Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

bacterial (presumed): high risk

1st line – empiric antibiotics plus supportive therapies

Back
INITIAL
|
bacterial (presumed): high risk
1st line – 

empiric antibiotics plus supportive therapies

High risk is defined as: stromal infiltrate diameter ≥2 mm, central infiltrate, moderate to severe anterior chamber reaction, and purulent discharge.​[4]​​​

High-risk patients should be treated empirically prior to culture and sensitivity results involving a combination regimen of fortified eye drops: tobramycin or gentamicin and cefazolin or vancomycin. Regimen should be adjusted according to sensitivity results as soon as possible. Fortified eye drops are specially compounded by a pharmacist and are not available commercially.​[4]​​

Use of ophthalmic fourth-generation topical fluoroquinolones may be as efficacious and better tolerated compared with fortified antibiotics.[37] Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.[4]

Systemic antibiotics are usually not indicated except in cases of corneal perforation or gonococcal infection.[4]​ In cases of corneal perforation, intravenous antibiotics (e.g., ceftazidime plus vancomycin) can be used for empiric coverage. If ceftazidime plus vancomycin is not tolerated or is contraindicated, regimens that include a cephalosporin (e.g., cefazolin, cefuroxime) plus a fluoroquinolone such as ciprofloxacin, or ciprofloxacin alone can be considered. The treatment course is typically 3 days.[38] When available, culture results should be used to guide the choice of antibiotic agent.

Systemic fluoroquinolone antibiotics such as ciprofloxacin may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[39]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

In the case of gonococcal eye infection, consultation with an infectious disease specialist should be considered, as well as appropriate antibiotic therapy. See Gonorrhea infection for more information.

Contact lens wear should be discontinued during therapy.​[4]​​ If corneal thinning is present, an eye shield should be placed without an eye patch over the involved eye.[1][19]

Primary options

tobramycin-fortified eye drops: (14 mg/mL) 1 drop into the affected eye(s) every 30-60 minutes until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

More

or

gentamicin-fortified eye drops: (14 mg/mL) 1 drop into the affected eye(s) every 30-60 minutes until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

More

-- AND --

cefazolin-fortified eye drops: (50 mg/mL) 1 drop into the affected eye(s) every 30-60 minutes until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

More

or

vancomycin-fortified eye drops: (25 mg/mL) 1 drop into the affected eye(s) every 30-60 minutes until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

More

OR

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Secondary options

ceftazidime sodium: 1-2 g intravenously every 8-12 hours, maximum 6 g/day

and

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

More

Tertiary options

cefazolin: 2 g intravenously every 8 hours, maximum 12 g/day

and

ciprofloxacin: 750 mg orally twice daily

OR

cefuroxime axetil: 250-500 mg orally twice daily

and

ciprofloxacin: 750 mg orally twice daily

OR

ciprofloxacin: 750 mg orally twice daily

Consider – symptom relief (for photophobia and anterior chamber reaction)

Back
INITIAL
|
bacterial (presumed): high risk
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

Back
INITIAL
|
bacterial (presumed): high risk
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Bacterial keratitis may be exquisitely painful and pain needs to be adequately addressed. Pain relief may consist of oral acetaminophen, nonsteroidal anti-inflammatory drugs, or opioids.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

ACUTE

bacterial

1st line – empiric antibiotics plus supportive therapies

Back
ACUTE
|
bacterial
|
moderate risk
1st line – 

empiric antibiotics plus supportive therapies

Moderate risk is defined as <2 mm peripheral infiltrate, associated epithelial defect, mild anterior chamber reaction, and moderate discharge.

A topical fluoroquinolone is indicated in these cases.[4]​​​ Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.​[4]​​

Systemic antibiotics are usually not indicated except in high-risk cases (e.g., pending corneal perforation) or gonococcal infection.[4]​ In cases of corneal perforation, intravenous antibiotics (e.g., ceftazidime plus vancomycin) can be used for empiric coverage. If ceftazidime plus vancomycin is not tolerated or is contraindicated, regimens that include a cephalosporin (e.g., cefazolin, cefuroxime) plus a fluoroquinolone such as ciprofloxacin, or ciprofloxacin alone can be considered. The treatment course is typically 3 days.[38] ​When available, culture results should be used to guide the choice of antibiotic agent.

