My TMOD Flashcards
RCE
Treatment
Acute episode: Cycloplegic drop (e.g., cyclopentolate 1%) three times daily and ophthalmic antibiotic ointment (e.g., erythromycin, bacitracin) four to six times daily. Can use 5% sodium chloride ointment q.i.d. in addition to antibiotic ointment. If the epithelial defect is large, a pressure patch or bandage contact lens and topical antibiotic drops q.i.d. may be placed (NEVER patch contact lens wearers). Oral analgesics as needed.
Never prescribe topical anesthetic drops.
After epithelial healing is complete, artificial tears four to eight times per day and artificial tear ointment q.h.s. for at least 3 to 6 months, or 5% sodium chloride drops four times per day and 5% sodium chloride ointment q.h.s. for at least 3 to 6 months.
If the corneal epithelium is loose or heaped and is not healing, consider epithelial debridement. Apply a topical anesthetic (e.g., proparacaine) and use a sterile cotton-tipped applicator or cellulose sponge (e.g., Weck-Cel surgical spear) to gently remove all the loose epithelium.
For erosions not responsive to the preceding treatment, consider the following:
Prophylactic medical treatment with 5% sodium chloride ointment q.h.s.
Oral doxycycline (matrix metalloproteinase inhibitor) 50 mg b.i.d. with or without a short course of topical corticosteroid drops (e.g., fluorometholone 0.1% b.i.d. to q.i.d. for 2 to 4 weeks).
Extended-wear bandage soft contact lens for several months with a topical antibiotic and routine changing of the lens.
Anterior stromal puncture can be applied to localized erosions, such as in traumatic cases, outside the visual axis in cooperative patients. It can be performed with or without an intact epithelium. Stromal puncture may be applied manually at the slit lamp or with Nd:YAG laser. This treatment may cause small permanent corneal scars that are usually of no visual significance if outside the visual axis.
Epithelial debridement with diamond burr polishing of Bowman membrane or phototherapeutic keratectomy (PTK). Both are highly effective (up to 90%) for large areas of epithelial irregularity and lesions in the visual axis. Excimer laser ablation of the superficial stroma can be particularly helpful if repeated erosions have created anterior stromal haze or scarring.
Follow-Up
Every 1 to 2 days until the epithelium has healed, and then every 1 to 3 months, depending on the severity and frequency of the episodes. It is important to educate patients that persistent use of lubricating ointment (5% sodium chloride or tear ointment) for 3 to 6 months following the initial healing process reduces the chance of recurrence.
Filamentary keratitis
Treatment
Treat the underlying condition.
Consider debridement of the filaments. After applying topical anesthetic (e.g., proparacaine), gently remove filaments at their base with fine forceps or a cotton-tipped applicator. This gives temporary relief, but the filaments will recur if the underlying etiology is not treated.
Lubrication with one of the following regimens:
Preservative-free artificial tears six to eight times per day and lubricating ointment q.h.s.
Punctal occlusion.
Acetylcysteine 10% q.i.d.
NOTE
Acetylcysteine is not commercially available as a drop but can be made by a compounding pharmacy.
If the symptoms are severe or treatment fails, then consider a bandage soft contact lens (unless the patient has severe dry eyes as underlying etiology). Extended-wear bandage soft contact lenses may need to be worn for weeks to months. Concomitant prophylactic or therapeutic topical antibiotics such as a fluoroquinolone drops are typically given, especially if associated with a corneal abrasion/epithelial defect.
Follow-Up
In 1 to 4 weeks. If the condition is not improved, consider repeating the filament removal or applying a bandage soft contact lens. Long-term lubrication must be maintained if the underlying condition cannot be eliminated.
Thygeson SPK
Treatment
Mild
Artificial tears four to eight times per day.
Artificial tear ointment q.h.s.
Note
Treatment is based more on patient symptoms than corneal appearance.
Moderate to Severe
Mild topical steroid (e.g., fluorometholone 0.1% or loteprednol 0.2% to 0.5% q.i.d.) for 1 to 4 weeks, followed by a very slow taper. May need prolonged low-dose topical steroid therapy.
If no improvement with topical steroids, a bandage soft contact lens can be tried.
Cyclosporine 0.05% drops daily to q.i.d. may be an alternative or adjunctive treatment, especially in patients with side effects from steroids.
Follow-Up
Weekly during an exacerbation, then every 3 to 6 months. Patients receiving topical steroids require intraocular pressure (IOP) checks every 4 to 12 weeks.
Band keratopathy
Treatment
Mild (e.g., Foreign Body Sensation)
Artificial tears four to six times per day and artificial tear ointment q.h.s. to q.i.d. as needed. Consider a bandage contact lens for comfort.
Severe (e.g., Obstruction of Vision, Irritation not Relieved by Lubricants, Cosmetic Problem)
Removal of the calcium may be performed at the slit lamp or under the operating microscope by chelation using disodium ethylenediamine tetraacetic acid (EDTA):
Disodium EDTA 3% to 4% is obtained from a compounding pharmacy.
Anesthetize the eye with a topical anesthetic (e.g., proparacaine) and place an eyelid speculum.
Debride the corneal epithelium overlying the calcium with a sterile scalpel or a sterile cotton-tipped applicator.
Wipe a cellulose sponge or cotton swab saturated with the EDTA solution over the band keratopathy until the calcium clears (which may take 10 to 60 minutes).
Irrigate with normal saline, place an antibiotic ointment (e.g., erythromycin), a cycloplegic drop (e.g., cyclopentolate 1% to 2%), and a pressure patch on the eye for 24 hours. Alternatively, a bandage soft contact lens or an amniotic membrane may be used to cover the epithelial defect with a topical antibiotic (e.g. moxifloxacin, gatifloxacin q.i.d.).
Consider giving the patient a systemic analgesic (e.g., acetaminophen with codeine).
Follow-Up
If surgical removal has been performed, the patient should be examined every few days until the epithelial defect has healed.
Residual anterior stromal scarring may be amenable to excimer laser PTK to improve vision. PTK may also be used to try to improve the ocular surface and prevent recurrent erosions.
The patient should be checked every 3 to 12 months, depending on the severity of symptoms. EDTA chelation can be repeated if the band keratopathy recurrs.
