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Controversies in ophthalmology
View 2: Empirical fluoroquinolone therapy is sufficient initial treatment
  1. N Morlet1,
  2. M Daniell2
  1. 1Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia
  2. 2Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, 3065, Australia; daniellm@ozemail.com.au

    https://doi.org/10.1136/bjo.87.9.1169

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      A lthough the treatment of microbial keratitis has changed with the introduction of new antimicrobials, the management principles still remain the same. In general, suspected microbial keratitis is treated with empirical therapy of intensive topical broad spectrum antimicrobials. This is because delaying treatment until the diagnosis is confirmed may worsen the visual outcome and allow further complications. Whether there is a need for microbiological investigation for all patients is contentious, as is empirical primary treatment with fluoroquinolone monotherapy.

      WHAT CAUSES MICROBIAL KERATITIS?

      Microbial keratitis is rare in the absence of predisposing risk factors. In the past trauma and ocular surface compromise (for example, bullous keratopathy, exposure, etc) were the major risks. However, with the introduction of soft contact lenses and their widespread use since the 1980s, the demographic profile of those presenting with suspected microbial keratitis has changed. Figure 1 shows the demographic change in the age groups of those presenting with suspected microbial keratitis from 1985 to 1995 at Moorfields Eye Hospital in London, United Kingdom.

      Figure 1

      (A) Corneal scrape results by age group, Moorfields Eye Hospital, 1985. (B) Corneal scrape results by age group, Moorfields Eye Hospital, 1995.

      The change in the presentation of suspected microbial keratitis over time was also reflected in the types of micro-organisms cultured as shown in Table 1.

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      Table 1

      Variation in the organisms cultured from corneal scrapes at Moorfields Eye Hospital from 1985 to 1995

      Not only are there temporal changes in the pattern of presentation of microbial keratitis, there are also geographic differences in the pattern of presentation. Table 2 shows the different patterns of infection from reports of keratitis from various locations around the world.

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      Table 2

      Regional variation in the organisms cultured from corneal scrapes

      So it is evident that the empirical choice of antibiotics in the primary treatment of suspected microbial keratitis requires local contemporaneous data regarding …

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