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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

• 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)

• 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 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

• 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 antimicrobial therapy

• Blepharitis

• Preferred regimen: Azithromycin 1% ophthalmic solution bid for 2 days followed by qd for 12-26 days
• Alternative regimen (1): Tobramycin/Dexamethasone 0.3%/0.05% ophthalmic suspension qid for 2 weeks
• Alternative regimen (2): Bacitracin ophthalmic ointment qhs for 2 weeks OR Bacitracin/Polymyxin B Sulfate ophthalmic ointment bid to qid for 2 weeks
• Alternative regimen (3): Erythromycinophthalmic ointment qhs for 2 weeks
• Alternative regimen (4): Metronidazole 2% gel bid for 1-2 weeks
• Note: Cyclosporine 0.05% ophthalmic emulsion bid for 6 months may be helpful in some cases of posterior 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.

• Preferred regimen: Bacitracin ophthalmic ointment qhs for 2 weeks OR Bacitracin/Polymyxin B Sulfate ophthalmic ointment bid to qid for 2 weeks OR Erythromycinophthalmic ointment qhs for 2 weeks OR Azithromycin 1% ophthalmic solution bid for 2 days followed by qd for 12-26 days OR Tobramycin/Dexamethasone 0.3%/0.05% ophthalmic suspension qid for 2 weeks

• 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

• 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 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 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

• 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 (mycotic) keratitis

• 1. Causative pathogens

• Candida spp.
• Fusarium spp.
• Aspergillus spp.
• Curvularia spp.

• 2. Empiric antimicrobial therapy

• Preferred regimen (1): Natamycin 5% ophthalmic suspension q30min to q1h for 2-3 weeks
• Preferred regimen (2): Fluconazole 1% ophthalmic suspension q1h for 2-3 weeks
• Preferred regimen (3): Natamycin 5% ophthalmic suspension q30min to q1h for 2-3 weeks AND Fluconazole 1% ophthalmic suspension q1h for 2-3 weeks
• Alternative regimen (1), unresponsive: Amphotericin B 0.15-0.25% prepared in distilled water q15min-q30min on day 1-2 then q1h to q2h for 2-3 weeks
• Alternative regimen (2), unresponsive: Natamycin 5% ophthalmic suspension q30min to q1h for 2-3 weeks AND Amphotericin B 0.15-0.25% prepared in distilled water q15min-q30min on day 1-2 then q1h to q2h for 2-3 weeks

• 3. Special considerations

• Immunocompromised status, spreading ulcer, impending perforation, true perforation

• Preferred regimen (1): Natamycin 5% ophthalmic suspension q30min to q1h for 2-3 weeks AND Fluconazole 1% ophthalmic suspension q1h for 2-3 weeks AND (Ketoconazole IV 200-400 mg q12h for 2-3 weeks OR Fluconazole IV 200 mg q12h for 2-3 weeks
• Preferred regimen (2): Natamycin 5% ophthalmic suspension q30min to q1h for 2-3 weeks AND Amphotericin B 0.15-0.25% prepared in distilled water q15min-q30min on day 1-2 then q1h to q2h for 2-3 weeks AND (Ketoconazole IV 200-400 mg q12h for 2-3 weeks OR Fluconazole IV 200 mg q12h for 2-3 weeks
• Note: Bacterial superinfection must be treated using 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 OR (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)

• Protozoal keratitis

• 1. Causative pathogens

• Acanthamoeba spp.
• Microsporidia spp.

