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. |
Trifluorothymidine 1% drops 9 times per day with tapering as lesions heal over 14 days; subsequent prophylaxis with oral acyclovir 400 mg BID |
|
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 |
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. |
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. |
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 µg/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 µg/0.1 mL 2 – 3 times per week for 2 –3 weeks |
200-2000 µg/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 |