New York State Medical Treatment Guidelines for Viral, Bacterial and Fungal Infections and Corneal Ulcers in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer general principles for managing Viral, Bacterial, and Fungal Infections, as well as Corneal Ulcers. These directives aim to assist healthcare professionals in determining appropriate strategies for diagnosing and addressing infections caused by viruses, bacteria, and fungi, along with the presence of ulcers on the cornea, as part of a comprehensive care plan.

Healthcare practitioners specializing in the management of Viral, Bacterial, and Fungal Infections, along with Corneal Ulcers, can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for assessing and treating these specific eye conditions in their patients.

It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of these infections and corneal ulcers should involve collaboration between the patient and their healthcare provider.


In most cases, additional diagnostic testing isn’t necessary for evaluating eye infections. However, in certain situations where there are accompanying symptoms or injuries, like sinus issues, further tests such as sinus x-rays, sinus CT scans, or imaging like CT or MRI of the orbits may be required.


Initial Care

When it comes to presumed viral conjunctivitis or mild bacterial conjunctivitis, no medication is typically needed. However, it’s crucial to provide clear instructions on maintaining meticulous hand-eye hygiene to minimize the risk of further spread. For cases of moderate to severe bacterial conjunctivitis, more attentive follow-up is essential to monitor progress and ensure recovery.

Now, when dealing with corneal infections or ulcers, medications become necessary, and it’s imperative to stay on top of close follow-up appointments to minimize the risk of visual loss.


Treatment Recommendations

For common cases of viral conjunctivitis, antibiotic treatment is not necessary. However, if it’s a corneal infection caused by herpes simplex or herpes zoster, anti-viral treatment is needed. Still, these conditions are beyond the scope of this guideline as they are not considered occupational.

In adults, the primary culprits of bacterial conjunctivitis are Streptococcus pneumoniae (51%), Pseudomonas (23%), Staphylococcus sp, and Hemophilus influenzae. Treating bacterial conjunctivitis with antibiotics can shorten the clinical course, but mild mucopurulent infections might not improve faster with antibiotics. The severity of ulcers is strongly linked to the outcome. Fungal infections, generally more severe, often require longer treatment times to resolve.


Antibiotics for Bacterial Conjunctivitis and Bacterial Infections Complicating Corneal Ulcer

In selected cases, it’s recommended to use antibiotics for treating bacterial conjunctivitis and bacterial infections complicating corneal ulcers. Antibiotics are indicated for moderate to severe bacterial conjunctivitis to reduce the duration of the clinical course. For mild cases, especially those with mild mucopurulent infections, antibiotics may not provide faster improvement.

Neisseria cases require both topical and systemic treatment, but such cases are beyond the scope of this guideline. Bacterial infections complicating corneal ulcers should be treated, with an additional indication to continue treatment until the corneal defect resolves. The baseline visual acuity can predict visual recovery.

Various ophthalmic antibiotic preparations have comparable efficacy, including gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, tobramycin-cefazolin, cefazolin-amikacin, and cefazolin-gentamicin, as well as thimerosal (not recommended due to toxicity concerns). Tailoring antibiotic selection based on estimated bacteria genus and species, along with local antibiotic resistance profiles, is advisable. While Gram stain is not commonly performed, it may assist in preliminary antibiotic tailoring.

Further adjustments based on culture and sensitivity results may be necessary, as evidence suggests antibiotic resistance correlates with worse outcomes. The duration of treatment is for the duration of symptoms, and for ulcers, it typically continues until the corneal defect is resolved.

Adjuvant Glucocorticosteroids for Bacterial Conjunctivitis and Bacterial Infections Complicating Corneal Ulcers: It’s not recommended to use glucocorticosteroids as an additional treatment for bacterial conjunctivitis or bacterial infections complicating corneal ulcers.

Antibiotics for Viral Conjunctivitis: Routine use of antibiotics is not recommended for treating viral conjunctivitis.

Non-steroidal Anti-inflammatory Drugs for Symptoms of Viral Conjunctivitis: Using non-steroidal anti-inflammatory drugs is not advised for alleviating symptoms of viral conjunctivitis.

Glucocorticosteroids for Symptoms of Viral Conjunctivitis: It’s not recommended to use glucocorticosteroids as a treatment for symptoms of viral conjunctivitis.


Antifungal Medications for Fungal Conjunctivitis and Fungal Infections Complicating Corneal Ulcers: It is recommended to use antifungal medications for the treatment of fungal conjunctivitis and fungal infections complicating corneal ulcers. When corneal defects are complicated by fungal infections, it’s generally advisable to refer the case to an ophthalmologist.

Indications: Antifungal medications are indicated for fungal conjunctivitis, and for fungal infections complicating corneal ulcers, treatment is necessary with the added indication to continue until the corneal defect resolves.

Frequency/Dose/Duration: Various ophthalmic antifungal preparations, including econazole 2%, natamycin 5%, voriconazole 1%, and Amphotericin B, have comparable efficacy. Treatment should generally be tailored to culture results. While potassium iodide (KOH) is not always used, it may assist in preliminary antifungal regimen.

Effective antifungal regimens based on high-quality studies include:

  • Econazole 2% drops: Administered hourly between 7 am to 9 pm.
  • Natamycin 5% drops: Every hour while awake until reepithelialization, then four times daily for at least 3 weeks.
  • Amphotericin B 0.2 mg/ml drops: Given every 2 hours for 21 days.
  • Amphotericin B 0.2 mg/ml drops: Administered every 2 hours for 21 days, coupled with subconjunctival injections of fluconazole 2mg/mL daily for 10 days.
  • Chlorhexidine gluconate 0.2% drops: Used half-hourly to two-hourly for up to 5 days, then with reduced frequency, with all patients reassessed at 21 days.

It’s important to note that in rare cases where the nature of the infectious pathology demands highly specialized medication formulations, these are typically only available at academic medical center pharmacies.

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