• 2. Empiric antimicrobial therapy

• Preferred regimen (1): Polyhexamethylene biguanide 0.02% ophthalmic ointment q1h for 1-2 weeks AND Chlorhexidine 0.02% ophthalmic ointment q1h for 1-2 weeks AND/OR (Propamidine 0.1% ophthalmic ointment q1h for 1-2 weeks OR Hexamidine 0.1% ophthalmic ointment q1h for 2 days then q1h for another 3 days)
• Preferred regimen (2): Propamidine 0.1% ophthalmic ointment q1h for 1-2 weeks AND Polyhexamethylene biguanide 0.02% ophthalmic ointment q1h for 1-2 weeks

• Preferred regimen (4): Propamidine ophthalmic ointment q1h for 1-2 weeks AND Chlorhexidine ophthalmic ointment q1h for 1-2 weeks
• Preferred regimen (4): Polyhexamethylene biguanide 0.02% ophthalmic ointment q1h for 1-2 weeks AND Hexamidine 0.1% ophthalmic ointment q1h for 2 days then q1h for another 3 days

• Viral keratitis

• 1. Causative pathogens

• Herpes simplex virus (HSV)

• 2. Empiric antimicrobial therapy

• Preferred regimen (1): Acyclovir 3% ophthalmic ointment q5h for 2-3 weeks AND Homatropine 2% ophthalmic solution bid for 2-3 weeks
• Preferred regimen (2): Idoxuridine 0.1% ophthalmic solution q1h in daytime and 0.5% ophthalmic ointment qhs for 1 week then 0.1% ophthalmic solution q2h in daytime and 0.5% ophthalmic ointment qhs for 2-3 weeks AND Homatropine 2% ophthalmic solution bid for 2-3 weeks

Ocular syphilis

• 1. Pathogen-directed antimicrobial therapy

• Preferred regimen (1): Penicillin 4 MU IV q4h for 10-14 days AND Benzathine penicillin 2.4 MU IM once weekly for 3 weeks
• Note (1): Corticosteroids (Prednisone 60-80 mg PO qd) are co-administered 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.

Ocular toxocariasis

• 1. Pathogen-directed antimicrobial therapy

• Preferred regimen: Albendazole 400 mg PO bid for 5 days
• Alternative regimen: Mebendazole 1 g PO qd for 3 weeks
• Note (1): Co-administration of corticosteroids is helpful for suppressing the intense allergic manifestations of the infection.
• Note (2): Ocular larval migrans is treated by surgery (vitrectomy) and antihelminthic chemotherapy with or without corticosteroids.

Ocular toxoplasmosis

• 1. Pathogen-directed antimicrobial therapy

• Preferred regimen: Pyrimethamine 200 mg PO qd on day 1 then 50-75 mg PO qd for 2 weeks beyond resolution of symptoms AND Sulfadiazine 1-1.5 g PO qid for 2 weeks beyond resolution of symptoms AND Leucovorin (Folinic acid) 5-20 mg PO 3 times/week for 3 weeks beyond resolution of symptoms

Ocular tuberculosis

• 1. Pathogen-directed antimicrobial therapy

• 1. Adult patients

• 1.1 Intensive phase

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

• 1.2 Continuation phase

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

• 2. Pediatric patients

• 2.1 Intensive phase

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

• 2.2 Continuation phase

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

• Note (1): Ethambutol may be administered at a dose of 15-20 mg/kg (max: 1 g) PO qd for 2 months but is generally avoided because of potential ocular toxicity.
• Note (2): A short course of systemic corticosteroids may be necessary initially if there is sight-threatening inflammation.

Orbital cellulitis

• 1. Causative pathogens

• Methicillin-sensitive staphylococcus aureus
• Methicillin-resistant staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus spp.
• Moraxella spp.
• Anaerobes

