Eye Conditions

Retinal Detachment (RD)

• Patients with high myopia, family history of RD, post cataract surgery, past episodes of chorioretinal inflammation should be warned of the premonitory signs of impending RD (sudden onset of floaters, flashes of light and sudden obscuration of one field of vision). In such cases they should immediately undergo a dilated fundus examination by indirect ophthalmoscopy by an ophthalmologist.
• Explain these patients not to indulge in contact sports.

Retinal Detachment. In: Principles and Practice of Ophthalmology, 2nd Edition, Vol 1-6, WB Saunders Co. 2000, pp 2352-2358.

Diabetic Retinopathy

• Explain the importance of yearly fundus examination.
• Laser treatment can prevent deterioration of vision but cannot correct existing visual deficit.

Diagnosis, Management and Treatment of Nonproliferative Diabetic Retinopathy and Macular Edema. In: Principles and Practice of Ophthalmology, 2nd ed, Vol 1-6, WB Saunders Co. 2000, pp 1900-1914.

Optic Neuritis

• Explain recurrent nature of disease and permanent visual loss can occur.
• Risk of developing multiple sclerosis.
• Avoid the factors provoking transient visual obscurations like physical exertion, hot bath, hot weather, stress, anxiety, anger etc.

1. Ophthalmic Drug Facts, 2000. Facts and Comparisons. A Wolters Kliever Company, St Louis, Missouri.
2. Kanski JJ. Clinical Ophthalmology, 4th edition, 1999. Butterworth Heinemann, Oxford.
3. Pawar Langshan D. In: Manual of Ocular Infection and Therapy, 4th ed. Little Brown Co., 1996.
4. Optics neuritis. In: Principles and Practice of Ophthalmology, 2nd ed, Vol 1-6, WB Saunders Co. 2000, pp 4117-4137.

Endophthalmitis

1. Intravitreal injection of antibiotics – (i) Inj. Vancomycin hydrochloride 1 mg in 0.1 ml plus Inj. Ceftazidime 2 mg in 0.1 ml or Inj. Amikacin sulfate 0.4 mg in 0.1 ml.
2. Subconjunctival injection Vancomycin 25 mg/0.5 ml plus Ceftazidime 100 mg/0.5 ml plus Dexamethasone 0.25 mg/0.5 ml.
3. Vancomycin eye drops 50 mg/ml plus Amikacin eye drops 15 mg/ml 1 drop every 6 hours.
4. Homatropine 2% eye drops 3 times a day or Atropine 1% eye ointment 2 times a day.
5. Prednisolone acetate 1% eye drops or Dexamethasone or Betamethasone 0.1% eye drops every 6 hours.
6. Tab. Prednisolone 1 mg/kg/day in a single morning dose after 24 hours of antibiotic use and continue for 10-14 days 2 times a day for 5-10 days.
7. Parenteral antibiotics are given only as a supportive therapy.

1. Inj. Gentamicin 2 mg/kg every 12 hour.
   Or
   Inj. Ceftazidime 2 g IV every 12 hour.
   Or
   Inj. Ceftriaxone 2 g IV/day.
2. Clindamycin should be considered in all cases until B. cereus infection has been excluded.
   Inj. Clindamycin 600-900 mg IV every 8 hour.
   In children 20-40 mg/kg/day IV 6-8 hourly. Continue antibiotics for 7-10 days.
3. Topical fortified eye drops, subconjunctival injection and intravitreal injection and cycloplegic drops as in cases of postoperative bacterial, endophthalmitis.

• Repair the ruptured eyeball at the earliest.
• Pars plana vitrectomy – indications are similar to that of postoperative bacterial endophthalmitis.

