Bacterial keratitis is a serious and urgent ocular condition in which patients often present with sudden onset of intense pain, photophobia, and redness. If not treated quickly and appropriately, corneal scarring, vision loss, and even loss of the globe can occur. These patients may not walk into your clinic often, but when they do, you should be comfortable with starting a treatment plan. 

Patients with infectious keratitis typically present urgently with sudden onset of pain, photophobia and redness. The degree of discomfort and light sensitivity may make examination challenging, and more aggressive presentations may result in permanent corneal scarring, loss of vision or even the loss of the globe. All this is enough to unsettle even a seasoned practitioner. However, with enough knowledge and careful attention to the details in presentation, successful treatment and preservation of the patient’s vision can be achieved in the majority of cases. 

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Dr. Dexter's Take

According to this article, empirical treatment (without culturing) for central or severe corneal ulcers should start with a loading dose of topical antibiotic (such as Besivance) every 5-15 minutes for the first 30-60 minutes. Afterwards, topical antibiotic drops should be administered once every 30-60 minutes around the clock (meaning the patient should be waking up at night to put drops in), with re-evaluation the following day. The dosing can then be altered from there depending on the clinical examination. 
Also, don't forget to review your state laws for treatment and referral protocols as optometrists in some states are limited to what types and locations of ulcers they can treat, in addition to when a patient must be referred to an ophthalmologist. 

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