Corneal Infections

Staph: (blepharitis, conjunctivitis, ulcers, phylctenules, styes, dacryocystitis, endophthalmitis)

• Cephalosporins, bacitracin (baci), penicillin (PCN)
• Reserve Vancomycin (Vanc) for MRSA or PCN allergy
• If 2^nd gen fluoroquinolone (fluor) resistance, then 4^th generation (moxi, gati)

Strep: (conjunctivitis, ulcers, dacryocystitis, endophthalmitis (acute AND delayed in blebs), necrotizing faciitis, infectious crystalline keratopathy)

• Baci, polytrim, PCN, Cephalosporins, Moxi, Gati >>>Aminoglycosides, 2^nd gen fluor

P. acnes (Gram + rod): MOST COMMON cause chronic post-op endophthalmitis

• Inject Vanc, remove capsule and iol if needed for endophthalmitis

Pseudomonas: (Ulcers in SCL wearers, scleritis)

• Tobramycin, ceftazidime, gent, amikacin (back-up), ciprofloxicin > gati > moxi

Presumed Bacterial Ulcers (no cx back yet):

• Fortified abx (Tobra, gent, and ceftaz) alternating with Ancef q 30 min to 60 min, after q 5 min x 5
• Vanc for resistant organism or PCN allergy
• Cipro, levoflox, moxi, gati q 30 min ATC
• Fluoroquinolones for small, fortified for large, unresponsive ulcers

Gonococcus: (hyperacute conj, ophthalmia neonatorum, ulcers), can penetrate an intact corneal epithelium quickly and perforate – **Recall CANALS (microorganisms that can penetrate through the cornea – make canals that is – Cornebacterium diptheria, Aegyptius (Hemophilus), Neisseria, Acanthamoeba, Listeria and Shigella**

• Ceftriaxone 1 g IM if conj only
• Ceftriaxone 1 g IV bid x 3 d if cornea too

H flu, Moraxella, Serratia (Gram – rods): Hflu (conjunctivitis, MOST COMMON cause of pediatric preseptal cellulitis, dacryocystitis, bleb infxns, ulcers), Moraxella (MOST COMMON cause of angular blepharitis, ulcers, chronic conj, bleb infxns) and Serratia (associated with contaminated eye drops, ulcers)

• Fluoroquinolones (aminoglycosides as a back up for Moraxella and Serratia only)

Bacillus Cereus (Gram + rod): (panophthalmitis post-trauma, associated with IVDA as well) – BE SERIOUS with B. cereus

• Gent and clinda or vanc, fluor (GOOD INTRAOCULAR PENETRATION), emergent PPV

Actinomyces and Nocardia (Filamentous Bacteria): Actinomyces (MOST COMMON cause of canaliculitis – treated with irrigation and oral PCN) and Nocardia (indolent ulcers)

• Amikacin, sulfa

Atypical Mycobacteria: (Important Post-LASIK infxn)

• Clarithromycin, moxi, gati

Syphilis: (uveitis, episcleritis, scleritis, retinitis, choroiditis)

• PCN IV x 10 days
• Doxy for PCN allergy

Lyme: (stromal keratitis, iritis, optic neuritis, etc.)

• Doxy, topical steroids with very slow taper

Fungus:

Septate – Fusarium, Aspergillus

Nonseptate – Mucor (important in diabetics, immunocompromised)

Yeast

Fusarium

• Natamycin

Aspergillus, Candida and Mucor

• Amphotericin

HSV: (HSV keratitis 2^nd to trauma as cause of U/L blindness)

Dendritic, geographic ulcers

• Viroptic 8x / day or Vira A 5x / day

Follicular conjuncitivitis, lid margin ulcers

• Viroptic 5x / day or Vira A 5x / day

Noninfectious epithelial ulcers (h/o HSV keratitis)

• Lubrication, d/c toxic antivirals, tarsorraphy, SCL controversial

Non-necrotizing stromal keratitis

• Topical steroids 4 – 8 x / day (GRADUAL taper when appropriate), prophylactic topical antivirals 2 – 4x / day
• **Note: lack of efficacy of PO acyclovir for Rx in HEDS

Uveitis (granulomatous KP), + / - active keratitis

• Topical steroids, antivirals, aqueous suppressants for INCREASED IOP

**ACYCLOVIR – Effective in prevention of recurrent HSV keratitis, oral / facial HSV, especially in patients with h/o stromal keratitis – DOSE for HSV: 400 mg bid (prophylaxis)

VZV: (herpes zoster ophthalmicus, uveitis, scleritis, episcleritis, CN palsies, optic neuritis, FATAL cranial arteritis, post-herpetic neuralgia – and like HSV, increases IOP)

• If within 72 hrs of sx: Acyclovir 800 mg 5x / day, or Famvir 500 3x / day, or Valtrex 1000 3x / day, NO VIROPTIC
• Steroids for stromal keratitis and uveitis (topical); optic neuritis, cranial arteritis, orbital involvement (oral)
• Also: Tricyclic antidepressants, gabapentin, lubrication, punctual occlusion, tarsorraphy, glue

Adenovirus: (acute follicular conj, REALLY contagious), EKC 8, 11, 19; PCF 3, 4, 7 (These add up nicely)

• Cool compresses, Ats
• If pseudomembranes, erosions, bad SEIs, prolonged infxn – then Steroids

Vaccinia: (lid vesicles, conjunctivitis, keratitis)

• Topical viroptic, IV vaccinia immune globulin (VIG) 1 dose

Chlamydia: (Trachoma – serotypes A – C, Inclusion conjunctivis – serotypes D – K)

Trachoma

• SAFE strategy (to eliminate it by 2020): Surgery for trichiasis, Antibiotics, Facial and Environmental hygiene
• Azithromycin 1 g x 1 dose

Adult Inclusion Conjunctivitis

• Azithromycin 1 g x 1, then either doxy or erythro 1 – 3 weeks, TREAT PARTNERS

Inclusion Blennorrhea (MOST COMMON neonatal conjunctivitis)

• Topical and PO erythromycin of patient AND parents

Acanthamoeba (parasite in H20 and soil): chronic, PAINFUL keratitis – ring infiltrate is a LATE finding (**Anesthetic abuse also gives a ring infiltrate)

• Topical brolene, neomycin, baquacil or chlorhexidine, + / - oral itraconazole, PK for scars after 1 year

Parasites (Onchocerciasis, Lice): Onchocerciasis (river blindness, carried by the Black fly)

• Ivermectin and removal of vector, plus ung, shampoo for lice