November 2010
ICO International Clinical Guidelines
This document contains 24 International Clinical Guidelines defined by the
International Council of Ophthalmology (ICO).
The Guidelines are designed to be translated and adapted by ophthalmologic
societies to help ophthalmologists assess how they are treating patients. They are
intended to serve a supportive and educational role and ultimately to improve the
quality of eye care for patients.
Below is a list of the Guidelines available with links to each Guideline in this
document, followed by the Preface to the Guidelines. Also see the Introduction to
the ICO International Clinical Guidelines
www.icoph.org/enhancing_eyecare/international_clinical_guidelines.html.
For the latest information on the ICO Clinical Guidelines and to download
individual Guidelines as separate PDF files, see the www.icoph.org resources
listings.
List of Guidelines Available
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Age-Related Macular Degeneration (Initial and Follow-up Evaluation)
Age-Related Macular Degeneration (Management Recommendations)
Amblyopia (Initial and Follow-up Evaluation)
Bacterial Keratitis (Initial Evaluation)
Bacterial Keratitis (Management Recommendations)
Blepharitis (Initial and Follow-up Evaluation)
Cataract (Initial and Follow-up Evaluation)
Conjunctivitis (Initial Evaluation and Therapy)
Diabetic Retinopathy (Initial and Follow-up Evaluation)
Diabetic Retinopathy (Management Recommendations)
Dry Eye Syndrome (Initial Evaluation)
Dry Eye Syndrome (Management Recommendations)
Esotropia (Initial and Follow-up Evaluation)
Exotropia (Initial and Follow-up Evaluation)
Eye Disease in Leprosy (Initial Evaluation and Management)
Idiopathic Macular Hole (Initial Evaluation and Therapy)
Keratorefractive Surgery (Initial and Follow-up Evaluation)
Ocular HIV/AIDS Related Diseases (Initial and Follow-up Evaluation)
Posterior Vitreous Detachment, Retinal Breaks and Lattice Degeneration
(Initial and Follow-up Evaluation)
Primary Open-Angle Glaucoma (Initial Evaluation)
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Primary Open-Angle Glaucoma (Follow-up Evaluation)
Primary Open-Angle Glaucoma Suspect (Initial and Follow-up Evaluation)
Primary Angle Closure (Initial Evaluation and Therapy)
Trachoma
Preface to the Guidelines
International Clinical Guidelines are prepared and distributed by the International
Council of Ophthalmology.
These Guidelines are to serve a supportive and educational role for
ophthalmologists worldwide. These guidelines are intended to improve the quality
of eye care for patients. They have been adapted in many cases from similar
documents (Benchmarks of Care) created by the American Academy of
Ophthalmology based on their Preferred Practice Patterns.
While it is tempting to equate these to Standards, it is impossible and inappropriate
to do so. The multiple circumstances of geography, equipment availability, patient
variation and practice settings preclude a single standard.
Guidelines on the other hand are a clear statement of expectations. These include
comments of the preferred level of performance assuming conditions that allow the
use of optimum equipment, pharmaceuticals and/or surgical circumstances.
Thus, a basic expectation is created and if the situation is optimum, the optimum
facets of diagnosis, treatment and follow up may be employed. Excellent,
appropriate and successful care can also be provided where optimum conditions
do not exist.
Simply following the Guidelines does not guarantee a successful outcome. It is
understood that, given the uniqueness of a patient and his or her particular
circumstance, physician judgment must be employed. This can result in a
modification in application of a guideline in individual situations.
Medical experience has been relied upon in the preparation of these guidelines,
and they are whenever possible, evidence-based. This means these Guidelines
are based on the latest available scientific information. The ICO is committed to
provide updates of these guidelines on a regular basis (approximately every two to
three years).
(Also see the Introduction to the ICO International Clinical Guidelines at
www.icoph.org/guide/guideintro.html and the list of other Guidelines at
www.icoph.org/guide/guidelist.html.)
ICO International Clinical Guidelines, 2010
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Age-Related Macular Degeneration
(Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)
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Symptoms (metamorphopsia, decreased vision) (A:II)
Medications and nutritional supplements (B:III)
Ocular history (B:II)
Systemic history (any hypersensitivity reactions) (B:II)
Family history, especially family history of AMD (B:II)
Social history, especially smoking (B:II)
Initial Physical Exam (Key elements)
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Visual acuity (A:III)
Stereo biomicroscopic examination of the macula (A:III)
Ancillary Tests
Intravenous fundus fluorescein angiography in the clinical setting of AMD is
indicated: (A:I)
o when patient complains of new metamorphopsia
o when patient has unexplained blurred vision
o when clinical exam reveals elevation of the RPE or retina, subretinal
blood, hard exudates or subretinal fibrosis
