Sandbox ID Eye

Conjunctivitis

• Conjunctivitis, acute

• Bacterial conjunctivitis

• Empiric antimicrobial therapy,

• Preferred regimen (1): Gentamicin ointment qid for 1 week OR Gentamicin solution 1-2 drops qid for 1 week OR Tobramycin ointment tid for 1 week
• Preferred regimen (2): Besifloxacin solution 1 drop 3 times for 1 week OR Ciprofloxacin ointment tid for 1 week OR Ciprofloxacin solution 1-2 drops topical qid for 1 week OR Gatifloxacin solution tid for 1 week OR Levofloxacin solution 1-2 drops qid for 1 week OR Moxifloxacin solution tid for 1 week OR Ofloxacin solution 1-2 drops qid for 1 week
• Preferred regimen (3): Azithromycin ointment bid for 2 days, then 1 drop qd for 5 days OR Erythromycin ointment qid for 1 week
• Preferred regimen (4): Sulfacetamide ointment qid and at bedtime for 1 week OR Sulfacetamide solution 1-2 drops q2-3h for 1 week
• Preferred regimen (5): Trimethoprim/Polymyxin B solution 1 or 2 drops qid for 1 week

Note: Topical steroids are not recommended for bacterial conjunctivitis.

• Pathogen-directed antimicrobial therapy

• Chlamydia trachomatis

• Inclusion conjunctivitis

• Preferred regimen: Azithromycin 1 g PO qd
• Alternative regimen: Doxycycline 100 mg PO bid for 7 days

• Conjunctivitis secondary to trachoma

• Preferred regimen: Azithromycin 20 mg/kg PO for one single dose
• Alternative regimen (1): Tetracycline OR Erythromycin ointment for 6 weeks
• Alternative regimen (2): Tetracycline PO for 3 weeks OR Erythromycin PO for 3 weeks

• Neisseria gonorrhoeae

• Hyperacute bacterial conjunctivitis, adult

• Preferred regimen: Ceftriaxone 1 g IM once

Note: Dual therapy to cover Chlamydia is indicated.

• Staphylococcus aureus, methicillin-resistant (MRSA)

• Preferred regimen: Vancomycin ointment 1% qid

• Herpetic conjunctivitis

• Herpes simplex virus

• Preferred regimen: Acyclovir 1 drop topical 9 times per day OR Acyclovir 400 mg PO 5 times per day for 7-10 days OR Valacyclovir 500 mg PO tid for 7-10 days

Note: Topical steroids should be avoided.

• Varicella zoster virus

• Preferred regimen: Acyclovir 800 mg PO 5 times per day for 7-10 days OR Famciclovir 500 mg PO tid for 7-10 days OR Valacyclovir 1000 mg PO tid for 7-10 days

Note: Treatment usually consists of a combination of oral antivirals and topical steroids.

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Blepharitis

• Empiric therapy

• Blepharitis

• Preferred regimen: Bacitracin OR Erythromycin topical/systemic once or more times daily or at bedtime for a few weeks AND topical anti-inflammatory drugs such as Corticosteroids, Cyclosporine
• Alternative regimen: Metronidazole gel OR Tobramycin/Dexamethasone ophthalmic suspension OR Azithromycin sustained release system.

Note (1): Cure is usually not possible with blepharitis. Eyelid hygiene may provide symptomatic relief for both anterior and posterior blepharitis.

Note (2): Cyclosporine topical drops 0.05% may be helpful in some patients with posterior blepharitis.

• Specific considerations

• Meibomian gland dysfunction :

• Preferred regimen: (Doxycycline 100 mg qd OR Minocycline 100 mg qd OR Tetracycline 1000 mg in divided doses), tapered to (Doxycycline 40-50 mg qd OR Minocycline 40-50 mg qd OR Tetracycline 250-500 mg qd) after clinical improvement is noted (ususally 2-6 weeks)
• Alternative regimen: Erythromycin 250-500 mg PO qd OR Azithromycin 250-500 mg 1-3 times a week or 1 g per week for 3 weeks

Note (1): Tetracyclines are contraindicated in pregnancy, nursing women and those with history of hypersenstivity to tetracycline.

