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Administer activated charcoal (see p 1362) Gastric lavage followed by administration of extra doses of activated charcoal may be needed in patients who ingest more than 10 g of aspirin (see p 1362) The desired ratio of charcoal to aspirin is about 10:1 by weight; while this cannot always be given as a single dose, it may be administered over the first 24 hours in divided doses every 2 4 hours Treat metabolic acidosis with intravenous sodium bicarbonate This is critical because acidosis (especially acidemia, pH < 740) promotes greater entry of salicylate into cells, worsening toxicity Brief hypoventilation during rapid sequence intubation may cause sudden and severe deterioration if the pH is allowed to fall

Corneal ulcers are most commonly due to infection by bacteria, viruses, fungi, or amebas Noninfectious causes all of which may be complicated by infection include neurotrophic keratitis (resulting from loss of corneal sensation), exposure keratitis (due to inadequate eyelid closure), severe dry eyes, severe allergic eye disease, and various inflammatory disorders that may be purely ocular or part of a systemic vasculitis Delayed or ineffective treatment of corneal infection may lead to devastating consequences with intraocular infection or corneal scarring Prompt referral is essential Patients present with pain, photophobia, tearing, and reduced vision The eye is red, with predominantly circumcorneal injection, and there may be purulent or watery discharge The corneal appearance varies according to the organisms involved

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Bacterial keratitis pursues an aggressive course Precipitating factors include contact lens wear especially overnight wear and corneal trauma, including refractive surgery The pathogens most commonly isolated are Pseudomonas aeruginosa, Pneumococcus, Moraxella species, and staphylococci The cornea is hazy, with a central ulcer and adjacent stromal abscess Hypopyon is often present The ulcer is scraped to recover material for Gram stain and culture prior to starting treatment with high-concentration topical antibiotics applied hourly day and night for at least the first 48 hours Fluoroquinolones such as ciprofloxacin 03%, ofloxacin 03%, and norfloxacin 03% are commonly used as first-line agents Levofloxacin 05% is more effective against pneumococci than ciprofloxacin The fourth-generation fluoroquinolones (moxifloxacin 05% and gatifloxacin 03%), which are also active against mycobacteria, may become the preferred agents Grampositive cocci can also be treated with a cephalosporin such as cefazolin, 100 mg/mL; and gram-negative bacilli can be treated with an aminoglycoside such as tobramycin, 15 mg/mL If no organisms are seen, these two agents can be used together

Fungal keratitis tends to occur after corneal injury involving plant material or in an agricultural setting, in eyes with chronic ocular surface disease, and increasingly in contact lens wearers It is usually an indolent process, with the cornea characteristically having multiple stromal abscesses and relatively little epithelial loss Intraocular infection is common Corneal scrapings are cultured on media suitable for fungi whenever the history or corneal appearance is suggestive of fungal disease Treatment is difficult Natamycin and amphotericin are the most commonly used topical agents Systemic imidazoles may be helpful Corneal grafting is often required

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Iyer SA et al Fungal keratitis: emerging trends and treatment outcomes Eye Contact Lens 2006 Dec;32(6):267 71 [PMID: 17099386]

Acanthamoeba is an important cause of suppurative keratitis in contact lens wearers Although severe pain with perineural and ring infiltrates in the corneal stroma is characteristic, earlier forms with changes confined to the corneal epithelium are identifiable Diagnosis is often delayed but is facilitated by confocal microscopy Culture requires specialized media Treatment is hampered by the organism s ability to encyst within the corneal stroma Various unusual agents have been used, principally polyhexamethyl biguanide, chlorhexidine, propamidine isethionate, and neomycin Epithelial debridement may be useful in early infections Corneal grafting may be required in the acute stage to arrest the progression of infection or after resolution to restore vision Systemic immunosuppression may be needed if there is scleral involvement

Hammersmith KM Diagnosis and management of Acanthamoeba keratitis Curr Opin Ophthalmol 2006 Aug;17(4): 327 31 [PMID: 16900022]

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