Sandbox ID Eye

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Conjunctivitis

  • Conjunctivitis, acute[1]
  • Bacterial conjunctivitis
  • Empiric antimicrobial therapy,
Note: Topical steroids are not recommended for bacterial conjunctivitis.
  • Pathogen-directed antimicrobial therapy
  • Chlamydia trachomatis
  • Inclusion conjunctivitis
  • Conjunctivitis secondary to trachoma
  • Neisseria gonorrhoeae
  • Hyperacute bacterial conjunctivitis, adult
Note: Dual therapy to cover Chlamydia is indicated.
  • Staphylococcus aureus, methicillin-resistant (MRSA)
  • Herpetic conjunctivitis
  • Herpes simplex virus
  • Preferred regimen: Acyclovir 1 drop topical 9 times per day OR Acyclovir 400 mg PO 5 times per day for 7-10 days OR Valacyclovir 500 mg PO tid for 7-10 days
Note: Topical steroids should be avoided.
  • Varicella zoster virus
Note: Treatment usually consists of a combination of oral antivirals and topical steroids.

Blepharitis

  • Empiric therapy[2]
  • Blepharitis
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 :
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
  • Dermatological conditions with seborrheic blepharitis and meibomian gland dysfunction
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
Note (1): In patients with chronic blepharitis that does not respond to therapy, the possibility of carcinoma should be considered, particularly if associated with a loss of eyelashes.
Note (2): Isotretinoin used to treat cystic acne is associated with significant increase in colonization of conjunctiva with Staphylococcus aureus blepharitis and disruption of tear function. Discontinuation of isotretinoin leads to improvement in most cases.

Endophthalmitis, bacterial

Endophthalmitis, bleb-related

Endophthalmitis, candidal

Endophthalmitis, chronic

Endophthalmitis, mold

Endophthalmitis, post-cataract surgery, acute

Endophthalmitis, post-cataract surgery, chronic

Endophthalmitis, post-tramatic

Keratitis, bacterial

  • Empiric therapy[3]
  • No organism identified (or) multiple types of organisms
Note (1) : Topical antibiotic eye drops are capable of achieving high tissue levels and are the preferred method of treatment in most cases.
Note (2) : Subconjunctival antibiotics may be helpful where there is imminent scleral spread or perforation or in cases where adherence to the treatment regimen is questionable.
Note (3) : Systemic therapy is necessary for suspected gonococcal infection.
  • Adjunctive therapy: ocular ointments may be useful at bedtime in less severe cases.
  • Organism specific bacterial keratitis
  • Gram positive cocci
Note (1) : Vancomycin and gentamycin have no gram negative activity and should not be used as a single agent in empirically treating bacterial keratitis.
  • Gram negative bacilli
  • Gram negative cocci
  • Nontuberculous mycobacteria
  • Nocardia
  • Note (1) : Topical antibiotic eye drops are capable of achieving high tissue levels and are the preferred method of treatment in most cases.
  • Note (2) : Subconjunctival antibiotics may be helpful where there is imminent scleral spread or perforation or in cases where adherence to the treatment regimen is questionable.

Keratitis, fungal

  • Empiric therapy[4]
  • (1) Topical antifungals
  • (a) For filamentous fungi
(i) 1st line : 5% Natamycin
(ii) 2nd line : 1% Itraconazole
  • (b)For candida
(i) 1st line : 0.15% Amphotericin B
(ii) 2nd line : Fluconazole
  • (2) Oral antifungals
(i) Ketoconazole 200 mg bid
(ii) Itraconazole 200mg qd
(iii) Fluconazole 50-100 mg qd

Keratitis, protozoal

  • For Acanthamoeba
(i) Biguanide - (polyhexamethylene biguanide [PHMB] 0.02% or chlorhexidine 0.02%) and
(ii) diamidine - (propamidine 0.1% or hexamidine 0.1%)
  • Recommended
propamidine 0.1% + polyhexamethylene biguanide 0.02% OR propamidine + chlorhexidine.
polyhexamethylene biguanide 0.02% AND hexamidine drops are administered every hour day, and night, for 48 hours initially, followed by hourly drops by day only for a further 72 hours.
note (1) : Intensive early treatment is given because organisms may be more susceptible before cysts have fully matured. Epithelial toxicity is common if the dosage is maintained at this intensity.
Note (2) : the diamidines and biguanides are currently the most effective cysticidal antiamoebics in vitro .
  • Toxicity of Biguanides and Diamidines : Cataract, iris atrophy,and peripheral ulcerative keratitis are all complications of Acanthamoeba keratitis that have been attributed to the use of topical biguanides and/or diamidines.
  • For microsporidia
(i) debridement
(ii) broad-spectrum antibiotics OR polyhexamethylene biguanide [PHMB] OR chlorhexidine.
  • Treatment for Limbitis and Scleritis:
  • Oral NSAIDS treatment, such as furbiprofen 50 to 100 mg, bid or tid. If it does not respond to flurbiprofen, then high-dose systemic steroid therapy prednisolone 1 mg/kg/day), with systemic Cyclosporine (3 to 7.5 mg/kg/day), can be used for successful control.

Keratitis, viral

  • Empiric therapy[4]
  • (a) HSV keratitis
  • (1) For epithelial disease:
(i) Acyclovir 3% ointment 5 times a day (is able to penetrate intact corneal epithelium)
(ii) Idoxuridine 0.1% drops now seldom used toxicity
(iii) Debridement in dendritic ulcer
  • (2) For necrotizing stromal disease:
Oral Acyclovir AND topical corticosteroids.
  • (3) For nonnecrotizing stromal disease
Topical corticosteroids when lesion involves visual axis.Possibly oral acyclovir (debatable)

Ocular syphilis

Ocular toxocariasis

Ocular toxoplasmosis

Ocular tuberculosis

Orbital cellulitis

Periocular Infection

Retinal necrosis, acute, CMV

Retinal necrosis, acute, HSV or VZV

Retinal necrosis, progressive outer, VZV

Retinitis, CMV

Stye

Uveitis, acute anterior

Uveitis, Lyme disease

References

  1. Azari, Amir A.; Barney, Neal P. (2013-10-23). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–1729. doi:10.1001/jama.2013.280318. ISSN 1538-3598. PMC 4049531. PMID 24150468.
  2. "Blepharitis PPP 2013".
  3. Template:Cite web / url = http: // http://www.aao.org/preferred-practice-pattern/bacterial-keratitis-ppp--2013
  4. 4.0 4.1 4.2 Thomas PA, Geraldine P (2007). "Infectious keratitis". Curr Opin Infect Dis. 20 (2): 129–41. doi:10.1097/QCO.0b013e328017f878. PMID 17496570.
  5. 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.