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DISORDERS OF THE EYES & LIDS
https://t.me/med1917
CMDT 2025
169
A. Gonococcal Conjunctivitis
Gonococcal conjunctivitis, usually acquired through contact with infected genital secretions, typically causes copious purulent discharge. It is an ophthalmologic emergency
because the cornea may perforate. The diagnosis should be
confirmed by Gram stain and culture of the discharge.
Systemic treatment is required with a single 500-mg dose
of intramuscular ceftriaxone if the patient weighs less than
150 kg or 1-g dose if patient weighs more than 150 kg (see
Chapter 35). Fluoroquinolone resistance is common. Eye
irrigation with saline may promote resolution. Topical
antibiotics such as erythromycin and bacitracin may be
added. Other STIs, including chlamydiosis, syphilis, and
HIV infection, should be considered. Standard treatment
for chlamydial infection is recommended.
Alsoudi AF … Seitzman GD. Purulent conjunctivitis and pro-
gressive corneal stromal necrosis. JAMA Ophthalmol.
2021;139:908. [PMID: 34081098]
B. Chlamydial Keratoconjunctivitis
1. Trachoma—Trachoma is the most common infectious
cause of blindness worldwide, with approximately 40
million people affected and 1.2 million blind. Recurrent
episodes of infection in childhood manifest as bilateral
follicular conjunctivitis, epithelial keratitis, and corneal
vascularization (pannus). Scarring (cicatrization) of the
tarsal conjunctiva leads to entropion and trichiasis in
adulthood with secondary central corneal scarring.
Immunologic tests or PCR on conjunctival samples
confirm the diagnosis but treatment should be started
based on clinical findings. A single 1-g dose of oral azithromycin is the preferred drug for mass treatment campaigns;
improvements in hygiene and living conditions probably
have contributed more to the marked reduction in the
prevalence of trachoma during the past 30 years. Local
treatment is not necessary. Surgical treatment includes correction of lid deformities and corneal transplantation.
Lietman TM et al. Frequency of mass azithromycin distribution
for ocular chlamydia in a trachoma endemic region of Ethio-
pia: a cluster randomized trial. Am J Ophthalmol.
2020;214:143. [PMID: 32171768]
2. Inclusion conjunctivitis—The eye becomes infected
after contact with secretions infected with chlamydia. The
disease starts with acute redness, discharge, and irritation.
Examination shows follicular conjunctivitis with mild keratitis. A nontender preauricular lymph node can often be
palpated. Healing usually leaves no sequelae. Diagnosis can
be rapidly confirmed by immunologic tests or PCR on
conjunctival samples. Treatment is doxycycline, 100 mg
orally twice daily for 7 days. All cases should be assessed
for genital tract infection and other STIs.
3. Dry Eyes
Dry eye, a common and chronic disorder, is an umbrella
term describing tear film instability and associated ocular
and visual complaints. Dry eye is more common in women
than men and increases with age. Hypofunction of the
lacrimal glands, causing loss of the aqueous component of
tears (keratoconjunctivitis sicca), may be due to aging,
hereditary disorders, systemic disease (eg, Sjögren syndrome), or systemic drugs. Excessive evaporation of tears
may be due to environmental factors (eg, excessive screen
time, windy climate) or abnormalities of the lipid component of the tear film, as in blepharitis. Mucin deficiency
may be due to vitamin A deficiency or conjunctival
scarring from trachoma, Stevens-Johnson syndrome,
mucous membrane pemphigoid, graft-versus-host disease,
chemical burns, or topical drug toxicity.
» Clinical Findings
The patient complains of dryness, redness, foreign body
sensation, and variable vision. In severe cases, there is persistent marked discomfort, with photophobia, difficulty in
moving the lids, and excessive mucus secretion. In many
cases, gross inspection reveals no abnormality, but on slitlamp examination there are abnormalities of tear film stability and reduced tear volume. In more severe cases, damaged
corneal and conjunctival cells stain with fluorescein and lissamine green. In the most severe cases, there is marked
conjunctival injection, mucoid discharge, loss of the normal
conjunctival and corneal luster, and epithelial keratopathy
that stains with fluorescein and may progress to frank ulceration. The Schirmer test, which measures the rate of production of the aqueous component of tears, may be helpful.
» Treatment
Aqueous deficiency can be treated with artificial tears
drops or ointments. More prolonged duration of action can
be achieved with drop preparations containing a mucomimetic such as hydroxypropyl methylcellulose (HPMC) or
carboxymethylcelluose (carmellose). Warm compresses to
the eyelid can help unclog meibomian glands.
Artificial tear preparations are generally safe and, in
most cases, are used three or four times a day. However,
preservatives included in some preparations to maintain
sterility are potentially toxic and allergenic and may cause
ocular surface toxicity in frequent users. Such reactions
may be misinterpreted as a worsening of the dry eye state
requiring more frequent use of the artificial tears and leading in turn to further deterioration, rather than being
recognized as a need to change to a preservative-free
preparation. Preservative-free preparations are recommended for any frequency of use greater than four times a
day. Eye drops claiming to “get the red out” are not recommended as they cause toxicity and rebound hyperemia
with prolonged use.
