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Conjunctivitis

  • Mild bacterial conjunctivitis is usually self-limited, and it typically resolves spontaneously without specific treatment in immune-competent adults (except for methicillin-resistant staphylococcal conjunctivitis, gonococcal conjunctivitis, and conjunctivitis due to C. trachomatis)
  • Severe bacterial conjunctivitis requires antimicrobial therapy and is characterized by copious purulent discharge, pain, and marked inflammation of the eye.
  • Systemic antibiotic therapy is necessary to treat conjunctivitis due to Neisseria gonorrhoeae and Chlamydia trachomatis
  • Methicillin-resistant Staphylococcal infections should be treated with topical antibiotics.
  • Topical and/or oral antiviral therapy is recommended for HSV conjunctivitis to prevent corneal infection
  • Neither topical nor oral antiviral treatment is recommended to treat either adenoviral or VZV conjunctivitis. Empiric topical antibiotics may be administered to prevent secondary bacterial infection

Conjunctivitis

  • Conjunctivitis, infectious[1][2]
  • Infectious conjunctivitis
  • 1. Causative pathogens
  • Neisseria gonorrhoeae
  • Neisseria meningitidis
  • Chlamydia trachomatis
  • Staphylococcus aureus
  • Staphylococcus epidermidis
  • Streptococcus pneumoniae
  • Streptococcus haemolyticus
  • Haemophilus influenzae
  • Moraxella spp.
  • Proteus mirabilis
  • Escherichia coli
  • Pseudomonas aeruginosa
  • Adenovirus
  • Herpes simplex virus
  • Herpes zoster virus
  • 2. Conjunctivitis, neonatal prophylaxis
  • Preferred regimen (1): 0.5% Erythromycin ophthalmic ointment, single dose
  • Alternative regimen: 2.5% [[|Providone|Providone-iodine]] solution ophthalmic ointment, single dose
  • 3. Empiric antimicrobial therapy
  • Preferred regimen (1): Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week
  • Preferred regimen (2): Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week
  • Preferred regimen (3): Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week
  • Preferred regimen (4): Erythromycin 0.5% ophthalmic ointment qhs to qid for 1 week OR Azithromycin 1% ophthalmic ointment bid for 2 days then qd for 5 days
  • Preferred regimen (5): Ciprofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Ofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Levofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Moxifloxacin 0.5% ophthalmic ointment bid to tid for 1 week OR Besifloxacin 0.6% ophthalmic suspension tid for 1 week OR Gatifloxacin 0.5% ophthalmic solution tid for 1 week
  • Preferred regimen (6): Polymyxin B/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week
  • Preferred regimen (7): Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week
  • Preferred regimen (8): Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week
  • Preferred regimen (9): Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week
  • Preferred regimen (10): Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week
  • Note (1): All regimens have similar efficacy.
  • Note (2): When empiric antimicrobial therapy is administered, the patient's age, environment, and related ocular findings may guide the treatment of choice.
  • Note (3): Some regimens are associated with transient blurring of vision.
  • Note (4): Topical steroids are not recommended for bacterial conjunctivitis.
  • 4. Pathogen-directed antimicrobial therapy
  • 4.1 Chlamydia trachomatis
  • Preferred regimen (1): Azithromycin 1 g PO, single dose
  • Preferred regimen (2): Doxycycline 100 mg PO bid for 7 days
  • Pediatric regimen (1): Children who weigh < 45 kg: Erythromycin solution 50 mg/kg/day PO qid for 2 weeks OR Ethylsuccinate 50 mg/kg/day PO qid for 2 weeks
  • Pediatric regimen (2): Chidren who weigh ≥ 45 kg but are aged < 8 years: Azithromycin 1 g PO, single dose