o to detect the presence of and determine the extent, type, size, and
location of CVN and to calculate the percentage of the lesion
composed of or consisting of classic CNV
o to guide treatment (laser photocoagulation surgery or verteporfin
PDT)
o to detect persistent or recurrent CNV following treatment
o to assist in determining the cause of visual loss that is not explained
by clinical exam
Each angiographic facility must have a care plan or an emergency plan and a
protocol to minimize the risk and manage any complications. (A:III)
ICO International Clinical Guidelines, 2010
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Follow-up Exam History
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Visual symptoms, including decreased vision and metamorphopsia (A:II)
Changes in medications and nutritional supplements (B:III)
Interval ocular history (B:III)
Interval systemic history (B:III)
Changes in social history, especially smoking (B:II)
Follow-up Physical Exam
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Visual acuity (A:III)
Stereo biomicroscopic examination of the fundus (A:III)
Follow-up Treatment after Neovascular AMD
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Discuss risks, benefits and complications with the patient and obtain
informed consent (A:III)
Examine patients treated with ranibizumab intravitreal injections
approximately 4 weeks after treatment (A:III)
Examine patients treated with bevacizumab intravitreal injections
approximately 4 to 8 weeks after treatment (A:III)
Examine patients treated with pegaptanib sodium injection approximately 6
weeks following the treatment (A:III)
Examine and perform fluorescein angiography at least every 3 months for
up to 2 years after verteporfin PDT (A:I)
Examine patients treated with thermal laser photocoagulation approximately
2 to 4 weeks after treatment and then at 4 to 6 weeks (A:III)
Optical coherence tomography, (A:III) fluorescein angiography, (A:I) and
fundus photography (A:III) may be helpful to detect signs of exudation and
should be used when clinically indicated
Subsequent examinations should be performed as indicated depending on
the clinical findings and the judgment of the treating ophthalmologist (A:III)
Patient Education
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Educate patients about the prognosis and potential value of treatment as
appropriate for their ocular and functional status (A:III)
Encourage patients with early AMD to have regular dilated eye exams for
early detection of intermediate AMD (A:III)
Educate patients with intermediate AMD about methods of detecting new
symptoms of CVN and about the need for prompt notification to an
ophthalmologist (A:III)
Instruct patients with unilateral disease to monitor their vision in their fellow
eye and to return periodically even in absence of symptoms, but promptly
after onset of new or significant visual symptoms (A:III)
Instruct patients to report symptoms suggestive of endophthalmitis,
including eye pain or increased discomfort, worsening eye redness, blurred
or decreased vision, increased sensitivity to light, or increased number of
floaters promptly (A:III)
ICO International Clinical Guidelines, 2010
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Encourage patients who are currently smoking to stop (A:I) because there
are observational data that support a causal relationship between smoking
and AMD (A:II) and other considerable health benefits of smoking cessation
Refer patients with reduced visual function for vision rehabilitation (see
www.aao.org/smartsight) and social services (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
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Age-Related Macular Degeneration
(Management Recommendations)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Treatment Recommendations and Follow-up Plans for
Age-Related Macular Degeneration
Recommended Treatment
Diagnoses Eligible for
Treatment
Observation with no medical
or surgical therapies (A:I)
No clinical signs of AMD
(AREDS category 1)
As recommended in the Comprehensive Adult
Medical Eye Evaluation PPP (A:III)
Early AMD (AREDS
category 2)
Return exam at 6 to 24 months if asymptomatic or
prompt exam for new symptoms suggestive of
CVN (A:III)
Advanced AMD with
bilateral subfoveal
geographic atrophy or
disciform scars
Antioxidant vitamin and
mineral supplements as
recommended in the AREDS
reports (A:I)
Follow-up Recommendations
No fundus photos or fluorescein angiography
unless symptomatic (A:I)
Intermediate AMD
(AREDS category 3)
Monitoring of monocular near vision
(reading/Amsler grid) (A:III)
Advanced AMD in one
eye (AREDS category 4)
Return exam at 6 to 24 months if asymptomatic or
prompt exam for new symptoms suggestive of
CVN (A:III)
Fundus photography as appropriate
Fluorescein angiography if there is evidence of
edema or other signs and symptoms of CVN
Ranibizumab intravitreal
injection 0.5 mg as
recommended in
ranibizumab literature (A:I)
Subfoveal CNV
Patients should be instructed to report any
symptoms suggestive of endophthalmitis
promptly, including eye pain or increased
discomfort, worsening eye redness, blurred or
decreased vision, increased sensitivity to light, or
increased number of floaters (A:III)
Return exam approximately 4 weeks after
treatment; subsequent follow-up depends on the
