-Dr.Prathibha.M.

Chachadi
for·ti·fy  (fôrt-f) v. for·ti·fied,
for·ti·fy·ing, for·ti·fies
v.tr. To make strong, as: a. To
strengthen and secure (a position)
with fortifications.
b. To reinforce by adding material
Most of the available ophthalmic antibiotics are
in the concentration of 0.3% which is not
sufficient to attain minimum inhibitory
concentration for organisms, especially the
resistant , non healing ulcers.
For moderate to severe corneal ulcers intensive
antibiotic treatment is needed, which reinforces
the need for fortified antibiotics to halt the
progression of ulcer and promote healing
Is started in the initial empirical treatment as
conventional method ( vs monotherapy with
quinolones)
Once culture reports are available for specific
organisms- pseudomonas; staphylococci;
candida; pneumococcus-streptococcus
Conventionally active corneal ulcer needs
intensive treatment where the drops are
applied topically- 1 hourly for 24-48 hrs(
stabilised); 2hrly- during day & 4 hrly in night
till healing ; 4-6 hrly.
BACTERIA TYPE DRUG OF CHOICE ALTERNATIVE DRUGS
(GRAM STAIN) (FORTIFIED) (FORTIFIED/ NON
-FORTIFIED)

GRAM POSITIVECOCCI Cefazolin- 50mg/ml 0r Vancomycin -25mg/ml

100mg/ml Bacitracin- 10000 u/ml
Ciprofloxacin
Ofloxacin
Levofloxacin
GRAM POSITIVE BACILLI Penicillin G-100000 u/ml Vancomycin 25-50mg/ml
Tobramycin -14mg/ml Bacitracin -10000 u/ml
Gentamicin -14mg/ml

GRAM NEGATIVE COCCI Ceftriaxone-50mg/ml or Ofloxacin

100mg/ml Levofloxacin
Ciprofloxacin

GRAM NEGATIVE Tobramycin -14mg/ml Gentamicin -14mg/ml

BACILLI Amikacin -10mg/ml Polymyxin B-50000 u/ml
Ticarcillin -6mg/ml Ciprofloxacin
Ofloxacin
Levofloxacin
NO ORGANISM SEEN Cefazolin- 50mg/ml or Gentamicin-
BUT BACTERIA 100mg/ml 14mg/ml(OR)
SUSPECTED + Amikacin-10mg/ml
Tobramycin -14mg/ml +
Vancomycin -25mg/ml
(OR)
Bacitracin 10000 u/ml
ORGANISM TOPICAL SUBCONJUNCTIVAL

PSEUDOMONAS Tobramycin -14mg Tobramycin -40mg

/ml(OR) Amikacin -25mg
Amikacin 10mg/ml Ticarcillin -100mg
/ a quinolone
STAPHYLOCOCCUS Cefazolin -50mg/ml Cefazolin 100mg
Vancomycin – 25-50 Oxacillin 100mg
mg/ml Vancomycin 25mg
Bacitracin 10000 u/ml

PROTEUS Tobramycin -14mg/ml Tobramycin -40mg

ENTEROBACTER Gentamicin -14mg/ml Amikacin – 25mg
E.COLI Amikacin -10mg/ml Carbenicillin -100mg
KLEBSIELLA Ceftriaxone -50mg/ml
ACINETOBACTER
 1.AMIKACIN- (atypical mycobacteria; post
lasik infectious keratitis)( poor corneal
penetration)
topical 100 mg/ml +9ml tears
10mg/ml
subconjunctival 100mg/ml +1ml tears
50mg/ml
Shelf life 30 Days
2. BACITRACIN – 6ml(10ml) of tear drops
TOPICAL 3ml 3ml

1 vial of bacitracin 1 vial of

bacitracin
(50000 u) (50000 u)
6ml(10ml) of tear drops
(1ml- 10000u)
SUBCONJUNCTIVAL 0.5ml (5000u)
SHELF LIFE 7 Days(4 deg)
 3.CEFAZOLIN -(non penicillinase gram+) (
topical 1g/10ml +2ml tears(100mg/ml+2ml)
33mg/ml
Also 500mg +10ml; 50mg/ml
Also 1g/7.5ml
133mg/ml
Subconjunctival 100mg/ml
Shelf life 10 Days ( yellow ; discard)
 GENTAMICIN
topical 80mg/2ml +3.6ml of tears
14mg/ml
Subconjunctival 40mg/ml
Shelf life 30 Days
 Penicillin G
topical 1 vial- 5 million u +5ml of tears- 1 million
u/ml
5ml+2.5 ml- 333333u/ml
Subconjunctival 1 million u/ml
Shelf life 7 Days
 TOBRAMYCIN –
topical - 80mg/2ml + 0.3 % tobramycin
e/d(5ml) - 13.6mg/ml
Subconjunctival - 40mg
Shelf life - 30 days