Bacterial keratitis
**corneal ulcer
Treatment summary
Small non-staining peripheral ulcers may be started on fluoroquinolone drops every 2 to 6 hours. For ulcers with epithelial defects and an anterior chamber reaction, a fluoroquinolone drop every hour around the clock is recommended. Large or vision threatening ulcers (with moderate to severe anterior chamber reaction and/or involving the visual axis) are usually treated with fortified tobramycin or gentamicin (15mg/ml) every hour around the clock alternating with fortified vancomycin (25mg/ml) every hour around the clock.
Treatment
Ulcers and infiltrates are initially treated as bacterial unless there is a high index of suspicion of another form of infection. Initial therapy should be broad spectrum. Remember that bacterial coinfection may occasionally complicate fungal and Acanthamoeba keratitis. Mixed bacterial infections can also occur.
Cycloplegic drops for comfort and to prevent synechiae formation (e.g., cyclopentolate 1% t.i.d.; atropine 1% b.i.d. to t.i.d. recommended if a hypopyon in present). The specific medication depends on severity of anterior chamber inflammation.
Topical antibiotics according to the following algorithm:
Low Risk of Visual Loss
Small, nonstaining peripheral infiltrate with at most minimal anterior chamber reaction and no discharge:
Noncontact lens wearer: Broad-spectrum topical antibiotics (e.g., fluoroquinolone [moxifloxacin, gatifloxacin, besifloxacin, levofloxacin] or polymyxin B/trimethoprim drops q1–2h while awake).
Contact lens wearer: Fluoroquinolone (e.g., moxifloxacin, gatifloxacin, ciprofloxacin, besifloxacin, levofloxacin) ± polymyxin B/trimethoprim drops q1–2h while awake; can add tobramycin or ciprofloxacin ointment one to four times a day.
Borderline Risk of Visual Loss Medium size (1 to 1.5 mm diameter) peripheral infiltrate, or any smaller infiltrate with an associated epithelial defect, mild anterior chamber reaction, or moderate discharge:
Fluoroquinolone (e.g., moxifloxacin, gatifloxacin, ciprofloxacin, besifloxacin, levofloxacin) ± polymyxin B/trimethoprim q1h around the clock. Consider starting with a loading dose of q5min for five doses and then q30min until midnight then q1h.
Note
Moxifloxacin and besifloxacin have slightly better gram-positive coverage. Gatifloxacin and ciprofloxacin have slightly better Pseudomonas and Serratia coverage.
Vision Threatening
Our current practice at Wills Eye is to start fortified antibiotics for most ulcers larger than 1.5 to 2 mm, in the visual axis, or unresponsive to initial treatment. If fortified antibiotics are not immediately available, start with a fluoroquinolone and polymyxin B/trimethoprim until fortified antibiotics can be obtained from a formulating pharmacy.
Fortified tobramycin or gentamicin (15 mg/mL) q1h, alternating with fortified cefazolin (50 mg/mL) or vancomycin (25 mg/mL) q1h. This means that the patient will be placing a drop in the eye every one-half hour around the clock. Vancomycin drops should be reserved for resistant organisms, patients at risk for resistant organisms (e.g., due to hospital or antibiotic exposure, unresponsive to initial treatment), and for patients who are allergic to penicillin or cephalosporins. An increasing number of methicillin-resistant Staphylococcus aureus (MRSA) infections are now community acquired. If the ulcer is severe and Pseudomonas is suspected, consider starting fortified tobramycin every 30 minutes and fortified cefazolin q1h; in addition, consider fortified ceftazidime q1h.
Note
All patients with borderline risk of visual loss or severe vision-threatening ulcers are initially treated with loading doses of antibiotics using the following regimen: One drop every 5 minutes for five doses, then every 30 to 60 minutes around the clock.
In some cases, topical corticosteroids are added after the bacterial organism and sensitivities are known, the infection is under control, and severe inflammation persists. Infectious keratitis may worsen significantly with topical corticosteroids, especially when caused by fungus, atypical mycobacteria, or Pseudomonas.
Eyes with corneal thinning should be protected by a shield without a pressure patch (a patch is never placed over an eye thought to have an infection). The use of a matrix metalloproteinase inhibitor (e.g., doxycycline 100 mg p.o. b.i.d.) and a collagen synthesis promoter such as systemic ascorbic acid (e.g., vitamin C 1 to 2 g daily) may help to suppress connective tissue breakdown and prevent the perforation of the cornea.
No contact lens wear.
Oral pain medication as needed.
Oral fluoroquinolones (e.g., ciprofloxacin 500 mg p.o. b.i.d.; moxifloxacin 400 mg p.o. daily) penetrate the eye well. These may have added benefit for patients with scleral extension or for those with frank or impending perforation. Ciprofloxacin is preferred for Pseudomonas and Serratia.
Systemic antibiotics are also necessary for Neisseria infections (e.g., ceftriaxone 1 g intravenously [i.v.] q12–24h if corneal involvement, or a single 1 g intramuscular [i.m.] dose if there is only conjunctival involvement) and for Haemophilus infections (e.g., oral amoxicillin/clavulanate [20 to 40 mg/kg/day in three divided doses]) because of occasional extraocular involvement such as otitis media, pneumonia, and meningitis.
Admission to the hospital may be necessary if:
- Infection is sight threatening and/or impending perforation.
- Patient has difficulty administering the antibiotics at the prescribed frequency.
- High likelihood of noncompliance with drops or daily follow-up.
- Suspected topical anesthetic abuse.
- Intravenous antibiotics are needed (e.g., gonococcal conjunctivitis with corneal involvement). Often employed in the presence of corneal perforation and/or scleral extension of infection.
- For atypical mycobacteria, consider prolonged treatment (q1h for 1 week, then gradually tapering) with one of the following topical agents: fluoroquinolone (e.g., moxifloxacin or gatifloxacin), amikacin (15 mg/mL), clarithromycin (1% to 4%), or tobramycin (15 mg/mL). Consider oral treatment with clarithromycin 500 mg b.i.d. Previous LASIK has been implicated as a risk factor for atypical mycobacteria infections.
