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
Molluscum contagiosum
Treatment
When associated with chronic conjunctivitis, lesions should be removed by simple excision, incision and curettage, or cryosurgery.
Follow-Up
Every 2 to 4 weeks until the conjunctivitis resolves, which often takes 4 to 6 weeks. If many lesions are present, consider human immunodeficiency virus (HIV) testing.
Perinaud’s Oculoglandular Conjunctivitis
Treatment
Warm compresses for tender lymph nodes.
Antipyretics as needed.
Disease specific:
Cat-scratch disease: Generally resolves spontaneously in 6 weeks. Consider azithromycin 500 mg p.o. q.i.d., then 250 mg daily for four doses (for children, 10 mg/kg q.i.d., then 5 mg/kg daily for four doses); alternatives include trimethoprim/sulfamethoxazole (160/800 mg b.i.d.) or ciprofloxacin 500 mg p.o. b.i.d. Duration should be individualized. Use a topical antibiotic (e.g., bacitracin/polymyxin B ointment or gentamicin drops q.i.d.). The cat does not need to be removed.
Tularemia: Recommended therapy is gentamicin 5 mg/kg once daily i.m. or i.v. for 10 days. For mild illness, alternative therapies include ciprofloxacin 500 mg p.o. b.i.d. for 10 to14 days or doxycycline 100 mg p.o. b.i.d. for 14 to 21 days. Systemic medication should coincide with gentamicin 0.3% drops q2h for 1 week, and then five times per day until resolved. Often patients are systemically ill and under the care of a medical internist for tularemia; if not, refer to a medical internist for systemic management.
Tuberculosis: Refer to an internist for antituberculosis medication.
Syphilis: Systemic penicillin (dose depends on the stage of the syphilis) and topical tetracycline ointment
Follow-Up
Repeat the ocular examination in 1 to 2 weeks. Conjunctival granulomas and lymphadenopathy can take 4 to 6 weeks to resolve for cat-scratch disease
Wellbutrin side effect
anti-depressant
ADE: suicidal thoughts
TB Meds and ADEs
RIPE
Rifampin: pink/orange tears, hepatotoxic
Isoniazid: optic neuritis, hepatotoxic
Ethambutl: optic neuritis RETRObubar
Corneal thickness for surgeries
CXL: 400 microns (after epi removal to protect endo)
LASIK: 250 microns (remaining
Superior Limbic Keratoconjunctivitis
**asociated with thyroid
Treatment
Mild
Aggressive lubrication with preservative-free artificial tears four to eight times per day and artificial tear ointment q.h.s.
Consider punctal occlusion with plugs or cautery because of association with dry eyes.
Treat any concurrent blepharitis.
Consider treatment with cyclosporine 0.05% b.i.d. if not responding to lubrication.
In the absence of dry eyes, a therapeutic bandage disposable soft contact lens can be placed to help relieve symptoms and facilitate healing.
Moderate to Severe (in Addition to Preceding)
Autologous serum drops may be tried with intermittent dosing throughout the day.
Consider treatment with topical tacrolimus 0.03% ointment b.i.d. if no improvement with aggressive lubrication.
If significant amount of mucus or filaments are present, add acetylcysteine 10% drops three to six times per day. Low potency topical steroids like loteprednol, rimexolone, or fluorometholone can be used for short courses to treat exacerbations.
Application of silver nitrate 0.5% solution on a cotton-tipped applicator for 10 to 20 seconds to the superior tarsal and superior bulbar conjunctiva after topical anesthesia (e.g., proparacaine). This is followed by irrigation with saline and use of antibiotic ointment (e.g., erythromycin) q.h.s. for 1 week.
Note
Do not use silver nitrate (75% to 95%) cautery sticks, which cause severe ocular burns.
A low dose of doxycycline can be a helpful adjuvant to counteract matrix metalloproteinase upregulation caused by superior limbic keratoconjunctivitis.
Botulinum toxin can be injected into the muscle of Riolan for temporary relief of symptoms.
Surgical considerations include conjunctival cautery, cryotherapy, conjunctival resection (with or without amniotic membrane graft), recession of the superior bulbar conjunctiva, or high-frequency radiowave electrosurgery.
Follow-Up
Every 2 to 4 weeks during an exacerbation. If signs and symptoms persist despite multiple medical treatment strategies, surgical options should be considered.
Episcleritis
**Instill 2.5% phenyl and check in 10-15 for conj vessel blanching
Treatment
If mild, treat with artificial tears q.i.d.
If moderate to severe, a topical NSAID (e.g., diclofenac 0.1% q.i.d.) or a mild topical steroid (e.g., fluorometholone 0.1% or loteprednol 0.5% q.i.d.) often relieves the discomfort. Occasionally, more potent or frequent topical steroid application is necessary.
Oral NSAIDs may be used as an alternate steroid-sparing initial therapy and should be given with food or antacids (e.g., ibuprofen 200 to 600 mg p.o. t.i.d. to q.i.d., naproxen 250 to 500 mg p.o. b.i.d., or flurbiprofen 50 to 100 mg p.o. b.i.d. to t.i.d.) for at least 10 to 14 days.
Note
Many physicians prefer oral NSAIDs to topical NSAIDs or steroids as initial therapy.