Dry eye is considered an inflammatory ocular surface
disease. Accordingly, disease modification may require
episodic treatment with low potency corticosteroid drops.
Topical corticosteroids should only be prescribed by eye
specialists to monitor for steroid induced glaucoma and
cataracts. All patients using topical corticosteroids should
have their intraocular pressure monitored by eye care professionals. Corticosteroid-sparing anti-inflammatory
170 CMDT 2025
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CHAPTER 7
drops such as cyclosporine 0.05% ophthalmic emulsion
(Restasis) and lifitegrast 5% are commonly used with no
universal consensus of efficacy. Lacrimal punctal occlusion
by canalicular plugs or cautery is useful in severe cases.
Blepharitis is treated as described above.
de Paiva CS et al. Topical cyclosporine A therapy for dry eye
syndrome. Cochrane Database Syst Rev. 2019;9:CD010051.
[PMID: 31517988]
Gonzales JA et al. Ocular clinical signs and diagnostic tests most
compatible with keratoconjunctivitis sicca: a latent class
approach. Cornea. 2020;39:1013. [PMID: 32251167]
4. Allergic Eye Disease
Allergic eye disease is common and takes a number of different forms, but all are expressions of atopy, which may
also manifest as atopic asthma, atopic dermatitis, or allergic
rhinitis.
» Clinical Findings
Symptoms include itching, tearing, redness, stringy
discharge, and occasionally, photophobia and visual loss.
Allergic conjunctivitis is common. It may be seasonal
(hay fever), developing usually during the spring or summer, or perennial. Clinical signs include conjunctival
hyperemia and edema (chemosis), the latter at times being
marked and sudden in onset.
Vernal keratoconjunctivitis tends to occur in late
childhood and early adulthood. It is usually seasonal, with
a predilection for the spring. Large “cobblestone” papillae
are noted on the upper tarsal conjunctiva. There may be
follicles at the limbus.
Atopic keratoconjunctivitis is a more chronic disorder of adulthood. Both the upper and the lower tarsal
conjunctivas exhibit a papillary conjunctivitis. Severe
cases demonstrate conjunctival fibrosis, resulting in forniceal shortening and entropion with trichiasis. Corneal
involvement, including refractory ulceration, is frequent
during exacerbations of both vernal and severe atopic
keratoconjunctivitis. The latter may be complicated by
herpes simplex keratitis.
» Treatment
A. Mild and Moderately Severe
Allergic Eye Disease
Topical anti-inflammatory agents include mast cell stabilizers and antihistamines (see Anti-Inflammatory Agents
in Table 7–2). Mast cell stabilization takes longer to act
than antihistamines but can be useful for prophylaxis.
Topical vasoconstrictors, such as ephedrine, naphazoline,
tetrahydrozoline, and phenylephrine, alone or in combination with antihistamines, are available as overthe-counter medications and not typically used because of
limited efficacy, rebound hyperemia, and follicular conjunctivitis. Systemic antihistamines (eg, loratadine 10 mg
orally daily) may be useful in prolonged atopic keratoconjunctivitis. In allergic conjunctivitis, specific allergens may
be avoidable.
B. Acute Exacerbations and Severe
Allergic Eye Disease
Topical corticosteroids (Table 7–2) are essential to control
acute exacerbations of both vernal and atopic keratoconjunctivitis. Corticosteroid-induced side effects should be
monitored by eye care professionals and include cataracts,
glaucoma, and exacerbation of herpes simplex keratitis.
The lowest potency corticosteroid that controls ocular
inflammation should be used. Topical cyclosporine or
tacrolimus may be effective. Systemic corticosteroid or
other immunosuppressant therapy may be required in
severe atopic keratoconjunctivitis.
PINGUECULA & PTERYGIUM
Pinguecula is a yellowish, elevated conjunctival nodule in
the area of the palpebral fissure. It is common in persons
over age 35 years. Pterygium is a fleshy, triangular
encroachment of the conjunctiva onto the cornea and is
usually associated with prolonged exposure to wind, sun,
sand, and dust. Pinguecula and pterygium are often bilateral and occur more frequently on the nasal side of the
conjunctiva.
Pingueculae rarely grow but may become inflamed
(pingueculitis). Pterygia become inflamed and may grow.
Treatment is rarely required for inflammation of pinguecula or pterygium, and artificial tears are often beneficial.
The indications for excision of pterygium are growth
that threatens vision by encroaching on the cornea, marked
induced astigmatism, or severe ocular irritation.
Shahraki T et al. Pterygium: an update on pathophysiology,
clinical features, and management. Ther Adv Ophthalmol.
2021;13:25158414211020152. [PMID: 34104871]
CORNEAL ULCER
Corneal ulcers are most commonly due to infection by
bacteria, viruses, fungi, or amoebas. Noninfectious
causes—all of which may be complicated by infection—
include neurotrophic keratitis (resulting from loss of corneal sensation), exposure keratitis (due to inadequate lid
closure), severe dry eye, severe allergic eye disease, and
inflammatory disorders that may be purely ocular or part
of a systemic vasculitis. Delayed or ineffective treatment of
corneal ulceration may lead to devastating consequences
with corneal scarring and rarely intraocular infection.