1. Vitrectomy to debulk the vitreous of fungi.
2. Intravitreal Amphotericin B 5-10 mcg/0.1 ml or Fluconazole 25 mcg/0.1 ml.
3. Inj. Amphotericin B 0.5-1.5 mg/kg/day IV slow infusion over 2-6 hours. (50 mg vial in powder form and is dissolved in 5% dextrose) for 10-14 days.
   Or
   Tab. Fluconazole 400 mg loading dose followed by 200 mg daily, total dose should not exceed 600 mg/day.
   In children 12 mg/kg loading dose followed by 6 mg/kg/day.
   Or
   Tab. Ketoconazole 200 mg orally 2 times a day or daily. In children above 2 years of age 3.3-6.6 mg/kg/day.
4. Homatropine 2% eye drops 4 times a day or Atropine 1% eye ointment 2 times a day.

• All patients with open globe injury must contact the ophthalmologist after getting initial treatment.
• Cataract operated cases should never ignore the pain, tearing & photophobia and decrease in vision in the operated eye and must consult the ophthalmologist at the earliest.

1. Endophthalmitis Vitrectomy Study Group: Results of tthe endophthalmitis vitrectomy. Arch Ophthalmol 1995; 113:1479-1496.
2. Fungal Infections and the Eye. In: Principles and Practice of Ophthalmology, 2nd ed. Vol 1-6, WB Saunders Co. 2000, pp 4884-4917.

Orbital Cellulitis

Suppurative inflammation of adipose and soft tissues of orbit is termed as orbital cellulitis. It occurs more frequently in children than adults. Spread of infection from paranasal sinuses, particularly ethmoid sinus is the commonest cause. Other causes include extension of infection from dental abscess, ear infection, face and lid infection, panophthalmitis, dacryocystitis, dacryoadenitis, postoperative to any facial or ocular surgery, perforating injury and haematogenous spread etc.

1. Cap Amoxycillin plus Cloxacillin 500 mg in 3 divided doses for 10-14 days.
   Or
   Cap Amoxycillin plus Clavulanic acid (375 mg) every 8 hours.
2. Inj. Gentamicin 5 mg/kg in 2 divided doses for 7-10 days.
   Or
   Inj. Cefotaxime 1-2 g in 10 ml sterile water for injection over a period of 3-5 min every 12 hours. In Neonates – 100-150 mg/kg in 2-3 divided doses; in Infants and
   children – 50-180 mg/kg/day in 4-6 divided doses. Antibiotics are changed according to the report of culture and sensitivity and continue till resolution occurs.
3. For anaerobic infections
   Inj. Metronidazole 500 mg IV infusion 8 hourly, shifted to oral dose of 400 mg 8 hourly based on the clinical response for 2 weeks.
4. Oxymetazoline 0.05% nasal drops 2-3 drops in each nostril 2 times a day, in children: 0.025%.
5. Symptomatic therapy for pain : antipyretics and analgesics in usual doses.
6. Lubricating eye drops/artificial tears : 1-2 hourly or antibiotic eye ointment 5 times a day to prevent exposure keratopathy.

• Tarsorrhaphy or Frost suture to prevent exposure keratopathy.
• Sinusotomy/Craniotomy for pus in paranasal sinus or brain abscess respectively.
• All the patients must be carefully monitored for vision, fundus, corneal exposure, ocular motility, pupillary reaction, corneal sensations, proptosis, systemic status including CNS function.

• Any ear, sinus or dental infection especially in children should be treated promptly.
• Any child presenting with unexplained lid oedema or cellulitis should be immediately referred to an ophthalmologist.

1. Conjunctivitis and Orbital Cellulitis in Childhood. In: Principles and Practice of Ophthalmology, Vol 1-6, 2nd edition, 2000, WB Saunders Co, pp 4474-4482.

Iridocyclitis (Anterior Uveitis)

Treatment (Refer immediately to an ophthalmologist)

Nonpharmacological

Dark glasses.