• 2. Empiric antimicrobial therapy

• Preferred regimen (1): Ampicillin/Sulbactam 3 g IV q6h for 1 week
• Preferred regimen (2): Ceftriaxone 1-2 g IV q12h for 1 week
• Preferred regimen (3): Clindamycin 300 mg IV q6h for 1 week
• Preferred regimen (4): Nafcillin 2 g IV q4h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided in 3 doses for 1 week
• Alternative regimen (1), MRSA suspicion: Vancomycin 1 g IV q12h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week
• Alternative regimen (2), MRSA suspicion: Vancomycin 1 g IV q12h for 1 week AND Levofloxacin 750 mg IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week
• Alternative regimen (3), pediatric: Ampicillin/Sulbactam 200-300 mg/kg/d IV divided q6h for 1 week
• Alternative regimen (4), pediatric: Ceftriaxone 100 mg/kg/d IV divided q12h for 1 week
• Alternative regimen (5), pediatric: Clindamycin 20-40 mg/kg/d IV divided q12 for 1 week
• Note (1): Oral antibiotic therapy may be extended beyond 2-3 weeks if the clinical presentation is consistent with either severe sinusitis or bony destruction
• Note (2): Consider surgical intervention if the patient has either visual loss, complete ophthalmoplegia, large abscess > 1 cm, or no clinical improvement following 1-2 days of antibiotic administration

• 3. Pathogen-directed antimicrobial therapy

• 3.1 Methicillin-resistant staphylococcus aureus (MRSA)

• Preferred regimen (1): Vancomycin 1 g IV q12h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week
• Preferred regimen (2): Vancomycin 1 g IV q12h for 1 week AND Levofloxacin 750 mg IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week

• 3.2 Non-MRSA organisms

• Preferred regimen (1): Ampicillin/Sulbactam 3 g IV q6h for 1 week

• Preferred regimen (2): Ceftriaxone 1-2 g IV q12h for 1 week

• Preferred regimen (3): Clindamycin 300 mg IV q6h for 1 week

• Preferred regimen (4): Nafcillin 2 g IV q4h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided in 3 doses for 1 week

Periocular Infection

• Periocular infection

• 1. Causative pathogens

• Streptococcus spp.
• Methicillin-sensitive Staphylococcus aureus (MSSA)
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Hemophilus influenzae

• 2. Empiric antimicrobial therapy

• Preferred regimen (1): Clindamycin 300-450 mg PO q6h for 1-2 weeks OR Clindamycin 600-900 mg IV q8h for 1-2 weeks
• Preferred regimen (2): Daptomycin 4 mg/kg IV qd for 1-2 weeks
• Alternative regimen (1): Trimethoprim/Sulfamethoxazole 160 mg PO q12h for 1-2 weeks OR Trimethoprim/Sulfamethoxazole 2.5 mgkg IV q12h for 1-2 weeks
• Alternative regimen (2): Doxycycline 100 mg IV or PO q12h for 1-2 weeks
• Alternative regimen (3): Linezolid 600 mg IV or PO q12h for 1-2 weeks
• Alternative regimen (4): Vancomycin 1 g IV q12h for 1-2 weeks

• 3. Pathogen-directed antimicrobial therapy

• 3.1 Methicillin-resistant Staphylococcus aureus

• Preferred regimen (1): Vancomycin 1 g IV q12h for 1-2 weeks

• 3.2 Non-MRSA organisms

• Preferred regimen (1): Clindamycin 300-450 mg PO q6h for 1-2 weeks OR Clindamycin 600-900 mg IV q8h for 1-2 weeks
• Preferred regimen (2): Daptomycin 4 mg/kg IV qd for 1-2 weeks
• Alternative regimen (1): Trimethoprim/Sulfamethoxazole 160 mg PO q12h for 1-2 weeks OR Trimethoprim/Sulfamethoxazole 2.5 mgkg IV q12h for 1-2 weeks
• Alternative regimen (2): Doxycycline 100 mg IV or PO q12h for 1-2 weeks
• Alternative regimen (3): Linezolid 600 mg IV or PO q12h for 1-2 weeks

Retinal necrosis

• Retinal necrosis

• 1. Causative pathogens

• Herpes simplex virus (HSV) 1 and 2
• Varicella-zoster virus (VZV)
• Cytomegalovirus (CMV)

• 2. Empiric antimicrobial therapy

• Preferred regimen: Acyclovir 10 mg/kg IV q8h for 1-2 weeks followed by Acyclovir 400 mg PO bid for chronic maintenance

