Treating a corneal infiltrate in a non-contact lens wearer
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There are a range of fortified and unfortified antibiotic options for corneal conditions.
Eric D. Donnenfeld, MD, and Nicole R. Fram, MD, discussed a corneal infiltrate case and the use of fortified and unfortified antibiotics.
Eric D. Donnenfeld, MD: This is a simple case that has grown on me. A 54-year-old man complained of decreased visual acuity and foreign body sensation for 3 days. He had a small corneal infiltrate and was not a contact lens wearer. When it comes to a corneal infiltrate with contact lenses, I usually know what I am dealing with. But this was not a contact lens wearer. He had no history of trauma, some blepharitis and a little infiltrate in the cornea.
Do you worry about this? Would you culture on the initial presentation? I would. Would you use a topical fluoroquinolone? Would you use fortified antibiotics with or without a topical fluoroquinolone? Would you culture and treat with topical antibiotics? Would you refer the patient?
In this case, this is a patient you want to refer. We should culture the patient and put them on a topical antibiotic. Would you use fortified antibiotics or just fluoroquinolones?
Nicole R. Fram, MD: Sometimes it takes time to get fortified antibiotics. Harrow makes a combined fortified antibiotic — vancomycin 5% and tobramycin 1.5% — that you can keep in your refrigerator, and it lasts for 180 days refrigerated. However, sometimes I can’t get fortified drops right away. So, I will do moxifloxacin every hour and Polytrim (polymyxin B sulfate and trimethoprim ophthalmic solution, AbbVie).
Donnenfeld: When you administer antibiotics, you want to use a fluroquinolone. To me, that makes sense. It is great for gram-negatives and a little gram-positive coverage. But what antibiotics can you get from a pharmaceutical company that are from a pharmacy that are not fortified that give good gram-positive coverage?
For me, it is Neosporin (neomycin, polymyxin and bacitracin), bacitracin and Polytrim. They all have pretty good gram-positive coverage. But if I want to go full speed, I am going to go with vancomycin every time.
We have a relationship with Harrow in which they give us fortified vancomycin and tobramycin. You can keep them in the freezer, and they last for about a year. If a patient comes in with an emergency, you can just take them out of the freezer and use them anytime you want. If you do not use them, Harrow will replace them at the end of the year. That way, they do not spoil.
Fram: The Harrow formulation is vancomycin 50 mg/mL and we typically use 25 mg/cc. I thought it was going to be more painful for the patient to administer. Although it is painful to take any fortified antibiotic drop in general, it was not as bad as expected.
Donnenfeld: Everyone should have topical vancomycin in their office. You never know when a Friday afternoon will roll around and you will need to use it. It is just a good tool to have on hand.
- For more information:
- Eric D. Donnenfeld, MD, of Ophthalmic Consultants of Long Island, can be reached at ericdonnenfeld@gmail.com.
- Nicole R. Fram, MD, of Advanced Vision Care in Los Angeles, can be reached at drfram@avceye.com.
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