Pharmacological

1. Dexamethasone 0.1% eye drops Or Betamethasone 0.1% eye drops Or Prednisolone sodium phosphate 1% eye drops Or Prednisolone acetate 1% eye drops. 1-2 hourly, tapered gradually on the basis of slit lamp evidence of anterior chamber activity.
2. Homatropine hydrobromide 2% eye drop solution.
   Or
   Atropine sulphate 1% eye ointment once or twice a day.
3. If no response (within 7 days), severe anterior uveitis, bilateral involvement and panuveitis.
   Tab. Prednisolone 1 mg/kg or 40 – 80 mg per day orally every morning breakfast or on alternate day. Gradually taper depending upon satisfactory clinical response over 2 to 4 week period.
4. If no response within 1 week or non-compliant, posterior uveitis or severe uveitis.
   Periocular corticosteroids – Subconjunctival or posterior subtenon injection (preferred).
   Methylprednisolone acetate – 20, 40, 80 mg/ml Or Triamcinolone acetonide (10, 40 mg/ml) 0.5 ml – 1.0 ml
   (Contraindication – Infectious uveitis e.g. herpetic or toxoplasmosis, known steroid responder, patients with glaucoma or elevated intra ocular pressure.)
5. Close monitoring of intraocular pressure and treat appropriately if elevated – Timolol maleate 0.5% eye drops 2 times a day and/or Acetazolamide 250 mg 4 times a day 6 hourly.
6. Tab. Ibuprofen 400 mg 3 times a day.
7. Identify the specific cause and give specific therapy (syphilis, tuberculosis, herpes simplex, herpes zoster, toxoplasmosis etc.)
8. Surgical treatment – surgical treatment is required for various complications of anterior uveitis.

• Recurrent/chronic nature of the disease which may interfere with vision should be explained.
• Patients with history of uveitis, juvenile rheumatic arthritis, ankylosing spondylitis should be instructed to report immediately to an ophthalmologist even if there is mild diminution of vision.
• Recurrent episodes of anterior uveitis and subsequent therapy may lead to various complications particularly complicated cataract and steroid induced glaucoma.
• Possible side effects or toxic effects of long term topical periocular and systemic corticosteroid therapy should be explained.

The Cornea, Uveitis and Intraocular Neoplasms. In: Gowerbed Pub. London, 1992 pp 3-38.

Strabismus (Squint)

• Refractive error – refraction should be done under full cycloplegia i.e. Atropine Ointment 1% 3 times a day for 3 days prior to performing retinoscopy. If any refractive error is present, that should be fully corrected by spectacles for at least 3-6 months, before performing definitive surgical therapy for strabismus.
• Any opacity in the media e.g. cataract, corneal opacity, retinoblastoma etc.
• Amblyopia element whether induced by strabismus or vice versa should be treated with occlusion therapy or other modality before treating the strabismus.

• Functional improvement in strabismus is best between 3-5 years of age.
• It is a misconception that squint is spontaneously corrected as the child grows, therefore, do not delay the treatment of strabismus.

Reference

1. Strabismus in Childhood. In: Principles and Practice of Ophthalmology, Vol 1-6, 2nd Edition,2000, WB Saunders Co, pp 4358-4366.

Refractive Errors

• Accurate retinoscopy and corrective spectacles or contact lenses.
• Keratorefractive surgery.

• Young patients opting for laser correction should wait till the refraction is stable for at least one year.

References

1. Optics of Prescribing Spectacles. In: Principles and Practice of Ophthalmology, Vol 1-6,2nd Edition, 2000, WB Saunders Co, pp 5345-5341.

Senile Cataract

• In early cataract decreased vision may be improved by accurate refraction and prescribing corrective spectacles.
• Pupillary dilatation by instillation of 2.5% Phenylephrine eye drops, or Tropicamide 0.5% eye drops or Cyclopentolate 1% eye drops in the morning may provide visual improvement in patient with minimal lenticular opacities in the axial area.
  (CAUTION: Dilatation of pupil is contraindicated in patients with shallow anterior chamber).

• Do not wait for maturation of cataract for undergoing cataract operation.
• Secondary glaucoma and other complications may develop if total cataract remains unoperated for a long time.
• Visual rehabilitation in the early postoperative period is faster in small incision cataract surgery
• Laser is not used for cataract surgery as such, however, Nd:YAG laser is used for posterior capsulotomy which is required in a large percent of intra ocular lens patients.