Prompt referral is essential.
Patients complain of pain, photophobia, tearing, and
reduced vision. The conjunctiva is injected, and there may
be purulent or watery discharge. The corneal appearance
varies according to the underlying cause.
» When to Refer
Any patient with an acute painful red eye and corneal
abnormality should be referred emergently to an ophthalmologist. Contact lens wearers with acute eye pain, redness, and decreased vision should be referred
immediately.
DISORDERS OF THE EYES & LIDS
https://t.me/med1917
CMDT 2025
Table 7–2. Topical ophthalmic agents (selected list).
Agent Recommended Regimen Indications
Antibiotic Agents
Azithromycin (AzaSite) One drop two times daily for 2 days, then once daily for
Bacitracin 500 U/g ointment (various)
Bacitracin/Polymyxin ointment
(Polysporin, AK-Poly)
Besifloxacin ophthalmic suspension, 0.6%
(Besivance)
Ciprofloxacin HCl 0.3% solution (Ciloxan) For bacterial conjunctivitis, typically one drop four times
Ciprofloxacin HCl 0.3% ointment Apply 0.5 inch into lower conjunctival sac or to eyelids
Erythromycin 0.5% ointment (various) Apply 0.5 inch into lower conjunctival sac or to eyelids
Fusidic acid 1% gel (Fucithalmic)
Not available in United States
Gatifloxacin 0.5% solution (Zymaxid) For bacterial conjunctivitis, typically one drop four times
Gentamicin sulfate 0.3% solution (various) One drop four times a day for bacterial conjunctivitis Ocular surface infection
Gentamicin sulfate 0.3% ointment (various) Apply 0.5 inch into lower conjunctival sac two to three
Gentamicin sulfate 1.5%
(fortified preparation)
Levofloxacin 0.5% solution (various) For bacterial conjunctivitis, typically one drop four times
Moxifloxacin 0.5% solution (Vigamox) For bacterial conjunctivitis, typically one drop three
Neomycin/Polymyxin B/Gramicidin (Neosporin) One drop three to four times a day for 1 week Ocular surface infection
Norfloxacin 0.3% solution
Not available in United States
Ofloxacin 0.3% solution (Ocuflox) For bacterial conjunctivitis, typically one drop four times
1
5 days
Apply 0.5 inch into lower conjunctival sac or to eyelids
three to four times daily for 7–10 days
Apply 0.5 inch into lower conjunctival sac or to eyelids
three to four times daily for 7–10 days
For bacterial conjunctivitis, typically one drop four times
a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
three to four times daily for 7–10 days
three to four times daily for 7–10 days
One drop two times daily Bacterial conjunctivitis, blepharitis,
a day for 1 week
For bacterial keratitis, depends on severity, often one
drops every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
times daily
One drop every hour for 48 hours, then gradually reduce Bacterial keratitis
a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
times a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
For bacterial conjunctivitis, typically one drop four times
a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
Bacterial conjunctivitis
Bacterial conjunctivitis, blepharitis,
stye
Corneal abrasion
Following corneal foreign body
removal
Bacterial conjunctivitis
Bacterial keratitis
Bacterial conjunctivitis
Bacterial keratitis
Bacterial conjunctivitis
Bacterial infection of the
conjunctiva or lid margin
stye, keratitis
Bacterial conjunctivitis
Bacterial keratitis
Ocular surface infection
Bacterial conjunctivitis
Bacterial keratitis
Bacterial conjunctivitis
Bacterial keratitis
Ocular surface infection
Bacterial keratitis
Bacterial conjunctivitis
Bacterial keratitis
171
(continued)
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CHAPTER 7
Table 7–2. Topical ophthalmic agents (selected list).
