Pseudomonas Keratitis

From EyeWiki
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 by Augustine Hong, MD on June 2, 2023.

Disease Entity


Pseudomonas aeruginosa is a gram-negative rod. It is an opportunistic human pathogen, known to cause a variety of infectious diseases. In the eye, P. aeruginosa is a common cause of bacterial keratitis, particularly in contact lens wearers. It is known to be particularly virulent, with pseudomonas keratitis being more difficult to treat and have worse prognosis than other forms of bacterial keratitis. P. aeruginosa secretes proteases that can cause liquefactive necrosis of the cornea, leading to rapid corneal weakening and perforation.


Pseudomonas is the leading cause of gram-negative bacterial keratitis, and one of the most common causes of bacterial keratitis overall. In one meta-analysis, prevalence of P. aeruginosa isolates in bacterial keratitis ranged from 6.8 to 55%[1].

It is widely known that pseudomonas keratitis is strongly associated with contact lens wear. In one study, incidence of pseudomonas keratitis was 2.76 cases per 10000 individuals per year, but rose to 13.04 cases per 10000 individuals when only considering contact lens wearers[2]. In the same study, 55% of cases of pseudomonas keratitis were associated with contact lens wear.

Extended contact lens use allows adhesion of P. aeruginosa to contact lens surfaces and subsequently the cornea. P. aeruginosa possesses specific virulence factors, including pili, glycocalyx, and exotoxins, which allow adherence and invasion into the cornea[3].

Pseudomonas keratitis in non-contact lens wearers tends to occur more commonly in the elderly and also causes significant morbidity. Worse initial visual acuity, older age, and size and extent of stromal involvment appear to be associated with worse outcomes in non-contact lens wearers.[4]

Diagnosis and treatment

All cases of suspected pseudomonas keratitis should be scraped and cultured. Empiric broad spectrum antibiotics should be initiated for infectious keratitis. Treatment regimens for pseudomonas keratitis are variable and include monotherapy or combination therapy with a topical fluoroquinolones, aminoglycosides, cephalosporins, and carbapenems [5][6][7] . A report by O'Brien et al in 1995 demonstrated that ofloxacin monotherapy was not inferior and had fewer side effects compared to combined tobramycin-cefazolin[8]. However, disease severity, regional microbial resistance rates, and pseudomonas strain type are important considerations [9][10]. Cytotoxic strains of Pseudomonas often confer resistance to fluoroquinolones [11]. Invasive strains of Pseudomonas may be less responsive to tobramycin initially[12]. Combination therapy is often utilized to take advantage of potential additive or synergistic effects of medication, especially in treatment-refractory cases[6].

While progression to endophthalmitis is rare, Pseudomonas is commonly cited as the causative pathogen of microbial keratitis leading to endophthalmitis leading to evisceration or enucleation. [13][14][15][16]

Steroid use in conjunction with antibiotics is controversial in the setting of pseudomonas keratitis as well as microbial keratitis as a whole. On subgroup analysis on patients from the steroids for corneal ulcers trial (SCUT), showed that pseudomonas ulcers had no overall benefit with the addition of corticosteroids[17]. However, the same study showed that the invasive subtype of P. aeruginosa may demonstrate a small improvement in visual acuity with steroids versus placebo.


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  2. Jeng BH, Gritz DC.Epidemiology of ulcerative keratitis in northern California. Arch Ophthalmol. 2010 Aug;128(8):1022-8.    
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  8. O'Brien TP, Maguire MG, Fink NE, Alfonso E, McDonnell. Efficacy of ofloxacin vs cefazolin and tobramycin in the therapy for bacterial keratitis. Report from the Bacterial Keratitis Study Research Group. P Arch Ophthalmol. 1995 Oct; 113(10):1257-65.
  9. Soleimani M, Tabatabaei SA, Masoumi A, Mirshahi R, Ghahvechian H, Tayebi F, Momenaei B, Mahdizad Z, Mohammadi SS. Infectious keratitis: trends in microbiological and antibiotic sensitivity patterns. Eye (Lond). 2021 Nov;35(11):3110-3115. doi: 10.1038/s41433-020-01378-w. Epub 2021 Jan 19. PMID: 33469134; PMCID: PMC8526825.
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  14. Tóth G, Pluzsik MT, Sándor GL, Németh O, Lukáts O, Nagy ZZ, Szentmáry N. Clinical Review of Microbial Corneal Ulcers Resulting in Enucleation and Evisceration in a Tertiary Eye Care Center in Hungary. J Ophthalmol. 2020 May 18;2020:8283131. doi: 10.1155/2020/8283131. PMID: 32509342; PMCID: PMC7254073.
  15. Stevenson LJ, Dawkins RCH, Sheorey H, McGuinness MB, Hurley AH, Allen PJ. Gram-negative endophthalmitis: A prospective study examining the microbiology, clinical associations and visual outcomes following infection. Clin Exp Ophthalmol. 2020 Aug;48(6):813-820. doi: 10.1111/ceo.13768. Epub 2020 May 11. PMID: 32348002.
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