Follow-Up
Patients treated with artificial tears need not be seen for several weeks unless discomfort worsens or persists. If topical steroids are used, recheck every 2 to 3 weeks until symptoms resolve. The frequency of steroid administration is then tapered. Episcleritis may recur in the same or contralateral eye.
Scleritis
** blue hue, boring pain wake sup at night
Classification
1. Diffuse anterior scleritis: Widespread inflammation of the anterior segment.
2. Nodular anterior scleritis: Immovable inflamed nodule(s)
3. Necrotizing scleritis with inflammation: thin, bluish sclera. Extreme pain. The sclera becomes transparent (choroidal pigment visible) because of necrosis. High association with systemic inflammatory diseases.
4. Necrotizing anterior scleritis without inflammation (scleromalacia perforans): Typically asymptomatic. Seen most often in older women with long-standing rheumatoid arthritis.
5. Posterior scleritis: May start posteriorly, or rarely be an extension of anterior scleritis, or simulate an amelanotic choroidal mass. Associated with exudative retinal detachment, disc swelling, retinal hemorrhage, choroidal folds, choroidal detachment, restricted motility, proptosis, pain, tenderness.
Treatment
Diffuse and nodular scleritis: One or more of the following may be required. Concurrent antiulcer medication (e.g., proton-pump inhibitor [e.g., omeprazole 20 mg p.o. daily] or histamine type 2 receptor blocker [e.g., ranitidine 150 mg p.o. b.i.d.]) may be helpful.
Oral NSAIDs (e.g., flurbiprofen 100 mg t.i.d., naproxen 250 to 500 mg p.o. b.i.d., or indomethacin 25 to 50 mg p.o. t.i.d.): Several different NSAIDs may be tried before therapy is considered a failure. If still no improvement, consider systemic steroids.
Oral steroids: Prednisone 60 to 80 mg p.o. daily for 1 week, followed by a taper to 20 mg daily over the next 2 to 6 weeks, followed by a slower taper. Once daily calcium with Vitamin D (e.g., 600 mg with 400 iU) supplements should be given to reduce risk of osteoporosis. An oral NSAID often facilitates the tapering of the steroid but significantly increases the risk of gastric ulceration. If unsuccessful or disease requires >7.5 to 10 mg prednisone/day for long-term control, immunosuppressive therapy is indicated.
Intravenous steroids: Methylprednisolone succinate 1,000 mg daily for 3 days (followed by oral steroids as above) is preferable to prednisone >80 mg/day because of reduced risk of ischemic necrosis of bone.
Immunosuppressive therapy (e.g., cyclophosphamide, methotrexate, cyclosporine, azathioprine, mycophenolate mofetil, anti-TNFα agents, other biologics): If one drug is ineffective or not tolerated, additional agents should be tried. Systemic steroids may be used in conjunction. Immunosuppressive therapy should be coordinated with an internist, rheumatologist, or uveitis specialist. Topical cyclosporine is rarely effective.
Conventional teaching is that topical therapy is of little benefit. However, difluprednate 0.05% drops are sometimes helpful (with or without a topical NSAID) and thus, in mild cases, may spare the need for systemic immunosuppressive agents.
Subconjunctival steroid injections (e.g., 0.1 to 0.3 mL of triamcinolone acetonide 40 mg/mL or dexamethasone sodium phosphate 4 mg/mL): May be very helpful in patients unable to tolerate systemic therapy. Side effects may include subconjunctival hemorrhage, cataract, glaucoma, and (rarely) catastrophic scleral melting. Do not use in cases of necrotizing scleritis.
Necrotizing scleritis: Necrotizing scleritis associated with rheumatoid arthritis is associated with increased mortality due to coronary arteritis or cerebral angiitis and requires urgent, aggressive immunosuppressive therapy.
Systemic steroids and immunosuppressive therapies are used as above during the first month; the former is tapered slowly.
Scleral patch grafting may be necessary if there is significant risk of perforation, ideally once the inflammation is better controlled.
Posterior scleritis: Therapy may include systemic aspirin, NSAIDs, steroids, or immunosuppressive therapy as described previously. Consult a retina or uveitis specialist.
Infectious etiologies: Debridement and cultures/stains are essential. Treat with appropriate topical and systemic antimicrobials. Oral fluoroquinolones have good ocular tissue penetration. If a foreign body (e.g., scleral buckle [associated with Proteus or Pseudomonas]) is present, surgical removal is indicated.
Glasses or eye shield should be worn at all times if there is significant thinning and risk of perforation.
Note
Remember that periocular steroids are contraindicated in necrotizing scleritis where they can lead to further scleral thinning and possible perforation.
Follow-Up
Depends on the severity of the symptoms and the degree of scleral thinning. Decreased pain is the first sign of response to treatment, even if inflammation appears unchanged.
Blepharitis
Treatment
Scrub the eyelid margins twice a day with a commercial eyelid scrub or mild shampoo on a washcloth.
Warm compresses for 5 to 10 minutes b.i.d. to q.i.d.
If associated with dry eyes, use preservative-free artificial tears four to eight times per day.
If moderately severe, add erythromycin ointment or azithromycin gel-drop to the eyelids q.h.s.
Consider omega-3 fatty acid oral supplementation as well as cyclosporine 0.05% drops b.i.d.