Agent Recommended Regimen Indications
Polymyxin B 10,000 U/mL/Trimethoprim
sulfate 1 mg/mL (Polytrim)
Sulfacetamide sodium 10% solution (various) For bacterial conjunctivitis, typically one drop four times
Tobramycin 0.3% solution (various) For bacterial conjunctivitis, typically one drop four times
Tobramycin 1.5% (fortified) solution One drop every hour during the day and every 2 hours
Tobramycin 0.3% ointment (Tobrex) Apply 0.5 inch into lower conjunctival sac or to eyelids
Antifungal Agents
Amphotericin 0.1–0.5% solution Fungal blepharitis, conjunctivitis,
Natamycin 5% suspension (Natacyn) One drop every 1–2 hours initially, then reduce as
Voriconazole 1% solution
Antiviral Agents
Acyclovir 3% ointment (Zovirax)
Not available in United States
Ganciclovir 0.15% gel (Zirgan) Five times daily
Trifluridine 1% solution (Viroptic) One drop onto cornea every 2 hours while awake for a
Anti-Inammatory Agents
Antihistamines
Emedastine difumarate 0.05% solution
(Emadine)
Not available in United States
Levocabastine (Livostin)
Not available in United States
Mast cell stabilizers
Cromolyn sodium 4% solution (Crolom) One drop four times daily
Lodoxamide tromethamine 0.1% solution
(Alomide)
Nedocromil sodium 2% solution (Alocril) One drop twice daily
Pemirolast potassium 0.1% solution
(Alamast)
Not available in United States
Combined antihistamines and mast cell stabilizers
Alcaftadine 0.25% ophthalmic solution
(Lastacaft)
Azelastine HCl 0.05% ophthalmic solution
(Optivar)
Bepotastine besilate 1.5% solution (Bepreve) One drop twice daily
Epinastine hydrochloride 0.05% ophthalmic
solution (Elestat)
Ketotifen fumarate 0.025% solution (Zaditor) One drop twice daily
3
2
For bacterial conjunctivitis, typically one drop four times
a day for 1 week
a day for 1 week
a day for 1 week
For bacterial keratitis, depends on severity, often one
drop every hour during the day and every 2 hours
during the night for 48 hours, then gradually reduce
during the night for 48 hours, then gradually reduce
three to four times daily for 7–10 days
dictated by the severity of the infection
Five times daily Herpes simplex keratitis
maximum daily dose of nine drops until resolution
occurs; then an additional 7 days of one drop every
4 hours while awake (minimum five times daily)
One drop four times daily Allergic eye disease
One drop twice daily
One or two drops twice a day
One drop four times daily
One drop once daily
One drop two to four times daily
One drop twice daily
(continued)
Ocular surface infection
Bacterial infection of the
conjunctiva or lid margin
Bacterial conjunctivitis
Bacterial keratitis
Bacterial keratitis
Bacterial conjunctivitis
keratitis
(continued)
DISORDERS OF THE EYES & LIDS
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173
Table 7–2. Topical ophthalmic agents (selected list).
Agent Recommended Regimen Indications
Ketotifen 0.025% preservative-free solution
(Alaway)
Olopatadine hydrochloride 0.1% solution
(Patanol)
Olopatadine hydrochloride 0.2% or 0.77%
solution
Nonsteroidal anti-inflammatory agents
Bromfenac 0.09% solution (Xibrom) One drop to operated eye twice daily beginning
Diclofenac sodium 0.1% solution (Voltaren) One drop to operated eye four times daily beginning
Flurbiprofen sodium 0.03% solution (various) One drop to operated eye four times daily beginning
Indomethacin 1% solution (Indocid)
Not available in United States
Ketorolac tromethamine 0.5% solution
(Acular)
Nepafenac 0.1% suspension (Nevanac) One drop to operated eye three times daily beginning
Corticosteroids
Dexamethasone sodium phosphate 0.1%
solution (various)
Difluprednate 0.05% suspension
Fluorometholone 0.1% suspension (various)6One drop four times a day and tapered off as
Fluorometholone 0.25% suspension
(FML Forte)
Fluorometholone 0.1% ointment (FML S.O.P.)
Not available in United States
Loteprednol etabonate 0.5% (Lotemax) One drop twice daily for severe allergies. More
Prednisolone acetate 0.12% suspension
(Pred Mild)
Prednisolone acetate 1% suspension
(various)
4
5
6
One drop twice daily
One drop twice daily
One drop daily
24 hours after cataract surgery and continuing
through 2 postoperative weeks
24 hours after surgery and continuing through
2 postoperative weeks
24 hours after cataract surgery
One drop four times daily Treatment of allergic eye disease,
One drop four times daily tapered with decreasing
inflammation, not to be used long term
24 hours after cataract surgery and continuing
through 2 postoperative weeks
One drop as often as indicated by severity; use every
hour during the day and every 2 hours during the
night in severe inflammation; taper off as
inflammation decreases
One drop four times daily beginning 24 hours after
surgery and continuing throughout 2 postoperative
weeks; then one drop twice daily for a week and then
taper based on the response
One drop four times daily for 2 weeks and then taper as
clinically indicated
inflammation decreases
One drop two to four times daily
Apply thin coating on lower conjunctival sac three or
four times daily
frequently for intraocular inflammation, tapered off
as inflammation decreases
One drop four times a day and tapered as inflammation
decreases
One drop as often as indicated by severity of inflamma-
tion; use every hour during the day and every 2 hours
during the night in severe inflammation; taper off as
inflammation decreases
(continued)
Treatment of postoperative
inflammation following cataract
extraction
Treatment of postoperative
inflammation following cataract
extraction and laser corneal
surgery
Inhibition of intraoperative miosis;
treatment of cystoid macular
edema and inflammation after
cataract extraction
postoperative inflammation
following cataract extraction
and laser corneal surgery
Treatment of postoperative
inflammation following cataract
extraction
Treatment of steroid-responsive
inflammatory conditions
Treatment after ocular surgery
and for non-infectious uveitis
Treatment of ocular surface
inflammatory conditions
Treatment of steroid-responsive
ocular inflammatory conditions
(continued)
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Table 7–2. Topical ophthalmic agents (selected list).
