OCULAR INFECTIONS

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Blepharitis

Common organisms:

Staphylococcus aureus

Staphylococcus epidermidis

Eyelid hygiene, warm compresses, massage and scrubs are the mainstay of therapy.

Topical antibiotics are not indicated as initial therapy

Fusidic acid 1% eye ointment applied q12h to the lid margin

OR

Oxytetracycline with Polymyxin B eye ointment applied q12h to lid margin

Chronic or severe blepharitis may need systemic therapy with oral Doxycycline 100mg PO q12h for 1 month then 100mg q24h for 2-3 months.

Meibomian Gland Dysfunction

Warm compresses and massage

Tetracycline 1% eye ointment applied q24h at lid margin with gentle massage

Systemic therapy is not indicated as an initial therapy

In resistant cases:

*Doxycycline 100mg PO q12h for 4-6 weeks

OR

Azithromycin 500mg PO q24h for 3 days

*Tetracyclines are contraindicated in children <8 years.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Internal Hordeolum with Secondary Infection

Staphylococcus aureus

Warm compresses Cloxacillin 500mg PO q6h

Amoxicillin-clavulanate 625mg PO q8h

Duration: 5 days

Systemic antibiotics are indicated in the presence of superficial cellulitis or abscess.

External Hordeolum (Stye) Staphylococcus aureus

Cloxacillin 500mg PO q6h

Amoxicillin-clavulanate 625mg PO q8h

Duration: 5 days

Epilation of affected eye lash and warm compresses

Antibiotics - In the presence of superficial cellulitis or abscess.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Bacterial Conjunctivitis

Common organisms:

Staphylococcus aureus

Streptococcus pneumoniae

Haemophilus influenzae

Chloramphenicol 0.5% eye drop q6h

Moxifloxacin 0.5% eye drop q6h

OR

Ciprofloxacin 0.3% eye drop q6h

OR

Levofloxacin 0.5% eye drop q6h

OR

Ofloxacin 0.3% eye drop q6h

Chloramphenicol or Ciprofloxacin ointment can be applied at bedtime.

Gonococcal Conjunctivitis (including neonates)

Neisseria gonorrhoeae

Ceftriaxone 50mg/kg IM single dose to a maximum of 125mg for neonates Ceftriaxone 1g stat IM for adults

Copious irrigation with topical saline drops or artificial tears every 30-60 minutes.

Topical antibiotics may be considered as ancillary therapy.

Chlamydial Conjunctivitis (including neonates)

Chlamydia trachomatis

Erythromycin 50mg/kg / day q6h for 2 weeks for neonates

Doxycycline 100mg PO q12h for 7 days

For pregnant Azithromycin 1g stat

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Bacterial Keratitis

Ciprofloxacin 0.3% eye drop q1-2h

OR

Moxifloxacin 0.5% eye drop q1-2h

OR

Levofloxacin 0.5% eye drop q1-2h

*Gentamicin 0.9% or 1.4% eye drop q1-2h

PLUS

*Cefuroxime 5% eye drop q1-2h

*Prepared extemporaneously using injectable forms

Contact Lens Related Bacterial Keratitis

Ciprofloxacin 0.3% eye drop q1-2h

OR

Levofloxacin 0.5% eye drop q1-2h

*Gentamicin 0.9% or 1.4% eye drop q1-2h

PLUS

*Ceftazidime 5% eye drop q1-2h

Bacterial Keratitis Gram-positive cocci

Moxifloxacin 0.5% eye drop q6h

*Cefuroxime 5% eye drop q1-2h

For MRSA:

*Vancomycin 5% eye drop q1-2h

Bacterial Keratitis Gram-negative rods

Ciprofloxacin 0.3% eye drop q1-2h

OR

Levofloxacin 0.5% eye drop q1-2h

*Gentamicin 0.9% or 1.4% eye drop q1-2h

PLUS

*Ceftazidime 5% eye drop q1-2h

Acanthamoeba Keratitis Acanthamoeba spp.

*Chlorhexidine 0.02% eye drop q1-2h

PLUS

Propamidine isethionate 0.1% eye drop q1-2h

Fungal Keratitis

Natamycin 5% eye drop q1-2

OR

*Amphotericin B 0.15%- 0.2% eye drop q1-2h

*Voriconazole 1% eye

drop q1-2h

OR

*Fluconazole 0.2% eye drop q1-2h

Natamycin is the choice therapy for fusariam. Amphotericin B is the choice therapy for candida

In severe fungal keratitis – combination therapy may be used.

