Goal

Early recognition and treatment to prevent long-term scarring of the cornea.

Minimum

- Moxifloxacin eye drops 1 drop every 15 minutes for the first 2 hours after diagnosis, then 1 drop every hour while awake
- Initiate pain control as needed. DO NOT use topical anesthetics for pain control; they significantly impair corneal healing.
- Initiate teleconsultation with photographs.
- Activate evacuation (goal is ophthalmic care within 24 hours if lesion is large, central, or affects vision).

Better

- Obtain a culture before beginning treatment for sight-threatening or severe keratitis with suspected infection, such as large central corneal infiltrate that extends to the middle to deep stroma.20
- Provide intense loading dose of moxifloxacin 0.5% eye drops 1 drop every 5–15 minutes for the first 30–60 minutes (patient can self-administer loading dose if reliable) after culture obtained.
- Treatment dose: 1 drop every 30–60 minutes around the clock until epithelial defect is closed.20
- Cycloplegic eye drop (cyclopentolate 1%), 1 drop every 8 hours for photophobia.

Best

- Real-time video telemedicine consultation
- Collagen corneal shield (national stock no. [NSN] 6515-01-482-9391) soaked in moxifloxacin drops for transport (generally 5–10 drops) and placed over the corneal infiltrate. This enables release of the medication to the ocular surface during transport, rather than administering repeated dosing.21
- No altitude restrictions for flight

NOTE: Topical steroid drops may be useful to reduce inflammation after the infection is controlled with topical antibiotics. Initiation of topical steroid drops should only be done under the direction of an eye care specialist after teleconsultation.

Herpes simplex virus (HSV) keratitis is an additional form of keratitis that usually occurs in patients with a history of previous episodes. HSV keratitis may demonstrate a specific dendritic staining pattern with fluorescein (Figure 19). After recognition, treatment can be initiated with oral acyclovir (400mg PO 5 times per day).

9. ANGLE-CLOSURE GLAUCOMA

Blockage of the normal flow of aqueous fluid in the anterior chamber of the eye will lead to increased IOP. If left untreated, blood flow to the posterior segment of the eye will be affected, leading to irreversible vision loss. The aqueous drain system can become blocked owing to anatomic variations, changes in lens size, inflammation, and trauma (Figure 20).