clinical findings and judgement of the treating
ophthalmologist (A:III)
Monitoring of monocular near vision
(reading/Amsler grid) (A:III)
ICO International Clinical Guidelines, 2010
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Recommended Treatment
Bevacizumab intravitreal
injection as described in
published reports (A:III)
Diagnoses Eligible for
Treatment
Subfoveal CNV
The ophthalmologist should
provide appropriate informed
consent with respect to the
off-label status (A:III)
Follow-up Recommendations
Patients should be instructed to report any
symptoms suggestive of endophthalmitis
promptly, including eye pain or increased
discomfort, worsening eye redness, blurred or
decreased vision, increased sensitivity to light, or
increased number of floaters (A:III)
Return exam approximately 4 to 8 weeks after
treatment; subsequent follow-up depends on the
clinical findings and judgement of the treating
ophthalmologist (A:III)
Monitoring of monocular near vision
(reading/Amsler grid) (A:III)
Pegaptanib sodium
intravitreal injection as
recommended in pegaptanib
sodium literature (A:I)
Subfoveal CNV, new or
recurrent, for
predominantly classic
lesions <12 MPS disc
area in size
Minimally classic, or
occult with no classic
lesions where the entire
lesion is <12 disc areas
in size, subretinal
hemorrhage associated
with CVN comprises
<50% of lesion, and/or
there is lipid present,
and/or the patient has
lost 15 or more letters of
visual acuity during the
previous 12 weeks
PDT with verteporfin as
recommended in the TAP
and VIP reports (A:I)
Subfoveal CNV, new or
recurrent, where the
classic component is
>50% of the lesion and
the entire lesion is <5400
microns in greatest linear
diameter
Patients should be instructed to report any
symptoms suggestive of endophthalmitis
promptly, including eye pain or increased
discomfort, worsening eye redness, blurred or
decreased vision, increased sensitivity to light, or
increased number of floaters (A:III)
Return exam with retreatments every 6 weeks as
indicated (A:III)
Monitoring of monocular near vision
(reading/Amsler grid) (A:III)
Return exam approximately every 3 months until
stable, with retreatments as indicated (A:III)
Monitoring of monocular near vision
(reading/Amsler grid) (A:III)
Occult CNV may be
considered for PDT with
vision <20/50 or if the
CVN is <4 MPS disc
areas in size when the
vision is >20/50
ICO International Clinical Guidelines, 2010
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Recommended Treatment
Thermal laser
photocoagulation surgery as
recommended in the MPS
reports (A:I)
Diagnoses Eligible for
Treatment
Extrafoveal classic CNV,
new or recurrent
May be considered for
juxtapapillary CVN
Follow-up Recommendations
Return exam with fluorescein angiography
approximately 2 to 4 weeks after treatment, and
then at 4 to 6 weeks and thereafter depending on
the clinical and angiographic findings (A:III)
Retreatments as indicated
Monitoring of monocular near vision
(reading/Amsler grid) (A:III)
AMD = Age-related Macular Degeneration; AREDS = Age-related Eye Disease Study; CNV =
choroidal neovascularization; MPS = Macular Photocoagulation Study; PDT = photodynamic
therapy; TAP = Treatment of Age-related Macular Degeneration with Photodynamic Therapy; VIP =
Verteporfin in Photodynamic Therapy
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
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Amblyopia (Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)
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Ocular symptoms and signs (A:III)
Ocular history (A:III)
Systemic history, including review of prenatal, perinatal, and postnatal
medical factors (A:III)
Family history, including eye conditions and relevant systemic diseases
(A:III)
Initial Physical Exam (Key elements)
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Assessment of visual acuity and fixation pattern (A:III)
Ocular alignment and motility (A:III)
Red reflex or binocular red reflex (Brückner) test (A:III)
Pupil examination (A:III)
External examination (A:III)
Anterior segment examination (A:III)
Cycloplegic retinoscopy/refraction (A:III)
Funduscopic examination (A:III)
Binocularity/stereoacuity testing (A:III)
Care Management
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Choose treatment based on patient's age; visual acuity; compliance with
previous treatment; and physical, social, and psychological status. (A:III)
Treatment goal is to achieve equalization/normalization of fixation patterns
or visual acuity. (A:III)
Once maximal visual acuity has been obtained, treatment should be tapered
and eventually stopped. (A:III)
Follow-up Evaluation
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Follow-up visits should include:
o Interval history (A:III)
o Tolerance to therapy (A:III)
o Examinations and testing as indicated (A:III)
ICO International Clinical Guidelines, 2010
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Amblyopia Follow-up Evaluation Intervals During Active Treatment Period
(A:III)
Age
(years)
0-1
1-2
2-3
3-4
4-5
5-7
7-9
High- Percentage
Occlusion
(70% or more of
waking hours/≥ 6
hours per day)
1-4 weeks
2-8 weeks
3-12 weeks
4-16 weeks
4-16 weeks
6-16 weeks
8-16 weeks
Low-Percentage
Occlusion
(<70% of waking
hours/<6 hours per
day) or Penalization
2-8 weeks
2-4 months
2-4 months