Note (2): Patients with contact-lens-associated giant papillary conjunctivitis have an increased frequency of meibomian gland dysfunction.

• Dry eye

• Preferred regimen: Cyclosporine topical and Omega-3 fatty acids two 1000 mg capsules tid

• Dermatological conditions with seborrheic blepharitis and meibomian gland dysfunction

• Preferred regimen: Azithromycin oral with Tacrolimus 0.1% topical
• Alternative regimen: Tetracycline oral

Note: In some patients Azithromycin oral may lead to abnormalities in electrical activity of heart with the potential to create serious irregularities in heart rhythm.

• Demodicosis

Preferred regimen: Metronidazole gel to eyelid skin

Alternative regimen: Ivermectin oral in recalcitrant Demodex bleharitis

• Ocular Rosacea

• Preferred regimen: Tetracyclines topical

Note (1): In patients with chronic blepharitis that does not respond to therapy, the possibility of carcinoma should be considered, particularly if associated with a loss of eyelashes.

Note (2): Isotretinoin used to treat cystic acne is associated with significant increase in colonization of conjunctiva with Staphylococcus aureus blepharitis and disruption of tear function. Discontinuation of isotretinoin leads to improvement in most cases.

Keratitis, bacterial

• Empiric therapy

• No organism identified (or) multiple types of organisms

• Preferred regimen: topical concentration - Cefazolin 50 mg/ml with Tobramycin/Gentamycin 9-14 mg/ml OR fluoroquinolones-Besifloxacin 6 mg/ml, Ciprofloxacin 3 mg/ml, Levofloxacin 15 mg/ml, Moxifloxacin 5 mg/ml, Ofloxacin 3 mg/ml AND subconjunctival dose - Cefazolin 100 mg in 0.5 ml with Tobramycin/Gentamycin 20 mg in 0.5 ml.

Note (1) : Topical antibiotic eye drops are capable of achieving high tissue levels and are the preferred method of treatment in most cases.

Note (2) : Subconjunctival antibiotics may be helpful where there is imminent scleral spread or perforation or in cases where adherence to the treatment regimen is questionable.

Note (3) : Systemic therapy is necessary for suspected gonococcal infection.

• Adjunctive therapy: ocular ointments may be useful at bedtime in less severe cases.

• Organism specific bacterial keratitis

• Gram positive cocci

• Preferred regimen: topical concentration - Cefazolin 50 mg/ml, Vancomycin 15-50 mg/ml, Bacitracin 10,000 IU topical concentration , fluoroquinolones-Besifloxacin 6 mg/ml, Ciprofloxacin 3 mg/ml, Levofloxacin 15 mg/ml, Moxifloxacin 5 mg/ml, Ofloxacin 3 mg/ml AND subconjunctival dose - Cefazolin 100 mg in 0.5 ml, Vancomycin25 mg in 0.5 ml

Note (1) : Vancomycin and gentamycin have no gram negative activity and should not be used as a single agent in empirically treating bacterial keratitis.

• Gram negative bacilli

• Preferred regimen: topical concentration - Tobramycin/Gentamycin 9-14 mg/ml, Ceftazidime 50 mg/ml,fluoroquinolones-Besifloxacin 6 mg/ml, Ciprofloxacin 3 mg/ml, Levofloxacin 15 mg/ml, Moxifloxacin 5 mg/ml, Ofloxacin 3 mg/ml AND subconjunctival dose - Tobramycin/Gentamycin 20 mg in 0.5 ml,Ceftazidime 100mg in 0.5 ml

• Gram negative cocci

• Preferred regimen: topical concentration - Ceftriaxone 50 mg/ml, Ceftazidime 50 mg/ml, fluoroquinolones-Besifloxacin 6 mg/ml, Ciprofloxacin 3 mg/ml, Levofloxacin 15 mg/ml, Moxifloxacin 5 mg/ml, Ofloxacin 3 mg/ml AND subconjunctival dose - Ceftriaxone 50 mg/ml,Ceftazidime 100mg in 0.5 ml

