11.1 Conjunctivitis & Keratitis
| Type of Infection | First Line (with Dosage and Duration) |
Alternative First Line (with dosage and Duration) |
Comments |
|---|---|---|---|
| Allergic (reaction is secondary to allergens such as pollen) | Cool compresses and artificial tears help in relieving discomfort. Topical and systemic anti- histaminics. Topical mast-stabilizers. Topical NSAIDs (Ketorolac 0.5%/ Flurbiprofen 0.03% w/v). Persistent allergic conjunctivitis may also require topical steroid eye drops (Topical steroids in short pulses-(1-2 weeks or longer):Lower potency steroids - Loteprednol/ Fluorometholone) Duration: Topical mast cell stabiliser eye drops are given for from a few days to at least 4-6 weeks depending on resolution of symptoms and signs | Topical glucocorticoids for refractory symptoms: Prednisolone acetate 1%/ Prednisolone sodium phosphate 1% Duration: Few days to weeks (For 3-4 weeks with gradual shifting to a steroid sparing agent), depending on resolution of clinical signs | NSAIDS and antihistamines to be considered as first line agents in milder cases. Opinion with ENT specialist/pulmon ologist to be taken in view of accompanying systemic symptoms. |
| Bacterial Conjunctivitis: starts commonly with one eye then both eyes stick with mucopurulent discharge | Chloramphenicol eye drops 6 hrly for 5 to 7 days Or Gentamicin 0.3% 6 hrly for 5 days Intensive instillation every 15 to 30 minutes until symptoms and signs are reduced, and then gradually taper | Ciprofloxacin eye drops q12h for 5-7 days Or Gatifloxacin 0.3% eye drops Dose: 1-2 drops every 2h during the first 2 days, then every 4-8hrs Duration: 7 days | Lid hygiene. Protective glasses Patient education regarding likelihood of transmission to others. If Contact lens associated & Pseudomonas spp. keratoconjunctivit is suspected- Gentamicin 14 mg/ml 1 drop 1 hrly or Tobramycin fortified e/d 1.3 % 1 drop 1 hrly (Contact lens solution to be sent for microbiological testing with cultures). Duration: 15 days. Steroid use with antibiotics is controversial as studies report mixed results in reducing corneal scarring. Conjunctival swab to be sent for Gram stain and culture. |
| Ophthalmia neonatorum | Ceftriaxone 50 mg/kg IM single dose | Azithromycin 20 mg/kg OD x 3 days | For prevention of both chlamydia and gonococcal ophthalmia: Erythromycin 0.5 % eye ointment / tetracycline 1% eye ointment to be applied in both eyes soon after birth. Conjunctival swab for Gram stain/ culture to be sent. Parents to be tested for evidence of Gonorrhoea. |
| Trachoma | Tetracycline 1 % eye ointment Or Erythromycin 0.5 % eye ointment + Azithromycin 20 mg/kg/dose in a child or Azithromycin 1g single dose in adult. | Adult: Doxycycline 100 mg BD for 21 days Or Tetracycline 250 mg QID for 14 days | India has been declared trachoma free by WHO in 2024. Ceftriaxone not to be given in neonates receiving calcium containing fluids. Avoid in infants with hyperbilirubinemi a. Wherever NAAT confirmation is not possible, treat for both Chlamydia and Gonococcus. |
| Viral Conjunctivitis (commonly both eyes together with watery discharge) | Antibiotics should not be routinely prescribed. Eyelid hygiene should be explained. Lubricating eye drops. Antibiotics administered if there is evidence of secondary bacterial infection: Gentamicin eye drops 0.3 % w/v QID for 1week May add - Topical Ganciclovir 0.15% gel 1 drop 5 times a day for 3 days and then 3 times daily for 1 week in severe cases | Acyclovir 800 mg PO 5 times a day for 7 to 10 days Or Famciclovir 500 mg PO 3 times a day | Inform patients about ways to maintain hygiene to prevent transmission of infection to others. |
| Bacterial Keratitis | Size of ulcer < 3 mm and not involving centre visual axis: Moxifloxacin eye drops 1 hrly for first 48hrs and then reduce as per response Size of ulcer > 3 mm or involving centre visual axis or non- resolving keratitis on single antibiotic within 48 hours: Cefazolin eye drops 5% 1 hrly Or Tobramycin eye drops 1.3% 1 hrly | Size of ulcer <3 mm and not involving centre visual axis: Gatifloxacin eye drops Or Levofloxacin eye drops Or Besifloxacin eye drops Or Ceftazidime eye drops 5% 1 hrly | Oral fluoroquinolones (Ciprofloxacin/ Moxifloxacin) maybe added in corneal ulcers over 5 mm in size or >50% deep accompanied with limbal involvement/ perforated ulcer or following keratoplasty. Corneal scrapings to be sent for microbiological testing (Gram stain/ KOH/cultures). Once the culture results are available after 48 to 72 hours, the treatment must be switched to targeted antibacterial therapy. Duration of therapy: Few weeks to months, depending on resolution of signs and symptoms until ulcer heals. |