2-6 months
2-6 months
2-6 months
3-6 months
Maintenance
Treatment or
Observation
1-4 months
2-4 months
2-4 months
2-6 months
2-6 months
2-6 months
3-12 months
Patient Education
• Discuss diagnosis, severity of disease, prognosis and treatment plan with
patient, parents and /or caregivers. (A:III)
• Explain the disorder and recruit the family in a collaborative approach to
therapy. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 10
Bacterial Keratitis (Initial Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History
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Ocular symptoms (A:III)
Contact lens history (A:II)
Review of other ocular history (A:III)
Review of other medical problems and systemic medications (A:III)
Current and recently used ocular medications (A:III)
Medication allergies (A:III)
Initial Physical Exam
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Visual acuity (A:III)
General appearance of patient (B:III)
Facial examination (B:III)
Eyelids and eyelid closure (A:III)
Conjunctiva (A:III)
Nasolacrimal apparatus (B:III)
Corneal sensation (A:III)
Slit-lamp biomicroscopy
o Eyelid margins (A:III)
o Conjunctiva (A:III)
o Sclera (A:III)
o Cornea (A:III)
o Anterior chamber (A:III)
o Anterior vitreous (A:III)
Contralateral eye (A:III)
Diagnostic Tests
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Manage majority of community-acquired cases with empiric therapy and
without smears or cultures. (A:III)
Indications for smears and cultures:
o Sight-threatening or severe keratitis of suspected microbial origin
prior to initiating therapy (A:III)
o A large corneal infiltrate that extends to the middle to deep stroma
(A:III)
o Chronic in nature (A:III)
o Unresponsive to broad spectrum antibiotic therapy (A:III)
o Clinical features suggestive of fungal, amoebic, or mycobacterial
keratitis (A:III)
The hypopyon that occurs in eyes with bacterial keratitis is usually sterile,
ICO International Clinical Guidelines, 2010
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and aqueous or vitreous taps should not be performed unless there is a
high suspicion of microbial endophthalmitis. (A:III)
Corneal scrapings for culture should be inoculated directly onto appropriate
culture media to maximize culture yield. (A:III). If this is not feasible, place
specimens in transport media. (A:III). In either case, immediately incubate
cultures or take promptly to the laboratory. (A:III)
Care Management
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Topical antibiotic eye drops are preferred method in most cases. (A:III)
Use topical broad-spectrum antibiotics initially in the empiric treatment of
presumed bacterial keratitis. (A:III)
For central or severe keratitis (e.g., deep stromal involvement or an infiltrate
larger than 2 mm with extensive suppuration), use a loading dose (e.g.,
every 5 to 15 minutes for the first 1 to 3 hours), followed by frequent
applications (e.g., every 30 minutes to 1 hour around the clock). (A:III) For
less severe keratitis, a regimen with less frequent dosing is appropriate.
(A:III)
Use systemic therapy for gonococcal keratitis. (A:II)
In general, modify initial therapy when there is a lack of improvement or
stabilization within 48 hours. (A:III)
For patients treated with ocular topical corticosteroids at time of
presentation of suspected bacterial keratitis, reduce or eliminate
corticosteroids until infection has been controlled. (A:III)
When the corneal infiltrate compromises the visual axis, may add topical
corticosteroid therapy following at least 2 to 3 days of progressive
improvement with topical antibiotics. (A:III) Continue topical antibiotics at
high levels with gradual tapering. (A:III)
Examine patients within 1 to 2 days after initiation of topical corticosteroid
therapy. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
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Bacterial Keratitis
(Management Recommendations)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Follow-up Evaluation
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Frequency depends on extent of disease, but follow severe cases initially at
least daily until clinical improvement or stabilization is documented. (A:III)
Patient Education
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Inform patients with risk factors predisposing them to bacterial keratitis of
their relative risk, the signs and symptoms of infection, and to consult an
ophthalmologist promptly if they experience such warning signs or
symptoms (A:III)
Educate about the destructive nature of bacterial keratitis and need for strict
compliance with therapy. (A:III)
Discuss possibility of permanent visual loss and need for future visual
rehabilitation. (A:III)
Educate patients with contact lenses about increased risk of infection
associated with contact lens, overnight wear, and importance of adherence
to techniques to promote contact lens hygiene. (A:III)
Refer patients with significant visual impairment or blindness for vision
rehabilitation if they are not surgical candidates (see
www.aao.org/smartsight). (A:III)
ICO International Clinical Guidelines, 2010
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Antibiotic Therapy of Bacterial Keratitis [A:III]
Organism
Antibiotic
Topical
Concentration
Subconjunctival
Dose
No organism identified