  • Pediatric regimen (3): Children ≥ 8 years: Azithromycin solution 1 g PO, single dose OR Doxycycline 100 mg PO bid for 1 week
  • Neonatal regimen: Erythromycin 50 mg/kg/day PO qid for 2 weeks OR Ethylsuccinate 50 mg/kg/day PO qid for 2 weeks
  • Note (1): Neonates administered Erythromycin should be followed for signs and symptoms of infantile hypertrophic pyloric stenosis
  • Note (2): Sexual contacts of patients with C. trachomatis conjunctivitis should be treated at the same time
  • 4.2 Neisseria gonorrhoeae
  • Hyperacute bacterial conjunctivitis, adult
  • Preferred regimen: Ceftriaxone 25 mg IM, single-dose AND (Azithromycin 1 g PO, single dose OR Doxycycline 100 mg PO bid for 1 week)
  • Alternative regimen, cephalosporin-allergic: Azithromycin 2 g PO, single dose
  • Pediatric dose: Children who weigh < 45 kg: Ceftriaxone 125 mg IM, single dose OR Spectinomycin 40 mg/kg (maximum dose 2 g) IM, single dose
  • Neonatal dose: Ceftriaxone 25-50 mg/kg (maximum dose 125 mg) IV or IM, single dose
  • Note (1): The regimen provides adequate coverage for both N. gonorrhea and C. trachomatis
  • Note (2): Children who weigh > 45 kg are administered adult doses for the management of N. gonorrhoeae conjunctivitis
  • Note (3): Neisseria meningitidis must be ruled out as a causative organism before concluding that Neisseria gonorroeae is responsible
  • Note (4): Patients diagnosed with gonococcal conjunctivitis should be seen daily until resolution of conjunctivitis. Interval history, visual acuity measurement, and slit-lamp biomicroscopy should be performed daily.
  • 4.3 Staphylococcus aureus
  • 4.3.1 Methicillin-sensitive Staphylococcus aureus (MSSA)
  • 4.3.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 1% ophthalmic ointment qid for 2 weeks
  • 4.3.3 Methicillin-sensitive Staphylococcus epidermidis (MSSE)
  • 4.3.4 Methicillin-resistant Staphylococcus aureus (MRSE)
  • Preferred regimen: Vancomycin 1% ophthalmic ointment qid for 2 weeks
  • 4.4 Streptococcus species
  • 4.4.1 Streptococcus pnuemoniae
  • 4.4.2 Streptococcus haemolyticus
  • 4.5 Haemophilus influenzae
  • 4.6 Moraxella spp.
  • 4.7 Proteus mirabilis
  • 4.8 Escherichia coli
  • 4.9 Pseudomonas aeruginosa
  • Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Ciprofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Ofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Levofloxacin 0.3%-0.5% ophthalmic ointment q2h to qid for 1 week OR Moxifloxacin 0.5% ophthalmic ointment bid to tid for 1 week OR Besifloxacin 0.6% ophthalmic suspension tid for 1 week OR Gatifloxacin 0.5% ophthalmic solution tid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week
  • 4.10 Herpes Simplex Virus
  • Preferred regimen: Ganciclovir 0.15% ophthlamic gel qid for 1 week
  • Alternative regimen (1): Trifluridine 1% solution q4h for 1 week
  • Alternative regimen (2): Acyclovir 200 mg to 400 mg PO q5h per day for 1 week
  • Alternative regimen (3): Valacyclovir 500 mg PO tid for 1 week
  • Alternative regimen (4): Famciclovir 250 mg PO bid for 1 week
  • Note: Corticosteroids should be avoided.
  • 4.11 Varicella Zoster Virus
  • Preferred regimen: Acyclovir 800 mg PO q5hr for 1 week
  • Alternative regimen (1): Valacyclovir 1000 mg PO q8h for 1 week
  • Alternative regimen (2): Famciclovir 500 mg PO tid for 1 week

Blepharitis

  • Blepharitis is a chronic condition that may not be fully cured. It often requires chronic care and follow-up
  • Warm compresses, eyelid cleansing, and eyelid massage twice daily are recommended in the management of infectious blepharitis
  • Topical antimicrobial therapy may be prescribed, but there is insufficient evidence to confirm their efficacy in the management of blepharitis
  • 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
  • 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 many cases.