Follow-Up
Daily evaluation at first, including repeat measurements of the size of the infiltrate and epithelial defect. The most important criteria in evaluating treatment response are the amount of pain, the epithelial defect size (which may initially increase because of scraping for cultures and smears), the size and depth of the infiltrate, and the anterior chamber reaction. The IOP must be checked and treated if elevated. Reduced pain is often the first sign of a positive response to treatment.
If improving, the antibiotic regimen is gradually tapered but is never tapered past the minimum dose to inhibit the emergence of resistance (usually t.i.d. to q.i.d. depending on the agent). Otherwise, the antibiotic regimen is adjusted according to the culture and sensitivity results.
Consider new or repeat cultures and stains (without stopping treatment) in the setting of non-responsive or worsening infiltrate/ulcer. Treat with fortified antibiotics and modify based on culture results and the clinical course. Hospitalization may be recommended.
A corneal biopsy may be required if the condition is worsening and infection is still suspected despite negative cultures.
For an impending or a complete corneal perforation, a corneal transplant or patch graft is considered. Cyanoacrylate tissue glue may also work in a treated corneal ulcer that has perforated despite infection control. Due to concern about drug penetration, antibiotics are often given for 1 to 2 days prior to glue application over an active area of infection.
Fungal keratitis
Treatment
Corneal infiltrates and ulcers of unknown etiology are treated as bacterial until proven otherwise. If the stains or cultures indicate a fungal keratitis, institute the following measures:
Admission to the hospital may be necessary, unless the patient is reliable. It may take weeks to achieve complete healing.
Natamycin 5% drops (especially for filamentous fungi), amphotericin B 0.15% drops (especially for Candida), or topical fortified voriconazole 1% initially q1–2h around the clock, then taper over 4 to 6 weeks.
Cycloplegic (e.g., cyclopentolate 1% t.i.d.; atropine 1% b.i.d. to t.i.d. is recommended if hypopyon is present).
No topical steroids. If the patient is currently taking steroids, they should be tapered rapidly and discontinued.
Consider adding oral antifungal agents (e.g., either fluconazole or itraconazole 200 to 400 mg p.o. loading dose, then 100 to 200 mg p.o. daily, or voriconazole 200 mg p.o. b.i.d.). Oral antifungal agents are often used for deep corneal ulcers or suspected fungal endophthalmitis.
Consider epithelial debridement to facilitate the penetration of antifungal medications. Topical antifungals do not penetrate the cornea well, especially through an intact epithelium. When culture results and sensitivities are known, intrastromal depot injections of amphotericin or voriconazole can also be considered.
Measure IOP (preferably with Tono-Pen). Treat elevated IOP if present
Eye shield, without patch, in the presence of corneal thinning.
Follow-Up
Patients are reexamined daily at first. However, the initial clinical response to treatment in fungal keratitis is much slower compared to bacterial keratitis. Stability of infection after initiation of treatment is often a favorable sign. Unlike bacterial ulcers, epithelial healing in fungal keratitis is not always a sign of positive response. Fungal infections in deep corneal stroma are frequently recalcitrant to therapy. These ulcers may require weeks to months of treatment, and therapeutic corneal transplantation may be necessary for infections that progress despite maximal medical therapy or corneal perforation. Intracameral antifungal medications (e.g., voriconazole 50 mcg/0.1 mL) at the time of therapeutic keratoplasty should be considered. Anterior lamellar keratoplasty is relatively contraindicated because there is a high risk of recurrence of infection
Acanthomoeba keratiitis
Treatment
One or more of the following are usually used in combination, sometimes in the hospital initially:
Polyhexamethylene biguanide 0.02% (PHMB) drops q1h or chlorhexidine 0.02% drops q1h.
Propamidine isethionate 0.1% drops q1h are typically added in addition to PHMB or chlorhexidine. Dibromopropamidine isethionate 0.15% ointment is also available.
Oral antifungal agent (e.g., itraconazole 400 mg p.o. for one loading dose, then 100 to 200 mg p.o. daily, ketoconazole 200 mg p.o. daily, or voriconazole 200 mg p.o. daily to b.i.d.).
Note
Alternative therapy includes hexamidine, clotrimazole 1% drops, miconazole 1% drops, or paromomycin drops q2h. Low-dose corticosteroid drops may be helpful in reducing inflammation after the infection is controlled, but steroid use is controversial.
All patients:
Discontinue contact lens wear in both eyes.
Cycloplegic (e.g., cyclopentolate 1% t.i.d. or atropine 1% b.i.d.).
In presence of inflammation, pain, and/or scleritis, oral nonsteroidal anti-inflammatory agents (e.g., naproxen 250 to 500 mg p.o. b.i.d.) may be used. Additional narcotic oral analgesics are often needed.
Follow-Up
Every 1 to 4 days until the condition is consistently improving, and then every 1 to 3 weeks. Medication may then be tapered judiciously. Treatment is usually continued for 3 months after resolution of inflammation, which may take up to 6 to 12 months.
HSV keratitis / conjunctivitis
Treatment
Eyelid/Skin Involvement
Topical acyclovir ointment, five times per day, is an option, although it has not been proven effective. Any dermatologic and nonocular preparation of acyclovir ointment should be used on the skin only. Erythromycin or bacitracin ophthalmic ointment is often used b.i.d. for bacterial prophylaxis. Ganciclovir 0.15% ophthalmic gel five times per day may also be effective.
Warm or cool soaks to skin lesions t.i.d. or p.r.n.
Eyelid margin involvement: Add ganciclovir 0.15% ophthalmic gel or trifluridine 1% drops, five times per day, to the eye. Vidarabine 3% ointment five times per day is useful for small children. These medications are continued for 7 to 14 days until resolution of the symptoms.
Note
Many physicians give oral acyclovir 400 mg five times per day, valacyclovir 500 mg p.o. t.i.d., or famciclovir 250 mg p.o. t.i.d. for 7 to 14 days, to adults suspected of having primary herpetic disease.
Conjunctivitis
Ganciclovir 0.15% ophthalmic gel, trifluridine 1% drops, or vidarabine 3% ointment five times per day. Discontinue the antiviral agent after 7 to 14 days; if the conjunctivitis has failed to improve, reevaluation is recommended.
