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ophtho.microbial-keratitis.core.v1PRODUCTION
ophtho.microbial-keratitis.core.v1

Infectious keratitis (corneal ulcer)

general_internal_medicineacutesubacuteadultpediatric
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Detailed

Frame as a SIGHT-THREATENING established corneal ulcer requiring pathogen-stratified work-up + intensive topical therapy — NOT undifferentiated red-eye triage (that is ophtho.acute-red-eye.core.v1, which routes here). The four-pathogen partition (bacterial / fungal / Acanthamoeba / herpetic) and the scrape-before-empiric / no-patch / no-empiric-steroid spine are set here. Perforation → endophthalmitis is recognised then routed OUT.

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definitive-keratitis scope confirmed; upstream-triage and endophthalmitis concerns delineated by engine_id

Patient inputs (16)

Contact-lens wear is THE dominant microbial-keratitis risk factor and shifts the pathogen prior to Pseudomonas / Acanthamoeba; overnight wear, water exposure, poor case hygiene each escalate risk (Stapleton Ophthalmology 2008 PMID 18538404; Carnt Ophthalmology 2022 PMID 35952937)

Vegetative / agricultural / organic-matter trauma is the dominant filamentous-fungal prior; metallic/abrasive trauma reframes toward bacterial (Prajna MUTT I 2013 PMID 23710492; Ung 2019 PMID 30590103)

Tap-water / shower / pool / hot-tub exposure while wearing lenses is the strongest Acanthamoeba pointer; pain-out-of-proportion + this history demands amoebic work-up (Carnt Br J Ophthalmol 2018 PMID 30232172)

Prior HSV keratitis / recurrent dendrites / V1 zoster shifts the prior to herpetic and gates the STEROID and ANTIVIRAL decisions (HEDS NEJM 1998 PMID 9696640)

Pain markedly out of proportion to slit-lamp signs is the cardinal Acanthamoeba discriminator; pain proportional/less than signs favours bacterial/fungal (Carnt Br J Ophthalmol 2018 PMID 30232172)

Feathery margins + satellite lesions + endothelial plaque → fungal; dense suppurative + mucopurulent → bacterial; ring infiltrate / radial perineuritis → Acanthamoeba; branching dendrite → HSV (AAO Bacterial Keratitis PPP (2018) PMID 30366799; Prajna MUTT I 2013 PMID 23710492)

Overlying epithelial defect (staining) + stromal infiltrate defines a corneal ulcer; a branching terminal-bulb dendrite favours HSV; pseudodendrite favours VZV (AAO Bacterial Keratitis PPP (2018) PMID 30366799)

Baseline best-corrected acuity per eye is the primary outcome anchor and a SCUT subgroup modifier (counting-fingers-or-worse benefits from later steroid) (Srinivasan SCUT 2012 PMID 21987582)

Smear (Gram/Giemsa/KOH/calcofluor) + culture (blood/chocolate/Sabouraud/non-nutrient agar with E. coli for Acanthamoeba) BEFORE broad empiric therapy for significant ulcers — the diagnostic spine (Ung Surv Ophthalmol 2019 PMID 30590103; AAO Bacterial Keratitis PPP (2018) PMID 30366799)

Hypopyon / dense AC reaction marks a severe/virulent ulcer (Pseudomonas, Streptococcus, fungal) and raises the perforation/endophthalmitis prior — drives admission + scrape (AAO Bacterial Keratitis PPP (2018) PMID 30366799)

Ulcer ≥ ~3 mm, central, or with deep stromal involvement defines a vision-threatening ulcer mandating scrape/culture and intensive therapy; baseline severity predicts SCUT steroid subgroup benefit (Srinivasan SCUT Arch Ophthalmol 2012 PMID 21987582)

Descemetocele / frank perforation / Seidel-positive leak is a surgical emergency and an endophthalmitis route-out (recognised, not managed here) (AAO Bacterial Keratitis PPP (2018) PMID 30366799)

In-vivo confocal microscopy / PCR for Acanthamoeba cysts and fungal hyphae when smear/culture negative but disease atypical or non-resolving (Carnt Br J Ophthalmol 2018 PMID 30232172)