Unresponsive meibomitis can be treated with topical ophthalmic antibiotic/steroid ointments (e.g., tobramycin 0.3%/dexamethasone 0.1% b.i.d. to t.i.d.). Also consider an oral agent such as doxycycline 100 mg p.o. daily for 1 to 2 weeks; slowly taper to one-fourth full dose and maintain for 3 to 6 months. Oral azithromycin 500 mg/day × 3 days for 3 cycles with 7-day intervals may also be used.
If demodex mite infestation is suspected, due to presence of collarettes, and patients have failed the above regimen, consider tea-tree oil eyelid scrubs or an eyelid cleansing agent with hypochlorous acid for a minimum of 6 weeks.
If little improvement has been made, consider LipiFlow, pulsed light laser therapy, microblepharoexfoliation, and probing of meibomian glands.
Note
Tetracycline derivatives such as doxycycline should not be used in pregnant women, nursing mothers, or children ≤ 8 years. Erythromycin 200 mg p.o. b.i.d. is an alternative in these cases.
Follow-Up
Two to 4 weeks depending on severity of presenting symptoms. Eyelid scrubs and warm compresses may be reduced to once daily as the condition improves but may need to be maintained indefinitely.
Ocular Rosacea
Treatment
Warm compresses and eyelid hygiene for blepharitis or meibomitis. Treat dry eyes if present .
Avoidance of exacerbating foods, beverages, and environmental factors.
Doxycycline 100 mg p.o. b.i.d. for 1 to 2 weeks then daily; taper the dose slowly once relief from symptoms is obtained. Some patients are maintained on low-dose doxycycline (e.g., 20 to 100 mg p.o. daily or less than daily) indefinitely if active disease recurs when the patient is off medication. Erythromycin 250 mg q.i.d. or oral azithromycin 500 mg/day × 3 days for 3 cycles with 7-day intervals is an alternative if doxycycline is contraindicated.
Note
Tetracycline derivatives such as doxycycline should not be given to pregnant women, nursing women, or children ≤8 years. Patients should be warned of increased sunburn susceptibility with use of this medication.
Note
Asymptomatic ocular rosacea without progressively worsening eye disease does not require oral antibiotics.
Consider oral omega-3 fatty acid supplements, cyclosporine 0.05% drops b.i.d., and topical steroids for chronic rosacea-related ocular and eyelid inflammation
Facial lesions can be treated with metronidazole gel (0.75%) application b.i.d.
Treat chalazia as needed
Corneal perforations may be treated with cyanoacrylate tissue adhesive if small (<3 mm), whereas larger perforations may require surgical correction. Doxycycline is indicated if there is concern for corneal thinning due to its anti-collagenase properties.
If infiltrates stain with fluorescein, an infectious corneal ulcer may be present. Smears, cultures, and antibiotic treatment may be necessary.
Follow-Up
Variable; depends on the severity of disease. Patients without corneal involvement are seen weeks to months later. Those with corneal involvement are examined more often. Patients with moderate-to-severe facial disease should also seek dermatologic consultation.
Tetracyclines
30s subunit - AT 30
- Doxycycline
- Minocycline
- teeth discoloration so cant use in pregnant, nursing or children
- need to take (not doxy) on empty stomach
- CATS - pseudotumor cerebri
Aminoglycosides
30s subunit - AT 30
- tobramycin
- gentamycin
TobraGent30
**SPK
Macrolides
50s subunit - CEL 50
- erythromycin
- azithromycin
- clarithromycin
- *Azithro - taken on empty stomach - PAT
- *Azithro - good for pregnant women - PAC
Conj condition w/ associated tumors
CIN –> SCC
- actinic keratosis —> SCC on lid
PAM –> melanoma 10-30%
Nevus –> melanoma
Nevus of Ota –> uveal melanoma (and glaucoma)
unilateral blepharoconunctivitis –> sebaceous carcinoma
Hordeolum/ Chalzion
Treatment
Warm compresses for 10 minutes q.i.d. with light massage over the lesion.
Consider a short course of topical antibiotic if lesion is draining or for associated blepharitis (e.g., bacitracin or erythromycin ointment b.i.d. for 1 to 2 weeks). Consider systemic therapy with doxycycline 100 mg p.o. daily to b.i.d. for its antibacterial and anti-inflammatory properties (e.g., multiple hordeola, ocular rosacea).
If a hordeolum worsens, consider incision and drainage and management as per preseptal cellulitis (see 6.10, Preseptal Cellulitis).
If the chalazion fails to resolve after 3 to 4 weeks of appropriate medical therapy and the patient wishes to have it removed, incision and curettage are performed. Occasionally, an injection of steroid (e.g., 0.2 to 1.0 mL of triamcinolone 40 mg/mL usually mixed 1:1 with 2% lidocaine with epinephrine) into the lesion is performed instead of minor surgery, especially if the chalazion is near the lacrimal apparatus. The total dosage depends on the size of the lesion. All recurrent or atypical chalazia must be sent for pathology.
Note
A steroid injection can lead to permanent depigmentation or atrophy of the skin at the injection site, especially in dark-skinned individuals. Similarly, vigorous injection can rarely result in retrograde intra-arterial infiltration with resultant central retinal artery occlusion. Because of these risks, some manufacturers of injectable steroids (e.g., triamcinolone, dexamethasone, and betamethasone) have historically recommended against their use intraocularly and in the periocular region. Off label use of the medications should include a detailed discussion between physician and patient.