*Prepared extemporaneously using injectable forms.

Oral Therapy: May be considered in the absence of contraindications: Fluconozole 200mg PO q24h

OR

Ketoconazole 200mg PO q24h

Herepes Simplex Keratitis

Herpes Simplex Type 1 and 2

Acyclovir 3% eye ointment 5 times/day

In presence of stromal or endothelial disease: Acyclovir 400mg PO 5times/day for 7-14 days

Prophylaxis for recurrent cases:

Acyclovir 400mg PO q12h for 12 months.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Herpes zoster Virus

Immunocompetent Acyclovir 800mg PO 5 times a day for 7days

Immunocompromised or sight threatening

Acyclovir 10mg/kg IV q8h for 7 days (switch to oral once there is improvement)

Systemic antiviral treatment for all immunocompromised patients or for immunocompetent patient with Age > 50y

Moderate or severe pain/ rash.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Toxoplasma gondii

Trimethoprim-sulfamethoxazole 160/800mg PO q12h for at least 6 weeks

Pyrimethamine 25-50mg PO q24H

PLUS

*Folinic acid 10-25mg PO q24H

PLUS

Sulfadiazine 1gm PO q6H

OR

Clindamycin 300mg PO q6h for 3-4 weeks, then 150mg q6h PO for 3-4 weeks

OR

Azithromycin 500mg PO q24h

Pregnancy: May consider intravitreal Clindamycin 1.0mg/0.1ml.

Systemic steroids are usually indicated in immunocompetent patients. It is advisable to start glucocorticoids 2-3 days after antimicrobial therapy.

*DO NOT replace folinic acid with folic acid.

Prophylaxis for recurrent lesions:

Trimethoprim-sulfamethoxazole  80/400mg q12h PO for 3 times a week for 3-6 months

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Herpes simplex

Acyclovir 10mg/kg/dose IV q8h (max. 800mg) for 10-14 days

Followed by

Acyclovir 800mg PO 5 times/day for 6 weeks

Valacyclovir 1gm PO q8h for 6 weeks

Systemic steroid is indicated depending on location or severity of the infection.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Cytomegalovirus

Systemic therapy: Ganciclovir 5mg/kg IV q12h for 2-3 weeks

Systemic therapy:

Valganciclovir: 900mg PO q12h for 3 weeks (induction) followed by 900mg PO q24h (maintenance)

Systemic therapy is indicated in all cases.

Maintenance may need to continue until CD4 count is > 150 cells/mm³ for 3 consecutive months.

Intravitreal therapy:

Intravitreal Ganciclovir 2mg/0.1ml biweekly

Intravitreal therapy:

Intravitreal Foscarnet 2.4mg/0.1ml (1-2 weekly)

Intravitreal therapy is indicated in zone 1 and 2 lesions.

Intravitreal to be tapered according to clinical response.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Treponema pallidum

Benzylpenicillin 2 MU q4h IV for 14 days

OR

Aqueous Procaine penicillin 1.2 MU IM for 10 days

PLUS

Probenecid 500mg q4h for 10-14 days

Penicillin allergy

Doxycycline 200mg PO q12h for 28 days

OR

Tetracycline 500mg q6h for 14 days

OR

Ceftriaxone 2g IV/IM q24h for 14 days (if no anaphylaxis to penicillin)

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Mycobacterium tuberculosis

Presents as a unilateral/ bilateral infective uveitis characterized by multifocal choroiditis/ granuloma and there may be supportive FFA findings of occlusive vasculitis.

Clinical response to anti-TB is often diagnostic.

Needs systematic therapy for Extra pulmonary TB usually for >6 months

*Ethambutol may cause optic neuropathy and should be avoided depending on the case.

Anti-tuberculosis Treatment (ATT) is started along with topical steroid eyedrop depending upon the anatomical site of uveitis.

Uveitis can occur secondary to TB Hypersensitivity due to an immune response to acid fast bacilli in the eye.

Systemic steroids may be indicated but is only for non-active systemic TB Immunocompetent patients

Tubercular retinal vasculitis Severe ocular inflammation developing after starting anti-TB treatment and vision threatening condition.