1. Preoperative Evaluation of the Cataract Patient. In: Principles and Practice of Ophthalmology,Vol 1-6, 2nd Edition,2000, WB Saunders Co, pp 1477-1486.
2. Extracapsular Cataract Extraction. In: Principles and Practice of Ophthalmology, Vol 1-6 2nd Edition,2000, WB Saunders Co, pp 1486-1500.
3. Phacoemulsification. In: Principles and Practice of Ophthalmology, Vol 1-6,2nd Edition,2000, WB Saunders Co, pp 1500-1514.

Corneal Ulcer (Ulcerative Keratitis)

• Avoid patching.
• Maintain proper ocular hygiene by regular cleaning of discharge twice a day.
• Removal of contributory factors e.g. trichiasis, foreign body, entropion, dacryocystitis etc.
• Removal of necrotic tissue increases efficacy of antibiotics.
• Prevention and treatment of complications – secondary glaucoma should be detected and treated adequately.

1. Cefazolin 5%eye drops(50 mg/ml) [mix 5 ml of distilled water in 250 mg of Cefazolin] solution instilled 1 drop every 30 minutes or 1 hourly round the clock for at least 24 hours.
2. Topical fortified Gentamicin 14 mg/ml (1.4%), [mix 2 ml 80 mg
   injectable solution of Gentamicin in one vial of commercially available 0.3% 4 ml Gentamicin eye drop solution (prepared fresh)] instill 1 drop every 1/2- 1 hour for first 24 hours.

1. Cefazolin 100 mg subconjunctival injection after anaesthetizing the conjunctiva (if required).
2. Subconjunctival Gentamicin 20 mg if compliance to topical drops is unreliable
   Or
   Fortified Tobramycin 14 mg/ml solution may be used in place of
   Gentamicin.
3. Ciprofloxacin or Ofloxacin 0.3%eye drops every 2 hours.
4. Atropine sulfate 1% eye ointment to be applied 2 or 3 times per day. Definitive therapy is started based on the culture and sensitivity of microorganisms. Parenteral antibiotics are indicated in perforated corneal ulcer, impending perforations, corneal ulcer following perforating injury and infections caused by Neisseria or Hemophilus microorganisms.

   (CAUTION: Corticosteroids are contraindicated) If associated with secondary glaucoma (see section on glaucoma).

1. Regular debridement of the necrotic tissue.
2. Cauterization of the edges with Trichloroacetic acid/povidone iodine under topical anaesthesia (preferably under the supervision of an ophthalmologist).
3. Natamycin 5% suspension 1 to 2 hourly.
   And/or
4. Fluconazole 1% eye drops 1 hourly round the clock.
   In case of no response within 48 hours substitute fluconazole with
   Amphotericin B.
   Amphotericin B 0.15 to 0.25% formulation prepared in distilled water, every 15 to 30 minutes for 24-48 hours then 1-2 hourly continued for 2-3 weeks or till resolution of keratitis.

   In case of immunocompromised patients, spreading ulcer, perforation or impending perforation,
   Cap. Ketoconazole 200-400 mg 2 times a day for 2-3 weeks.
   Or
   Cap. Fluconazole 200 mg 2 times a day for 2-3 weeks.

   Since superadded bacterial infection is common, Ciprofoxacin or Tobramycin eye drops (see section on bacterial conjunctivitis).

1. Acyclovir eye ointment 3% five times a day for 2-3 weeks.
   Or
   Idoxuridine (IDU) 0.1% eye drops 1 hourly in day time and IDU ointment 0.5% at bed time for 7 days or till definite improvement occurs then (IDU) drops 2 hourly in day and ointment at night for 2-3 weeks till resolution.
2. Topical Cycloplegics – Homatropine 2%eye drops 2 times a day.
3. Broad spectrum antibiotic as in the treatment of mucopurulent conjunctivitis till ulcer heals.

1. Ophthalmic Drug Facts 2000. Facts and Comparisons. A Wolterss Kliewer Company, St Louis, Missouri.
2. Clinical Ophthalmology, 4th Edition,1999. Butterwoth Heinemann, pp 183-260.
3. Allergic and toxic reactions.In: Principles and Practice of Ophthalmology, Vol 1-6, 2nd Edition,2000, WB Saunders Co, pp 781-803.
4. Manual of Ocular Infection and Therapy. 4th Edition,1996, Little Brown hhhhjjjCo, pp 781-803.