(continued)
Agent Recommended Regimen Indications
Prednisolone sodium phosphate 1%
solution (various)
One drop as often as indicated by severity of inflamma-
tion; use every hour during the day and every 2 hours
during the night in severe inflammation; taper off as
inflammation decreases
Immunomodulators
Cyclosporine 0.05% emulsion (Restasis)
0.4 mL/container
One drop twice daily Dry eyes and severe allergic eye
disease
Tacrolimus 0.1% ointment Apply to lower conjunctival sac twice daily Severe allergic eye disease
Glaucoma and Ocular Hypertension Agents
Sympathomimetics
Apraclonidine HCl 0.5% solution (Iopidine) One drop three times daily Reduction of intraocular pressure;
expensive; reserve for treatment
of resistant cases
Apraclonidine HCl 1% solution (Iopidine) One drop 1 hour before and immediately after anterior
segment laser surgery
To control or prevent elevations of
intraocular pressure after laser
trabeculoplasty or iridotomy
Brimonidine tartrate 0.2% solution
One drop two or three times daily Reduction of intraocular pressure
(Alphagan, Alphagan P [benzalkonium
chloride-free])
Beta-adrenergic blocking agents
Betaxolol HCl 0.5% solution (Betoptic) and
0.25% suspension (Betoptic S)
Carteolol HCl 1% and 2% solution (various,
Levobunolol HCl 0.25% and 0.5% solution
Metipranolol HCl 0.3% solution
8
Teoptic)
9
(Betagan)
(OptiPranolol)
9
7
One drop twice daily Reduction of intraocular pressure
One drop twice daily
One drop once or twice daily
One drop twice daily
Timolol 0.25% and 0.5% solution (Betimol)9One drop once or twice daily
Timolol maleate 0.25% and 0.5% solution
One drop once or twice daily
(Istalol, Ocudose [preservative-free],
Timoptic) and 0.1%, 0.25%, and 0.5% gel
(Timoptic-XE, Timoptic GFS)
9
Miotics
Pilocarpine HCl 1–4% solution
10
One drop up to four times daily for elevated intraocular
pressure
Reduction of intraocular pressure,
treatment of acute or chronic
angle-closure glaucoma, and
pupillary constriction
Carbonic anhydrase inhibitors
Brinzolamide 1% suspension (Azopt) One drop two to three times daily Reduction of intraocular pressure
Dorzolamide HCl 2% solution (Trusopt) One drop two to three times daily
Prostaglandin analogs
Bimatoprost 0.03% solution (Lumigan) One drop once daily at night Reduction of intraocular pressure
Latanoprost 0.005% solution (Xalatan,
One drop once or twice daily at night
Monopost [preservative-free])
(Monopost not available in United States)
Latanoprostene bunod 0.024% solution
One drop daily at night
(Vyzulta)
(continued)
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Table 7–2. Topical ophthalmic agents (selected list).
(continued)
Agent Recommended Regimen Indications
Tafluprost 0.0015% solution (Saflutan
One drop once daily at night
[preservative-free], Taflotan, Zioptan
[preservative-free])
(Saflutan not available in United States)
Travoprost 0.004% solution (Travatan,
One drop once daily at night
Travatan Z [benzalkonium chloride-free])
Rho kinase inhibitor
Netarsudil ophthalmic solution 0.02%
One drop daily in the evening Reduction of intraocular pressure
(Rhopressa)
Combined preparations
Bimatoprost 0.03% and timolol 0.5%
One drop daily in the morning Reduction of intraocular pressure
(Ganfort)
Not available in United States
Brimonidine 0.2% and timolol 0.5%
One drop twice daily
(Combigan)
Brimonidine 0.2% and brinzolamide 1%
One drop three times a day
(Simbrinza)
Brinzolamide 1% and timolol 0.5% (Azarga)
One drop twice daily
Not available in United States
Dorzolamide 2% and timolol 0.5%
One drop twice daily
(Cosopt, Cosopt PF [preservative-free])
Latanoprost 0.005% and timolol 0.5%
One drop daily in the morning
(Xalacom)
Not available in United States
Tafluprost 0.0015% and timolol 0.5%
One drop daily
(Taptiqom [preservative-free])
Not available in United States
Travoprost 0.004% and timolol 0.5%
One drop daily
(DuoTrav)
Not available in United States
Mydriatic Agents for Pupillary Dilation
Tropicamide 1% and phenylephrine 2.5% One drop Shorter-acting mydriatic for eye
examination
Cyclopentolate 1% and homatropine 5% One drop twice daily Long-acting cycloplegic for
Atropine 1% One drop daily
treatment of uveitis to prevent
iris synechiae and relieve pain
from ciliary spasm
1
Little efficacy against gram-negative organisms (except Neisseria).
2
No gram-positive coverage.
3
May produce rebound hyperemia and local reactions.
4
Frequency of corticosteroid use is determined by the severity of the inflammation and is tapered as inflammation decreases. Long-term
use may increase intraocular pressure (eye pressure should be monitored), may contribute to cataract development, and predisposes to
bacterial, herpes simplex virus, and fungal keratitis.
5
Because of its high potency, this is the corticosteroid most likely to cause increased intraocular pressure.
