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.

---

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.

Endophthalmitis, bacterial

• Endogenous bacterial endophthalmitis

• Empiric antimicrobial therapy

• Preferred regimen (intravitreal): Vancomycin 1 mg/0.1 mL normal saline AND (Ceftazidime 2.25 mg/0.1 mL OR Amikacin 0.4 mg/0.1 mL)
• Preferred regimen (intravenous): antibiotic active against underlying source of bacteremia

Note (1): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.

Note (2): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.

Note (3): Endogenous bacterial endophthalmitis arises from bacteremic seeding associated with endocarditis, urinary tract infections, indwelling central venous catheters, illicit injection drug use, procedures (e.g., endoscopy), or liver abscess. Common pathogens include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus milleri group, group A and B streptococci, and Gram-negative bacilli (e.g., Escherichia coli, Klebsiella pneumoniae).

Endophthalmitis, bleb-related

• Empiric antimicrobial therapy

• Preferred regimen (intravitreal): Vancomycin 1 mg/0.1 mL normal saline AND Ceftazidime 2.25 mg/0.1 mL

Note (1): In conjunction with intravitreal antibiotic therapy, a vitrectomy is necessary in most cases.

Note (2): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.

Note (3): It is reasonable to give an oral quinolone, such as Moxifloxacin, that achieves good vitreous levels and treats the major pathogens.

Endophthalmitis, candidal

• Endogenous candida endophthalmitis

• Empiric therapy'

• Preferred regimen (intravitreal): Amphotericin intravitreal OR Voriconazole intravitreal.
• Preferred regimen (intravenous): Fluconazole (if suspectable) OR Voriconazole OR Amphotericin

Note (1): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary if viritis (endophthalmitis) is present.

Note (2): often there is a need to remove artificial intra-ocular lense.

Note (3) : Systemic antibiotics alone are not effective in treating endophthalmitis, except for most cases of Candida chorioretinitis without vitritis. They are indicated in endogenous endophthalmitis and fungal endophthalmitis. Whether they are beneficial as adjunctive therapy in exogenous bacterial endophthalmitis is unknown.

• Exogenous candida endophthalmitis

• Empiric therapy

• Preferred regimen (intraocular) : Amphotericin is 5-10 mcg in 0.1 mL of sterile water intravitreal OR Voriconazole is usually 100 mcg in 0.1 mL of sterile water intravitreal.
• Preferred regimen (intravenous) : High-dose Fluconazole (400-800 mg qd assuming the normal kidney function) is also indicated for susceptible strains, OR Voriconazole for fluconazole-resistant but voriconazole-susceptible strains.

Note (1): Candida parapsilosis is the most common species, especially in postsurgical outbreaks.

Note (2): if infection follows cataract surgery, it is often necessary to remove the intra ocular lense as well.

Endophthalmitis, mold

• Exogenous mould endophthalmitis
• Empiric therapy

• Preferred regimen (intravitreal and intracameral): Amphotericin OR Voriconazole intravitreal and intracameral injections
• Preferred regimen (intravenous): Voriconazole

Note (1) : Unless the fungus is known, the initial intra-ocular injection should be amphotericin; subsequent injections may be voriconazole for sensitive fungi. Repeated intra-ocular injections of voriconazole (if the organism is susceptible) or amphotericin can be given, at least 48 hours apart.

Note (2) : In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.

Note (3) : Artificial intra-ocular lense needed to be removed.

• Endogenous mould endophthalmitis
• Empiric therapy

• Preferred therapy (intravitreal) : Amphotericin intravitreal or voriconazole intravitreal
• Preferred regimen (intravenous): In immunocompromised patients, treatment must include systemic antifungal therapy

Note (1): if the patient is able to tolerate surgery , vitrectomy and removal of any IOL, followed by intravitreal amphotericin or voriconazole should be performed.

Note (2): If too ill for surgery, the patient should have intravitreal injection of amphotericin or voriconazole, with repeated injections as needed.

Note (3): In injection drug users with no evidence of ongoing fungaemia, vitrectomy, intravitreal anti-fungal injection and systemic therapy should be given.

Endophthalmitis, post-cataract surgery, acute

• Empiric therapy

• Preferred regimen (intravitreal):Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
• Preferred regimen (intravenous): rarely given

Note (1) : In conjunction with intravitreal antibiotic therapy, a vitrectomy is necessary if severe infection or fungal etiology

Note (2) : If there is no improvement in 48 h, a repeat intravitreal injection may be given with either vancomycin or ceftazidime, depending on culture results.

Note (3) : Repeated injections of amikacin are avoided, owing to concerns about retinal toxicity.

Note (4): No need to remove intra-ocular lense, unless fungal etiology.

Endophthalmitis, post-cataract surgery, chronic

• Empiric therapy

• Preferred regimen (intravitreal): Vancomycin 1 mg/0.1 mL normal saline intravitreal

Note (1) : Artificial intra-ocular lense needed to be removed.

Note (2) : Most common pathogen causing post-cataract endophthalmitis is Propionibacterium acnes.