1. Moderate to severe disease
   Dexamethasone 0.1% or Prednisolone 1% eye drops every 3 hours, tapered gradually on the basis of clinical response. For milder disease lower concentration of 0.12% Prednisolone Or 1: 100 dilution Dexamethasone 0.1% eye drops 4 times a day, tapered slowly to once daily or once a week before stopping.
2. Prophylactic Acyclovir eye ointment 2 times a day.
3. Homatropine 2% eye drops 1 drop 2 times a day.
   (CAUTION: Avoid corticosteroids in presence of epithelial ulceration; 1% Medroxyprogesterone may be used)

• To report an ophthalmologist in every case of eye redness, pain or diminution of vision. Regular follow up at 6 monthly intervals since viral keratitis is known to recur.

Viral diseases of the cornea and External Eye. In: Principles and Practice of Ophthalmology, Vol 1-6, 2nd Edition, 2000, WB Saunders Co, pp 846-893.

Lens induced glaucoma

1. Improving the therapeutic index of Topically Applied Ocular Drugs. Arch Ophthalmol 184; 102: pp 551.
2. Long term drift and continued efficacy after multi-year Timolol therapy. Arch Ophthalmol 181; 99: pp 100.
3. Mosby’s Ocular Drug Handbook 1996. Mosby Year Book Inc., Missouri, pp 52-59.
4. Pavan-Langston D. Manual of ocular diagnosis and therapy. 4th edition Little Brown Company 1996, pp 229-269.
5. Kanski JJ. Clinical Ophthalmology, 4th edition, 1999, Butterwoth Heinemann, pp 183-260.

Primary open angle glaucoma

Primary open angle glaucoma

1. Timolol 0.5% Or Betaxolol 0.5% eye drops 1 drop 12 hourly and the morning dose should be as early upon waking usually.
   Or
   Pilocarpine 1-4% eye drops 3 times a day or 4% gel once at bedtime.
   If initial therapy fails, refer to a higher center and substitute with another agent preferably belonging to a different group.
   Latanoprost 0.005% eye drops given only once at bedtime.
   (CAUTION: Maintain constant cold chain)
   Or
   Dipivefrine hydrochloride 0.1% eye drops, 2 to 3 times a day.
   Or
   Dorzolamide 2% eye drops 2 to 3 times a day.
   If patient is not controlled on 2 topical drugs then consider alternative treatment with either laser trabeculoplasty or glaucoma filtering surgery.
   Ideally all parameters- IOP, nerve head and visual field assessment should be conducted at 3-6 monthly interval.

• Pilocarpine can cause accommodative spasm and induce myopia leading to browache and a need to readjust reading spectacles of patient.
• Avoid instillation of more than one drop of the drug or double doses in case morning dose is missed.
• Most drugs especially beta-blockers cause burning and stinging sensation on instillation. Chronic use can lead to dry eyes and tear supplements may need to be given.
• Punctual occlusion i.e. pressing medial end of lower lid to increase drug and cornea contact time should be explained to patients
• In diabetics the use of timolol eye drops can mask the warning symptoms of hypoglycemia.
• Avoid sedentary life-style.
• High risk individuals i.e., high myopia, large cups more than 0.5:1 or asymmetry in cups of more than 0.2 or any person with a positive family history of glaucoma, or aged >35 years should routinely get his intraocular eye pressures and fundus evaluated on an annual basis.