Systemic fluoroquinolone antibiotics such as ciprofloxacin may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[39]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

In the case of gonococcal eye infection, consult with an infectious disease specialist should be considered, as well as appropriate antibiotic therapy. See Gonorrhea infection for more information.

Contact lens wear should be discontinued during therapy.[4]​ If corneal thinning is present, an eye shield should be placed without an eye patch over the involved eye.[1][19]

Primary options

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Secondary options

ceftazidime sodium: 1-2 g intravenously every 8-12 hours, maximum 6 g/day

and

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

More

Tertiary options

cefazolin: 2 g intravenously every 8 hours, maximum 12 g/day

and

ciprofloxacin: 750 mg orally twice daily

OR

cefuroxime axetil: 250-500 mg orally twice daily

and

ciprofloxacin: 750 mg orally twice daily

OR

ciprofloxacin: 750 mg orally twice daily

Consider – symptom relief (for photophobia and anterior chamber reaction)

Back
ACUTE
|
bacterial
|
moderate risk
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

Back
ACUTE
|
bacterial
|
moderate risk
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Bacterial keratitis may be exquisitely painful and pain needs to be adequately addressed. Pain relief may consist of oral acetaminophen, nonsteroidal anti-inflammatory drugs, or opioids.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

1st line – empiric antibiotics plus supportive therapies

Back
ACUTE
|
bacterial
|
low risk
1st line – 

empiric antibiotics plus supportive therapies

Low risk is defined as a nonstaining peripheral infiltrate less than 1 mm in diameter in a noncontact lens wearer.

Broad-spectrum topical antibacterials such as polymyxin B/trimethoprim or a fluoroquinolone are recommended. Topical fluoroquinolones may be used if keratitis is recurrent or if resistance is suspected. Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.​[4]​​

Systemic antibiotics are usually not indicated except in high-risk cases (e.g., pending corneal perforation) or gonococcal infection.​[4]​ In cases of corneal perforation, intravenous antibiotics (e.g., ceftazidime plus vancomycin) can be used for empiric coverage. If ceftazidime plus vancomycin is not tolerated or is contraindicated, regimens that include a cephalosporin (e.g., cefazolin, cefuroxime) plus a fluoroquinolone such as ciprofloxacin, or ciprofloxacin alone can be considered. The treatment course is typically 3 days.[38]​ When available, culture results should be used to guide the choice of antibiotic agent.

Systemic fluoroquinolone antibiotics such as ciprofloxacin may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[39]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions. 

In the case of gonococcal eye infection, consult with an infectious disease specialist should be considered, as well as appropriate antibiotic therapy. See Gonorrhea infection.

Contact lens wear should be discontinued during therapy.​[4]​ If corneal thinning is present, an eye shield should be placed without an eye patch over the involved eye.[1][19]​​​

Primary options

polymyxin B/trimethoprim ophthalmic: (10,000 units/1 mg/mL) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Secondary options

ceftazidime sodium: 1-2 g intravenously every 8-12 hours, maximum 6 g/day

and

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

More

Tertiary options

cefazolin: 2 g intravenously every 8 hours, maximum 12 g/day

and

ciprofloxacin: 750 mg orally twice daily

OR

cefuroxime axetil: 250-500 mg orally twice daily

and

ciprofloxacin: 750 mg orally twice daily

OR

ciprofloxacin: 750 mg orally twice daily

Consider – symptom relief (for photophobia and anterior chamber reaction)

Back
ACUTE
|
bacterial
|
low risk
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

Back
ACUTE
|
bacterial
|
low risk
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Bacterial keratitis may be exquisitely painful and pain needs to be adequately addressed. Pain relief may consist of oral acetaminophen, nonsteroidal anti-inflammatory drugs, or opioids.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

herpetic

1st line – antiviral therapy plus supportive therapies

Back
ACUTE
|
herpetic
|
dendritic or geographic (epithelial) herpetic keratitis
1st line – 

antiviral therapy plus supportive therapies

Herpetic epithelial disease is usually self-limited and treatment is used to shorten the duration of symptoms.