| Viral Keratitis HSV is the most common cause of viral keratitis | |||
| Epithelial | Eye ointment Acyclovir 3% 5 times per day for 2 weeks | Topical Ganciclovir 0.15% gel 1 drop 5 times a day for 3 days and then 3 times daily for 1 week | Oral antiviral needed if associated stromal/endotheli al involvement or in recurrent episodes. Diagnosis predominantly clinical. |
| Stromal | Tab. Acyclovir (10-20 mg/kg/day in 5 divided doses in < 18 years; 30 mg/kg/day in 5 divided doses for > 18 years) 400 mg 5 times per day for 2 weeks Eye drop Prednisolone acetate 6 times per day along-with eye drop Moxifloxacin QID Eye drop Homatropine 2 % TDS | Tab. Valacyclovir 1g TDS or 60 mg/kg/day in 2 to 18 years in 3 divided doses | |
| Endothelial | Tab Acyclovir 400 mg 5 times per day for 2 weeks Eye drop Prednisolone acetate 6 times per day along with eye drop Moxifloxacin QID Eye drop Homatropine 2 % TDS | ||
| VZV (Varicella Zoster Ophthalmicus/Her pes zoster ophthalmicus) | Tab Acyclovir 800 mg 5 times in a day for 2 weeks Eye drop: Ciprofloxacin/Gentamicin QID (Antibiotics to be administered if evidence of secondary bacterial infection) | Tab Valacyclovir 1g TDS for 2 weeks Eye drop Moxifloxacin QID | |
| Fungal Keratitis: Aspergillus, Fusarium, Candida species | Natamycin: first line treatment For filamentous fungi: Natamycin 5% Eye drops half hrly for the first two days after which it is reduced to one drop every hour. Further reduction based on response to treatment. Based on response to treatment and clinical course over 48-72 hours and no results coming on culture, decision to add another topical antifungal agent is to be taken. In resistant cases or poor response to Natamycin- Voriconazole to be used alone or in combination with Natamycin. For Candida spp., Aspergillus spp., Scedosporium spp., Fusarium spp., and Paecilomyces spp.: Voriconazole eye drops (1 mg/ml) q1h, then tapered over 4-6 weeks Amphotericin B 0.15% eye drops (Good activity against Aspergillus and Candida) : initially q1-2h, then tapered over 4-6 weeks. (For cases not responding to topical Natamycin, first line choice for Candida) Atropine 1% eye ointment or Homatropine eye drops 2 % BD to be added as cycloplegics Duration: 4 weeks Corneal scraping to be sent at presentation Debridement- Every 48 hours Systemic antifungal therapy: Large corneal ulcers reaching the limbus, severe deep keratitis or if ulcer is associated with scleritis/endophthalmitis or patients being considered for keratoplasty: Oral fluconazole 200 mg OD Or Voriconazole 200 mg BD for 4 to 6 weeks | Diagnosis based on clinical presentation, history of trauma with vegetative matter. Corneal scraping to be sent for Gram stain/KOH test with culture/sensitivity |
For common etiological agents of Conjunctivitis & Keratitis, see Annexure B.11.1
Additional Information
- Eye discomfort caused by inflammation or infection of the conjunctiva of viral or bacterial conjunctivitis can be alleviated by applying cold compresses to the affected eyes.
- Trachoma is a form of chronic Chlamydiaconjunctivitis. It is the leading cause of preventable blindness in the world.
References
1. Azari AA, Arabi A. Conjunctivitis: A Systematic Review. J Ophthalmic Vis Res. 2020 Aug 6;15(3):372-395. doi: 10.18502/jovr. v15i3.7456.
2. Cabrera-Aguas M, Khoo P, Watson SL. Infectious keratitis: A review. Clin Exp Ophthalmol. 2022 Jul;50(5):543-562. doi: 10.1111/ceo.14113.
3. Koganti R, Yadavalli T, Naqvi RA, Shukla D, Naqvi AR. Pathobiology and treatment of viral keratitis. Exp Eye Res. 2021 Apr; 205:108483. doi: 10.1016/j.exer.2021.
4. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO.Available from: https://www.who.int/publications/i/item/9789240062382