Corneal Epithelial Disease
Ganciclovir 0.15% ophthalmic gel five times per day, trifluridine 1% drops nine times per day, or vidarabine 3% ointment five times per day. (Topical ganciclovir gel appears to have a lower incidence of corneal toxicity than trifluridine.) Oral antiviral agents (e.g., acyclovir 400 mg p.o. five times per day, valacyclovir 500 mg p.o. t.i.d., or famciclovir 250 mg p.o. t.i.d. for 7 to 10 days) are effective alternatives to topical antiviral agents and can be used when topical medications cannot be given due to compliance problems, especially in children.
Consider cycloplegic agent (e.g., cyclopentolate 1% t.i.d.) if an anterior chamber reaction or photophobia is present.
Patients taking topical steroids should have them tapered rapidly.
Limited debridement of infected epithelium can be used as an adjunct to antiviral agents.
Technique: After topical anesthetic instillation, a sterile, moistened cotton-tipped applicator or semisharp instrument is used carefully to peel off the lesions at the slit lamp. After debridement, antiviral treatment should be instituted or continued as described earlier.
For epithelial defects that do not resolve after 1 to 2 weeks, bacterial coinfection or Acanthamoeba keratitis should be suspected. Noncompliance and topical antiviral toxicity should also be considered. At that point, the topical antiviral agent should be discontinued, and a nonpreserved artificial tear ointment or an antibiotic ointment (e.g., erythromycin) should be used four to eight times per day for several days with careful follow-up. Smears for Acanthamoeba should be performed whenever the diagnosis is suspected.
Disciform keratitis
Mild. Consider treatment with cycloplegic (e.g., cyclopentolate 1% t.i.d.) in conjunction with antiviral prophylaxis.
Moderate to severe or central (i.e., vision is reduced).
Cycloplegic, as above.
Topical steroid (e.g., prednisolone acetate 1% or loteprednol 0.5% q.i.d. to q2h). If an epithelial lesion is present, it should be treated before starting high frequency corticosteroids.
Antiviral prophylaxis: Ganciclovir 0.15% ophthalmic gel three to five times a day, trifluridine 1% t.i.d. to q.i.d., acyclovir 400 mg p.o. b.i.d., valacyclovir 500 mg p.o. one to two times a day.
Note
Chronic use of prophylactic oral antivirals may help prevent subsequent episodes of HSV keratouveitis.
Adjunctive medications which may be used include:
- Topical antibiotic (e.g., erythromycin ointment q.h.s.) in the presence of epithelial defects.
- Aqueous suppressants for increased IOP. Avoid prostaglandin analogues due to association with recurrent HSV infections and uveitis.
Necrotizing IK: Treated as severe disciform keratitis. The first priority is to diagnose and treat any associated overlying epithelial defect and bacterial superinfection with antibiotic drops or ointment. Tissue adhesive or corneal transplantation may be required if the cornea perforates (this is more common with neurotrophic keratitis). Oral antiviral treatment may be beneficial.
Note
Topical steroids are contraindicated in those with infectious epithelial disease.
Rarely, a systemic steroid (e.g., prednisone 40 to 60 mg p.o. daily tapered rapidly) is given to patients with severe stromal disease accompanied by an epithelial defect and hypopyon. Cultures should be done to rule out a superinfection.
While oral antivirals (e.g., acyclovir, famciclovir, and valacyclovir) have not been shown to be beneficial in the treatment of stromal disease, they are typically employed, and may be beneficial in the treatment of herpetic uveitis.
Valacyclovir has greater bioavailability than acyclovir. Little has been published on famciclovir for HSV, but it may be better tolerated in patients who have side effects to acyclovir such as headache, fatigue, or gastrointestinal upset.
Dosing of antivirals discussed above (e.g., acyclovir, famciclovir, and valacyclovir) need to be adjusted in patients with renal insufficiency. Checking BUN and creatinine is recommended in patients at risk for renal disease before starting high doses of these medications.
Valacyclovir should be used with caution in patients with human immunodeficiency virus due to reports of thrombocytopenic purpura and hemolytic uremic syndrome in this population.
The persistence of an ulcer with stromal keratitis is commonly due to the underlying inflammation (requiring cautious steroid therapy); however, it may be due to antiviral toxicity or active HSV epithelial infection. When an ulcer deepens, a new infiltrate develops, or the anterior chamber reaction increases, smears and cultures should be taken for bacteria and fungi.
Follow-Up
Patients are reexamined in 2 to 7 days to evaluate the response to treatment and then every 1 to 2 weeks, depending on the clinical findings. The following clinical parameters are evaluated: the size of the epithelial defect and ulcer, the corneal thickness and the depth of corneal involvement, the anterior chamber reaction, and the IOP. Patients with necrotizing keratitis need to be followed daily or admitted if there is threat of perforation.
Topical antiviral medications for corneal dendrites and geographic ulcers should be continued five times (for ganciclovir and vidarabine ophthalmic gel) to nine times (for trifluridine drops) per day for 7 to 14 days until healed, then two to four times per day respectively for 4 to 7 days, then stopped.
Topical steroids used for corneal stromal disease are tapered slowly (often over months to years). The initial concentration of the steroid (e.g., prednisolone acetate 1%) is eventually reduced (e.g., loteprednol 0.5% or prednisolone acetate 0.125%). Extended taper includes dosing q.o.d., twice weekly, once weekly, etc., especially with a history of flare-ups when steroids are stopped. Prophylactic systemic agents (e.g., acyclovir 400 mg b.i.d.) or less commonly, topical antiviral agents (e.g., ganciclovir 0.15% or trifluridine 1% t.i.d.), are used until steroids are used once daily or less.
Corneal transplantation may eventually be necessary if inactive postherpetic scars significantly affect vision, though an RGP lens and maximization of the ocular surface with aggressive lubrication should be tried first.
Recommend long-term oral antiviral prophylaxis (e.g., acyclovir 400 mg b.i.d.) if a patient has had multiple episodes of epithelial disease or stromal disease.