Topical trifluridine, vidarabine, or acyclovir have been shown to shorten the disease duration.​[40] [ Cochrane Clinical Answers logo ] ​ However, vidarabine is no longer manufactured, and acyclovir is seldom used for this indication. For the treatment of herpes simplex virus keratitis, ganciclovir ophthalmic gel has been shown to be at least as effective as acyclovir ointment, but it is better tolerated and results in lower rates of blurred vision, eye irritation, and punctate keratitis.[41] May use oral treatment (e.g., acyclovir) if the patient is intolerant of topical treatments.[40]

Epithelial debridement may be an alternative or adjunctive therapy for small dendrites.[40]

If intraocular pressure is high, as is often the case in herpetic disease, antiglaucoma therapy must be instituted. Prostaglandin analogs are generally avoided in these cases due to theoretical proinflammatory effects.

Contact lens wear should be discontinued during therapy.[4]​ If corneal thinning >50% is present, an eye shield without an eye patch should be placed over the involved eye.[1][19]

Active herpetic disease should be differentiated from a neurotrophic corneal ulcer, a lesion caused by corneal nerve damage and medication toxicity. Neurotrophic corneal ulcers are treated by ceasing toxic medication, lubrication, and patching.[50]

Primary options

ganciclovir ophthalmic: (0.15% gel) 1 drop into the affected eye(s) five times daily (every 3 hours while awake) until ulcer heals, then reduce dose to three times daily for an additional 7 days

OR

trifluridine ophthalmic: (1%) 1 drop into the affected eye(s) every 2 hours (up to nine times daily) for 7-10 days, then taper dose to 1 drop every 4 hours (up to 5 times daily) for an additional 7 days

OR

acyclovir ophthalmic: (3%) apply 0.5 inch of ointment to the affected eye(s) five times daily (every 3 hours) until ulcer heals, then reduce dose to three times daily for an additional 7 days

Secondary options

acyclovir: herpes simplex: 400 mg orally five times daily for 7-10 days; herpes zoster: 800 mg orally five times daily for 7-10 days

Consider – topical polymyxin B/trimethoprim or a fluoroquinolone

Back
ACUTE
|
herpetic
|
dendritic or geographic (epithelial) herpetic keratitis
Consider – 

topical polymyxin B/trimethoprim or a fluoroquinolone

Treatment recommended for SOME patients in selected patient group

If a large epithelial defect is present, a broad-spectrum topical antibiotic such as polymyxin B/trimethoprim, or a fluoroquinolone should be added.

Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.[4]

Primary options

polymyxin B/trimethoprim ophthalmic: (10,000 units/1 mg/mL) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Consider – symptom relief (for photophobia and anterior chamber reaction)

Back
ACUTE
|
herpetic
|
dendritic or geographic (epithelial) herpetic keratitis
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

Back
ACUTE
|
herpetic
|
dendritic or geographic (epithelial) herpetic keratitis
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Herpetic keratitis may be less symptomatic than expected from the clinical picture due to corneal hypoesthesia. If pain relief is required, it may consist of oral acetaminophen, nonsteroidal anti-inflammatory drugs, or opioids.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

1st line – oral antiviral therapy plus topical corticosteroid plus supportive therapies

Back
ACUTE
|
herpetic
|
interstitial or disciform herpetic keratitis
1st line – 

oral antiviral therapy plus topical corticosteroid plus supportive therapies

Interstitial herpetic keratitis and disciform keratitis (endotheliitis) are driven by an inflammatory reaction to viral antigen and require treatment with topical corticosteroids. Active infection may also be present and oral antivirals should be used concurrently.[7]

May use topical loteprednol instead of topical prednisolone in mild cases.

If intraocular pressure is high, as is often the case in herpetic disease, antiglaucoma therapy should be instituted. Prostaglandin analogs are generally avoided in these cases due to theoretical proinflammatory effects.

Contact lens wear should be discontinued during therapy.[4]​ If corneal thinning >50% is present, an eye shield without an eye patch should be placed over the involved eye.[1][19]

If a large epithelial defect is present, and if there is marked inflammation, topical corticosteroids should be replaced by oral corticosteroids.

