Overview 

Pediatric keratitis is the inflammation of the cornea in children.

The cornea is a protective tissue layer that covers the iris and pupil of the eyes.

It is a serious eye condition that, if left untreated, can cause more tissue breakdown and infection in other parts of the eyes and eventually lead to blindness.¹

It can also lead to poor vision development, which happens when one or both eyes don’t get enough clear vision or when there is a big difference in vision between the two eyes.⁵

Pediatric keratitis can start as a slow-developing sore on the cornea or as a rapid infection that causes pus and damages any part of the corneal tissue.⁸

Though not so common in children (3%-13%)³ of cases, pediatric keratitis is a significant health concern¹ because of factors associated with diagnosis and treatment.  

It's difficult to check children's eyes, and they often can’t clearly explain their symptoms.²

Common causes of pediatric keratitis

The causes can be categorised into infectious and non-infectious causes.

Infectious causes:

When the eye’s natural defences that fight against infection are damaged, it becomes easier for microorganisms to penetrate the eye layers, causing this condition. These organisms can be bacteria, fungi, viruses or parasites.⁶

1. Bacterial keratitis:

The most common species causing this keratitis are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Pseudomonas aeruginosa. 

2. Fungal keratitis: 

Occurs most especially due to trauma. Fusarium, Aspergillus, and Candida species are often responsible.¹⁰

The type of fungus that causes fungal keratitis varies depending on the local weather, climate, and whether urban or rural area.¹⁰

People who work on farms are also more likely to get this kind of infection because of soil and vegetative matter entering the eyes.¹⁰

3. Viral Keratitis: 

Herpes simplex virus (HSV) is the causative organism.

Both HSV-1 and HSV-2 can lead to eye infections, but HSV-1 is more commonly found in the eye.

The virus can hide in the nerves after the first infection and later become active again, causing repeated eye problems.¹¹

Children usually have more serious problems with their vision when they get HSV keratitis.

4.  Parasitic keratitis:

Happens when parasites from the environment get directly into the eye, when they spread from nearby parts of the body, or when the body’s immune response to a parasite infection elsewhere causes damage to the eye. 

Most pediatric keratitis cases are caused by Acanthamoeba and Microsporidia.²

Non-infectious causes 

1. Traumas: 

Like scratches, foreign bodies in the eyes that can introduce microorganisms in the eyes, chemical injuries and surgeries that can affect the protective layer of the eyes. 

2. Contact lens: 

Contact lens use is one of the major causes of this condition. 

Wearing contact lenses the wrong way can increase the risk of serious eye infections. 

Some other risky habits include:

• Sleeping with contact lenses in
• Wearing them for too long 
• Not cleaning them properly
• Rinsing them with tap water instead of the proper solution
• Using dirty or contaminated lens cases or solutions
• Not washing hands before handling children's lenses
• Sharing contact lenses with others
• Swimming or showering while wearing contact lenses
• Getting small injuries from the lenses themselves

3. Exposure Keratopathy:⁵

A condition where the front surface of the eye (the cornea) becomes dry and irritated because it is not properly protected. 

Usually happens when the eyelids don’t close fully, blink correctly, or if the eyes stick out too much.

When the cornea is exposed for too long, it can start to dry out and become damaged.

This makes the eyes more vulnerable to germs, irritants, and injury. The cornea can become inflamed or infected.⁴

Risk factors that can predispose infants to keratitis

Predisposing risk factors include:

1. Immunosuppression: Means the body might not be able to fight infections as it should
2. Pre-existing eye surface conditions, such as blepharitis,⁹ keeping the eyes in a compromised state.
3. Vitamin A deficiency:⁷ Vitamin A supports the health of the cornea and aids in the healing of eye injuries. Its deficiency affects the eyes
4. Corticosteroids:² While reducing inflammation, it can weaken the immune system and lower the eyes’ ability to fight infections
5. Systemic illness that makes the immune system weak against infections

How to identify the symptoms of pediatric keratitis in children 

The symptoms of pediatric keratitis can vary depending on the cause and severity, but common signs include:

1. Eye redness which is often the first noticeable symptom
2. Eye pain or irritation, making the child rub their eyes frequently
3. Tearing or watery eyes
4. The child may avoid bright lights or squint (photophobia)
5. They might complain or show signs of poor vision
6. Eye discharge may occur
7. Frequent blinking or twitching due to irritation or discomfort
8. White or grey spots on the cornea in more serious cases
9. Difficulty keeping the eyes open because of pain or sensitivity

In infants and toddlers who can’t express what they’re feeling, excessive crying and restlessness should not be ignored. 