6
Less likely to elevate intraocular pressure.
7
Cardioselective (beta-1) beta-blocker.
8
Teoptic is not available in the United States.
9
Nonselective (beta-1 and beta-2) beta-blocker. Monitor all patients for systemic side effects, particularly exacerbation of asthma.
10
Decreased night vision and headaches possible.
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Ting DSJ … Seitzman GD et al. Diagnostic armamentarium of
infectious keratitis: a comprehensive review. Ocul Surf.
2022;23:27. [PMID: 34781020]
INFECTIOUS KERATITIS
1. Bacterial Keratitis
Risk factors for bacterial keratitis include contact lens
wear—especially overnight wear—and corneal trauma,
including surgery. The pathogens most commonly isolated are staphylococci, including MRSA; streptococci;
and Pseudomonas aeruginosa, Moraxella species, and
other gram-negative bacilli. The cornea has an epithelial
defect and an underlying opacity on slit-lamp examination, or may have a “white spot” on direct visualization.
Hypopyon may be present. Topical fluoroquinolones, such
as levofloxacin 0.5%, ofloxacin 0.3%, norfloxacin 0.3%, or
ciprofloxacin 0.3%, are commonly used as first-line agents
as long as local prevalence of resistant organisms is low
(Table 7–2). For severe central ulcers, diagnostic scrapings
can be sent for Gram stain and culture. Treatment may
include compounded high-concentration topical antibiotic
drops applied hourly day and night for at least the first
48 hours. Fourth-generation topical fluoroquinolones
(moxifloxacin 0.5% and gatifloxacin 0.3%) are also frequently used in this setting. Although early adjunctive
topical corticosteroid therapy may improve visual outcome, it should be prescribed only by an ophthalmologist.
» When to Refer
Any patient with suspected bacterial keratitis must be
referred emergently to an ophthalmologist.
Lin A et al; American Academy of Ophthalmology Preferred
Practice Pattern Cornea and External Disease Panel. Bacterial
keratitis: Preferred Practice Pattern®. Ophthalmology.
2019;126:P1. [PMID: 30366799]
2. Herpes Simplex Keratitis
Primary ocular herpes simplex virus infection may manifest as lid, conjunctival, or corneal ulceration. The ability of
the virus to colonize the trigeminal ganglion leads to recurrences that may be precipitated by fever, excessive exposure
to sunlight, or immunodeficiency. Herpetic corneal disease
is typically unilateral but can be seen bilaterally in the setting of atopy or immunocompromise. The dendritic
(branching) corneal ulcer is the most characteristic manifestation of herpetic corneal disease. More extensive “geographic” ulcers also occur, particularly if topical
corticosteroids have been used. The corneal ulcers are most
easily seen with a slit lamp after instillation of fluorescein
and examination with a cobalt blue light. Resolution of
corneal herpetic disease is hastened by treatment with topical antiviral agents (eg, ganciclovir 0.15% gel, one drop five
times daily until healing has occurred and then one drop
three times daily for 1 more week, trifluoride drops, or
acyclovir ointment) or oral antiviral agents (eg, acyclovir,
400–800 mg five times daily or valacyclovir 500–1000 mg
three times daily for 7–14 days). Topical antiviral agents
may cause corneal toxicity after approximately 10–14 days
of therapy and for that reason are not commonly used for
long-term suppressive therapy.
Stromal herpes simplex keratitis produces increasingly
severe corneal opacity with each recurrence. Antiviral agents
alone are insufficient to control stromal disease, so topical
corticosteroids are also used, but they may enhance viral
replication and steroid dependence frequently occurs. Cau-
tion: For patients with known or possible herpetic disease,
topical corticosteroids should be prescribed only with ophthalmologic consultation. Severe stromal scarring may require
corneal transplantation; recurrence in the new cornea is
common and long-term oral antiviral agents are required.
The rate of recurrent corneal herpetic disease is reduced
by using long-term oral acyclovir, 400 mg twice daily; famciclovir, 250 mg once daily; or valacyclovir, 500 mg once
daily. Long-term oral antiviral dosing may be adjusted if
the disease breaks through suppressive dosing or if kidney
dysfunction is present.
» When to Refer
Any patient with a history of herpes simplex keratitis and
an acute red eye should be referred urgently to an
ophthalmologist.
Poon SHL et al. A systematic review on advances in diagnostics
for herpes simplex keratitis. Surv Ophthalmol. 2021;66:514.
[PMID: 33186564]
3. Herpes Zoster Ophthalmicus
Herpes zoster frequently involves the ophthalmic division
of the trigeminal nerve. It presents with malaise, fever,
headache, and periorbital burning and itching. These
symptoms may precede the eruption by a day or more. The
rash is initially vesicular, quickly becoming pustular and
then crusting. Involvement of the tip of the nose or the lid
margin predicts involvement of the eye. Ocular signs
include conjunctivitis, keratitis, episcleritis, and anterior
uveitis, often with elevated intraocular pressure. If needed,
PCR from aqueous or corneal pseudodendrites can confirm the clinical diagnosis. Recurrent anterior segment
inflammation, neurotrophic keratitis, and posterior subcapsular cataract are long-term complications. Optic neuropathy, cranial nerve palsies, acute retinal necrosis, and
cerebral angiitis occur infrequently. HIV infection is an
important risk factor for herpes zoster ophthalmicus and
increases the likelihood of complications.