Angle closure glaucoma – Acute and Chronic

Angle closure glaucoma – acute

1. Inj. Mannitol 20%, 1.5-2 g/kg, IV infusion over half an hour.
   Or
   Glycerol 50%, 1 to 1.5 g/kg in 50% solution orally, mixed with cold lemon or orange juice in 3-4 divided doses.
   (Caution: Can cause hyperglycemia in diabetic patients. Do not drink water for 1 hour after ingesting, Contraindications include dehydration or cardiac decompensation).
2. Pilocarpine 2% eye drops every 15 min for 1 hour and thereafter 6 hourly started after IOP has been lowered by hyperosmotics as above.
3. Tab. Acetazolamide 500 mg stat followed by 250 mg every 6 hours and maintained till the definitive treatment of laser peripheral iridotomy relieves the pupillary block.
4. Timolol 0.5% eye drops 2 times a day (if pressure is still high) to be continued till surgery.
   Or
   Betaxolol 0.5% eye drops 2 times a day (Preferred in asthmatics and patients with cardiac conduction defects).
   (CAUTION: All mydriatics/cycloplegic drugs which dilate pupils are contraindicated)

• Do not ignore headache and chronic ache in the eyes and report to the eye specialist if coloured halos around light appear.
• Pilocarpine can induce myopia, increase inflammation and cause accommodative spasm in the young patient and the miosis in an older patient who has concomitant cataract leading to diminished vision.

Angle closure glaucoma – chronic

The IOP is raised due to progressive angle closure or by repeated intermittent subacute attacks secondary to pupillary block. Commonly asymptomatic until significant visual loss has occurred. The presentation is thus more akin to open angle glaucoma.

1. Timolol 0.5% or Betaxolol 0.5% eye drops 2 times a day usually required lifelong.
2. Pilocarpine 2-4% eye drops 4 times a day usually required for life. Laser or surgical iridotomy is done to eliminate any element of papillary block. If the glaucoma is still uncontrolled on maximal tolerable medical therapy (i.e. 2 topical antiglaucoma medications), then glaucoma filtering surgery or trabeculectomy should be performed.

• Since the disease is asymptomatic, patients who complain of nonspecific headache or eye ache should not be ignored.

Glaucoma

• IOP is usually normal as sclera in children distends leading to increased corneal diameter.
• Excessive tearing and photophobia.

1. Timolol drops 0.25% eye drops one drop instilled at 12 hourly interval
   Or
   Betaxolol 0.25% eye drops one drop instilled at 12 hourly interval.
2. Tab. Acetazolamide 12 mg/kg in 3-4 divided doses.

• It is a slowly progressive disease, usually amenable to surgery. Regular follow up life long is must for early detection of any failure/complications.
• Eye is vulnerable to trauma and thus contact sports may be restricted in these children.
• Screening of any child particularly the siblings who have a large cornea, photophobia or excessive watering of the eyes should be done.

Painful Red Eye

All painful red eye or visual loss should be referred immediately to a tertiary care level.

Conjunctival Allergic Disorders

1. Topical combination of antihistamine (Antazoline 0.5% or Pheniramine) and vasoconstrictor (Naphazoline hydrochloride 0.05%) eye drops 4 times a day till the resolution of symptoms.
2. Disodium cromoglycate 4% eye drops 4 times a day till resolution of symptoms.
   Or
   Ketorolac tromethamine 0.5% eye drops 4 times a day till resolution of symptoms.
   (CAUTION: Topical corticosteroids are contraindicated as a first line therapy. If required should only be administered by an ophthalmologist)
3. If severe systemic antihistaminics should be administered Tab. Cetrizine hydrochloride 10 mg once a day for duration of acute symptoms. In children 5 mg once a day.

• Symptomatic therapy and avoidance of allergen as far as possible is the mainstay of the therapy.
• Minimum use of topical eye drops should be advocated.

1. Dexamethasone 0.1% eye drops or Betamethasone 0.1% eye drops combined with antibiotic Neomycin 0.5%, or Chloromycetin 0.5% eye drops 4 times a day for 7 days.
2. If cornea is involved (see section on corneal ulcer).
3. Rule out any systemic cause and treat accordingly, especially if recurrent or bilateral keratoconjunctivitis.