or multiple types of
organisms
Cefazolin with
Tobramycin or
gentamicin
or Fluoroquinolones
50 mg/ml 9-14
mg/ml
3 or 5 mg/ml
Various**
100 mg in 0.5 ml
20 mg in 0.5 ml
Gram-positive Cocci
Cefazolin
Vancomycin***
Bacitracin***
Fluoroquinolones*
50 mg/ml
15-50 mg/ml
10,000 IU
Various**
100 mg in 0.5 ml
25 mg in 0.5 ml
Gram-negative rods
Tobramycin or
gentamicin
Ceftazidime
Fluoroquinolones
9-14 mg/ml
50 mg/ml
Various**
20 mg in 0.5 ml
100 mg in 0.5 ml
Gram-negative
Cocci****
Ceftriaxone
Ceftazidime
Fluoroquinolones
50 mg/ml
50 mg/ml
Various**
100 mg in 0.5 ml
100 mg in 0.5 ml
Nontuberculous
Mycobacteria
Amikacin
Clarithromycin
Azithromycin*****
Fluoroquinolones
Sulfacetamide
Amikacin
Trimethoprim/Sulfa
methoxazole:
Trimethoprim
Sulfamethoxazole
20-40 mg/ml
10 mg/ml
10 mg/ml
Various**
100 mg/ml
20-40 mg/ml
20 mg in 0.5 ml
Nocardia
20 mg in 0.5 ml
16 mg/ml
80 mg/ml
*Fewer gram-positive cocci are resistant to gatifloxacin and moxifloxacin than other
fluoroquinolones.
**Ciprofloxacin 3 mg/ml; gatifloxacin 3 mg/ml; levofloxacin 15 mg/ml; moxifloxacin 5mg/ml;
ofloxacin 3 mg/ml, all commercially available at these concentrations.
***For resistant Enterococcus and Staphylococcus species and penicillin allergy.
Vancomycin and Bacitracin have no gram-negative activity and should not be used as a
single agent empirically in treating bacterial keratitis.
**** Systemic therapy is necessary for suspected gonococcal infection.
***** Data from Chandra NS, Torres MF, Winthrop KL. Cluster of Mycobacterium chelonae
keratitis cases following laser in-situ keratomileusis. Am J Ophthalmol 2001; 132:819-30.
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 14
Blepharitis (Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History
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Ocular symptoms and signs (A:III)
Time of day when symptoms are worse (A:III)
Duration of symptoms (A:III)
Unilateral or bilateral presentation (A:III)
Exacerbating conditions (e.g., smoke, allergens, wind, contact lens, low
humidity, retinoids, diet, alcohol consumption, eye makeup) (A:III)
Symptoms related to systemic diseases (e.g., rosacea, allergy) (A:III)
Current and previous systemic and topical medications (A:III)
Recent exposure to an infected individual (e.g., pediculosis) (C:III)
Ocular history (e.g., previous intraocular and eyelid surgery, local trauma,
including mechanical, thermal, chemical, and radiation injury) (A:III)
Systemic history (e.g., dermatological diseases, such as rosacea, atopic
disease, and herpes zoster ophthalmicus) (A:III)
Initial Physical Exam
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Visual acuity (A:III)
External examination
o Skin (A:III)
o Eyelids (A:III)
Slit-lamp biomicroscopy
o Tear film (A:III)
o Anterior eyelid margin (A:III)
o Eyelashes (A:III)
o Posterior eyelid margin (A:III)
o Tarsal conjunctiva (A:III)
o Bulbar conjunctiva (A:III)
o Cornea (A:III)
Measurement of IOP (A:III)
Diagnostic Tests
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Cultures may be indicated for patients with recurrent anterior blepharitis with
severe inflammation as well as for patients who are not responding to
therapy. (A:III)
Biopsy of the eyelid to exclude the possibility of carcinoma may be indicated
in cases of marked asymmetry, resistance to therapy or unifocal recurrent
chalazia that do not respond well to therapy. (A:II)
Consult with the pathologist prior to obtaining the biopsy if sebaceous cell
carcinoma is suspected.(A:II)
ICO International Clinical Guidelines, 2010
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Care Management
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Treat patients with blepharitis initially with a regimen of warm compress and
eyelid hygiene. (A:III)
For patients with staphylococcal blepharitis, a topical antibiotic such as
erythromycin can be prescribed to be applied one or more times daily or at
bedtime on the eyelids for one or more weeks. (A:III)
For patients with meibomian gland dysfunction, whose chronic symptoms
and signs are not adequately controlled with eyelid hygiene, oral
tetracyclines can be prescribed. (A:III)
A brief course of topical corticosteroids may be helpful for eyelid or ocular
surface inflammation. The minimal effective dose of corticosteroids should
be utilized and long-term corticosteroid therapy should be avoided if
possible. (A:III)
Follow-up Evaluation
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Follow-up visits should include:
o Interval history (A:III)
o Visual acuity (A:III)
o External exam (A:III)
o Slit-lamp biomicroscopy (A:III)
 If corticosteroid therapy is prescribed, re-evaluate patient within a few
weeks to
determine the response to therapy, measure intraocular pressure, and
assess treatment compliance (A:III)
Patient Education
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Counsel patients about the chronicity and recurrence of the disease
process. (A:III)
Inform patients that symptoms can frequently be improved but are rarely
eliminated. (A:III)
Advise patient that if warm compress and eyelid hygiene treatment is
effective, symptoms often recur if treatment is stopped so may be
necessary long term (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 16
Cataract (Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History