Blepharitis

  • Blepharitis, infectious[3]
  • Infectious blepharitis
  • 1. Causative pathogens
  • Staphylococcus aureus
  • Coagulase-negative Staphylococcus spp.
  • Demodex folliculorum
  • Streptococcus pyogenes
  • Herpes simplex virus
  • Varicella zoster virus
  • Papillomavirus
  • Vaccinia
  • Molluscum contagiosum
  • 2. Empiric therapy[4]
  • Blepharitis
  • 3. Specific considerations
  • 3.1 Meibomian gland dysfunction:
  • Preferred regimen: Doxycycline 100 mg PO qd until clinical improvement followed by 40 mg PO qd for 2-6 weeks OR Minocycline 100 mg PO qd until clinical improvement followed by 50 mg PO for 2-6 weeks OR Tetracycline 1000 mg PO until clinical improvement followed by 250-500 mg PO qd for 2-6 weeks.
  • Alternative regimen (1): Erythromycin 250-500 mg PO qd for 3 weeks OR Azithromycin 250-500 mg PO 1-3 times a week for 3 weeks OR Azithromycin 1 g PO once per week for 3 weeks
  • Note: Tetracyclines are contraindicated among pregnant women, nursing women, and young children < 8 years of age
  • 3.2 Dry eye
  • Preferred regimen: Cyclosporine 0.05% ophthalmic emulsion bid for 6 months
  • 3.3 Ocular Rosacea
  • Preferred regimen: Doxycycline 100 mg PO qd until clinical improvement followed by 40 mg PO qd for 2-6 weeks OR Minocycline 100 mg PO qd until clinical improvement followed by 50 mg PO for 2-6 weeks OR Tetracycline 1000 mg PO until clinical improvement followed by 250-500 mg PO qd for 2-6 weeks OR (Azithromycin 250-500 mg PO 1-3 times a week for 3 weeks AND Tacrolimus 0.1% topical bid for 3 weeks) OR (Azithromycin 1 g PO once per week for 3 weeks AND Tacrolimus 0.1% topical bid for 3 weeks)
  • 4. Pathogen-directed antimicrobial therapy
  • 4.1 Staphylococcus spp.
  • 4.2 Demodex folliculorum
  • Preferred regimen: Metronidazole 2% gel bid for 1-2 weeks
  • Alternative regimen: Ivermectin 200 microgram/kg once weekly for 2 weeks

Endophthalmitis

  • Endogenous endophthalmitis is caused by the hematologic dissemination of an infection to the eyes. Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is distant from the eye.
  • Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection.
  • Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
  • Immediate vitrectomy is often necessary

Endophthalmitis

  • Endophthalmitis, infectious[5]
  • 1. Causative pathogens
  • Staphylococcus epidermidis
  • Staphylococcus aureus
  • Streptococci
  • Enterococci
  • Bacillus spp.
  • Escherichia coli
  • Neisseria meningitidis
  • Klebsiella spp.
  • Propionibacterium spp.
  • Corynebacterium spp.
  • Pseudomonas aeruginosa
  • Candida spp.
  • Aspergillus spp.
  • Fusarium spp.
  • 2. Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
  • Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
  • Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
  • 3. Pathogen-directed antimicrobial therapy
  • 3.1 Bacillus spp.
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.2 Non-Bacillus gram-positive bacteria
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.3 Gram-negative bacteria
  • Preferred regimen: Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.4 Candida spp.
  • Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.5 Aspergillus spp.
  • Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy
  • 4. Special Considerations
  • 4.1 Endogenous endophthalmitis
  • 4.1.1 Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
  • Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary::* Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
  • 4.2 Bleb-related endophthalmitis
  • 4.2.1 Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
  • Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
  • 4.3 Post-operative endophthalmitis
  • 4.3.1 Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose
  • Note (1): In addition to intravitreal antibiotic therapy, vitrectomy is necessary
  • Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be administered
  • Note (3): Late post-operative endophthalmitis is often caused by Propionibacterium acnes (several years post-op)
  • 4.3.2 Pathogen-directed antimicrobial therapy
  • 4.3.2.1 Gram-positive bacteria
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose
  • 4.3.2.2 Gram-negative bacteria
  • Preferred regimen: Amikacin 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
  • Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
  • 4.4 Post-traumatic endophthalmitis
  • 4.4.1 Empiric therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): Removal of foreign bodies and debridement of necrotic tissue is necessary
  • Note (2): In addition to antimicrobial therapy, vitrectomy is necessary
  • Note (3): Systemic broad spectrum antibiotics are recommended in post-traumatic endophthalmitis

