5.9 Keratitis, Peripheral, Infiltrative, Contact Lens-Associated

eyes.nhs.scot/
Eyecare Guidelines/
Section 5 - Corneal/
5.9 Keratitis, Peripheral, Infiltrative, Contact Lens-Associated

Date of last review:

7/9/2026

Date of next review:

7/9/2028

Date of publication:

16/9/2026

Differential diagnosis ⁽¹⁾ 

Microbial keratitis (bacterial or fungal) – must be carefully excluded
- Clinical appearance may be similar; requires close monitoring, particularly within the first 24–48 hours if diagnosis is uncertain
Marginal keratitis
Corneal scar
Herpes simplex keratitis
Adenoviral keratoconjunctivitis
Toxic keratopathy (e.g. preservative or medication toxicity)

Possible management by optometrist

Advice

Address modifiable risk factors ⁽¹⁾:
- Discontinue contact lens wear immediately
- Counsel against extended (or continuous/overnight ⁽⁷⁾) wear
- Review and optimise lens fit and care system
- Reinforce contact lens hygiene and wearing schedules
Advise that ⁽¹⁾:
- Symptoms typically improve within ~48 hours
- Infiltrates generally resolve over 2–3 weeks
Warn of risk of recurrence ⁽¹⁾:
- Consider switching to daily disposable lenses if recurrent
Advise lid hygiene where associated blepharitis is present ⁽¹⁾

Treatment 

Ocular lubricants for symptomatic relief as required (drops/gel for use during the day ± unmedicated ointment for use at bedtime) ⁽¹⁾. Refer to local formularies for suitable options ⁽⁶⁾
Where associated blepharitis is present ⁽¹⁾:
- Consider topical antibiotic therapy (e.g. chloramphenicol, or azithromycin (off-label)) ⁽¹⁾
- Oral tetracyclines may be considered in selected cases ⁽¹⁾
  - where tetracyclines are contraindicated, consider prescribing oral erythromycin ⁽⁷⁾

Typical dosage/duration

(Blue text = IP, black text = non-IP)

NB. The following recommendations are strictly for the treatment of associated Blepharitis, and NOT for treatment of contact lens related corneal infiltrates ⁽⁷⁾:

Chloramphenicol 1% eye ointment ^(1,5)(POM, off-label): Apply 3–4 times daily. The course of treatment should be 5 days (even if symptoms improve) ^(2,3) (Consult local guidance as they may vary on timescales ⁽⁷⁾)
Azithromycin 15mg/g eye drops ^(1,4) (POM, off-label): One drop twice daily, morning and evening, for 3 days. It is usually unnecessary to prolong treatment beyond three days ^(2,3,7)
Oral Doxycycline tablets/capsules ^(1,5) (POM): 100mg daily for up to 2–3 months ⁽⁶⁾
Oral Erythromycin tablets ^(1,5) (POM): 500mg twice daily for up to 2-3 months ^(2,3,6)

NB. Chloramphenicol 0.5% eye drops and 1% eye ointment are available via the NHS Pharmacy First service for the treatment of infected eye conditions only and not for prophylactic use in this condition. Where prophylactic antibiotic treatment is clinically indicated, chloramphenicol can be supplied by a prescription or written order. In an emergency situation chloramphenicol (0.5% & 1%) can be supplied to the patient from practice stock if there is no alternative as above ⁽⁷⁾

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and national guidance where available ⁽⁷⁾

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options

Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate ⁽⁷⁾
Normally no referral required ⁽¹⁾, provided ⁽⁷⁾:
- Diagnosis is clear
- No features suggestive of microbial keratitis
- Appropriate monitoring is undertaken

Possible management in secondary care or local/community pathways where available

See Further management options ^(1,7)
Not normally required ⁽¹⁾

College of Optometrists Clinical Management Guideline⁽¹⁾ 

Keratitis, CL-associated infiltrative - College of Optometrists *

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

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