Diagnosis of pediatric keratitis 

To make a diagnosis for pediatric keratitis, a complete eye examination is done, and a sample of the cornea surface using a cotton swab or biopsy is taken for examination.

Treatment for pediatric keratitis 

Pediatric keratitis is an eye emergency that requires prompt and specific management to preserve the eye.

Treatment for pediatric keratitis includes:

• Medical management 
  • For bacterial keratitis, treatment can be started with broad-spectrum antibiotics and switched to targeted antibacterial therapy when the main organism is identified⁸
  • For fungal infections, topical antifungals like Natamycin 5%, Amphotericin B, and Voriconazole can be used. In severe cases, systemic antifungals can be used⁸
  • For viral keratitis, treatment with topical or oral antiviral agents is effective for the treatment of HSV keratitis. Topical medications include trifluridine and ganciclovir, and current oral antivirals include acyclovir, valacyclovir and famciclovir¹¹
  • For parasitic keratitis, biguanides, pentamidine isethionate, and phosphocholine are effective for treatment²

Corticosteroids can also be used for treatment. They can help reduce the swelling of the eye and lower the risk of scarring on the cornea.⁸ However, it has some disadvantages, like the return of the infection, reduced local immune response, increased eye pressure, risk of developing cataracts, slower healing, and, in severe cases, damage to the cornea.⁸ Hence, it must be used with care.

• Surgery 

In severe cases or when medication is not effective, surgery is done. 

Complications of pediatric keratitis

Some complications as a result of late diagnosis and treatment include

• Corneal scarring leading to blurry vision or vision loss
• Corneal perforation, which is a hole in the cornea, may require surgery
• Vision loss, which can be temporary or permanent, depending on severity
• Amblyopia (lazy eye) if vision is reduced during the critical period of visual development
• Glaucoma: increased pressure in the eye, sometimes triggered by inflammation or treatment
• Need for a corneal transplant in severe cases where damage is extensive

How to prevent pediatric keratitis 

• Handle children's contact lenses with care in storing and cleaning
• Remove contact lenses before sleeping or swimming
• Protect their eyes from injury and dirt that can introduce infection
• Report any symptoms
• Make sure your hand is neat before touching their eyes
• Visiting an eye doctor regularly
• Ensure their meals are enriched with vitamin A-rich foods
• Don't put drugs in their eyes without consultation
• Keep chemicals and drugs out of children's reach

Summary 

Pediatric keratitis is an inflammation of the cornea in children and is considered a serious condition that can lead to vision loss or blindness if not treated promptly.

Common symptoms include redness, eye pain, tearing, light sensitivity, blurred vision, discharge, and excessive blinking.

Understanding the symptoms, causes, and treatment for pediatric keratitis in children is crucial for early diagnosis and prevention. 

Be sure to consult an eye specialist if your child shows any signs of eye discomfort, and before administering any medications

FAQs

Is Pediatric Keratitis Contagious?

No, pediatric keratitis itself is not contagious, but the underlying infection, such as viral keratitis from the Herpes simplex virus, can be transmitted through contact with infected bodily fluids.

How Does Pediatric Keratitis Affect Vision?

If left untreated, pediatric keratitis can result in scarring on the cornea, leading to vision impairment or blindness.

What should I do if my child shows symptoms of pediatric keratitis?

The best thing to do is to take the child to the hospital for proper diagnosis and treatment.

Is pediatric keratitis an emergency?

Yes. Pediatric keratitis should be treated as an eye emergency to prevent complications like vision loss.

Can keratitis be prevented in children?

Yes. By ensuring proper hygiene, safe contact lens use, avoiding eye trauma, ensuring good nutrition, and regular eye checkups.