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 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 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-based 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

Endophthalmitis

Endophthalmitis, endogenous

• Endogenous bacterial 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.
• Cultures from vitreous samples are necessary in the management of endogenous endophthalmitis
• Intravitreal antibiotic injections are indicated when the focus of inflammation is either in the anterior segment with dehiscent posterior capsule / aphakic eye or in the posterior segment with evidence of vitritis
• 1. Causative pathogens

• Staphylococcus epidermidis
• Staphylococcus aureus
• Streptococci
• Enterococci
• Bacillus spp.
• Escherichia coli
• Neisseria meningitidis
• Klebsiella spp.
• Propioninbacterium spp.

• 2. Empiric antimicrobial therapy

Preferred regimen: Vancomycin AND clindamycin AND Aminoglycoside OR cephalosporin

• Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose Template:AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose
• Alternative regimen, penicillin-allergic (1): Amikacin 400 microgram per 0.1 mL normal saline intravitreal injection, single dose
• Alternative regimen (2): Gatifloxacin 400 microgram/0.1 mL normal saline intravitreal injection, single dose
• Alternative regimen (3): Moxifloxacin 400 microgram/0.1 normal saline intravitreal injection, single dose
• Preferred regimen (intravenous): antibiotic active against underlying source of bacteremia

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 conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.

Note (3): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.

Note (4): 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, chronic

• Chronic endophthalmitis
• Empiric therapy

• Preferred regimen (intial therapy) : oral Clarithromycin 500 mg bid for 2-4 weeks.

Note : Consider adding oral Moxifloxacin (400 mg daily for a week) as it also has good intraocular penetration and a broad spectrum of antimicrobial activity.

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).