Note (3) : Necessity for vitrectomy is varied.

Endophthalmitis, post-tramatic

• Empiric therapy

• Preferred regimen (intravitreal): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal ( AND Amphotericin intravitreal if fungi suspected)

Note : intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.

• Preferred regimen (intravenous):Intravenous Vancomycin AND (Ceftazidime OR Ciprofloxacin)

Note (1): Systemic antibiotics alone are not effective in treating endophthalmitis, except for most cases of Candida chorioretinitis without vitritis. They are indicated in endogenous endophthalmitis and fungal endophthalmitis. Whether they are beneficial as adjunctive therapy in exogenous bacterial endophthalmitis is unknown.

Note (2): In conjunction with intravitreal antibiotic therapy and intravenous antibiotic therapy , a vitrectomy is necessary in most cases.

Note (3): Need to remove artificial intra-ocular lens varies (always if fungal).

Note (4) : Treatment should be aggressive, with vitrectomy, intravitreal antibiotics (e.g. vancomycin plus ceftazidime), and systemic therapy.

Note (5) : Most common pathogens are Bacillus cereus, coagulase-negative staphylococci (fungi in some cases).

Keratitis, bacterial

• Empiric therapy

• No organism identified (or) multiple types of organisms

• Preferred regimen (topical) : 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
• Preferred regimen (subconjunctial): 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): Cefazolin 50 mg/ml OR Vancomycin 15-50 mg/ml OR Bacitracin 10,000 IU topical concentration OR fluoroquinolones-Besifloxacin 6 mg/ml OR ( Ciprofloxacin 3 mg/ml OR Levofloxacin 15 mg/ml OR Moxifloxacin 5 mg/ml OR Ofloxacin 3 mg/ml ) AND
• Preferred regimen (subconjunctival): Cefazolin 100 mg in 0.5 ml OR Vancomycin 25 mg in 0.5 ml

Note: 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): Tobramycin/Gentamycin 9-14 mg/ml OR Ceftazidime 50 mg/ml OR fluoroquinolones-Besifloxacin 6 mg/ml, OR ( Ciprofloxacin 3 mg/ml OR Levofloxacin 15 mg/ml OR Moxifloxacin 5 mg/ml OR Ofloxacin 3 mg/ml ) AND
• Preferred regimen (subconjunctival) :[ [Tobramycin]]/Gentamycin 20 mg in 0.5 ml OR Ceftazidime 100mg in 0.5 ml

• Gram negative cocci

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

• Nontuberculous mycobacteria

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

• Nocardia

• Preferred regimen (topical) : Sulfacetamide 100 mg/ml OR Amikacin 20-40 mg/ml OR Trimethoprim/Sulfamethoxazole: Trimethoprim 16 mg/ml, Sulfamethoxazole 80 mg/ml AND
• Preferred regimen (subconjuctival) : 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)

Ocular syphilis

• Empiric therapy

• Preferred regimen (1) : Penicillin intravenous (4 million units every 4 hours,assuming normal renal function) for 10 to 14 days. Intravenous penicillin with injections of 2.4 million units of intra muscular benzathine penicillin, once weekly for 3 weeks.
• Preferred regimen (2) : Systemic corticosteroids (e.g., oral Prednisone , 60 to 80 mg qd ) should be started along with the antibiotic therapy and then tapered over days to weeks.

Note (1) : Corticosteroids are given to decrease intra-ocular inflammation and prevent rebound inflammation from Jarisch Herxheimer reaction.

Note (2) : All patients with presumed ocular syphilis should be tested for HIV, and all should have a lumbar puncture before starting therapy to exclude concurrent neurosyphilis.

Note (3) : If there is evidence of neurosyphilis, antibiotic treatment is the same, but a follow-up lumbar puncture at 6 months is necessary to document resolution of infection.

Ocular toxocariasis

Active chorioretinitis; meningitis; lowered resistance due to steroids or cytotoxic drugs

Ocular toxoplasmosis

-newline"> [Pyrimethamine (pyri) 200 mg po once on 1st day, then 50–75 mg q24h] + [sulfadiazine (see footnote4) 1–1.5 gm po qid] + [leucovorin (folinic acid) 5–20 mg 3x/wk]—see Comment. Treat 1–2 wk beyond resolution of signs/symptoms; continue leucovorin 1 wk after stopping pyri. For congenital toxo, toxo meningitis in adults, & chorioretinitis, add prednisone 1 mg/kg/day in 2 div. doses until CSF protein conc. falls or vision-threatening inflammation subsides. Adjust folinic acid dose by following CBC results.

Ocular tuberculosis

• Ocular tuberculosis

• Intensive phase (adult)

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

• Continuation phase (adult)

• Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 4 months AND Rifampin 10 mg/kg (max: 600 mg) for 4 months

• Intensive phase (pediatric)

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

• Continuation phase (pediatric)

• Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 4 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 4 months

Note (1): Ethambutol should be avoided if possible because of potential ocular toxicity.

Note (2): A short course of systemic corticosteroids may be necessary initially if there is sight-threatening inflammation.