eye disorders
Corneal Ulcer
Treatment of Corneal Ulcer
Initially empiric topical broad-spectrum antibiotic therapy More specific antimicrobial therapy directed at the cause Treatment for corneal ulcers, regardless of cause, begins withmoxifloxacin0.5% orgatifloxacin0.3 to 0.5% for small ulcers and fortified (higher than stock concentration) antibiotic drops, such astobramycin15 mg/mL andcefazolin50 mg/mL, for more significant ulcers, particularly those that are near the center of the cornea. Frequent dosing (eg, every 15 minutes for 4 doses, followed by every hour around the clock) is necessary initially. Patching is contraindicated because it creates a stagnant, warm environment that favors bacterial growth and prevents the administration of topical drugs. Herpes Simplex Keratitis is treated with Fungal infections are treated with topical antifungal drops, such asnatamycin5% (drug of choice for filamentous fungus, eg,Fusarium),amphotericin B0.15% (drug of choice for yeast, eg,Candida), or sometimesvoriconazole1% (which is less effective but has the broadest spectrum). All are dosed initially 1 drop every hour during the day and every 2 hours overnight. Deep infections may require addition of oralvoriconazole400 mg twice/day for 2 doses, then 200 mg twice/day;ketoconazole400 mg once/day;fluconazole400 mg once then 200 mg once/day; oritraconazole400 mg once then 200 mg once/day. IfAcanthamoebais identified, therapy can include topical propamidine 0.1%,neomycin0.175%, and polyhexamethylene biguanide 0.02% orchlorhexidine0.02% supplemented withmiconazole1%,clotrimazole1%, or oralketoconazole400 mg once/day oritraconazole400 mg once then 200 mg once/day. The drops are used every 1 to 2 hours until clinical improvement is evident, then gradually reduced to 4 times/day and continued for a number of months until all inflammation has resolved. Polyhexamethylene biguanide andchlorhexidineare not commercially available as ocular agents but can be prepared by a compounding pharmacy. Oralmiltefosinecan be used for recalcitrant cases. For all ulcers, treatment may also include a cycloplegic, such asatropine1% orscopolamine0.25% 1 drop 3 times/day, to decrease the ache of a corneal ulcer and to reduce the formation of posterior synechiae. In severe cases, debridement of the infected epithelium or even penetrating keratoplasty may be required. Patients who may have difficulty administering eye drops at home or who have large, central, or refractory ulcers may need to be hospitalized. Very selectively, patients can be treated adjunctively with a corticosteroid drop (eg,prednisoloneacetate 1% 4 times/day for 1 week then tapered over 2 to 3 weeks). The final appearance of the scar and final visual acuity are not improved with topical corticosteroids. Topical corticosteroids do decrease the pain and photophobia, and speed the increase in visual acuity, significantly. Because there is a very small risk of the ulcer worsening, adding topical corticosteroids is only indicated when a patient needs to get back to normal functioning (eg, work, driving) as soon as possible. Such treatment should only be prescribed by ophthalmologists and should be restricted to patients in whom clinical and microbiologic evidence indicates a favorable response to antimicrobial treatment and who can be closely followed. 