Sandbox-ID-Yaz

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

• 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: 0.5% Erythromycin ophthalmic ointment, single dose
• Alternative regimen: 2.5% Providone-iodine solution ophthalmic ointment, single dose

• 3. Empiric antimicrobial therapy

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week
• Alternative regimen (1): Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week
• Alternative regimen (2): Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week
• Alternative regimen (3): 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
• Alternative regimen (4): 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
• Alternative regimen (5): Polymyxin B/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week
• Alternative regimen (6): Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week
• Alternative regimen (7): Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week
• Alternative regimen (8): Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week
• Alternative regimen (9): 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: Azithromycin 1 g PO, single dose
• Alternative regimen: 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)

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week OR 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 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 OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week

• 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)

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week OR 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 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 OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week

• 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

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR 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 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/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.4.2 Streptococcus haemolyticus

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Bacitracin zinc 500U/g ophthalmic ointment qhs to qid for 1 week OR 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 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/Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution q3h for 1 week OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.5 Haemophilus influenzae

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 1.0% ophthalmic ointment q2h to qid for 1 week OR Chloramphenicol 0.5% solution q2h to qid for 1 week OR 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 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 OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.6 Moraxella spp.

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Sodium sulfacetamide 10%-30% ophthalmic solution q2hr to qid for 1 week OR Sulfisoxazole diolamine 4.0% ophthalmic solution qid for 1 week

• 4.7 Proteus mirabilis

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week

• 4.8 Escherichia coli

• Preferred regimen: Gentamicin/Tobramycin 0.3% ophthalmic ointment q2h to qid for 1 week OR Polymyxin B/Neomycin 16,250 U, 3.5 mg/mL ophthalmic solution qid for 1 week OR Tetracycline 1.0% ophthalmic ointment q2h to qid for 1 week

• 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 7 days
• Alternative regimen (1): Trifluridine 1% solution q4h for 7 days
• Alternative regimen (2): Acyclovir 200 mg to 400 mg PO q5h per day for 7 days
• Alternative regimen (3): Valacyclovir 500 mg PO tid for 7 days
• Alternative regimen (4): Famciclovir 250 mg PO bid for 7 days
• Note: Corticosteroids should be avoided.

• 4.11 Varicella Zoster Virus

• Preferred regimen: Acyclovir 800 mg PO q5hr for 7 days
• Alternative regimen (1): Valacyclovir 1000 mg PO q8h for 7 days
• Alternative regimen (2): Famciclovir 500 mg PO tid for 7 days

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.