Immunosuppression, prior keratoplasty, dry-eye / neurotrophic / chronic ocular-surface disease broaden the pathogen spectrum (Candida, atypical) and worsen prognosis (Ung Surv Ophthalmol 2019 PMID 30590103)

Antiviral / antifungal systemic-safety gating (oral voriconazole teratogenic; valaciclovir/aciclovir pregnancy category considerations) (Prajna MUTT II JAMA Ophthalmol 2016 PMID 27787540)

Renal dosing for systemic antiviral (aciclovir/valaciclovir) and systemic antifungal where used (HEDS NEJM 1998 PMID 9696640; Prajna MUTT II 2016 PMID 27787540)

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Severity triggers (8)

8 need judgement
  • informationallife_threateningimpending_or_actual_corneal_perforation
    Descemetocele, frank perforation, or Seidel-positive aqueous leak in an infected cornea (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningendophthalmitis_extension
    Worsening intraocular inflammation, vitritis, hypopyon out of proportion to a deepening ulcer — keratitis-to-endophthalmitis progression (Ung Surv Ophthalmol 2019 PMID 30590103)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacanthamoeba_suspected
    Severe pain out of proportion to signs, ring infiltrate / radial perineuritis, contact-lens wearer with water exposure, or an HSV-mimic failing antiviral (Carnt Br J Ophthalmol 2018 PMID 30232172)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefungal_keratitis_suspected
    Feathery-margined infiltrate, satellite lesions, endothelial plaque, hypopyon, or vegetative/organic-matter trauma in a warm climate (Prajna MUTT I JAMA Ophthalmol 2013 PMID 23710492)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecentral_or_large_vision_threatening_ulcer
    Ulcer central, ≥3 mm, deep stromal, or with hypopyon — high perforation/scar/vision-loss risk; counting-fingers-or-worse baseline acuity is the SCUT steroid-benefit subgroup (Srinivasan SCUT Arch Ophthalmol 2012 PMID 21987582)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecontact_lens_pseudomonas_ulcer
    Rapidly destructive, dense suppurative, mucopurulent ulcer in a contact-lens wearer — Pseudomonas-skewed bacterial keratitis (Stapleton Ophthalmology 2008 PMID 18538404)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenon_resolving_on_empiric_therapy
    No improvement or worsening infiltrate / epithelial defect at 48-72 h despite appropriate empiric therapy (Ung Surv Ophthalmol 2019 PMID 30590103)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateherpetic_keratitis_steroid_and_antiviral_gate
    Branching terminal-bulb dendrite / pseudodendrite + V1 zoster rash + Hutchinson sign / prior HSV / reduced corneal sensation (HEDS NEJM 1998 PMID 9696640)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Sight-threatening corneal ulcer — pathogen-stratified intensive topical ladder
axis: microbial_keratitis_pathogen_stratified_topicalstep 1 - Step 1 — Scrape/culture FIRST, then empiric broad fortified / fluoroquinolone HOURLY
Selected step "Step 1 — Scrape/culture FIRST, then empiric broad fortified / fluoroquinolone HOURLY" — Significant / central / ≥3 mm / atypical / non-resolving ulcer, pathogen not yet known; scrape + smear + culture obtained before empiric therapy started (small peripheral non-vision-threatening ulcer may go straight to monotherapy fluoroquinolone without scrape per AAO PPP)
  • corneal_scrape_smear_and_culture_before_empiric_therapy
    first line
    diagnostic_gate
    triggers: significant_ulcer, central_or_large, atypical_or_non_resolving
    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
    first line
    topical_4th_gen_fluoroquinolone
    1 drop • topical • q1h around-the-clock then taper
    triggers: empiric_bacterial, small_peripheral_monotherapy, community_bacterial
    AAO Bacterial Keratitis PPP (2018) PMID 30366799 — fluoroquinolone monotherapy is non-inferior to fortified for non-severe bacterial keratitis; hourly loading then taper
    rxcui 139462
  • ciprofloxacin (ophthalmic)
    first line
    topical_fluoroquinolone
    1 drop • topical • q1h around-the-clock then taper
    triggers: empiric_bacterial, pseudomonas_cover
    AAO Bacterial Keratitis PPP (2018) PMID 30366799 — antipseudomonal fluoroquinolone; preferred when contact-lens Pseudomonas risk
    rxcui 2551
  • fortified_vancomycin_plus_fortified_tobramycin_compounded
    first line
    fortified_topical_antibiotic
    triggers: severe_or_central_ulcer, hypopyon, gram_positive_plus_gram_negative_cover
    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)

ed playbook — drug actions (5)