Keratitis

  • Microbial keratitis should be managed as bacterial keratitis until proven otherwise.
  • Steroids are indicated in the management of keratitis to reduce inflammation that may damage the eye.
  • Keratitis, infectious[6]
  • Bacterial keratitis
  • 1. Causative pathogens
  • Pseudomonas aeruginosa
  • Staphylococcus epidermidis
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • Serratia spp.
  • Hemophilus spp.
  • Moraxella spp.
  • Neisseria gonorrhea
  • Corynebacterium diphtheriae
  • Listeria spp.
  • Shigella spp.
  • Nocardia spp.
  • Mycobacterium spp.
  • 2. Empiric antimicrobial therapy
  • Preferred regimen (1): Ciprofloxacin 0.3% ophthalmic ointment q15min for 6 hours then q30min for the remainder of day 1 then q1h on day 2, then q4h on days 3-14
  • Preferred regimen (2): Ofloxacin 0.3% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (3): Levofloxacin 1.5% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (4): Moxifloxacin 0.5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (5): Gatifloxacin 0.3% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (6): Cefazolin 5% q30min to q1h on day 1 then q2h on day 2 then q4h on days 3-14 AND (Tobramycin 5% ophthalmic ointment q1h on day 1 then q2h on day 2 then q4h on days 3-14 OR Gentamicin 1.5% ophthalmic ointment q30min to q1h on day 1 then q1h on day 2 then q4h on days 3-14)
  • Alternative regimen (1), unresponsive keratitis: Vancomycin 5% q30 min on day 1 then q2h on day 2 then q4h on days 3-14 AND Amikacin 5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Alternative regimen (2): Erythromycin 0.5% ophthalmic ointment qhs for 1 week AND (Amikacin 5% AND/OR Vancomycin 5% q30 min on day 1 then q2h on day 2 then q4h on days 3-14)
  • Note (1) : 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 (2) : Systemic therapy is necessary for suspected gonococcal infection.
  • 3. Pathogen-directed antimicrobial therapy
  • 3.1 Non-streptococcal gram-positive bacteria
  • Preferred regimen (1): Moxifloxacin 0.5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (2): Gatifloxacin 0.3% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (3): Ciprofloxacin 0.3% ophthalmic ointment q15min for 6 hours then q30min for the remainder of day 1 then q1h on day 2, then q4h on days 3-14
  • Preferred regimen (4): Ofloxacin 0.3% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (5): Levofloxacin 1.5% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (6): Cefazolin 5% q30min to q1h on day 1 then q1h on day 2 then q4h on days 3-14 AND (Tobramycin 5% ophthalmic ointment q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • 3.2 Streptococcus pneumoniae
  • Preferred regimen (1): Moxifloxacin 0.5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (2): Gatifloxacin 0.3% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (3): Ciprofloxacin 0.3% ophthalmic ointment q15min for 6 hours then q30min for the remainder of day 1 then q1h on day 2, then q4h on days 3-14
  • Preferred regimen (4): Ofloxacin 0.3% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (5): Levofloxacin 1.5% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (6): Cefazolin 5% q30min to q1h on day 1 then q1h on day 2 then q4h on days 3-14 AND (Tobramycin 5% ophthalmic ointment q1h on day 1 then q2h on day 2 then q4h on days 3-14
Alternative regimen, unresponsive keratitis: Vancomycin 5% q30 min on day 1 then q2h on day 2 then q4h on days 3-14 AND Amikacin 5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • 3.3 Nocardia spp.
  • Preferred regimen (1): Vancomycin 5% q30 min on day 1 then q2h on day 2 then q4h on days 3-14 AND Amikacin 5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (2): Erythromycin 0.5% ophthalmic ointment qhs for 1 week AND (Amikacin 5% AND/OR Vancomycin 5% q30 min on day 1 then q2h on day 2 then q4h on days 3-14)
  • 3.3 Gram-negative bacteria
  • Preferred regimen (1): Moxifloxacin 0.5% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (2): Gatifloxacin 0.3% q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • Preferred regimen (3): Ciprofloxacin 0.3% ophthalmic ointment q15min for 6 hours then q30min for the remainder of day 1 then q1h on day 2, then q4h on days 3-14
  • Preferred regimen (4): Ofloxacin 0.3% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (5): Levofloxacin 1.5% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (6): Cefazolin 5% q30min to q1h on day 1 then q1h on day 2 then q4h on days 3-14 AND (Tobramycin 5% ophthalmic ointment q1h on day 1 then q2h on day 2 then q4h on days 3-14
  • 3.4 Anaerobes
  • Preferred regimen (1): Ciprofloxacin 0.3% ophthalmic ointment q15min for 6 hours then q30min for the remainder of day 1 then q1h on day 2, then q4h on days 3-14
  • Preferred regimen (2): Ofloxacin 0.3% ophthalmic ointment q2h for 2-3 weeks
  • Preferred regimen (3): Levofloxacin 1.5% ophthalmic ointment q2h for 2-3 weeks
  • Fungal keratitis
  • Empiric therapy[7]
  • 1. Topical antifungals
  • 1.1 For filamentous fungi
  • 1.2 For candida
  • 2. Oral antifungals