High-dose oral acyclovir (800 mg five times a day),
valacyclovir (1 g three times a day), or famciclovir (500 mg
three times a day) for 7–10 days started within 72 hours
after the appearance of the rash reduces the incidence of
ocular complications but not of postherpetic neuralgia.
Treatment of keratitis is discussed above. Anterior uveitis
requires additional treatment with topical corticosteroids
and cycloplegic agents (eg, cyclopentolate). Topical corticosteroids, which promote viral replication, may have to be
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delayed until the keratitis has resolved. Neurotrophic keratitis is an important cause of long-term morbidity.
» When to Refer
Any patient with herpes zoster ophthalmicus and ocular
symptoms or signs should be referred urgently to an
ophthalmologist.
Davis AR et al. Herpes zoster ophthalmicus review and preven-
tion. Eye Contact Lens. 2019;45:286. [PMID: 30844951]
4. Fungal Keratitis
Fungal keratitis tends to occur after corneal injury involving plant material or in an agricultural setting, in eyes with
chronic ocular surface disease, and in contact lens wearers.
It may be an indolent process. The corneal infiltrate may
have feathery edges and multiple “satellite” lesions. A hypopyon may be present. Unlike bacterial keratitis, an epithelial defect may or may not be present. Corneal scrapings
should be cultured on media suitable for fungi. Diagnosis
is often delayed and treatment is difficult, commonly
requiring 6 months or longer for severe disease. Natamycin
5%, amphotericin 0.1–0.5%, and voriconazole 0.2–1% are
the most frequently used topical agents (Table 7–2). Systemic azoles are probably not helpful unless there is scleritis or intraocular infection. Corneal grafting is often
required.
Donovan C et al. Fungal keratitis: mechanisms of infection and
management strategies. Surv Ophthalmol. 2022;67:758.
[PMID: 34425126]
5. Amoebic Keratitis
Amoebic infection, usually due to Acanthamoeba, is an
important cause of keratitis. The two greatest risk factors
in developed countries are contact lens wear and freshwater or hot-tub exposure. Although severe pain with
perineural and ring infiltrates in the corneal stroma is
characteristic, it is not specific and earlier forms with
changes confined to the corneal epithelium are identifiable. Diagnosis is facilitated by confocal microscopy and
Giemsa staining of cornea smears. Culture requires specialized media. Intensive topical compounded biguanide
(polyhexamethylene or chlorhexidine) is initiated immediately, and long-term treatment is required. Topical
diamidine (propamidine or hexamidine) may be added.
Oral miltefosine is FDA approved for the treatment of
Acanthamoeba keratitis, but indications and efficacy have
yet to be established. There should be close monitoring for
systemic toxicity (vomiting, diarrhea, elevation of transaminases, and kidney function studies) during its use.
Delayed diagnosis and prior treatment with topical corticosteroids adversely affect the visual outcome. Corneal
grafting may be required after resolution of infection to
restore vision. If there is scleral involvement, systemic
anti-inflammatory and immunosuppressant medication is
helpful in controlling pain, but the prognosis is poor.
Alsoudi AF … Seitzman GD et al. Comparison of two confocal
microscopes for diagnosis of acanthamoeba keratitis. Eye
(Lond). 2021;35:2061. [PMID: 32760010]
Kaufman AR. Advances in the management of Acanthamoeba
keratitis: a review of the literature and synthesized algorithmic approach. Ocul Surf. 2022;25:26. [PMID: 35462076]
ACUTE ANGLECLOSURE GLAUCOMA
ESSENTIALS OF DIAGNOSIS
»
Older age group, particularly farsighted individuals.
»
Rapid onset of severe pain and profound visual
loss with “halos around lights.”
»
Red eye, cloudy cornea, dilated pupil.
»
Hard eye on palpation.
» General Considerations
Primary acute angle-closure glaucoma (acute angleclosure crisis) results from closure of a preexisting narrow
anterior chamber angle. The predisposing factors are shallow anterior chamber, which may be associated with farsightedness or a small eye (short axial length); enlargement
of the crystalline lens with age; and inheritance, such as
among persons of Inuit and Asian ancestry. Closure of the
angle is precipitated by pupillary dilation and thus can occur
from sitting in a darkened theater, during times of stress,
following nonocular administration of anticholinergic or
sympathomimetic agents (eg, nebulized bronchodilators,
atropine, antidepressants, bowel or bladder antispasmodics,
nasal decongestants, or tocolytics), or, rarely, from pharmacologic mydriasis (see Precautions in Management of Ocular
Disorders, below). Subacute primary angle-closure glaucoma may present as recurrent headache.