  1. 1. corneal scrape + smear + culture (significant ulcer) BEFORE empiric therapy
    diagnostic • corneal • once
    trigger: Central / ≥3 mm / atypical / non-resolving ulcer (Ung Surv Ophthalmol 2019 PMID 30590103)
    Scrape-before-broad-empiric is the diagnostic spine
  2. 2. moxifloxacin (empiric topical, non-severe / small peripheral)
    rxcui 139462
    1 drop • topical • q1h around-the-clock
    trigger: Empiric bacterial cover after scrape (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
    Fluoroquinolone monotherapy non-inferior for non-severe bacterial keratitis
  3. 3. fortified vancomycin + tobramycin (severe/central/hypopyon) — compounded
    fortified • topical • alternating q1h
    trigger: Severe / central / vision-threatening or culture-directed (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
    Broad fortified Gram-positive+Gram-negative cover for severe ulcers
  4. 4. natamycin 5% (suspected/confirmed filamentous fungal)
    rxcui 7268
    1 drop • topical • q1h around-the-clock
    trigger: Feathery margins / satellites / vegetative trauma (Prajna MUTT I 2013 PMID 23710492)
    Topical natamycin superior to voriconazole for filamentous (esp. Fusarium)
  5. 5. oral aciclovir (HSV/HZO) — debride dendrite
    rxcui 281
    400 mg (HSV) / 800 mg (VZV) • PO • 5×/day
    trigger: Dendrite / prior HSV / V1 zoster (HEDS NEJM 1998 PMID 9696640)
    Antiviral for herpetic keratitis; NO empiric steroid

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Infectious keratitis (corneal ulcer)** (ophtho.microbial-keratitis.core.v1).
Phenotype framing: Terminal differential with pivot findings: microbial keratitis vs corneal abrasion (epithelial defect WITHOUT stromal infiltrate / no AC reaction pivot — route back to ophtho.corneal-abrasion.core.v1); vs sterile / marginal infiltrate (small, peripheral, sub-epithelial, intact epithelium, lid-margin staph hypersensitivity, minimal pain pivot); vs recurrent corneal erosion (recurrent on-waking pain, prior abrasion, no infiltrate pivot); Acanthamoeba vs HSV stromal (pain-out-of-proportion + ring + lens-in-water vs dendrite + prior HSV + reduced corneal sensation pivot); vs anterior uveitis (deep ciliary ache + cell/flare WITHOUT a corneal infiltrate or epithelial defect pivot — route ophtho.acute-red-eye.core.v1 / uveitis arm).
Scope: Frame as a SIGHT-THREATENING established corneal ulcer requiring pathogen-stratified work-up + intensive topical therapy — NOT undifferentiated red-eye triage (that is ophtho.acute-red-eye.core.v1, which routes here). The four-pathogen partition (bacterial / fungal / Acanthamoeba / herpetic) and the scrape-before-empiric / no-patch / no-empiric-steroid spine are set here. Perforation → endophthalmitis is recognised then routed OUT.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Sight-threatening corneal ulcer — pathogen-stratified intensive topical ladder** — step "Step 1 — Scrape/culture FIRST, then empiric broad fortified / fluoroquinolone HOURLY".
1. corneal_scrape_smear_and_culture_before_empiric_therapy (diagnostic_gate, first line) — 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
2. moxifloxacin 1 drop topical q1h around-the-clock then taper (topical_4th_gen_fluoroquinolone, first line) — AAO Bacterial Keratitis PPP (2018) PMID 30366799 — fluoroquinolone monotherapy is non-inferior to fortified for non-severe bacterial keratitis; hourly loading then taper
3. ciprofloxacin (ophthalmic) 1 drop topical q1h around-the-clock then taper (topical_fluoroquinolone, first line) — AAO Bacterial Keratitis PPP (2018) PMID 30366799 — antipseudomonal fluoroquinolone; preferred when contact-lens Pseudomonas risk
4. fortified_vancomycin_plus_fortified_tobramycin_compounded (fortified_topical_antibiotic, first line) — 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)