Symptoms (A:II)
Ocular history (A:III)
Systemic history (A:III)
Assessment of visual functional status (A:II)
Initial Physical Exam









Visual acuity, with current correction (A:III)
Measurement of BCVA (with refraction when indicated) (A:III)
Ocular alignment and motility(A:III)
Pupil reactivity and function (A:III)
Measurement of IOP (A:III)
External examination (A:III)
Slit-lamp biomicroscopy (A:III)
Evaluation of the fundus (through a dilated pupil) (A:III)
Assessment of relevant aspects of general and mental health (B:III)
Care Management




Treatment is indicated when visual function no longer meets the patient's
needs and cataract surgery provides a reasonable likelihood of
improvement. (A:II)
Cataract removal is also indicated when there is evidence of lens-induced
diseases or when it is necessary to visualize the fundus in an eye that has
the potential for sight. (A:III)
Surgery should not be performed under the following circumstances: (A:III)
glasses or visual aids provide vision that meets the patient's needs’, surgery
will not improve visual function; the patient cannot safely undergo surgery
because of coexisting medical or ocular conditions; appropriate
postoperative care cannot be obtained.
Indications for second eye surgery are the same as for the first eye. (A:II)
(with consideration given to the needs for binocular function)
Preoperative Care
Ophthalmologist who is to perform the surgery has the following responsibilities:



