This handout is for infectious keratitis (corneal ulcer). Your care team identified this based on: painful red eye with a visible corneal opacity / white infiltrate ± epithelial defect on fluorescein — the defining microbial-keratitis presentation (aao bacterial keratitis ppp (2018) pmid 30366799; ung surv ophthalmol 2019 pmid 30590103).
Other reasons your team may use this plan: contact-lens wearer with an acute painful red eye — keratitis until excluded; pseudomonas-skewed bacterial / acanthamoeba risk (stapleton ophthalmology 2008 pmid 18538404; carnt ophthalmology 2022 pmid 35952937); corneal trauma with vegetative / organic matter (branch, plant, crop, soil) — filamentous fungal keratitis prior, esp. warm climate (prajna mutt i jama ophthalmol 2013 pmid 23710492; ung 2019 pmid 30590103); prior herpetic eye disease, current dendritic ulcer, or zoster vesicular rash in v1 (hutchinson sign) — herpetic keratitis pathway (heds nejm 1998 pmid 9696640).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| corneal_scrape_smear_and_culture_before_empiric_therapy | — | — | — | Ung Surv Ophthalmol 2019 PMID 30590103 + AAO Bacterial Keratitis PPP (2018) PMID 30366799 — scrape/culture BEFORE broad empiric fortified antibiotics for significant ulcers; gold-standard stain+culture, low yield so directed sampling matters; small peripheral non-vision-threatening ulcer is the explicit empiric-monotherapy exception |
| moxifloxacin | 1 drop | topical | q1h around-the-clock then taper | AAO Bacterial Keratitis PPP (2018) PMID 30366799 — fluoroquinolone monotherapy is non-inferior to fortified for non-severe bacterial keratitis; hourly loading then taper |
| ciprofloxacin (ophthalmic) | 1 drop | topical | q1h around-the-clock then taper | AAO Bacterial Keratitis PPP (2018) PMID 30366799 — antipseudomonal fluoroquinolone; preferred when contact-lens Pseudomonas risk |
| fortified_vancomycin_plus_fortified_tobramycin_compounded | — | — | — | AAO Bacterial Keratitis PPP (2018) PMID 30366799 — fortified vancomycin (~25-50 mg/mL) + fortified tobramycin/ceftazidime (~14 mg/mL) compounded, alternating hourly, for severe/central/vision-threatening or culture-directed Gram-positive+Gram-negative cover (compounded — no single stable RxCUI) |
Plan: Sight-threatening corneal ulcer — pathogen-stratified intensive topical ladder
Call 911 or go to the nearest emergency room right away if you have:
Taper topical therapy with re-epithelialisation; manage residual scar / irregular astigmatism affecting acuity (corneal-scar density + irregular astigmatism are the dominant residual-VA drivers — Menda JAMA Ophthalmol 2020 PMID 31804657) with rigid-lens trial / referral for optical or therapeutic keratoplasty. HERPETIC: long-term oral aciclovir 400 mg BID ×12 mo prophylaxis halves recurrence, esp. stromal (HEDS NEJM 1998 PMID 9696640). CONTACT-LENS: hygiene re-education (no overnight wear, no water exposure, replace case, switch to daily disposables) — the dominant preventable driver (Stapleton Ophthalmology 2008 PMID 18538404; Carnt Ophthalmology 2022 PMID 35952937). Counsel contralateral-eye risk.
Guideline: AAO Preferred Practice Pattern — Bacterial Keratitis (2018, Ophthalmology 126(1):P1-P55, PMID 30366799) + SCUT Steroids for Corneal Ulcers Trial (Srinivasan, Arch Ophthalmol 2012, PMID 21987582) + MUTT I natamycin vs voriconazole (Prajna, JAMA Ophthalmol 2013, PMID 23710492) + MUTT II oral voriconazole (Prajna, JAMA Ophthalmol 2016, PMID 27787540) + HEDS Acyclovir Prevention Trial (NEJM 1998, PMID 9696640) + Ung microbial-keratitis global-burden review (Surv Ophthalmol 2019, PMID 30590103) + Stapleton / Carnt contact-lens & Acanthamoeba keratitis epidemiology