VANCOMYCIN –
Topical - 500mg/10ml + 5ml of tears – 25mg/ml
Subconjunctival – 25mg
Shelf life – 14 days
 Amphotericin B-
topical – 50mg+10ml- 5mg/ml(STOCK
SOLUTION)
1.5 ml of stock solution+ 3.5 ml of tears- 0.15%
Refrigerate; not exposed to light ; look for
turbidity, precipitation, contamination
Original Article
British Journal of Ophthalmology. 84(4):378-384, April 1, 2000.
Gangopadhyay, Nibaran; Daniell, Mark; Weih, LeAnn; Taylor, Hugh R
Abstract:
AIM: To compare the clinical efficacy of commercially available
fluoroquinolone drops with the use of combined fortified
antibiotics (tobramycin 1.3%-cefazolin 5%) in treatment of
bacterial corneal ulcer
CONCLUSIONS: Monotherapy with fluoroquinolone eye drops
for the treatment of bacterial corneal ulcers led to shorter duration
of intensive therapy and shorter hospital stay compared with
combined fortified therapy (tobramycin-cefazolin). This finding
may have resulted from quicker clinical response of healing as a
result of less toxicity found in the patients treated with
fluoroquinolone. However, as some serious complications were
encountered more commonly in the fluoroquinolone group,
caution should be exercised in using fluoroquinolones in large,
deep ulcers in the elderly.
Effect of Fortified Antibiotic Solutions on Corneal Epithelial
Wound Healing.
Basic Investigation
Cornea. 19(2):204-206, March 2000.
Lin, Chang-Ping M.D.; Boehnke, Matthias M.D.
Abstract:
Purpose. To evaluate the influence of fortified antibiotic eyedrops
on corneal epithelial wound healing
Methods. We developed an in vitro epithelial wound-healing model to evaluate the
toxicity of antibiotics. An excimer laser was used to create an epithelial defect 1.5 mm in
diameter, 70 [mu]m in depth on the central area of porcine cornea. The intact animal
globes were maintained in the incubator by a perfusion system. Fortified antibiotics:
10% piperacillin, 5% cefazolin, 0.5% chloramphenicol, 5% vancomycin, 1% amikacin, 2%
gentamicin, and 0.1% amphotericin B were applied to the wound in three applications.
The wounds were evaluated 24 h after setup with fluorescein stain and a scoring
system.
Results. The 0.1% amphotericin B and 2% gentamicin disturbed the corneal epithelial
healing rate significantly. The remaining antibiotics did not interfere with the epithelial
healing rate in our study design.
Conclusion. Fortified antibiotic eyedrops demonstrated ealvaried degrees of influence
on corn epithelial wound healing. When antibiotic eyedrops are used, both the efficacy
and toxicity of the antibiotics should be the major concern. If efficacy is equivalent, less-
toxic agents should be given preference.
IJO ORIGINAL ARTICLE Year : 2007  |  Volume : 55  |  Issue :
1  |  Page : 15-19 Activity of newer fluoroquinolones against
gram-positive and gram-negative bacteria isolated from ocular
infections: An in vitro comparison

Background: To determine the antibacterial activity of newer

fluoroquinolones and compare their activity between
ciprofloxacin-susceptible and resistant bacterial isolates from
patients with keratitis and endophthalmitis
Conclusions: Levofloxacin, gatifloxacin and moxifloxacin are
statistically more effective against gram-positive bacteria, the
latter two being equally effective. Ciprofloxacin remains the most
effective fluoroquinolone against gram-negative bacteria.
PARSON’S TEXT BOOK OF OPHTHALMOLOGY
INDIAN JOURNAL OF OPHTHALMOLOGY

CURRENT OPHTHALMOLOGY Year : 1994  |  Volume : 42  |  Issue : 4  |  Page : 171-

192   Current perspectives in infectious keratitis
Agrawal Vinay1, Biswas Jyotirmay2, Madhavan HN2, Mangat Gurmeet3, Reddy Madhukar
K4, Saini Jagjit S3, Sharma Savitri4, Srinivasan M5

 
SYMPOSIUM Year : 2008  |  Volume : 56  |  Issue : 3  |  Page : 215-220   Medical
management approach to infectious keratitis
Gokhale Nikhil S
 Gokhale Eye Hospital and Eyebank, Anant Building, Gokhale Road (S), Dadar West,
Mumbai-400 028, India