Examine the patient preoperatively (A:III)
Ensure that the evaluation accurately documents symptoms, findings and
indications for treatment (A:III)
Inform the patient about the risks, benefits and expected outcomes of
ICO International Clinical Guidelines, 2010
Page 17



surgery (A:III)
Formulate surgical plan, including selection of an IOL (A:III)
Review results of presurgical and diagnostic evaluations with the patient
(A:III)
Formulate postoperative plans and inform patient of arrangements (A:III)
Follow-up Evaluation





High-risk patients should be seen within 24 hours of surgery. (A:III)
Routine patients should be seen within 48 hours of surgery. (A:III)
Frequency and timing of subsequent visits depend on refraction, visual
function, and medical condition of the eye.
More frequent follow-up usually necessary for high risk patients.
Components of each postoperative exam should include:
o Interval history, including new symptoms and use of postoperative
medications (A:III)
o Patient's assessment of visual functional status (A:III)
o Assessment of visual function (visual acuity, pinhole testing) (A:III)
o Measurement of IOP (A:III)
o Slit-lamp biomicroscopy (A:III)
Nd:YAG Laser Capsulotomy


Treatment is indicated when vision impaired by posterior capsular
opacification does not meet the patient's functional needs or when it
critically interferes with visualization of the fundus. (A:III)
Educate about the symptoms of posterior vitreous detachment, retinal tears
and detachment and need for immediate examination if these symptoms are
noticed. (A:III)
Patient Education

For patients who are functionally monocular, discuss special benefits and
risks of surgery, including the risk of blindness. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 18
Conjunctivitis (Initial Evaluation and Therapy)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History















Ocular symptoms and signs (e.g., itching, discharge, irritation, pain,
photophobia, blurred vision) (A:III)
Duration of symptoms (A:III)
Exacerbating factors (A:III)
Unilateral or bilateral presentation (A:III)
Character of discharge (A:III)
Recent exposure to an infected individual (A:III)
Trauma (mechanical, chemical, ultraviolet) (A:III)
Contact lens wear (e.g., lens type, hygiene and use regimen) (A:III)
Symptoms and signs potentially related to systemic diseases (e.g.,
genitourinary discharge, dysuria, upper respiratory infection, skin and
mucosal lesions) (A:III)
Allergy, asthma, eczema (A:III)
Use of topical and systemic medications (A:III)
Use of personal care products (A:III)
Ocular history (e.g., previous episodes of conjunctivitis (A:III) and previous
ophthalmic surgery) (B:III)
Systemic history (e.g., compromised immune status, current and prior
systemic diseases) (B:III)
Social history (e.g., smoking, occupation and hobbies, travel and sexual
activity) (C:III)
Initial Physical Exam



Visual acuity (A:III)
External examination
o Regional lymphadenopathy (particularly preauricular) (A:III)
o Skin (A:III)
o Abnormalities of the eyelids and adnexae (A:III)
o Conjunctiva (A:III)
Slit-lamp biomicroscopy
o Eyelid margins (A:III)
o Eyelashes (A:III)
o Lacrimal puncta and canaliculi (B:III)
o Tarsal and forniceal conjunctiva (A:II)
o Bulbar conjunctiva/limbus (A:II)
o Cornea (A:I)
o Anterior chamber/iris (A:III)
o Dye-staining pattern (conjunctiva and cornea) (A:III)
ICO International Clinical Guidelines, 2010
Page 19
Diagnostic Tests





Cultures, smears for cytology and special stains are indicated in cases of
suspected infectious neonatal conjunctivitis. (A: I)
Smears for cytology and special stains are recommended in cases of
suspected gonococcal conjunctivitis. (A:II)
Confirm diagnosis of adult and neonate chlamydial conjunctivitis with
immunodiagnostic test and/or culture. (A:III)
Biopsy the bulbar conjunctiva and take a sample from an uninvolved area
adjacent to the limbus in an eye with active inflammation when ocular
mucous membrane pemphigoid is suspected. (A:III)
A full-thickness lid biopsy is indicated in cases of suspected sebaceous
carcinoma. (A:II)
Care Management