Follow-Up
Patients are not routinely seen after instituting medical therapy unless the lesion persists beyond 3 to 4 weeks. Patients who have a procedure such as incision and curettage are usually reexamined in 1 week or PRN
Canaliculitis
Treatment
Remove obstructing concretions or retained plug. Concretions may be expressed through the punctum at the slit lamp. A canaliculotomy is usually required for complete removal or in the setting of a retained punctual plug. If necessary, marsupialize the horizontal canaliculus from a conjunctival approach and allow incision to heal by secondary intention.
If concretions are removed, consider irrigating the canaliculus with an antibiotic solution (e.g., trimethoprim sulfate/polymyxin B, moxifloxacin, penicillin G solution 100,000 units/mL, iodine 1% solution). The patient is irrigated while in the upright position, so the solution drains out of the nose and not into the nasopharynx.
Treat the patient with antibiotic drops (e.g., trimethoprim sulfate/polymyxin B or moxifloxacin) q.i.d. and oral antibiotics for 1 to 2 weeks (e.g., doxycycline 100 mg b.i.d.).
If a fungus is found on smears and cultures, nystatin 1:20,000 drops t.i.d. and nystatin 1:20,000 solution irrigation several times per week may be effective. If evidence of herpes virus is found on smears, treat with trifluridine 1% drops five times per day. Silicone intubation along with appropriate antiviral therapy is sometimes required in viral canaliculitis.
Apply warm compresses to the punctal area q.i.d.
Follow-Up
Five to 7 days depending on severity. This is usually not an urgent condition.
Dacryocystitis
Treatment
Systemic antibiotics in the following regimen: Children older than 5 years and <40 kg:
Afebrile, systemically well, mild case, and reliable parent: Amoxicillin/clavulanate: 25 to 45 mg/kg/day p.o. in two divided doses for children, maximum daily dose of 90 mg/kg/day.
Alternative treatment: Cefpodoxime: 10 mg/kg/day p.o. in two divided doses for children, maximum daily dose of 400 mg.
Febrile, acutely ill, moderate-to-severe case, or unreliable parent: Hospitalize and treat with cefuroxime, 50 to 100 mg/kg/day intravenously (i.v.) in three divided doses in consultation with infectious disease specialist.
Adults:
Afebrile, systemically well, mild case, and reliable patient: Cephalexin 500 mg p.o. q6h.
Alternative treatment: Amoxicillin/clavulanate 500/125 mg t.i.d. or 875/125 mg p.o. b.i.d.
Febrile, acutely ill, or unreliable: Hospitalize and treat with cefazolin 1 g i.v. q8h. See 7.3.1, Orbital Cellulitis.
The antibiotic regimen is adjusted according to the clinical response and the culture/sensitivity results. The i.v. antibiotics can be changed to comparable p.o. antibiotics depending on the rate of improvement, but systemic antibiotic therapy should be continued for at least a full 10- to 14-day course.
Topical antibiotic drops (e.g., trimethoprim/polymyxin B q.i.d.) may be used in addition to systemic therapy. Topical therapy alone is not adequate.
Apply warm compresses and gentle massage to the inner canthal region q.i.d.
Administer pain medication (e.g., acetaminophen with or without codeine) p.r.n.
Consider incision and drainage of a pointing abscess.
Consider surgical correction (e.g., dacryocystorhinostomy with silicone intubation) only after the acute episode has resolved, particularly with chronic dacryocystitis.
Follow-Up
Daily until improvement confirmed. If the condition of an outpatient worsens, hospitalization and i.v. antibiotics are recommended.
Preseptal Cellulitis
Treatment
Antibiotic therapy
Mild preseptal cellulitis, older than 5 years (<40 kg), afebrile, reliable patient/parent:
Amoxicillin/clavulanate: 25 to 45 mg/kg/day p.o. in two divided doses for children, maximum daily dose of 90 mg/kg/day; 875/125 mg p.o. q12h for adults.
or
Cefpodoxime: 10 mg/kg/day p.o. in two divided doses for children, maximum daily dose of 400 mg; 200 mg p.o. q12h for adults.
or
Cefdinir: 14 mg/mg/day p.o. in two divided doses for children with maximum daily dose of 600 mg; 600 mg p.o. once daily for adults.
If the patient is allergic to penicillin, then
Trimethoprim/sulfamethoxazole: 8 to 12 mg/kg/day trimethoprim with 40 to 60 mg/kg/day sulfamethoxazole p.o. in two divided doses for children; 160 to 320 mg trimethoprim with 800 to 1,600 mg sulfamethoxazole (one to two double-strength tablets) p.o. b.i.d. for adults.
or
Moxifloxacin 400 mg p.o. daily (contraindicated in children).