Active herpetic disease should be differentiated from a neurotrophic corneal ulcer, a lesion caused by corneal nerve damage and medication toxicity. Neurotrophic corneal ulcer should be treated by ceasing toxic medications, lubrication, and patching.[50]

Primary options

acyclovir: herpes simplex: 400 mg orally five times daily for 10-14 days, then decrease to suppression dose indefinitely; herpes zoster: 800 mg five times daily for 10-14 days, then decrease to suppression dose indefinitely

-- AND --

prednisolone sodium phosphate ophthalmic: (1%) 1 drop into the affected eye(s) up to four times daily for 1-3 weeks

or

loteprednol ophthalmic: (0.5%) 1 drop into the affected eye(s) up to four times daily for 1-3 weeks

Secondary options

acyclovir: herpes simplex: 400 mg orally five times daily for 10-14 days, then decrease to suppression dose indefinitely; herpes zoster: 800 mg five times daily for 10-14 days, then decrease to suppression dose indefinitely

and

prednisone: 60 mg orally once daily for 7 days, then taper over the next 7 days

Consider – topical polymyxin B/trimethoprim or a fluoroquinolone

Back
ACUTE
|
herpetic
|
interstitial or disciform herpetic keratitis
Consider – 

topical polymyxin B/trimethoprim or a fluoroquinolone

Treatment recommended for SOME patients in selected patient group

If a large epithelial defect is present, in addition to replacing the topical corticosteroid with an oral corticosteroid, a broad-spectrum topical antibiotic such as polymyxin B/trimethoprim or a fluoroquinolone should be added.

Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.[4]

Primary options

polymyxin B/trimethoprim ophthalmic: (10,000 units/1 mg/mL) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Consider – symptom relief (for photophobia and anterior chamber reaction)

Back
ACUTE
|
herpetic
|
interstitial or disciform herpetic keratitis
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

Back
ACUTE
|
herpetic
|
interstitial or disciform herpetic keratitis
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Herpetic keratitis may be less symptomatic than expected from the clinical picture due to corneal hypoesthesia.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

fungal

1st line – topical or oral antifungal therapy plus supportive therapies

Back
ACUTE
|
fungal
1st line – 

topical or oral antifungal therapy plus supportive therapies

Treatment is generally prolonged and complicated, especially because the diagnosis is often missed initially.

Topical or oral antifungal therapy is recommended. A Cochrane review has found no evidence that any particular antifungal, or combination of antifungals, is more effective in the management of fungal keratitis. Previous studies showed topical natamycin may be superior compared with topical voriconazole.[42] Fungal keratitis with severe inflammation or stromal infiltrate >2 mm or poor response to topical therapy should be treated with systemic antifungal therapy (e.g., itraconazole, voriconazole).[43][44]

If corneal ulcer has re-epithelialized but infiltrate appears active, epithelial debridement may improve drug penetration.

Contact lens wear should be discontinued during therapy.[4]​ If corneal thinning >50% is present, an eye shield should be placed without an eye patch over the involved eye.[1][19]

Primary options

natamycin ophthalmic: (5%) 1 drop into the affected eye(s) every 1-2 hours until clinical and symptomatic improvement (usually 1-3 weeks), then taper slowly

Secondary options

voriconazole ophthalmic: (1%) 1 drop into the affected eye(s) every 1-2 hours until clinical and symptomatic improvement (usually 1-3 weeks), then taper dose slowly

More

OR

amphotericin B ophthalmic: (1.5 mg/mL) 1 drop into the affected eye(s) every 1-2 hours until clinical and symptomatic improvement (usually 1-3 weeks), then taper dose slowly

More

Tertiary options

itraconazole: 200 mg orally once daily until lesion heals, then 100 mg once daily for 5 days, followed by 50 mg once daily for 5 days

OR

voriconazole: 200-400 mg orally twice daily for at least 8 weeks

Consider – topical polymyxin B-based regimen or a fluoroquinolone

Back
ACUTE
|
fungal
Consider – 

topical polymyxin B-based regimen or a fluoroquinolone

Treatment recommended for SOME patients in selected patient group

If a large epithelial defect is present, a broad-spectrum topical antibiotic such as a polymyxin B-based regimen or a fluoroquinolone should be added.

Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.[4]

Primary options

polymyxin B/trimethoprim ophthalmic: (10,000 units/1 mg/mL) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

neomycin/polymyxin B/gramicidin ophthalmic: (1.75 mg/10,000 units/0.025 mg/mL) 1 drop into the affected eye(s) every 30 minutes to 2 hours until clinical and symptomatic improvement (usually 2-3 weeks), then taper dose slowly

OR

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Consider – symptom relief (for photophobia and anterior chamber reaction)

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ACUTE
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fungal
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

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ACUTE
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fungal
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Fungal keratitis can result in severe pain that needs to be adequately addressed. Pain medications consist of oral acetaminophen, nonsteroidal anti-inflammatory drugs, or opioids.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

protozoan (Acanthamoeba)

1st line – antiseptic plus supportive therapies

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ACUTE
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protozoan (Acanthamoeba)
1st line – 

antiseptic plus supportive therapies

Treatment is particularly difficult, long, and controversial due to lack of effective antimicrobial medications and frequent delay in diagnosis.

One or more of the following topical preparations may be tried: polyhexamethylene biguanide or chlorhexidine. These agents are not currently commercially available in all countries and may need to be specially compounded.

If corneal ulcer has re-epithelialized but infiltrate appears active, epithelial debridement may improve drug penetration.

If corneal thinning >50% is present, an eye shield should be placed without an eye patch over the involved eye.[1][19]

Treatment for 2 to 6 months or more is usually required.

Primary options

chlorhexidine ophthalmic: (0.02%) 1 drop into the affected eye(s) every 30 minutes to 2 hours until clinical and symptomatic improvement (usually 2-3 weeks), then taper dose slowly

OR

polyhexamethylene biguanide ophthalmic: (0.02%) 1 drop into the affected eye(s) every 30 minutes to 2 hours until clinical and symptomatic improvement (usually 2-3 weeks), then taper dose slowly

Consider – topical polymyxin B-based regimen or a fluoroquinolone

Back
ACUTE
|
protozoan (Acanthamoeba)
Consider – 

topical polymyxin B-based regimen or a fluoroquinolone

Treatment recommended for SOME patients in selected patient group

If a large epithelial defect is present, a broad-spectrum topical antibiotic such as a polymyxin B-based regimen or a fluoroquinolone should be added.

Older generation topical fluoroquinolones (e.g., ofloxacin, levofloxacin) are not usually used unless fourth-generation topical fluoroquinolones (e.g., gatifloxacin, moxifloxacin, besifloxacin) are unavailable.[4]

Primary options

polymyxin B/trimethoprim ophthalmic: (10,000 units/1 mg/mL) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

neomycin/polymyxin B/gramicidin ophthalmic: (1.75 mg/10,000 units/0.025 mg/mL) 1 drop into the affected eye(s) every 30 minutes to 2 hours until clinical and symptomatic improvement (usually 2-3 weeks), then taper dose slowly

OR

gatifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

moxifloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

besifloxacin ophthalmic: (0.6%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

ofloxacin ophthalmic: (0.3%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

OR

levofloxacin ophthalmic: (0.5%) 1 drop into the affected eye(s) every 1-6 hours until clinical and symptomatic improvement (usually 4-10 days), then taper slowly

Consider – oral itraconazole or oral/topical voriconazole

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ACUTE
|
protozoan (Acanthamoeba)
Consider – 

oral itraconazole or oral/topical voriconazole

Treatment recommended for SOME patients in selected patient group

Oral itraconazole or topical or systemic voriconazole are often added in severe or recalcitrant cases. The duration of treatment depends on response to therapy and may last 1 to 4 weeks or even longer.[46][47][48]

Primary options

itraconazole: 200 mg orally once daily until lesion heals, then 100 mg once daily for 5 days, followed by 50 mg once daily for 5 days

OR

voriconazole: 200-400 mg orally twice daily for at least 8 weeks

OR

voriconazole ophthalmic: (1%) 1 drop into the affected eye(s) every 30 minutes to 2 hours until clinical and symptomatic improvement (usually 2-3 weeks), then taper dose slowly

More

Consider – symptom relief (for photophobia and anterior chamber reaction)

Back
ACUTE
|
protozoan (Acanthamoeba)
Consider – 

symptom relief (for photophobia and anterior chamber reaction)

Treatment recommended for SOME patients in selected patient group

Cycloplegic drops paralyze the ciliary muscles thus dilating the eye, provide pain relief by preventing ciliary spasm and prevent posterior synechiae in cases of severe anterior chamber reaction.