Secondary acute angle-closure glaucoma, for which
the mechanism may differ between cases, does not require
a preexisting narrow angle. Secondary acute angle-closure
glaucoma may occur in anterior uveitis, with dislocation of
the lens, with hemodialysis, or due to various drugs (see
Adverse Ocular Effects of Systemic Drugs, below). The
reduction in serum osmolarity that occurs with hemodialysis causes an osmotic gradient between the plasma and
aqueous fluid, leading to a buildup of fluid in the aqueous
compartment. Patients with a compromised outflow system (as with narrow angle) cannot accommodate the
buildup and the intraocular pressure rises. Symptoms are
the same as in primary acute angle-closure glaucoma, but
differentiation is important because of differences in
management.
» Clinical Findings
Patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though
there are subacute cases. Typically, the blurred vision is
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associated with halos around lights. Nausea and abdominal
pain may occur. The eye is red, the cornea cloudy, and the
pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard
eye on palpation.
» Differential Diagnosis
Acute glaucoma must be differentiated from conjunctivitis,
acute uveitis, and corneal disorders (Table 7–1).
» Treatment
Initial treatment, regardless of mechanism, is reduction of
intraocular pressure. A single 500-mg intravenous dose of
acetazolamide, followed by 250 mg orally four times a
day, together with topical medications such as timolol
maleate (a beta-blocker) that lower intraocular pressure
(Table 7–2), is usually sufficient. Osmotic diuretics, such
as oral glycerin and intravenous urea or mannitol—the
dosage of all three being 1–2 g/kg—may be necessary if
there is no response to acetazolamide. Definitive treatment
depends on the mechanism.
A. Primary Angle-Closure Glaucoma
In primary acute angle-closure glaucoma, once the intraocular pressure has started to fall, topical 4% pilocarpine,
1 drop every 15 minutes for 1 hour and then four times a
day, is used to reverse the underlying angle closure. The
definitive treatment is cataract extraction. Laser peripheral
iridotomy is also a first-line treatment.
All patients with primary acute angle closure should
undergo prophylactic laser peripheral iridotomy to the
unaffected eye, or early cataract extraction should be considered, unless that eye has already undergone cataract or
glaucoma surgery.
B. Secondary Angle-Closure Glaucoma
In secondary acute angle-closure glaucoma, additional
treatment is determined by the cause.
» Prognosis
Untreated acute angle-closure glaucoma results in severe
and permanent visual loss within 2–5 days after onset of
symptoms. Affected patients need to be monitored for
development of chronic glaucoma.
» When to Refer
Any patient with suspected acute angle-closure glaucoma
must be referred emergently to an ophthalmologist.
Gedde SJ et al. American Academy of Ophthalmology Preferred
Practice Pattern Glaucoma Panel. Primary Angle-Closure
Disease Preferred Practice Pattern®. Ophthalmology.
2021;128:30. [PMID: 34933744]
CHRONIC GLAUCOMA
ESSENTIALS OF DIAGNOSIS
»
Three types of chronic glaucoma: open-angle
glaucoma, angle-closure glaucoma, and normaltension glaucoma.
»
No symptoms in early stages.
»
Insidious progressive bilateral loss of peripheral
vision resulting in tunnel vision; visual acuities
preserved until advanced disease.
»
Pathologic cupping of the optic disks.
»
Intraocular pressure is usually elevated.
» General Considerations
Chronic glaucoma is characterized by gradually progressive excavation (“cupping”) of the optic disk with loss of
vision progressing from slight visual field loss to complete
blindness.
In chronic open-angle glaucoma, primary or second-
ary, intraocular pressure is elevated due to reduced drainage of aqueous fluid through the trabecular meshwork. In
chronic angle-closure glaucoma, the flow of aqueous fluid
into the anterior chamber angle is obstructed, which is
particularly common in persons of Inuit and eastern Asian
ancestry. In normal-tension glaucoma, intraocular pres-
sure is not elevated in this disorder, but the same pattern of
optic nerve damage occurs.
Primary chronic open-angle glaucoma is usually bilateral. There is an increased prevalence in first-degree relatives of affected individuals and in patients with diabetes.
In Afro-Caribbean and African persons, and probably in
Latino persons, it is more frequent, occurs at an earlier age,
and results in more severe optic nerve damage. Secondary
chronic open-angle glaucoma may result from ocular disease, eg, pigment dispersion, pseudoexfoliation, uveitis, or
trauma; or corticosteroid therapy, whether it is intraocular,
topical, inhaled, intranasal, or systemic.
In the United States, it is estimated that 2% of people
over 40 years of age have chronic glaucoma, affecting over
2.5 million individuals. At least 25% of cases are undetected.
Over 90% of cases are of the open-angle type. The incidence
of normal-tension glaucoma ranges from 10% to 50%.
Worldwide, about 45 million people have open-angle glaucoma, of whom about 4.5 million are bilaterally blind. About
4 million people, of whom approximately 50% live in China,
are bilaterally blind from chronic angle-closure glaucoma.
» Clinical Findings
Because initially there are no symptoms, chronic glaucoma
is often first suspected at a routine eye test. Diagnosis
requires consistent and reproducible abnormalities in at
least two of three parameters—optic disk or retinal nerve
fiber layer (or both), visual field, and intraocular pressure.
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