1. Topical antihistamine + vasoconstrictor combinations. Boric acid 1.25%; Naphazoline 0.05%; Zinc sulphate 0.12%; Antazoline hydrochloride 0.5%, Chlorpheniramine 0.01% 4 times a day.
2. Disodium cromoglycate 4% eye drops 4 times a day.
   Or
   Ketorolac tromethamine 0.5% Or Ketotifen eye drops 4 times a day.
   In acute attacks and severe cases not resolving with above treatment, refer to an ophthalmologist for treatment with following:
   Prednisolone sodium phosphate 1% Or Dexamethasone 0.1% or
   Betamethasone 0.1% four times a day for 2 days, twice daily for four days, once daily for next 3 days and then discontinue.
   (CAUTION: Should be given under the close supervision of an ophthalmologist).

• Long term use of a steroid may cause glaucoma and cataract.

1. Ophthalmic Drug Facts, 2000. A Wolters Kliever Company, St. Louis, Missouri.
2. Clinical Ophthalmology, 4th edition, 1999, Butterworth Heinemann, Oxford.
3. Manual of Ocular Infection and Therapy, 4th edition,1996, Little Brown Co.

Chlamydial Conjunctivitis – Trachoma

1. Tab. Roxithromycin 150 mg 2 times a day for 7 days.
   In children 5.8 mg/kg in 2 divided doses.
   Or
   Cap. Doxycycline 100 mg 2 times a day for two weeks.
   (CAUTION: Contraindicated in children, pregnant women and nursing mothers)
   Or
   Tab. Sulfamethoxazole 400 mg + Trimethoprim 80 mg 2 tablet twice
   daily for 3 weeks;
   In children 6-12 years: half the above dosage for 3 weeks.
   And/Or
2. Tetracycline 1% eye ointment at night for 6 weeks.
3. Sulfacetamide 10-20% eye drops 3-4 times for 6 weeks.
   Or
   Ciprofloxacin 0.3% ophthalmic solution 4 times a day and Ciproflaxacin 0.3% eye ointment at night for 8 weeks.

• Treat the whole family even if only one child has active trachoma.
• Improve ocular hygiene – facial cleanliness in children.
• Environmental improvement – eliminate flies, provision of adequate running water supply and latrines etc.

1. Chlamydia and Acanthamoeba infections of the eye. In: Principles and Practice of Ophthalmology. Albert and Jakobiec Azar Gragoudas (eds), 2nd Edition, 2000. WB Saunders Co, pp 915-925
2. Primary Health Care Level Management of Trachoma, 1993, WHO/PBL/93.33.

1. Tab. Roxithromycin 150 mg 2 times a day for 7 days.
   In children 5.8 mg/kg in 2 divided doses.
   Or
   Cap. Doxycycline 100 mg 2 times a day for two weeks.
   (CAUTION: Contraindicated in children, pregnant women and nursing mothers)
   Or
   Tab. Sulfamethoxazole 400 mg + Trimethoprim 80 mg 2 tablet twice
   daily for 3 weeks;
   In children 6-12 years: half the above dosage for 3 weeks.
   And/Or
2. Tetracycline 1% eye ointment at night for 6 weeks.
3. Sulfacetamide 10-20% eye drops 3-4 times for 6 weeks.
   Or
   Ciprofloxacin 0.3% ophthalmic solution 4 times a day and Ciproflaxacin 0.3% eye ointment at night for 8 weeks.

• Treat the whole family even if only one child has active trachoma.
• Improve ocular hygiene – facial cleanliness in children.
• Environmental improvement – eliminate flies, provision of adequate running water supply and latrines etc.

1. Chlamydia and Acanthamoeba infections of the eye. In: Principles and Practice of Ophthalmology. Albert and Jakobiec Azar Gragoudas (eds), 2nd Edition, 2000. WB Saunders Co, pp 915-925
2. Primary Health Care Level Management of Trachoma, 1993, WHO/PBL/93.33.

Viral Conjunctivitis

1. Antibiotic eye drops (as in mucopurulent conjunctivitis) prevent secondary infection.
2. Naphazoline 0.05% eye drops 1 drop 4 times a day or Zinc sulphate 0.125% eye drops 1 drop 4 times a day. Patient should be referred to an ophthalmologist if there is no response in 7 to 10 days .

• Not to share towels, handkerchief and other objects with other persons. Also patient’s bottle of eye drops/ointments should not be used by other persons in the family.