HZV
Treatment
Skin involvement:
In adults with a moderate-to-severe skin rash for <4 days in which active skin lesions are present and (consider) if the patient presents later in the first week with active lesions:
Oral antiviral agent (e.g., acyclovir 800 mg p.o. five times per day, famciclovir 500 mg p.o. t.i.d., or valacyclovir 1,000 mg p.o. t.i.d.) for 7 to 10 days. If the condition is severe, as manifested by orbital, optic nerve, or cranial nerve involvement, or the patient is systemically ill, hospitalize and prescribe acyclovir 5 to 10 mg/kg i.v. q8h for 5 to 10 days.
Ophthalmic antibiotic ointment (e.g., bacitracin or erythromycin) to skin lesions b.i.d.
Warm compresses to periocular skin t.i.d.
Adults with a skin rash of more than 1-week duration or without active skin lesions:
Ophthalmic antibiotic ointment (e.g., bacitracin or erythromycin) to skin lesions b.i.d.
Warm compresses to periocular skin t.i.d.
Children: Discuss with a pediatrician and consider weight-based acyclovir dosing (20 mg/kg q8h) for children <12 years of age or under 40 kg, otherwise use adult dosage above. Treat as in (2) unless evidence of systemic spread. For systemic spread, hospitalize and prescribe intravenous acyclovir in conjunction with pediatric and infectious disease comanagement.
Ocular Involvement
Note
It is common clinical practice at Wills Eye for all patients with VZV ocular findings to receive 7 to 10 days of systemic oral antivirals (e.g., acyclovir 800 mg p.o. five times per day, famciclovir 500 mg p.o. t.i.d., or valacyclovir 1,000 mg p.o. t.i.d.) usually in conjunction with the following therapies.
Conjunctival involvement: Cool compresses and ophthalmic ointment (e.g., bacitracin or erythromycin) to the eye b.i.d.
SPK: Lubrication with preservative-free artificial tears q1–2h and ointment q.h.s.
Corneal or conjunctival pseudodendrites: Lubrication with preservative-free artificial tears q1–2h and ointment q.h.s. Topical antivirals (e.g., ganciclovir 0.15% gel or vidarabine 3% ointment) t.i.d. to q.i.d. may also be helpful. Consider antibiotic ointment to prevent bacterial superinfection.
Immune stromal keratitis: Topical steroid (e.g., prednisolone acetate 1%) started at a frequency of four to eight times per day and adjusted according to clinical response. Topical steroids are tapered over months to years using weaker steroids with a goal of less than daily dosing (e.g., q.o.d., twice weekly, once weekly, etc.).
Uveitis (with or without immune stromal keratitis): Topical steroid (e.g., prednisolone acetate 1%) four to eight times per day and cycloplegic (e.g., cyclopentolate 1% t.i.d.). Treat increased IOP with aggressive aqueous suppression; avoid prostaglandin analogues.
Neurotrophic keratitis: Treat mild epithelial defects with ophthalmic antibiotic ointment (e.g., erythromycin) four to eight times per day. If a corneal infiltrate occurs, obtain appropriate smears and cultures to rule out infection. If the infiltrate is sterile, and there is no response to ointment, consider a bandage contact lens, tarsorrhaphy, amniotic membrane graft, or conjunctival flap along with prophylactic topical antibiotics.
Scleritis
Retinitis, choroiditis, optic neuritis, or cranial nerve palsy: Acyclovir 10 mg/kg i.v. q8h for 1 week and prednisone 60 mg p.o. for 3 days, then taper over 1 week. Management of ARN or PORN may require intraocular antivirals. Consult infectious disease. Recommend neurologic consultation to rule out central nervous system involvement. Patients with severe disease can develop a large vessel cranial arteritis resulting in a massive CVA.
Increased IOP: May be steroid response or secondary to inflammation. If uveitis is present, increase the frequency of the steroid administration for a few days and use topical aqueous suppressants (e.g., timolol 0.5% daily or b.i.d., brimonidine 0.2% t.i.d., or dorzolamide 2% t.i.d. Oral carbonic anhydrase inhibitors may be necessary if the IOP is >30 mm Hg. If IOP remains increased and the inflammation is controlled, substitute fluorometholone 0.25%, rimexolone 1%, or loteprednol 0.5% drops for prednisolone acetate and attempt to taper the dose.
Note
Pain may be severe during the first 2 weeks, and narcotic analgesics may be required. An antidepressant (e.g., amitriptyline 25 mg p.o. t.i.d.) may be beneficial for both postherpetic neuralgia and depression that can develop in VZV. Capsaicin 0.025% or doxepin ointment may be applied to the skin t.i.d. to q.i.d. after the rash heals (not around the eyes) for postherpetic neuralgia. Oral gabapentin or pregabalin can be helpful for acute pain and for postherpetic neuralgia. Management of postherpetic neuralgia should involve the patient’s primary medical doctor or a pain management specialist.
Follow-Up
If ocular involvement is present, examine the patient every 1 to 7 days, depending on the severity. Patients without ocular involvement can be followed every 1 to 4 weeks. After the acute episode resolves, check the patient every 3 to 6 months (3 if on steroids) because relapses may occur months to years later, particularly as steroids are tapered. Systemic steroid use is controversial and requires collaboration with the patient’s internist.
Note
VZV is contagious for children and adults who have not had chickenpox or the chickenpox vaccine and is spread by inhalation. Varicella-naïve pregnant women must be especially careful to avoid contact with a VZV-infected patient. A vaccine for VZV is recommended for people aged 50 to 60 years or older; it was demonstrated to decrease the frequency and severity of HZO versus placebo.
Varicella Zoster Virus (Chickenpox)
Symptoms
Facial rash, red eye, foreign body sensation.
Signs
Early: Acute conjunctivitis with vesicles or papules at the limbus, on the eyelid, or on the conjunctiva. Pseudodendritic corneal epithelial lesions, stromal keratitis, anterior uveitis, optic neuritis, retinitis, and ophthalmoplegia occur rarely.
Late: Immune stromal or neurotrophic keratitis.
Treatment
Conjunctival involvement and/or corneal epithelial lesions: Cool compresses and ophthalmic antibiotic ointment (e.g., erythromycin t.i.d.) to the eye and periorbital lesions.
Stromal keratitis with uveitis: Topical steroid (e.g., prednisolone acetate 1% q.i.d.), cycloplegic (e.g., cyclopentolate 1% t.i.d.), and erythromycin ointment q.h.s.