• Alternative regimen (1): Acyclovir 10 mg/kg IV q8h for 1-2 weeks followed by Valacyclovir 1 g IV q8h for 6 weeks to several months followed by Acyclovir 400 mg PO bid for chronic maintenance
• Alternative regimen (2), unresponsive: Foscarnet 1.2-2.4 mg/0.1 mL intravitreal injection 1-3 times per week AND (Ganciclovir 5 mg/kg IV q12 for 2 weeks followed by 5 mg/kg q24h for 5-7 weeks OR Foscarnet 60 mg/kg IV q8h for 2 weeks followed by 90-120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2 weeks followed by 5 mg/kg IV q2weeks) followed by (Acyclovir 400 mg PO bid for chronic maintenance OR Valganciclovir 900 mg PO qd for chronic maintenance)

• Note: Ganciclovir is administered for patients with suspected CMV acute retinal necrosis. Whereas Foscarnet is administered for patients who are not immunocompromised

• 3. Pathogen-directed antimicrobial therapy

• 3.1 HSV or VZV

• Preferred regimen: Acyclovir 10 mg/kg IV q8h for 1-2 weeks followed by Acyclovir 400 mg PO bid for chronic maintenance
• Alternative regimen: Acyclovir 10 mg/kg IV q8h for 1-2 weeks followed by Valacyclovir 1 g IV q8h for 6 weeks to several months followed by Acyclovir 400 mg PO bid for chronic maintenance

• 3.2 Cytomegalovirus

• Preferred regimen: Foscarnet 1.2-2.4 mg/0.1 mL intravitreal injection 1-3 times per week AND Ganciclovir 5 mg/kg IV q12 for 2 weeks followed by 5 mg/kg q24h for 5-7 weeks followed by Valganciclovir 900 mg PO qd for chronic maintenance

Stye

• Hordeolum

• 1. External hordeolum, for a single lesion

• Supportive therapy: application of warm compresses 4-6 times/day.
• Note: Antibiotic therapy is questionable value for a single lesion and often not indicated.

• 2. External hordeolum, for multiple/recurrent lesions

• Preferred regimen (1): antistaphylococcal antibiotic therapy Bacitracin topical qd-tid
• Preferred regimen (2): Erythromycin topical ointment up to 6 times/day, along with lid hygiene.

• 3. Internal hordeolum

• Supportive therapy: warm compressess in conjugation with systemic antistaphylococcal antibiotics
• Note (1): If the lesion do not respond to this regimen, incision and drainage are indicated.
• Note (2): Chalazion effectively treated with lid hygiene and warm compression in most circumstances.

Uveitis

• Infectious uveitis

• 1. Causative pathogens

• Viruses

• Herpes simples (common)
• Herpes zoster (common)
• CMV (common)
• EBV
• Ebola
• Chikungunya
• HIV
• HTLV-1
• Mumps
• Parechovirus
• Rubella
• Rubeola
• Vaccinia
• West Nile virus

• Bacteria

• Mycobacteria (atypical and tuberculosis)
• Bartonella henselae
• Brucella spp.
• Leptospira spp.
• Borrelia spp.
• Propionibacterium spp.
• Syphilis
• Tropheryma whipplei

• Fungi

• Aspergillus spp.
• Blastomyces spp.
• Candida spp.
• Coccidioides spp.
• Cryptococcus spp.
• Histoplasma spp.
• Pneumocystis jirovecii
• Sporothrix spp.

• Parasites

• Acanthamoeba
• Taenia solium
• Onchocerca spp.
• Toxocara spp.
• Toxoplasma

• 2. Empiric antimicrobial therapy

• Preferred regimen: Acyclovir 800 mg PO q5h for 7-10 days
• Note: Long-term prophylactic Acyclovir 400 mg PO bid may be beneficial in preventing recurrences of herpetic uveitis and development of complications

Uveitis, Lyme disease

• Lyme uveitis

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 days