1. Ophthalmic Drug Facts 2000. Facts and Comparisons: A Wolters Kliewer Company, St. Louis, Missouri.
2. In: Kanki JJ. Clinical Ophthalmology, 4th Edition, 1999. Butterworth Heinema…..nn, Oxford.
3. Drugs used in Bacterial Infections: WHO Model Prescribing Information. World Health Organization, 2001.
4. WHO Bulletin: Conjunctivitis of the New Born 1986, pp 1-15.
5. Conjunctival and Corneal Pathology. In: Principles and Practice of Ophthalmology, 2nd Edition, 2000, Vol 1-6 WB Saunders Co. 2000, pp 3609-3634.
6. Chlamydial Disease. In: Principles and Practice of Ophthalmology, 2nd Edition, 2000. Vol 1-6 WB, Saunders Co. pp 4955-4960.

Ophthalmia Neonatorum

1. Crystalline Benzyl penicillin aqueous solution 10,000 to 20,000 U/ml, (mix 5-10 ml of distilled water in a vial containing 5 lacs units of Penicillin G) instilled 1 drop every hour for 6 to 12 days and then 1 drop every 2-3 hours till the infection is resolved.
   Or
   Tobramycin 0.3% eye drops every two hourly for 10 days
   Or
   Gentamicin 0.3% eye drops at every one hour interval
   Or
   Ciprofloxacin 0.3% eye drops every hour and 0.3% eye ointment at night.
2. If corneal involvement (see section on corneal ulcer).
3. Systemic Treatment: In full term babies with normal birth weight after sensitivity testing
   Inj. Procaine Penicillin G 4.8 million units in 2 divided doses IM for 7 days. In preterm low birth weight babies,
   Inj. Procaine Penicillin G 20,000 units/kg/day 2-3 divided doses IM or IV for 3 days.
   Or
   Inj. Ceftriaxone 125 mg as a single IM dose (for penicillin allergic patients).
   Or
   Inj. Cefotaxime 100 mg/kg IM as a single injection.
4. Also treat mother with systemic therapy.
5. Treat Chlamydial infection simultaneously as it may also coexist. Non gonococcal bacterial Ophthalmia Neonatorum. It is a milder disease occurring within 5-14 days after birth. It is caused by chlamydial, bacterial or herpetic infection.

1. Ciprofloxacin 0.3% eye drops 1 drop every 2-4 hours and 0.3% eye ointment at night for 2 weeks.
   Or
   Gentamicin 0.3% eye drops every 1 drop 2-4 hours and eye ointment at night for 2 weeks.
2. If evidence of systemic involvement
   Syp. Erythromycin 50 mg/kg/day in 4 divided doses for 14 days.
   If extensive conjunctival or corneal involvement also treat the parents primarily mother. If no response after 1 week of therapy refer for an appropriate culture and sensitivity testing to a tertiary care level.

1. Inj. Procaine penicillin 4.8 million IV/IM injection with 1 g oral probenecid.
2. In Penicillin resistant cases, Inj. Spectinomycin 4 g in 2 divided doses IM single injection in gluteal region.

Bacterial Infections of the Conjunctiva and Cornea. In: Principles and Practice of Ophthalmology. Albert and Jakobiec Azar Gragoudas (eds), 2nd Edition, 2000, WB Saunders Co, pp 893-905.

Bacterial Conjunctivitis

1. Eye drops Gentamicin 0.3% eye drops or Framycetin 0.5 to 1% or Ciprofloxacin 0.3% or Chloramphenicol 0.5 to 1% eye drops 1 drop every 2-3 hourly in day time and Gentamicin or Ciprofloxacin eye ointment instilled in inferior fornix at bed time for 5-7 days.
2. If there is evidence of cellulitis or fever treat accordingly (see section on cellulitis – Cellulitis and erysipelas & Orbital cellulitis).
   (CAUTION: corticosteroid drops are contraindicated)
   If there is no response to empirical therapy after 7 days stop all antibiotics and conjunctival scrapping should be obtained for Gram’s stain and culture and sensitivity studies. Appropriate antibiotic should be selected based on culture sensitivity reports.