Neurotrophic keratitis: Uncommon
Canalicular obstruction: Uncommon. Managed by intubation of puncta.
Note
Aspirin is contraindicated because of the risk of Reye syndrome in children.
Immunocompromised children with chickenpox may require i.v. acyclovir.
VZV vaccination is available and will likely prevent ophthalmic complications of chickenpox in immunocompetent patients if given at least 8 to 12 weeks before exposure.
Follow-Up
Follow-up in 1 to 7 days, depending on the severity of ocular disease. Taper the topical steroids slowly.
Watch for stromal or neurotrophic keratitis approximately 4 to 6 weeks after the chicken pox infection resolves. Stromal keratitis can have a chronic course requiring long-term topical steroids with a very gradual taper.
Interstitial Keratitis
Treatment
Acute disease:
Topical cycloplegic (e.g. cyclopentolate 1% t.i.d. or atropine 1% b.i.d.). Topical steroid (e.g., prednisolone acetate 1% q2–6h depending on the degree of inflammation). Treat any underlying disease.
Old inactive disease with central scarring:
Corneal transplantation may improve vision if minimal amblyopia is present.
Late decrease in vision often due to cataracts.
Recently inactive or old inactive disease:
If the treponemal-specific assay or FTA-ABS is positive and the patient has active or untreated syphilis, or if the VDRL or RPR titer is positive and has not declined the expected amount after treatment, then treatment for syphilis is indicated.
If PPD or IGRA is positive and the patient is <35 years and has not been treated for TB in the past, or there is evidence of active systemic TB (e.g., positive finding on chest radiograph), then refer the patient to an internist and infectious disease specialist for TB treatment.
If Cogan syndrome is present, refer the patient to an otolaryngologist and rheumatologist.
If Lyme antibody and titers are positive, treat
Follow-Up
Acute disease: Every 3 to 7 days initially, and then every 2 to 4 weeks. The frequency of steroid administration is slowly reduced as the inflammation subsides over the course of months (may take years). IOP is monitored closely and reduced with medications based on the degree of IOP elevation and overall health of the optic nerve.
Old inactive disease: Yearly follow-up, unless treatment is required for underlying
Staph Marginal Keratitis
Treatment
Mild
Warm compresses, eyelid hygiene, and an antibiotic drop q.i.d. (e.g., fluoroquinolone or trimethoprim/polymyxin B) and antibiotic ophthalmic ointment q.h.s. (e.g. bacitracin, erythromycin, bacitracin/polymyxin B).
Moderate to Severe
Treat as described for mild, but add a low-dose topical steroid (e.g., loteprednol 0.2% to 0.5% or prednisolone 0.125% q.i.d.) with an antibiotic (e.g., fluoroquinolone or trimethoprim/polymyxin B q.i.d.). A combination antibiotic/steroid can also be used q.i.d. (e.g., loteprednol 0.5%/tobramycin 0.3% or dexamethasone 0.1%/tobramycin 0.3%). Never use steroids without antibiotic coverage. Maintain until the symptoms improve and then slowly taper.
If episodes recur despite eyelid hygiene, add systemic doxycycline (100 mg p.o. b.i.d., for 2 weeks, and then daily for 1 month, and then 50 to 100 mg daily titrated as necessary) until the ocular disease is controlled for several months. This medication has an anti-inflammatory effect on the sebaceous glands in addition to its antimicrobial action. Topical azithromycin q.h.s. or cyclosporine b.i.d. may be helpful in controlling eyelid inflammation.
Low-dose antibiotics (e.g., bacitracin or erythromycin ointment q.h.s.) may have to be maintained indefinitely.
Note
Tetracyclines such as doxycycline are contraindicated in children <8 years, pregnant women, and breast-feeding mothers. Erythromycin 200 mg p.o. one to two times per day can be used in children to decrease recurrent disease.
Follow-Up
In 2 to 7 days, depending on the clinical picture. IOP is monitored while patients are taking topical steroids
Phlyctenulosis
Treatment
Indicated for symptomatic patients.
Topical steroid (e.g., loteprednol 0.5% or prednisolone acetate 1% q.i.d., depending on the severity of symptoms). A combination antibiotic/steroid can also be used q.i.d. (e.g., loteprednol 0.5%/tobramycin 0.3% or dexamethasone 0.1%/tobramycin 0.3%). If there is significant tearing, a steroid/antibiotic ointment (e.g., dexamethasone/tobramycin) may be more effective.
Topical ophthalmic antibiotic regimen in the presence of corneal ulcer. Otherwise antibiotic ointment (e.g., erythromycin, bacitracin) q.h.s.
Eyelid hygiene b.i.d. to t.i.d. for blepharitis. .
Preservative-free artificial tears four to six times per day.
In severe cases of blepharitis or acne rosacea, use doxycycline 100 mg p.o. daily. to b.i.d., or erythromycin 200 mg p.o. daily to b.i.d. See 5.8, Blepharitis/Meibomitis.
If the PPD, IGRA, or chest radiograph is positive for TB, refer the patient to an internist or infectious disease specialist for management.
Follow-Up
Recheck in several days. Healing usually occurs over a 10- to 14-day period, with a residual stromal scar. When the symptoms have significantly improved, slowly taper the steroid. Maintain the antibiotic ointment and eyelid hygiene indefinitely. Continue oral antibiotics for 3 to 6 months. Topical azithromycin or cyclosporine may be beneficial steroid-sparing agents in patients with recurrent inflammation
Acute Corneal Hydrops
Treatment
Cycloplegic agent (e.g., cyclopentolate 1% t.i.d.), ophthalmic antibiotic ointment (e.g., erythromycin or bacitracin) q.i.d.
Consider an aqueous suppressant such as brimonidine 0.1% b.i.d. to t.i.d.
Start sodium chloride 5% ointment b.i.d. until resolved (usually several weeks to months).
Glasses or a shield should be worn by patients at risk for trauma or by those who rub their eyes.
Intracameral air, SF6, or C3F8 may help edema resolve more quickly, but may be equivalent to conservative management in final BCVA.
Follow up
After an episode of hydrops, examine the patient every 1 to 4 weeks until resolved (which can take several months).
Fuch’s Endothelial Dystrophy
Treatment
Topical sodium chloride 5% drops q.i.d. and ointment q.h.s.
