In India a large share of infective keratitis is fungal, often after trauma with vegetable matter in agricultural workers. Steroid drops given for a red, painful eye can make fungal keratitis rapidly worse. A feathery-edged infiltrate, satellite lesions or a history of plant injury should raise suspicion, but only a corneal scraping with KOH mount and culture settles it.
- Never start steroid or steroid-antibiotic drops for a corneal infiltrate before a diagnosis.
- Ask about injury with plant material, soil or a finger-nail, and about contact lens wear.
- Scrape for KOH mount, Gram stain and culture before starting treatment.
- Start topical natamycin for suspected filamentous fungal keratitis and review within 48 hours.
- Refer any ulcer that is large, central or worsening despite treatment.
Why it matters
Steroid drops for an undiagnosed ulcer are a common, avoidable cause of corneal perforation.
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