Keratitis, protozoal

  • 1. For acanthamoeba
  • Preferred regimen (1): Biguanide - (Polyhexamethylene biguanide [PHMB] 0.02% or chlorhexidine 0.02%) AND Diamidine - (propamidine 0.1% or hexamidine 0.1%)
  • Alternative regimen (1): Propamidine 0.1% AND Polyhexamethylene biguanide 0.02%
  • Alternative regimen (2): Propamidine and Chlorhexidine
  • Alternative regimen (3): Polyhexamethylene biguanide 0.02% AND Hexamidine drops 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 .
  • Note (3): Toxicity of Biguanides AND Diamidines is Cataract, iris atrophy,and peripheral ulcerative keratitis are all complications of acanthamoeba keratitis that have been attributed to the use of Biguanides topical with or without Diamidines topical.
  • 2. For microsporidia
  • Treatment for limbitis and scleritis:
  • Preferred regimen: NSAIDS Furbiprofen 50-100 mg PO bid or tid.
  • Note: If it does not respond to Furbiprofen THEN
  • Preferred regimen: high-dose systemic steroid therapy prednisolone 1 mg/kg/day PO), with systemic Cyclosporine (3 to 7.5 mg/kg/day PO), can be used for successful control.

Keratitis, viral

  • Empiric therapy[7]
  • HSV keratitis
  • 1. For epithelial disease
  • Preferred regimen (1): Acyclovir 3% ointment 5 times a day (is able to penetrate intact corneal epithelium)
  • Preferred regimen (2): Idoxuridine 0.1% drops now seldom used toxicity
  • Supportive therapy: Debridement in dendritic ulcer
  • 2. For necrotizing stromal disease
  • 3. For non-necrotizing stromal disease

References

  1. ↑ Quinn, Christopher J.; Mathews, Dennis E. (Nov 8 2002). "Optometric clinical practice guideline care of the patient with conjunctivitis". Check date values in: |date= (help)
  2. ↑ McLeod, Stephen D.; Feder, Robert S. (2013). "Conjunctivitis: Preferred Practice Pattern - American Academy of Ophthalmology".
  3. ↑ McLeod, Stephen D.; Chang, David F. (2013). "Blepharitis: Preferred Practice Pattern - American Academy of Ophthalmology".
  4. ↑ "Blepharitis PPP 2013".
  5. ↑ Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  6. ↑ "= bacterial keratitis ppp 2013".
  7. ↑ 7.0 7.1 7.2 Thomas PA, Geraldine P (2007). "Infectious keratitis". Curr Opin Infect Dis. 20 (2): 129–41. doi:10.1097/QCO.0b013e328017f878. PMID 17496570.
  8. ↑ Dart JK, Saw VP, Kilvington S (2009). "Acanthamoeba keratitis: diagnosis and treatment update 2009". Am J Ophthalmol. 148 (4): 487–499.e2. doi:10.1016/j.ajo.2009.06.009. PMID 19660733.
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