May gently blow warm air from a hair dryer at arm’s length toward the eyes for a few minutes every morning to dehydrate the cornea.
IOP reduction if indicated; also may help with corneal edema.
Ruptured corneal bullae are painful and should be treated as recurrent erosions (see 4.2, Recurrent Corneal Erosion).
Surgery: Endothelial keratoplasty is usually indicated when visual acuity decreases due to corneal edema; PK is indicated if significant anterior stromal scarring is present.
Follow-Up
Every 3 to 12 months to check IOP and assess corneal edema. The condition progresses very slowly, and visual acuity typically remains good until stromal edema, epithelial edema, or corneal scarring develop.
Corneal Graft Rejection
Treatment Endothelial Rejection (Endothelial Rejection Line, Corneal Edema, and/or Keratic Precipitates)
Topical steroids (e.g., prednisolone acetate 1% q1h or difluprednate 0.05% q2h while awake; can add dexamethasone 0.1% ointment q.h.s.).
If rejection is severe, recurrent, or recalcitrant, consider systemic steroids (e.g., prednisone 40 to 80 mg p.o. daily) or, rarely, subconjunctival steroids (e.g., betamethasone 3 mg per 0.5 mL). In high-risk patients with severe rejection, consider hospitalization and methylprednisolone 500 mg i.v for a total of one to three doses.
In select cases, other systemic immunosuppressives may be considered including cyclosporine and tacrolimus.
Cycloplegic agent (e.g., cyclopentolate 1% t.i.d.).
Control IOP if increased. See 9.7, Inflammatory Open Angle Glaucoma.
Topical cyclosporine 0.05% to 2% b.i.d. to q.i.d. may be helpful in the treatment and prevention of graft rejection.
Epithelial and Stromal Rejection (Subepithelial Infiltrates or Epithelial Rejection Line)
Double the current level of topical steroids or use prednisolone acetate 1% q.i.d. (whichever is more).
Cycloplegic agent, topical cyclosporine, and IOP control as above.
Follow-Up
Institute treatment immediately to maximize the likelihood of graft survival. Examine the patient every 3 to 7 days. Once improvement is noted, the steroids are tapered very slowly and may need to be maintained at low doses for months to years. IOP must be checked regularly in patients taking topical steroids.
Viral Conjunctivitis/ EKC
Treatment
Counsel the patient that viral conjunctivitis is a self-limited condition that typically gets worse for the first 4 to 7 days after onset and may not resolve for 2 to 3 weeks (potentially longer with corneal involvement).
Viral conjunctivitis is highly contagious (usually for 10 to 12 days from onset) as long as the eyes are red (when not on steroids) or have active discharge/tearing. Patients should avoid touching their eyes, shaking hands, sharing towels or pillows, etc. Restrict work and school for patients with significant exposure to others while the eyes are red and weeping.
Frequent handwashing.
Preservative-free artificial tears or tear ointment four to eight times per day for 1 to 3 weeks. Advise single-use vials to limit tip contamination and spread of the condition.
Cool compresses several times per day.
Antihistamine drops (e.g., epinastine 0.05% b.i.d.) if itching is severe.
If a membrane/pseudomembrane is present, it should be gently peeled with a cotton-tip applicator or smooth forceps to enhance comfort, minimize corneal defects, and help prevent symblepharon formation.
If a membrane/pseudomembrane is present or if SEIs reduce vision and/or cause significant photophobia, topical steroids should be initiated. For membranes/pseudomembranes, use a more frequent steroid dose or stronger steroid (e.g., loteprednol 0.5% or prednisolone acetate 1% q.i.d.). Consider a steroid ointment (e.g., fluorometholone 0.1% ointment q.i.d. or dexamethasone/tobramycin 0.1%/0.3% ointment q.i.d.) in the presence of significant tearing to maintain longer medication exposure. For SEIs alone, a weaker steroid with less frequent dosing is usually sufficient (e.g., loteprednol 0.2% or 0.5% b.i.d.). Given the possible side effects, prescription of topical steroids is cautionary in the emergency room setting or in patients with questionable follow-up. Steroids may hasten the resolution of the symptoms but prolong the infectious period. Additionally, steroids often necessitate a long-term taper and delayed SEIs can recur during or after such a taper.
Note
Routine use of topical antibiotics for viral conjunctivitis is discouraged unless corneal erosions are present or there is mucopurulent discharge suggestive of bacterial conjunctivitis (see Bacterial Conjunctivitis).
Follow-Up
In 2 to 3 weeks, but sooner if the condition worsens significantly or if topical steroids are prescribed.
Allergic Conjunctivitis
Treatment
Eliminate the inciting agent. Frequent washing of hair and clothes may be helpful.
Cool compresses several times per day.
Topical drops, depending on the severity.
Mild: Artificial tears four to eight times per day.
Moderate: Use antihistamine and/or mast-cell stabilizer drops. Convenient medications with daily dosing include olopatadine 0.2% or 0.7% and alcaftadine 0.25% drops. Common medications with b.i.d. dosing include olopatadine 0.1%, epinastine 0.05%, nedocromil 2%, bepotastine 1.5%, or ketotifen 0.025% (over-the-counter) drops. Pemirolast 0.1% and lodoxamide 0.1% drops can also reduce symptoms but are recommended at q.i.d. dosing.
Note
An ophthalmic nonsteroidal anti-inflammatory drug (NSAID) such as ketorolac 0.5% q.i.d. can also be effective in reducing ocular inflammation, but its use should be monitored given the known risk of corneal toxicity with chronic instillation.
Severe: Mild topical steroid (e.g., loteprednol 0.2% or fluorometholone 0.1% q.i.d. for 1 to 2 weeks) in addition to the preceding medications.
Oral antihistamine (e.g., diphenhydramine 25 mg p.o. t.i.d. to q.i.d. or loratadine 10 mg p.o. daily) in moderate-to-severe cases can be very helpful.
Note
Routine use of topical antibiotics or steroids for allergic conjunctivitis is discouraged.
Follow-Up
Two weeks. If topical steroids are used, tapering is required and patients should be monitored for side effects.