If exposure to methicillin-resistant Staphylococcus aureus (MRSA) is suspected, then
Trimethoprim/sulfamethoxazole: 8 to 12 mg/kg/day trimethoprim with 40 to 60 mg/kg/day sulfamethoxazole p.o. in two divided doses for children; one to two tablets double strength trimethoprim-sulfamethoxazole 160/800 mg p.o. q12h for adults.
or
Doxycycline: 100 mg p.o. b.i.d (contraindicated in children, pregnant women, and nursing mothers).
or
Clindamycin: 10 to 30 mg/kg/day p.o. in three to four divided doses for children; 450 mg p.o. t.i.d. for adults. In addition to covering MRSA, this antibiotic also gives good coverage for streptococci and methicillin-sensitive S. aureus.
or
Linezolid: 20 to 30 mg/kg/day p.o. in two to three divided doses for children; 400 to 600 mg p.o. b.i.d. for adults. In addition to covering MRSA, this antibiotic also gives good coverage for streptococci. Limit use of this medication without infectious disease consultation so as to prevent resistance, and caution long-term therapy which can cause hematologic toxicity (e.g., thrombocytopenia, anemia).
Note
Patients with the following risk factors should be covered for MRSA: history of MRSA infection or colonization, recurrent skin infections, contact with someone known to have MRSA, admission to a healthcare or long-term care facility within the past year, placement of a permanent indwelling catheter, on hemodialysis, i.v. drug use, incarceration within the last 12 months, participation in sports that include skin-to-skin contact or sharing of equipment and clothing, poor personal hygiene.
Note
Oral antibiotics are maintained for 10 to 14 days.
Moderate-to-severe preseptal cellulitis, or any one of the following:
Patient appears toxic.
Patient may be noncompliant with outpatient treatment and follow-up.
Child 5 years or younger.
No noticeable improvement or worsening after 24 to 48 hours of oral antibiotics.
Admit to the hospital for i.v. antibiotics as follows:
Vancomycin: 10 to 15 mg/kg i.v. every 6 hours in children; 0.5 to 1 g i.v. q12h for adults. (Dose adjustment is needed in cases of impaired renal function.)
Plus one of the following:
Ampicillin/sulbactam: 300 mg/kg/day i.v. in four divided doses for children; 3.0 g i.v. q6h for adults.
Piperacillin–tazobactam: 240 mg/kg/day i.v. in three divided doses for children; 4.5 g i.v. q6h adults.
Ceftriaxone: 80 to 100 mg/kg/day i.v. in two divided doses for children with maximum of 4 g/day; 2 g i.v. q12h for adults.
Cefepime: 50 mg/kg q12h (max 2 g/dose) in children; 1 to 2 g i.v. q12h in adults.
Ceftazidime: 90 to 150 mg/kg/day i.v. in three divided doses for children; 1 g i.v. q8–12h in adults.
If the patient is allergic to penicillin, see 7.3.1, Orbital Cellulitis, for alternatives.
Note
Intravenous antibiotics can be changed to comparable oral antibiotics after significant improvement is observed. Systemic antibiotics are maintained for a complete 10- to 14-day course. See 7.3.1, Orbital Cellulitis, for alternative treatment. In complicated cases or patients with multiple allergies, consider consultation with infectious disease specialist for antibiotic management.
Warm compresses to the inflamed area t.i.d. p.r.n.
Polymyxin B/bacitracin ointment to the eye q.i.d. if secondary conjunctivitis is present.
Tetanus toxoid if needed. See Appendix 2, Tetanus Prophylaxis.
Nasal decongestants if sinusitis is present.
Orbital exploration and debridement is warranted if a fluctuant mass or abscess is present, or if a retained foreign body is suspected. Obtain Gram stain and culture of any drainage. Avoid the orbital septum if possible. A drain may need to be placed.
Consider an infectious disease consult in patients who have failed oral antibiotics and require i.v. treatment.
Follow-Up
Daily until clear and consistent improvement is demonstrated, then every 2 to 7 days until the condition has totally resolved. If a preseptal cellulitis progresses despite antibiotic therapy, the patient is admitted to the hospital and a repeat (or initial) orbital CT scan is obtained. For patients already on p.o. antibiotics, switch to i.v. antibiotics
Tumors of the Eyelid
Treatment
Basal cell carcinoma: Surgical excision with histologic evaluation of the tumor margins either by frozen sections or by Mohs techniques. The entire tumor should be excised with clean margins. Patients are informed about the etiologic role of the sun and are advised to avoid unnecessary sunlight exposure and to use protective sunscreens.
Sebaceous carcinoma: The approach is two-staged with stage 1 using map biopsies on the entire surface of the eye to ascertain the extent of Pagetoid spread or deep tumor. Stage 2 is performed after all biopsies are reviewed; Pagetoid spread is treated with cryotherapy whereas deep tumor requires excision. Reconstruction is then provided. Close follow-up of regional nodes is indicated. Exenteration is often required when orbital invasion is present. Referral to an oncologist or internist for systemic work-up and surveillance is important with attention to the lymph nodes, lungs, brain, liver, and bone.
Squamous cell carcinoma: Same as for basal cell carcinoma. Radiation therapy is the second best treatment after surgical excision. Patients are informed about the etiologic role of the sun. Referral to an oncologist or internist for regional and/or systemic work-up and surveillance is important.
Malignant melanoma: Treatment requires wide surgical excision. The margins must be free of tumor and require permanent sections. Sentinel lymph node biopsy may be required depending on the depth of the tumor. Referral to an oncologist or internist for regional and/or systemic work-up and surveillance is imperative.
