Table 1. Episcleritis vs. Scleritis

 

Episcleritis

Scleritis

Distribution

More commonly sectoral

Can be sectoral or diffuse

Pain

None or mild

Deep, severe, boring

Change with 2.5% phenylephrine

Injected vessels blanch

Injected vessels do not blanch

Qtip test

Injected vessels can be moved with a Q tip

Injected vessels cannot be moved with a Q tip

 

 

Table 2. Viral vs. Bacterial Conjunctivitis

 

 

Viral Conjunctivitis

Bacterial Conjuncitivitis

Discharge

Watery, mucous

Purulent

Conjunctival pathology

Follicles

Papillae

Preauricular adenopathy

Common

Uncommon

Itching

Common

Less Common

 

 

 Table 3.  Treatment of Selected Ocular Diseases

 

Disease

Treatment

Fungal corneal ulcers

Natamycin 5% drops or Amphotericin B 0.15% drops initially every 1 -2 hours with a slow taper over weeks once infection is controlled.  Topical steroids should be avoided.  Consider adding oral fluconazole or voricanazole in severe cases.

Acanthamoeba corneal ulcers

Polyhexamethyl biguanide 0.02%, Chlorhexidine 0.02%, or Propamidine isethionate 0.1% drops every hour.  Discontinue contact lens wear.

Herpes Simplex epithelial keratitis

Trifluorothymidine 1% drops 9 times per day with tapering as lesions heal over 14 days; subsequent prophylaxis with oral acyclovir 400 mg BID

Herpes Zoster ophthalmicus

Intravenous acyclovir 30 mg/kg/day in 3 doses, for 7 10 days in severely immuncompromised individuals.  Famiciclovir 500mg PO TID or Valacyclovir 1g TID in immunocompetent patients or reliable, immunocompromised patients with less severe disease.  Bacitracin ointment to skin lesions.

Immune-recovery uveitis associated with healed CMV retinitis

Topical prednisolone acetate with frequency depending on severity. Periocular steroid injection for visually symptomatic cystoid macular edema or vitritis. Avoid intravitreal injection of triamcinolone acetonide.

Necrotizing herpetic retinitis

Intravenous acyclovir 1,500 mg/m2 of body surface area in three divided doses for 7 10 days (associated with high rate of failure); consider addition of foscarnet to improve efficacy.

Intravenous foscarnet and/or ganciclovir if no response to acyclovir, or patient judged to be severely immunocompromised; complete induction courses of both drugs, then place on maintenance therapy with oral valacyclovir or valganciclovir.

Adjunctive local therapy for severe disease: Intravitreal injections of ganciclovir 2.0 mg and/or foscarnet 1.2 to 2.4 mg three times per week for two weeks, then once or twice per week until lesions healed

Toxoplasmosis chorioretinitis

Oral pyrimethamine 200 mg load then 25 mg BID, sulfadiazine 2 g load then 1 g QID, clindamycin 300 mg QID, folinic acid 10 mg twice weekly or 5 mg daily, for 4 to 6 weeks.

Alternatives: 1) Oral trimethoprim-sulfamethoxazole DS plus clindamycin 300 mg QID for 4 to 6 weeks. 2) Oral atovaquone 750 mg TID, clarithromycin 500 mg BID for 4 to 6 weeks (sulfa-intolerant patients or those who are uncontrolled on clindamycin or clindamycin plus pyrimethamine).

Pneumocystis choroiditis

Intravenous trimethoprim (5 mg/kg)/ sulfamethaxazole (25 mg/kg) Q 8 hours for 3 weeks or intravenous pentamidine 4 mg/kg daily.

Syphilitic chorioretinitis

Intravenous aqueous penicillin G 24 million units per day for ten days.  Alternative: intramuscular procaine penicillin G 2.4 million units per day for ten days; must be given with oral probenecid 500 mg QID. Intravenous treatment preferred in HIV infection.

Tuberculous choroiditis

Oral isoniazid 300 mg daily, rifampin 300 mg BID, ethambutol 15 mg/kg daily, or other three or four drug regimen.

Bartonella retinitis

Oral doxycycline 100 mg BID and rifampin 300 mg BID for 4 - 6 weeks.

Bacterial endophthalmitis

Intravitreal injection of vancomycin 1 mg and ceftazidime 2.25 mg. Treatment of underlying infection if endogenous endophthalmitis.

Fungal endophthalmitis

Local: Intravitreal injection of amphotericin 5 micrograms or voriconazole 100 micrograms usually at the time of pars plana vitrectomy to clear vitreous fungal colonies.

Systemic: Oral fluconazole 200 to 400 mg daily or intravenous amphotericin in escalating doses. Alternative:  voriconazole 200 mg PO BID

Intraocular lymphoma

High-dose intravenous methotrexate with or without radiation therapy.

Intrathecal chemotherapy for CNS involvement.

Salvage therapy with intravitreal injection of methotrexate 400 micrograms weekly X 4, then monthly for one year, for sight-threatening disease.

 

 

Table 4.  Treatment of CMV Retinitis: Dosing and Toxicities

Drug

Induction

Maintenance

Safety

 Monitoring

Toxicities/Comments

 

 

 

 

 

Ganciclovir, Intravenous

 

5 mg/kg IV BID for 2-3 weeks

 

5 mg/kg IV daily

 

CBC, creatinine

Hematologic toxicity.  Dosage adjustment for reduced creatinine clearance.

Ganciclovir Intraocular Device

May be used for induction.  Releases 1.4 g/hour.

Drug delivery lasts for 6-8 months. 

Ocular exams

Systemic antiviral often used perioperatively and during maintenance

Valganciclovir, Systemic

900 mg PO BID for 3 weeks

900 mg PO daily

CBC, creatinine

Hematologic toxicity.  Dosage adjustment for reduced creatinine clearance.

Foscarnet, Systemic

60 mg/kg IV TID or 90 mg/kg BID for 2-3 weeks

90 120 mg/kg IV daily

Creatinine, BUN, Ca++, Mg++

Nephrotoxicity, electrolyte imbalance

Cidofovir, Systemic

5 mg/kg IV Q week X 2 weeks

3-5 mg/kg IV Q 2 weeks

Creatinine, BUN, CBC

Nephrotoxicity, hematologic toxicity, uveitis.  Pre- and post-infusion probenecid 500 mg PO QID.

Ganciclovir, Intraocular Injection

200 to 2000 g/0.1 mL 2 3 times per week for 2 3 weeks

200-2000 g/0.1 mL one time per week

Ocular exams

Off-label use

Foscarnet, Intraocular Injection

1.2 to 2.4 mg/0.1 mL 2 3 times per week

1.2 2.4 mg/.05 or .1 mL 1 time per week

Ocular exams

Off-label use