Primary options

atropine ophthalmic: (1%) 1-2 drops into the affected eye(s) up to four times daily

OR

homatropine ophthalmic: (2% or 5%) 1-2 drops into the affected eye(s) every 3-4 hours

Consider – pain relief

Back
ACUTE
|
protozoan (Acanthamoeba)
Consider – 

pain relief

Treatment recommended for SOME patients in selected patient group

Acanthamoeba keratitis may be particularly painful due to the characteristic corneal perineuritis.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

Tertiary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required

noninfectious keratitis

1st line – ophthalmology referral

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ACUTE
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noninfectious keratitis
1st line – 

ophthalmology referral

Many of the noninfectious keratitides are treated with topical or systemic corticosteroids. However, corticosteroids are only appropriate under the care of an ophthalmologist who is following the patient very closely.

Patients with severe autoimmune keratitis associated with systemic disease may need systemic immunomodulating therapies to control their disease under the care of a uveitis specialist or a rheumatologist.

Peripheral ulcerative keratitis can be rapidly progressive and may lead to perforation of the globe requiring emergent surgical intervention. Marginal keratitis is a self-limiting condition.[49]​ Symptomatic relief may include ocular lubricants and oral analgesia, use of sunglasses for photophobia and regular lid hygiene for associated blepharitis. Referral to an ophthalmologist may be appropriate for consideration of topical antibiotics (to reduce bacterial load) and topical steroids.​

Neurotrophic keratitis is characterized by absence of corneal sensitivity that renders the corneal surface vulnerable to occult injury and decreased reflex tearing. Cenegermin is a recombinant human nerve growth factor formulated as an eye drop that has received marketing authorization in Europe and the US for the treatment of neurotrophic keratitis.

Persistent neurotrophic keratitis may lead to the formation of a neurotrophic corneal ulcer. Active herpetic disease should be differentiated from a neurotrophic corneal ulcer. Neurotrophic corneal ulcers are treated by ceasing toxic medication, lubrication, and patching.[50]

Primary options

cenegermin (recombinant) ophthalmic: (0.002%) 1 drop into the affected eye(s) six times daily (every 2 hours) for 8 weeks

ONGOING

recurrent herpetic infection

1st line – antiviral therapy

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ONGOING
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recurrent herpetic infection
1st line – 

antiviral therapy

Patients with recurrent episodes of herpetic infection may benefit from prophylactic antivirals such as acyclovir. For the treatment of herpes simplex virus keratitis, ganciclovir ophthalmic gel has been shown to be at least as effective as acyclovir ointment, but it is better tolerated and results in lower rates of blurred vision, eye irritation, and punctate keratitis.[41]

corneal scarring impairing vision

1st line – topical corticosteroid

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ONGOING
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corneal scarring impairing vision
1st line – 

topical corticosteroid

Topical corticosteroids may minimize corneal scarring that occurs due to stromal inflammation once the infection is controlled, in a small subgroup of patients.

In bacterial corneal ulcers, adjunctive treatment with topical corticosteroids does not provide benefit to the majority of patients in terms of improved visual acuity, infiltrate or scar size, time to re-epithelialization, and corneal perforation.[33][34] However, a small subgroup of patients with vision of counting fingers or worse, and those with large, central corneal ulcers may benefit from topical corticosteroid use with improvement in visual acuity. In Nocardia ulcers, corticosteroids may be associated with poorer outcomes.[35][36]

Fungal keratitis should prompt more caution and the use of a topical ophthalmic should be delayed until the inflammatory infiltrate appears inactive.

In Acanthamoeba keratitis, use of topical corticosteroids is controversial due to the ability of the pathogen to enter a cystic phase resistant to most medications. The cysts can survive for months and may be reactivated by corticosteroids.

Treatment is generally continued until no change in the scar appearance is observed.

Primary options

prednisolone sodium phosphate ophthalmic: (1%) 1 drop into the affected eye(s) up to three times daily for 1-6 weeks

OR

loteprednol ophthalmic: (0.5%) 1 drop into the affected eye(s) up to three times daily for 1-6 weeks

2nd line – surgery

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ONGOING
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corneal scarring impairing vision
2nd line – 

surgery

Superficial scarring may be corrected with laser surgery (phototherapeutic keratectomy).

Severe scarring requires corneal transplantation (penetrating keratoplasty).​

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