Vernal/ Atopic Conjunctivitis
**trantas dots, cobblestone papillae
Treatment
Treat as for allergic conjunctivitis except ensure prophylactic use of a mast-cell stabilizer or combination antihistamine/mast-cell stabilizer (e.g., olopatadine 0.2% or 0.7% daily, alcaftadine 0.25% daily, olopatadine 0.1% b.i.d., ketotifen 0.1% b.i.d., lodoxamide 0.1% q.i.d., pemirolast 0.1% q.i.d.) for 2 to 3 weeks before the allergy season starts.
If a shield ulcer is present, add:
Topical steroid (e.g., loteprednol 0.5% or prednisolone acetate 1% drops, dexamethasone 0.1% ointment) four to six times per day.
Topical antibiotic drop (trimethoprim/polymyxin B q.i.d) or ointment (e.g., erythromycin q.i.d., bacitracin/polymyxin B q.i.d.).
Cycloplegic agent (e.g., cyclopentolate 1% t.i.d.).
Note
Shield ulcers may need to be scraped to remove superficial plaque-like material before reepithelialization will occur.
Cool compresses q.i.d.
Consider cyclosporine 0.05% to 2% b.i.d. to q.i.d. if not responding to the preceding treatment. Inform the patient that maximal effect of this drop is not seen for several weeks.
If associated with atopic dermatitis of eyelids, consider tacrolimus 0.03% to 0.1% ointment q.h.s. or b.i.d. (preferred), pimecrolimus 1% cream b.i.d., or topical steroid ophthalmic ointment (e.g., fluorometholone 0.1% q.i.d.) to the affected skin for 1 to 2 weeks.
Follow-Up
Every 1 to 3 days in the presence of a shield ulcer; otherwise, every few weeks. Topical medications are tapered slowly as improvement is noted. Anti-allergy drops are maintained for the duration of the season and are often reinitiated a few weeks before the next spring. Patients on topical steroids should be monitored regularly with attention to IOP, even if used only on the skin.
Bacterial Conjununctivitis (non-gonnoccocal)
Treatment
Use topical antibiotic therapy (e.g., trimethoprim/polymyxin B or fluoroquinolone drops or ointment q.i.d.) for 5 to 7 days.
H. influenzae conjunctivitis should be treated with oral amoxicillin/clavulanate (20 to 40 mg/kg/day in three divided doses) because of occasional extraocular involvement (e.g., otitis media, pneumonia, and meningitis).
If associated with dacryocystitis, systemic antibiotics are necessary. See 6.9, Dacryocystitis/Inflammation of the Lacrimal Sac.
Follow-Up
Every 2 to 3 days initially, then every 5 to 7 days when stable until resolved. Antibiotic therapy is adjusted according to culture and sensitivity results.
Gonnorheal Conjunctivitis
Treatment
Initiated if the Gram stain shows gram-negative intracellular diplococci or there is a high clinical suspicion of gonococcal conjunctivitis.
A dual treatment regimen of ceftriaxone 1 g intramuscularly (i.m.) PLUS azithromycin 1 g p.o. both in a single dose is recommended. If corneal involvement exists, or cannot be excluded because of chemosis and eyelid swelling, hospitalize the patient and treat with ceftriaxone 1 g intravenously (i.v.) every 12 to 24 hours in place of i.m. ceftriaxone. The duration of treatment may depend on the clinical response. Consider an infectious disease consultation in all cases of gonococcal conjunctivitis.
If ceftriaxone is not available or unable to be tolerated (e.g., cephalosporin-allergic patients), consider the following treatment regimens:
Gemifloxacin 320 mg p.o. in a single dose PLUS azithromycin 2 g p.o. in a single dose
Gentamicin 240 mg i.m. in a single dose PLUS azithromycin 2 g p.o. in a single dose”
Note
Not only are fluoroquinolones contraindicated in pregnant women and children, but due to increased resistance, they are no longer recommended monotherapy for treatment of gonoccocal infections.
Topical fluoroquinolone ointment q.i.d. or fluoroquinolone drop q2h. If the cornea is involved, use a fluoroquinolone drop q1h (e.g., gatifloxacin, moxifloxacin, besifloxacin, levofloxacin, or ciprofloxacin).
Saline irrigation q.i.d. until the discharge resolves.
Treat for possible chlamydial coinfection (e.g., azithromycin 1 g p.o. single dose or doxycycline 100 mg p.o. b.i.d. for 7 days).
Treat sexual partners with oral antibiotics for both gonorrhea and chlamydia as described.
Follow-Up
Daily until consistent improvement is noted and then every 2 to 3 days until the condition resolves. The patient and sexual partners should be evaluated by their medical doctors for other sexually transmitted diseases.
Pediculosis Conjunctivitis
Treatment
Mechanical removal of lice and eggs with jeweler’s forceps.
Any bland ophthalmic ointment (e.g., erythromycin) to the eyelids t.i.d. for 10 days to smother the lice and nits.
Anti-lice lotion and shampoo as directed to nonocular areas for patient and close contacts.
Thoroughly wash and dry all clothes, towels, and linens.
Chlamydial Inclusion Conjunctivitis
Treatment
Azithromycin 1 g p.o. single dose, doxycycline 100 mg p.o. b.i.d., or erythromycin 500 mg p.o. q.i.d. for 7 days is given to the patient and his or her sexual partners.
Topical erythromycin or tetracycline ointment b.i.d. to t.i.d. for 2 to 3 weeks.
Follow-Up
In 2 to 3 weeks, depending on the severity. The patient and sexual partners should be evaluated by their medical doctors for other sexually transmitted diseases. Occasionally a 6-week course of doxycycline may be required.
Trachoma
Treatment
Azithromycin 20 mg/kg p.o. single dose, doxycycline 100 mg p.o. b.i.d., or erythromycin 500 mg p.o. q.i.d. for 2 weeks.
Tetracycline, erythromycin, or sulfacetamide ointment b.i.d. to q.i.d. for 3 to 4 weeks.
Note
Tetracycline derivatives are contraindicated in children younger than 8 years, pregnant women, and nursing mothers.
Follow-Up
Every 2 to 3 weeks initially, then as needed. Although treatment is usually curative, reinfection is common if hygienic conditions do not improve.
Tetracycline contraindications
Children <8yo, pregnant women or nursing