Systemic steroids should not be started ALONE without anti-TB treatment.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Postoperative Bacterial Endophthalmitis

Common Organisms:

Staphylococcus epidermidis 

Staphylococcus aureus

Pseudomonas aeruginosa

Bacteroides species

Streptococcus pneumoniae 

Alpha-haemolytic

Streptococcus spp.

Intravitreal antibiotic injections:

Vancomycin 1-2mg/0.1ml

PLUS

Ceftazidime 2mg/0.1ml

PLUS

Intravitreal Amphotericin B 0.005mg/0.1ml (If suspicious of fungal endophthalmitis)

Intravitreal antibiotic injections:

Vancomycin 1-2mg/0.1ml

PLUS

Amikacin 0.4mg/0.1ml

Systemic antibiotics are indicated in severe, virulent endophthalmitis. Repeat intravitreal antivitreal antibodies after 48 to 72 hours if indicated.

*Prepared extemporaneously using injectable forms.

Topical treatment-options: *Gentamicin 1.4% eye drop *Ceftazidime 5% eye drop *Vancomycin 5% eye drop Ofloxacin 0.3% eye drop Moxifloxacin 0.5% eye drop Levofloxacin 0.5% eye drop (monotherapy or combination)

Systemic treatment: Ciprofloxacin 750mg PO q12h for 10 days

For culture negative cases: PLUS

Clarithromycin 250-500mg PO q12h for 7-14 days

Systemic treatment

Vancomycin 15-20mg/ kg IV q8-12h; not exceed 2gm/dose

PLUS

Ceftazidime 1-2gm IV q8h

Postoperative Fungal Endophthalmitis

Intravitreal therapy: Intravitreal Amphotericin B 0.005mg/0.1ml

Intravitreal therapy: Intravitreal Miconazole 0.01mg/0.1ml

Intravitreal and systemic therapy are indicated in all cases.

Systemic therapy: Fluconazole 200mg PO q24h for 6 weeks (minimum)

Systemic therapy: Voriconazole 200mg PO q12h

Endogenous Endophthalmitis Systemic treatment

Systemic therapy: Ciprofloxacin 750mg PO q12h for 10 days

PLUS*

Clarithromycin 250- 500mg PO q12h for 7-14 days (*for culture negative cases)

Systemic therapy:

Vancomycin 15-20mg/kg IV q8-12h; not to exceed 2gm/dose

PLUS

Ceftazidime 1-2gm IV q8h

All cases require systemic therapy.

Intravitreal injection is indicated in cases with vitreous involvement and sight threatening choroidal lesions.

Topical therapy may supplement therapy. Not to use systemic steroids in these cases.

Review antibiotic regimen after microbiology results. Repeat intravitreal antibiotics after 48 to 72 hours if indicated.

*Prepared extemporaneously using injectable forms

Topical treatment-options: Gentamicin 0.3% eye drop *Ceftazidime 5% eye drop *Vancomycin 5% eye drop Moxifloxacin 0.5% eye drop Levofloxacin 0.5% eye drop (monotherapy or combination)

Intravitreal antibiotic injections:

Vancomycin 1-2mg/0.1ml

PLUS

Ceftazidime 2mg/0.1ml

PLUS

Intravitreal Amphotericin B 0.005mg/0.1ml (If suspicious of fungal endophthalmitis)

Intravitreal antibiotic injections:

Vancomycin 1-2mg/0.1ml

PLUS

Amikacin 0.4mg/0.1ml

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Dacryocystitis

Common Organisms:

Streptococcus pneumoniae 

Staphylococcus aureus

Gram-negative anaerobes

Amoxicillin-clavulanate 625mg PO q8h

Cefuroxime 250mg PO q12h

Consider intravenous antibiotics in severe infections.

Duration: 7 days

Preseptal Cellulitis

Common Organisms:

Streptococcus pneumoniae

Staphylococcus aureus

Streptococcus spp.

Cloxacillin 500-1000mg PO q6h for 5 days

Amoxicillin-clavulanate 625mg PO q8h for 7 days

OR

Ceftriaxone 1-2gm IV q24h

Consider intravenous antibiotics in severe infections.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Common Organisms:

Streptococcus pneumoniae

Staphylococcus aureus

Streptococcus spp. 

Gram-negative anaerobes

Amoxicillin-clavulanate 1.2gm IV q8h

Ceftriaxone 1-2gm IV q24h

If anaerobes suspected:

PLUS

Metronidazole 500mg IV q8h

Duration: 7-10 days