Setting playbook (ed) — Recognise the sight-threatening ulcer, obtain corneal scrape/culture before broad empiric therapy for significant ulcers, start hourly topical loading, enforce no-patch/no-anaesthetic guardrails, and arrange same-hour ophthalmology / admission (AAO Bacterial Keratitis PPP (2018) PMID 30366799; Ung Surv Ophthalmol 2019 PMID 30590103)
5. corneal scrape + smear + culture (significant ulcer) BEFORE empiric therapy diagnostic corneal once — Central / ≥3 mm / atypical / non-resolving ulcer (Ung Surv Ophthalmol 2019 PMID 30590103) (Scrape-before-broad-empiric is the diagnostic spine)
6. moxifloxacin (empiric topical, non-severe / small peripheral) 1 drop topical q1h around-the-clock — Empiric bacterial cover after scrape (AAO Bacterial Keratitis PPP (2018) PMID 30366799) (Fluoroquinolone monotherapy non-inferior for non-severe bacterial keratitis)
7. fortified vancomycin + tobramycin (severe/central/hypopyon) — compounded fortified topical alternating q1h — Severe / central / vision-threatening or culture-directed (AAO Bacterial Keratitis PPP (2018) PMID 30366799) (Broad fortified Gram-positive+Gram-negative cover for severe ulcers)
8. natamycin 5% (suspected/confirmed filamentous fungal) 1 drop topical q1h around-the-clock — Feathery margins / satellites / vegetative trauma (Prajna MUTT I 2013 PMID 23710492) (Topical natamycin superior to voriconazole for filamentous (esp. Fusarium))
9. oral aciclovir (HSV/HZO) — debride dendrite 400 mg (HSV) / 800 mg (VZV) PO 5×/day — Dendrite / prior HSV / V1 zoster (HEDS NEJM 1998 PMID 9696640) (Antiviral for herpetic keratitis; NO empiric steroid)

Non-pharmacologic actions:
- NEVER patch an infected cornea; NEVER dispense a take-home topical anaesthetic (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- Stop contact-lens wear; bring lenses + case for culture (Stapleton Ophthalmology 2008 PMID 18538404)
- Cycloplegic for ciliary-spasm comfort (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- WITHHOLD empiric topical steroid until infection controlled + HSV/fungus/Acanthamoeba excluded (Srinivasan SCUT 2012 PMID 21987582)
- Rigid shield + emergent ophthalmology + route ophtho.acute-vision-loss.core.v1 if perforation / endophthalmitis (AAO Bacterial Keratitis PPP (2018) PMID 30366799)

AVOID / contraindication checks:
- No empiric topical steroid until infection controlled and HSV fungus acanthamoeba excluded (Srinivasan SCUT Arch Ophthalmol 2012 PMID 21987582 — no overall benefit; harm if used on fungal/amoebic/herpetic/uncontrolled disease)
- Never patch an infected cornea (AAO Bacterial Keratitis PPP (2018) PMID 30366799 — occlusion accelerates microbial proliferation)
- Never dispense take home topical anaesthetic (AAO Bacterial Keratitis PPP (2018) PMID 30366799 — epithelial toxicity / ring keratopathy / corneal melt)
- No contact lens wear during and after active keratitis (Stapleton Ophthalmology 2008 PMID 18538404; Carnt Ophthalmology 2022 PMID 35952937)
- Oral voriconazole not routine and teratogenic in pregnancy (Prajna MUTT II JAMA Ophthalmol 2016 PMID 27787540)
- Renal dose systemic aciclovir valaciclovir (HEDS NEJM 1998 PMID 9696640 — neurotoxicity/nephrotoxicity if unadjusted)

