05) but not significant in Group B (X = 2.06, p < 0.5). 0 weeks 2 weeks 6 weeks shown in table 6. p p IOP was also evaluated on the basis of depth of infiltrate as t test t test p value t test value value Group A Group B Group C Bacterial vs Infiltrate 1.9 0.4 2.84 G NG Total G NG Total G NG Total Fungal 6 20 26 6 11 1 3 4 Bacterial vs 0.05 0.55 0.005 1.96 1.06 stromal indeterminate Superficial 5 Mid stromal 14 6 20 10 14 24 1 6 Fungal vs 1.75 0.05 0.05 0.15 4.1 0.001 2.43 0.01 1.20 Deep stromal 4 3 7 1 0 1 7 2 9 indeterminate 5 0.25 Descemetocele 2 3 2 0 2 2 7 Table 4: Comparison of mean IOP. 26 32 18 20 38 18 8 26 5 5 58 Table 6: At 2 weeks follow up, the difference in bacterial vs fungal was G for glaucomatous Infiltrate and NG depthfor non vs glaucomatous IOP. weeks. insignificant. However, IOP significantly rose in fungal group at 6 - 2 When extent of infiltrate was correlated with IOP, IOP was sig 2 nificantly raised in Group A (X = 10.57, p < 0.02). In Group B and In bacterial vs indeterminate, the IOP was significantly higher in 2 indeterminate at 2 weeks but insignificant at 6 weeks. Group C, the corresponding values were (X = 3.66 with p < 0.5) and(XThe =maximum 5.43 with incidence p < 0.5), respectively was seen at andmid-stromal were insignificant. extent of the On comparing fungal vs indeterminate, the IOP was significantly highAll at the 2 weeks groups in wereindeterminate divided on but the insignificant basis of presence at 6 weeks. of raised infiltrate. On applying Fisher Exact test between infiltration at mid IOP and referred to as glaucomatous or non-glaucomatous at the stromal level and others, it was found significant in Group A (p = time of presentation. The0.0066) visual while acuity statistically at 6 weeks not follow significant up is given in Group in table B and 7. Group C. The size of corneal ulcer was correlated to IOP in all the cases.

any of the 3 groups. The details are given in table 5. The IOP was not significantly related to visual acuity (BCVA) in

42 A non-contact tonometry in these cases can serve as a reliable Group A Group B Group C Vision method of IOP assessment as opposed to digital palpation, which is G NG Total G NG Total G NG Total often employed but gives a very subjective and gross assessment. 6/6-6/18 14 29 3 2 6/18-6/60 7 14 21 7 7 3 8 15 5 5 5 In our study, we measured IOP at presentation and at subse- 6/60-3/60 3 2 4 4 1 6 5 3/60-PL 1 2 3 2 2 2 7 started based on IOP readings. 5 5 quent follow up visits of the patient and anti-glaucoma therapy was 26 5

Table 7:58 Visual acuity at 6 weeks. bacterial and indeterminate keratitis. A significant rise of IOP in our study was seen in patients with

Pain scoring was done for all the patients at 0, 2 and 6 weeks chamber reaction is usually more severe in cases of bacterial kera- These findings can be explained on the basis that the anterior titis but responds to appropriate therapy and anti-glaucoma treat- with treatment in all the three groups. ment. as shown in table 8. A significant decrease in pain score was noted 0 weeks 2 weeks 6 weeks Increased IOP was seen in cases of fungal keratitis later in the Bacterial 6.86 +/-1.04 keratitis < 0.001 fungal keratitis is often prolonged and protracted and hence the 3.07p < +/- 0.001 1.51 1.93+/- 1.53 p study period. This could reflect the fact that treatment in cases of (Group A) delay in control of IOP as compared to bacterial keratitis. Fungal keratitis p < 0.001 p < 0.0001 Increased IOP in cases of indeterminate keratitis can be due to (Group B) 5.47+/- 1.33 2.68 +/- 0.65 1.605+/- 1.04 Indeterminate of inconclusive microbiological work up. keratitis p < 0.001 p < 0.001 persistent inflammation owing to lack of targeted therapy because 6.85+/- 1.85 3.27 +/- 1.45 2.04+/- 1.285 (Group C) In our study, increased IOP was also found in ulcers with size et al. where Table 8: Pain score. they found elevated IOP in larger ulcer size of more than 4mm [3]. more than 5 mm. This was similar to a study by G.J. Lee.,

hence increased IOP. Discussion As the ulcer size increases it leads to increased inflammation and A patient of keratitis usually presents with pain, redness, photo- Increased IOP was also noted in mid stromal and deep stro- phobia and decreased vision. Pain in almost all cases is attributable

