Is ocular hypertension an indication for anterior chamber irrigation in patients with keratitis?

Ocular Hypertension in Keratitis: Not an Indication for Anterior Chamber Irrigation

Ocular hypertension in keratitis is not an indication for anterior chamber irrigation; it should be managed medically with topical and systemic IOP-lowering agents, as anterior chamber irrigation is not a standard treatment modality for elevated IOP in this context. 1, 2

Understanding Ocular Hypertension in Keratitis

Elevated intraocular pressure (IOP) is a common complication during active bacterial keratitis, occurring in approximately 28-45% of moderate to severe cases. 2, 3 This represents a significant clinical challenge that requires prompt recognition and appropriate management to prevent optic nerve damage and preserve visual outcomes.

Risk Factors for IOP Elevation in Keratitis

The following factors increase the likelihood of secondary ocular hypertension during active keratitis:

• Severe corneal infiltration (ulcer size ≥4.0 mm) is strongly associated with IOP elevation 2, 3
• Severe anterior chamber cellular reaction significantly increases risk 2
• Prior ocular surgery and diabetes mellitus are additional risk factors 3
• Corticosteroid use can induce or worsen IOP elevation, particularly when used aggressively 1

Medical Management of Elevated IOP in Keratitis

Primary Treatment Approach

The standard management of ocular hypertension in keratitis involves medical therapy with IOP-lowering medications, not anterior chamber irrigation. 1, 2 The treatment strategy should include:

• Topical beta-adrenergic antagonists (e.g., timolol) 1
• Topical alpha2-adrenergic agonists (e.g., brimonidine) 1
• Topical or systemic carbonic anhydrase inhibitors 1
• Oral or intravenous hyperosmotic agents for rapid IOP reduction in severe cases 1

Important Clinical Considerations

Routine IOP monitoring should be performed in all patients with moderate to severe keratitis to detect elevation early and prevent optic nerve damage. 3 The following points are critical:

• Elevated IOP during active keratitis is associated with longer time to ulcer resolution (mean 50 days vs. 32 days in normotensive eyes) 3
• Patients with secondary ocular hypertension have worse visual outcomes, with only 20% achieving 20/40 or better vision compared to 47% in the control group 3
• Approximately one-third of patients with secondary OHT develop persistent IOP elevation after keratitis resolves 2

Role of Anterior Chamber Paracentesis

While anterior chamber paracentesis is mentioned in ophthalmic literature, it is specifically indicated for acute angle closure crisis to break pupillary block when medical therapy fails or laser iridotomy cannot be performed due to corneal edema. 1 This is a completely different clinical scenario from keratitis-associated ocular hypertension.

Anterior chamber irrigation is not a standard intervention for managing elevated IOP in keratitis and could potentially:

• Introduce additional infection risk in an already compromised eye
• Cause further inflammation
• Provide only temporary IOP reduction without addressing the underlying inflammatory mechanism

Corticosteroid Management Considerations

A critical pitfall involves corticosteroid-induced IOP elevation in keratitis patients:

• Corticosteroids should only be added after at least 2-3 days of antibiotic therapy when the organism is identified and the infection is responding 1
• Aggressive topical corticosteroid use can lead to pressure-induced intralamellar stromal keratitis (PISK), which paradoxically worsens with steroids but improves with IOP reduction 1, 4
• If IOP elevation occurs during corticosteroid therapy, reduce or discontinue steroids and initiate IOP-lowering medications 1, 4

Long-term Outcomes and Monitoring

Patients who develop ocular hypertension during keratitis require:

• Close follow-up even after keratitis resolution, as persistent IOP elevation develops in 32.9% of cases 2
• Older age is significantly associated with both persistent IOP elevation and blindness in patients with secondary OHT 2
• Use of hyperosmotic agents during active keratitis is associated with persistent IOP elevation, though this may reflect disease severity rather than causation 2

Clinical Algorithm

1. Detect: Measure IOP routinely in all moderate-severe keratitis cases 3
2. Treat medically: Initiate topical beta-blockers, alpha-agonists, and/or carbonic anhydrase inhibitors 1
3. Consider systemic agents: Use hyperosmotic agents for severe IOP elevation 1
4. Reassess corticosteroids: If using steroids, reduce or discontinue if IOP elevation occurs 1, 4
5. Monitor closely: Follow IOP during and after keratitis resolution 2, 3