Monitoring

Regimen monitoring:
- daily slit lamp infiltrate and epithelial defect measurement vs baseline map (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- reassess at 48-72h for non response reculture consider fungal acanthamoeba polymicrobial (Ung Surv Ophthalmol 2019 PMID 30590103)
- watch corneal thinning to perforation endophthalmitis route out (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- fungal and acanthamoeba courses are weeks to months with very slow taper (Prajna MUTT I 2013 PMID 23710492; Carnt Ophthalmology 2022 PMID 35952937)
- residual scar density and irregular astigmatism drive final acuity (Menda JAMA Ophthalmol 2020 PMID 31804657)

Setting (ed) monitoring:
- Re-examine within 24 h (or admit) for significant ulcer (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- Document infiltrate size + acuity baseline for the receiving ophthalmologist (Srinivasan SCUT 2012 PMID 21987582)

Follow-up plan: 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.
- Close-out criterion: scar/astigmatism plan + HSV-prophylaxis decision + contact-lens prevention counselling documented

Monitoring phase: Daily slit-lamp review while severe: infiltrate size, epithelial-defect area, AC reaction, thinning — measured against the baseline map. Expect slow change; clinical worsening at 48-72 h on appropriate therapy mandates re-scrape / culture review / consider fungal-Acanthamoeba-polymicrobial / adjust regimen — NOT silent escalation of the same agent. Re-image (confocal) if non-resolving. Watch corneal thinning → perforation route-out.

Disposition

Current setting: ed — Recognise the sight-threatening ulcer, obtain corneal scrape/culture before broad empiric therapy for significant ulcers, start hourly topical loading, enforce no-patch/no-anaesthetic guardrails, and arrange same-hour ophthalmology / admission (AAO Bacterial Keratitis PPP (2018) PMID 30366799; Ung Surv Ophthalmol 2019 PMID 30590103)

Disposition criteria:
- Small peripheral non-vision-threatening ulcer on reliable empiric monotherapy → outpatient ophthalmology review in 24-48 h (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- Vision-threatening / fungal / Acanthamoeba / contact-lens Pseudomonas / non-resolving → admit or same-hour ophthalmology (Ung Surv Ophthalmol 2019 PMID 30590103)

Escalation triggers (move to higher acuity):
- Hypopyon / ≥3 mm / central / perforation risk / monocular / immunocompromised → admit + same-hour ophthalmology (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- Perforation / suspected endophthalmitis → emergent surgery, route ophtho.acute-vision-loss.core.v1 (Ung Surv Ophthalmol 2019 PMID 30590103)
- Pain out of proportion + ring infiltrate + lens-in-water → urgent Acanthamoeba work-up + cornea specialist (Carnt Br J Ophthalmol 2018 PMID 30232172)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Descemetocele, frank perforation, or Seidel-positive aqueous leak in an infected cornea (AAO Bacterial Keratitis PPP (2018) PMID 30366799)
- [LIFE_THREATENING] Worsening intraocular inflammation, vitritis, hypopyon out of proportion to a deepening ulcer — keratitis-to-endophthalmitis progression (Ung Surv Ophthalmol 2019 PMID 30590103)
- [SEVERE] Severe pain out of proportion to signs, ring infiltrate / radial perineuritis, contact-lens wearer with water exposure, or an HSV-mimic failing antiviral (Carnt Br J Ophthalmol 2018 PMID 30232172)

Citations

- 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 [PMID:30366799](https://pubmed.ncbi.nlm.nih.gov/30366799/)
- Cited evidence (PMID 21987582) [PMID:21987582](https://pubmed.ncbi.nlm.nih.gov/21987582/)
- Cited evidence (PMID 23710492) [PMID:23710492](https://pubmed.ncbi.nlm.nih.gov/23710492/)
- Cited evidence (PMID 27787540) [PMID:27787540](https://pubmed.ncbi.nlm.nih.gov/27787540/)
- Cited evidence (PMID 9696640) [PMID:9696640](https://pubmed.ncbi.nlm.nih.gov/9696640/)

Last reconciled with current guidelines: 2026-05-17.
References
  • 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 — PMID:30366799
  • Cited evidence (PMID 21987582) — PMID:21987582
  • Cited evidence (PMID 23710492) — PMID:23710492
  • Cited evidence (PMID 27787540) — PMID:27787540
  • Cited evidence (PMID 9696640) — PMID:9696640