But it is often seen in some cases of keratitis that pain remains out mal level of infiltrate. Uneven distribution of proteoglycans and to loss of epithelium and subsequent exposure of nerve endings. stromal thickness [6]. This may possibly lead to relative angle clo- arrangement of collagen fibrils play a role in increased posterior sure. Associated trabeculitis may compound the rise in IOP. of proportion to the ulcer findings. In such cases it is believed that inflammation due to anterior chamber reaction plays an important - preventing permanent damage to trabecular meshwork and optic titis. Sakiyalak., et al. in their study had seen higher rates of glau- role and therapy to counter inflammation would go a long way in Both these findings were seen more in cases of bacterial kera disc [1]. coma procedures after active infection was controlled in patients of fungal keratitis although it was not found to be statistically sig- - [2]. tient is often in severe pain and uncooperative for measurement of Documentation of IOP in cases of keratitis is always difficult. Pa IOP. All contact methods of measurement of IOP are avoided due to nificantWe correlated pain scores over the duration of disease and non-intact epithelium. [7]. Although this

found a significant relief in pain with therapy

43 can be attributed to healing of keratitis but in some patients severe 6. Costagliola C., et al. “Corneal oedema and its medical treat- pain is reported even after complete resolution of ulcer. This shows ment”. Clinical and Experimental Optometry that pain could be in part due to high IOP and can be taken care of 96.6 (2013): 529- with proper IOP management. 7. Bendinger535. T and Plunkett N. “Measurement in pain medicine”. Conclusion BJA Education

Monitoring IOP in patients of keratitis although very important 16.9 (2016): 310-315. - erative patient due to extreme pain and an infected discontinuous is often neglected in the face of multiple difficulties like an uncoop Assets from publication with us epithelium. The extreme anterior chamber reaction and hypopyon - • Prompt Acknowledgement after receiving the article cal damage to the angles due to debris. This damage if not picked • Thorough Double blinded peer review associated with keratitis frequently cause trabeculitis or mechani on early in the course of disease can lead to irreversible glaucoma • Rapid Publication and permanent loss of vision in spite of successful resolution of • • High visibility of your Published work keratitis. A blanket treatment of anti-glaucoma drugs in cases of Issue of Publication Certificate keratitis, although employed by some has danger of being epith- Website: eliotoxic to an already compromised epithelium. Submit Article: www.actascientific.com/ Email us: www.actascientific.com/submission.php Thus it is important to monitor IOP with non-contact methods Contact us: +91 9182824667 [email protected] and treat if required. Bibliography 1. Zarei-Ghanavati S., et al a common complication during active microbial keratitis”. . “Elevated intraocular pressure is American Journal of Ophthalmology

2. Sakiyalak D and Chattagoon Y. “Incidence 152.4 (2011): of and 575-581.risk factors for secondary ocular hypertension in moderate to severe infectious ulcerative keratitis”. Clinical Ophthalmology 12 (2018): 2121-2128.

3. Lee GJ., et al Complication During Severe Infectious Keratitis”. Investigative . “Elevated Intraocular Pressure is a Common Ophthalmology and Visual Science

4. Takenaka J., et al. “Intraocular pressure 51 (2010): readings 2887. obtained through soft contact lenses using four types of tonometer”. Clinical Ophthalmology

Kumar M., et al. “Comparison 9 (2015): of intraocular 1875-1881. pressure measure-

5. without hydrogel contact lenses”. Indian Journal of Ophthal- ment with scheimpflug-based noncontact tonometer with and mology

63 (2015): 323-326.

Citation: Shikha Jain., et al. “Relevance of Intraocular Pressure Measurement in Ulcerative Microbial Keratitis". Acta Scientific Ophthalmology 4.4 (2021): 39-43.