Severe Microbial Keratitis in Virgin and Transplanted Cornea—Probability of Visual Acuity Improvement

<b>Purpose:</b> To evaluate visual acuity improvement and identify contributing factors in patients with severe keratitis affecting both virgin and transplanted corneas, treated at a hospital. <b>Methods:</b> A retrospective analysis was conducted on 497 patients with unilateral corneal ulcers treated at a tertiary referral center between 2008 and 2023. Data included distance (BCVA) and near best-corrected visual acuity at initial presentation and at discharge, treatments before hospital admission, demographic details, risk factors, clinical signs and symptoms, ancillary test results, and management strategies. Patients were categorized into two groups: Group A (naïve corneal ulcers, 379 patients) and Group B (post-keratoplasty infectious keratitis, 118 patients). Additional analysis focused on patients with presenting visual acuity of at least 1.0 logMAR (≤5/50 Snellen charts = legal blindness) to predict final visual outcomes. <b>Results:</b> The median BCVA at presentation for the entire cohort was 1.9 logMAR, advancing to 1.5 logMAR at discharge (<i>p</i> < 0.001). At least one line improvement in BCVA was observed in 47% of patients (52% of naïve cornea and 33% of transplanted cornea patients). Significantly worse results were observed in Group B were observed for BCVA at presentation, BCVA improvement, and distance and near vision improvement. Among patients with legal blindness at presentation, vision status improved for 52/379 (14%) in Group A and 6/118 (5%) in Group B during hospital admission (<i>p</i> < 0.001), while 67% of the cohort was discharged with VA equal or worse than 5/50. The average hospital stay was 9 days. Near visual acuity got better in 23% of patients (27% in Group A vs. 9% in Group B). A multivariate regression model showed that older age and worse distance BCVA on admission were independent negative predictors of improvement (<i>p</i> < 0.001, <i>p</i> < 0.001, respectively) while midperiphery ulcers were associated with better visual outcomes. <b>Conclusions:</b> Hospital admission leads to BCVA improvement in 47% of the patients with severe corneal ulcer, though the prognosis is significantly worse for those with post-keratoplasty microbial keratitis. At discharge, 67% of patients remained at the legal blindness level. Older age and lower BCVA at first presentation are associated with worse prognosis, while ulcers located in the corneal midperiphery are linked to better visual outcomes.