Note
Because both melanoma and sebaceous carcinoma are difficult to diagnose by frozen section, multiple excisions utilizing permanent sectioning may be necessary until all surgical margins are free of tumor. The cornea and globe must be protected during this interim time with lubrication or temporary tarsorrhaphy.
Follow-Up
Initial follow-up is every 1 to 4 weeks to ensure proper healing of the surgical site. Patients are then reevaluated every 6 to 12 months, or more frequently, for more aggressive lesions. Patients who have had one skin malignancy are at greater risk for additional malignancies.
TED = Grave’s Disease
- *eyelid lag on downward gaze = von Graefe sign
- *IMSLO = order of muscle involvement (I = can’t elevate)
Treatment
Smoking cessation: All patients with TED who smoke must be explicitly told that continued tobacco use increases the risk of progression and the severity of the orbitopathy. This conversation should be clearly documented in the medical record.
Refer the patient to a medical internist or endocrinologist for management of systemic thyroid disease, if present. If TFTs are normal, the patient’s TFTs should be checked every 6 to 12 months. Not infrequently, a euthyroid patient with TED will have an elevated TSI.
Treat exposure keratopathy with artificial tears and lubrication or by taping eyelids closed at night. Goggles at night may be helpful. The use of topical cyclosporine drops for the treatment of ocular surface inflammation in TED is still under investigation, but is a reasonable long-term treatment option if dry eye syndrome is present.
Treat eyelid edema with cold compresses in the morning and head elevation at night. This management may not be very effective. Avoid diuretics.
Indications for orbital decompression surgery include: Optic neuropathy, worsening or severe exposure keratopathy despite adequate treatment, globe luxation, uncontrollably high IOP, morbid proptosis.
A stepwise approach is used for surgical treatment, starting with orbital decompression (if needed), followed by strabismus surgery (for significant strabismus, if present), followed by eyelid surgery. Alteration of this sequence may lead to unpredictable results. Note that only a minority of patients with TED will need to undergo the entire surgical algorithm.
The following recommendations are somewhat controversial:
Corticosteroids: During the acute inflammatory phase, prednisone 1 mg/kg p.o. daily, tapered over 4 to 6 weeks, is a reasonable temporizing measure to improve proptosis and diplopia in preparation for orbital decompression surgery. There is evidence that the use of pulsed intravenous corticosteroids followed by a course of oral corticosteroids may result in better long-term control of TED with fewer systemic side effects than oral corticosteroids and is a reasonable option to offer patients in the acute phase of TED; other experts questions the long-term efficacy of this regimen.
Selenium supplementation: Data from Europe has concluded that the use of selenium supplementation (an antioxidant) reduces the severity and progression of mild-to-moderate TED. It is reasonable to offer this therapy to women with mild-to-moderate, active TED at a dose of 100 μg p.o. b.i.d. Caution should be used in the use of selenium supplementation in men, especially with a family history of prostate cancer.
Visual loss from optic neuropathy: Treat immediately with prednisone 1 mg/kg/day with close monitoring. In cases of severe visual loss, admission for pulsed intravenous therapy may be indicated. Radiation therapy may be offered for mild-to-moderate optic neuropathy, with the understanding that there is typically a lag in the treatment effect. Posterior orbital decompression surgery (for mild-to-severe optic neuropathy), either medial or lateral, is essential and usually effective in rapidly reversing or stabilizing the optic neuropathy. Anterior orbital decompression is usually ineffective in treating TED optic neuropathy.
Follow-Up
Optic nerve compression requires immediate attention and close follow-up.
Patients with advanced exposure keratopathy and severe proptosis also require prompt attention and close follow-up.
Patients with minimal-to-no exposure problems and mild-to-moderate proptosis are reevaluated every 3 to 6 months. Because of the potential risk of optic neuropathy, patients with restrictive strabismus may be followed more frequently.
Patients with fluctuating diplopia or ptosis should be evaluated for myasthenia gravis
All patients with TED are instructed to return immediately with any new visual problems, worsening diplopia, or significant ocular irritation. All smokers with TED must be reminded to discontinue smoking at every office visit, and appropriate referral to their primary physician for a smoking cessation program is indicated.
Idiopathic Orbital Inflammatory Syndrome - Orbital pseudotumor
** painful, explosive onset, unilateral
Treatment
Prednisone 1 to 1.2 mg/kg/day as an initial dose in adults and children, along with gastric prophylaxis (e.g., ranitidine 150 mg p.o. b.i.d., omeprazole 40 mg p.o. daily). All patients are warned about potential systemic side effects and are instructed to follow up with their primary physicians to monitor blood sugar and electrolytes.
Low-dose radiation therapy may be used when the patient does not respond to systemic corticosteroids, when disease recurs as corticosteroids are tapered, or when corticosteroids pose a significant risk to the patient. Radiation therapy should only be used once orbital biopsy, if anatomically and medically feasible, has excluded other etiologies.
Steroid-sparing agents (e.g., methotrexate, cyclophosphamide, etc.) in cases that do not respond to or recur with corticosteroid therapy. Biopsy of affected tissue, when feasible, is indicated to rule out malignancy.