• Nontuberculous mycobacteria

• Preferred regimen: topical concentration - Amikacin 20-40 mg/ml, Clarithromycin 10 mg/ml, Azithromycin 10 mg/ml, fluoroquinolones-Besifloxacin 6 mg/ml, Ciprofloxacin 3 mg/ml, Levofloxacin 15 mg/ml, Moxifloxacin 5 mg/ml, Ofloxacin 3 mg/ml AND subconjunctival dose - Amikacin 20 mg in 0.5 ml

• Nocardia

• Preferred regimen: topical concentration - Sulfacetamide 100 mg/ml, Amikacin 20-40 mg/ml, Trimethoprim/Sulfamethoxazole: Trimethoprim 16 mg/ml, Sulfamethoxazole 80 mg/ml AND subconjuctival dose - Amikacin 20 mg in 0.5 ml

• Note (1) : Topical antibiotic eye drops are capable of achieving high tissue levels and are the preferred method of treatment in most cases.
• Note (2) : Subconjunctival antibiotics may be helpful where there is imminent scleral spread or perforation or in cases where adherence to the treatment regimen is questionable.

Keratitis, fungal

• Empiric therapy

• (1) Topical antifungals

• (a) For filamentous fungi

(i) 1st line : 5% Natamycin

(ii) 2nd line : 1% Itraconazole

• (b)For candida

(i) 1st line : 0.15% Amphotericin B

(ii) 2nd line : Fluconazole

• (2) Oral antifungals

(i) Ketoconazole 200 mg bid

(ii) Itraconazole 200mg qd

(iii) Fluconazole 50-100 mg qd

• (3) Recently topical and oral Variconazole

Keratitis, protozoal

• Empiric therapy ,

• For Acanthamoeba

(i) Biguanide - (polyhexamethylene biguanide [PHMB] 0.02% or chlorhexidine 0.02%) and

(ii) diamidine - (propamidine 0.1% or hexamidine 0.1%)

• Recommended

propamidine 0.1% + polyhexamethylene biguanide 0.02% OR propamidine + chlorhexidine.

polyhexamethylene biguanide 0.02% AND hexamidine drops are administered every hour day, and night, for 48 hours initially, followed by hourly drops by day only for a further 72 hours.

note (1) : Intensive early treatment is given because organisms may be more susceptible before cysts have fully matured. Epithelial toxicity is common if the dosage is maintained at this intensity.

Note (2) : the diamidines and biguanides are currently the most effective cysticidal antiamoebics in vitro .

• Toxicity of Biguanides and Diamidines : Cataract, iris atrophy,and peripheral ulcerative keratitis are all complications of Acanthamoeba keratitis that have been attributed to the use of topical biguanides and/or diamidines.

• For microsporidia

(i) debridement

(ii) broad-spectrum antibiotics OR polyhexamethylene biguanide [PHMB] OR chlorhexidine.

• Treatment for Limbitis and Scleritis:

• Oral NSAIDS treatment, such as furbiprofen 50 to 100 mg, bid or tid. If it does not respond to flurbiprofen, then high-dose systemic steroid therapy prednisolone 1 mg/kg/day), with systemic Cyclosporine (3 to 7.5 mg/kg/day), can be used for successful control.

Keratitis, viral

• Empiric therapy

• (a) HSV keratitis

• (1) For epithelial disease:

(i) Acyclovir 3% ointment 5 times a day (is able to penetrate intact corneal epithelium)

(ii) Idoxuridine 0.1% drops now seldom used toxicity

(iii) Debridement in dendritic ulcer

• (2) For necrotizing stromal disease:

Oral Acyclovir AND topical corticosteroids.

• (3) For nonnecrotizing stromal disease

Topical corticosteroids when lesion involves visual axis.Possibly oral acyclovir (debatable)