Biologic therapy may be considered in cases that fail other modalities. The efficacy of specific biologic agents (e.g., CD20 antibody, TNF antibody, etc.) in IOIS is not known.
Follow-Up
Reevaluate in 1 to 2 days. Patients who respond dramatically to corticosteroids are maintained at the initial dose for 3 to 5 days, followed by a slow taper to 40 mg/day over 2 weeks, and an even slower taper below 20 mg/day, usually over several weeks. If the patient does not respond dramatically to appropriate corticosteroid doses, biopsy should be strongly considered. Recurrences of IOIS are not uncommon, especially at lower corticosteroid doses.
Toxocariasis
**leukocoria
**nematode
**vitritis, vitreous traction
Treatment
Steroids (topical, periocular, or systemic routes may be used, depending on the severity of the inflammation).
Consider a surgical vitrectomy when vitreoretinal traction bands form or when the condition does not improve or worsens with medical therapy.
Consider laser photocoagulation of the nematode if it is visible.
Coat’s Disease
**leukocoria - from exudative RD
Treatment
Laser photocoagulation or cryotherapy to leaking vessels. Though associated with a poor outcome, surgery may be required for a retinal detachment. Consider anti-VEGF agents if significant exudate, subretinal or intraretinal fluid is present.
ROP
Treatment
Always based on severity and location. Therapeutic goal is ablation of immature, avascular zones of retina. Laser photocoagulation is preferred over cryotherapy. Treatment should be instituted within 48–72 hours. Use of intravitreal anti-VEGF agents is an emerging treatment modality, especially when photocoagulation is not available or in very posterior Zone 1 cases; however the long-term effects and potential risks of these medications in preterm infants have yet to be determined.
Type 1 ROP needs treatment.
- Defines high-risk eyes that meet the criteria for treatment:
Zone I (posterior pole), any stage with plus disease (2 quadrants of tortuous
vessels).
Zone I, stage 3 without plus disease.
Zone II (nasal periphery), stage 2 or 3 with plus disease.
Type 2 ROP should be followed closely.
- Defines less severely advanced eyes that should be monitored closely for
progression to Type 1 disease:
Zone I, stage 1 and 2 without plus disease.
Zone II, stage 3 without plus disease.
For stages 4 and 5: Surgical repair of retinal detachment by scleral buckling,
vitrectomy surgery, or both is recommended.
Follow-Up
A single ocular examination is sufficient only if it unequivocally shows full retinal vascularization in both eyes.
One week or less: immature vascularization, zone I, no ROP; immature retina localized to boundary of zone I and II; zone I, stage 1 or 2; zone II, stage 3; or any concern for aggressive posterior ROP.
One to 2 weeks: immature vascularization localized to posterior zone II; or zone II, stage 2; or zone I, regressing ROP.
Two weeks: immature vascularization localized to zone II, no ROP; zone II, stage 1; or zone II, regressing ROP.
Two to 3 weeks: zone III, stage 1 or 2; or zone III, regressing ROP.
Children who have had ROP have a higher incidence of myopia, strabismus, amblyopia, macular dragging, cataracts, glaucoma, and retinal detachment. An untreated fully vascularized fundus needs examination at age 6 months to rule out these complications.
Note
Because of the possibility of late retinal detachments and other ocular complications, ROP patients should be followed at yearly intervals for life.
Acute-phase ROP screening can be discontinued when any of the following signs is present, indicating that the risk of visual loss from ROP is minimal or passed:
- Zone III retinal vascularization attained without previous zone I or II ROP. If there is doubt about the zone or if the postmenstrual age is <35 weeks, confirmatory examinations may be warranted.
- Postmenstrual age of 50 weeks and no ROP disease equivalent to or worse than zone I, any stage or zone II, stage 3.
- Full retinal vascularization in close proximity to the ora serrata (for cases treated with anti-VEGF therapy).
If treated with anti-VEGF, follow-up should be extended due to risk of ROP recurring after 45 weeks.
Familial Exudative Vitreoretinopathy (FEVR)
**Peripheral retinal capillary nonperfusion, most prominently temporally, and may be present for 360 degrees. Macular dragging temporally.
**AD
Treatment
Laser of peripheral nonperfused retina is sometimes considered if there is documented progression. Small, stable tufts of neovascularization can be observed. Scleral buckling and vitrectomy can be considered for retinal detachments. Often complicated by proliferative vitreoretinopathy. Treat amblyopia as needed. Genetic testing for common mutations may be considered.
Follow-Up
Asymptomatic patients should be followed every 6 to 12 months throughout life to monitor for progression.
Esotropia
Treatment
In all cases, correct refractive errors of +2.00 diopters or more. In children, treat any underlying amblyopia (see 8.7, Amblyopia).
Congenital esotropia: Almost always requires strabismus surgery. However, prescribe glasses and initiate treatment of any underlying amblyopia prior to surgical intervention as appropriate.
Accommodative esotropia: Glasses must be worn full time.
If the patient is <6 years, correct the hyperopia with the full cycloplegic refraction.
If the patient is >6 years, attempts should be made to give as close to the full-plus refraction as possible, knowing that some may not tolerate the full prescription. Attempts to push plus lenses during the manifest (noncycloplegic) refraction until distance vision blurs may be tried to give the most plus lenses without blurring distance vision. The goal of refractive correction should be straight alignment without sacrificing visual acuity.
If the patient’s eyes are straight at distance with full correction, but still esotropic at near fixation (high AC/A ratio), treatment options include the following:
- Bifocals (flat-top or executive type) +2.50 or +3.00 diopter add, with top of the bifocal at the lower pupillary border.
- Extraocular muscle surgery targeting the near deviation only may be indicated. This typically requires posterior fixation sutures to the muscle to modify the surgical effect for near only.
- Wearing full-plus distance glasses only.
Nonaccommodative, partially accommodative, or decompensated accommodative esotropia: Muscle surgery is usually performed to correct the nonaccommodative deviation or the significant residual esotropia that remains when glasses are worn.
Sensory-deprivation esotropia:
- Attempt to identify and correct the cause of poor vision.
- Amblyopia treatment.
- Give the full cycloplegic correction (in fixing eye) if the patient is <6 years of age, otherwise give as much plus as tolerated during manifest refraction.
- Muscle surgery to correct the manifest esotropia.
- All patients with low vision in one eye need to wear protective polycarbonate lens glasses at all times.
Follow-Up
At each visit, evaluate for amblyopia and measure the degree of deviation with prisms (with glasses worn).
In the absence of amblyopia, the child is reevaluated in 3 to 6 weeks after a new prescription is given. If no changes are made and the eyes are straight, the patient should be followed several times a year when young, decreasing to annually when stable.
When a residual esotropia is present while the patient wears glasses, an attempt is made to add more plus power to the current prescription. Children <6 years should receive a new cycloplegic refraction; plus lenses are pushed without cycloplegia in older children. The maximal additional plus lens that does not blur distance vision is prescribed. If the eyes cannot be straightened with more plus power, then a decompensated accommodative esotropia has developed (see above in Section 8.4, Comitant OR Concomitant Esotropic Deviations).
Hyperopia often decreases slowly after age 5 to 7 years, and the strength of the glasses may need to be reduced so as not to blur distance vision. If the strength of the glasses must be reduced to improve visual acuity and the esotropia returns, then this is a decompensated accommodative esotropia.
Aplastic Anemia meds
Acetazolamide (diamox)
Methazolamide (Neptazane)
Chloramphenicol
Pseudotumor cerebri meds
CATS contraceptives accutane tetracyclines synthroid
Meds for MRSA tx
BCD - bacteria can’t decide
Bactrim
Clindamycin
Doxycyxline
Bone marrow suppression meds
TMP - treat marrow poorly
Trimethoprim
Methotrexate
Pyrimethamine
Cholinergic Agonists
Pilocarpine MG meds - Neostigmine - Pyridostigmine - Edrophonium Ecothiophate
Systemic
- Donepezil
Cholinergic Antagonist
ASH CiTy
- Atropine
- Scopolamine
- Homatropine
- Cyclopentolate
- Tropicamide
Systemic: - Antianxiety Diazepam - Antipsychotics Chlorpromazine Thioradazine - Antidepressants Amitryptiline Imipramine Phenelzine - Antihistamines Promethazine (phenergan) Bropheniramine Chlorpheniramine Dipheniramine
Adrenergic Agonist
Phenylephrine a2 agonists - Apraclonidine - Brimonidine Decongestant - Naohazoline - Tetrahydrozoline
Systemic: - Clonidine - Isoproterenol - Asthma Salmeterol Albuterol Levalbuterol Terbutaline Metaproterenol - Dopamine agonists Methylphenidate Dextroamphetamine Bromomcriptine Amantadine
Adrenergic Antagonist
B-blocker
- Timolol
- Carteolol
- Metipranolol
- Betaxolol
- Levobunolol
Systemic - BPH - a1 antagonists Tamsulosin Prazosin Terazosin - B antagonists Labetolol Propranolol - B1 antagonists Atenolol Metoprolol
Exotropia
Treatment
In all cases, correct significant refractive errors and treat amblyopia.
Exophoria:
- No treatment necessary unless it progresses to intermittent exotropia.
Intermittent exotropia: Phase 1 (XT at D no N): Follow patient closely. Phase 2 (XT at D some N): Muscle surgery may be considered to maintain normal binocular vision. Phase 3 (XT at D and N): Muscle surgery is often indicated at this point. Bifixation or peripheral fusion can occasionally be attained.
Sensory-deprivation exotropia:
- Correct the underlying cause, if possible.
- Treat any amblyopia.
- Muscle surgery may be performed for manifest exotropia.
- When one eye has very poor vision, protective glasses (polycarbonate lens glasses) should be worn at all times to protect the good eye.
Congenital exotropia:
- Muscle surgery early in life, as in patients with congenital esotropia.
Consecutive exotropia: (post surgery)
- Additional muscle surgery may be considered.
- Prism correction in glasses can be used.
- Over-minus or under-plus correction can stimulate accommodative convergence.
Dissociated horizontal deviation:
- Muscle surgery may be considered.
Convergence paralysis:
- Base-in prisms at near to alleviate diplopia.
- Plus lenses if accommodation is also weakened.
Follow-Up
If no amblyopia is present, then reexamine every 4 to 6 months. The parents and patient are asked to return sooner if the deviation increases, becomes more frequent, stays out longer, or if the patient begins to close one eye.