Avoid indiscriminate use of topical antibiotics or corticosteroids because
antibiotics can induce toxicity and corticosteroids can prolong adenoviral
infections and worsen herpes simplex virus infections (A:III)
Treat mild allergic conjunctivitis with an over-the-counter
antihistamine/vasoconstrictor agent or second-generation topical histamine
H1-receptor antagonists. (A:III) If the condition is frequently recurrent or
persistent, use mast-cell stabilizers (A:I)
For contact lens-related keratoconjunctivitis, discontinue contact lens wear
for 2 or more weeks (A:III)
If corticosteroids are indicated, prescribe the minimal amount based on
patient response and tolerance (A:III)
If corticosteroids are used, perform baseline measurement of intraocular
pressure (A:III)
Use systemic antibiotic treatment for conjunctivitis due to Neisseria
gonorrhoeae (A:I) or Chlamydia trachomatis. (A:II)
Treat sexual partners to minimize recurrence and spread of disease when
conjunctivitis is associated with sexually transmitted diseases and refer
patients and their sexual partners to an appropriate medical specialist.
(A:III)
Refer patients with manifestation of a systemic disease to an appropriate
medical specialist. (A:III)
Follow-up Evaluation

Follow-up visits should include:
o Interval history (A:III)
o Visual acuity (A:III)
o Slit-lamp biomicroscopy (A:III)
 If corticosteroids are used, perform periodic measurement of intraocular
pressure and
pupillary dilation to evaluate for cataract and glaucoma (A:III)
ICO International Clinical Guidelines, 2010
Page 20
Patient Education



Counsel patients with contagious varieties to minimize or prevent spread of
diseases in the community (A:III)
Inform patients who may require repeat short-term therapy with topical
corticosteroid of potential complications of corticosteroid use (A:III)
Advise patients with allergic conjunctivitis that frequent clothes washing and
bathing/showering before bedtime may be helpful (B:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 21
Diabetic Retinopathy
(Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)





Duration of diabetes (A:I)
Past glycemic control (hemoglobin A1c) (A:I)
Medications (A:III)
Systemic history (e.g., obesity (A:III), renal disease (A:II), systemic
hypertension (A:I), serum lipid levels (A:II), pregnancy (A:I))
Ocular history (A:III)
Initial Physical Exam (Key elements)






Visual acuity (A:I)
Measurement of IOP (A:III)
Gonioscopy when indicated (for neovascularization of the iris or increased
IOP) (A:III)
Slit-lamp biomicroscopy (A:III)
Dilated funduscopy including stereoscopic examination of the posterior pole
(A:I)
Examination of the peripheral retina and vitreous, best performed with
indirect ophthalmoscopy or with slit-lamp biomicroscopy, combined with a
contact lens (A:III)
Diagnosis

Classify both eyes as to category and severity of diabetic retinopathy, with
presence/absence of CSME.(A:III) Each category has an inherent risk for
progression.
Follow-up History



Visual symptoms (A:III)
Systemic status (e.g., pregnancy, blood pressure, serum cholesterol, renal
status) (A:III)
Glycemic status (hemoglobin A1c) (A:I)
Follow-up Physical Exam




Visual acuity (A:I)
Measurement of IOP (A:III)
Slit-lamp biomicroscopy with iris examination (A:II)
Gonioscopy (if neovascularization is suspected or present or if intraocular
pressure is increased) (A:II)
ICO International Clinical Guidelines, 2010
Page 22


Stereo examination of the posterior pole after dilation of the pupils (A:I)
Examination of the peripheral retina and vitreous when indicated (A:II)
Ancillary Tests





Fundus photography is seldom of value in cases of minimal diabetic
retinopathy or when diabetic retinopathy is unchanged from the previous
photographic appearance. (A:III)
Fundus photography may be useful for documenting significant progression
of disease and response to treatment. (B:III)
Fluorescein angiography is used as a guide for treating CSME (A:I) and as
a means of evaluating the cause(s) of unexplained decreased visual acuity.
(A:III) Angiography can identify macular capillary nonperfusion (A:II) or
sources of capillary leakage resulting in macular edema as possible
explanations for visual loss.
Fluorescein angiography is not routinely indicated as part of the
examination of patients with diabetes. (A:III)
Fluorescein angiography is not needed to diagnose CSME or PDR, both of
which are diagnosed by means of the clinical exam.
Patient Education







Discuss results or exam and implications. (A:II)
Encourage patients with diabetes but without diabetic retinopathy to have
annual dilated eye exams. (A:II)
Inform patients that effective treatment for diabetic retinopathy depends on
timely intervention, despite good vision and no ocular symptoms. (A:II)
Educate patients about the importance of maintaining near-normal glucose
levels and near-normal blood pressure and lowering serum lipid levels.
(A:III)
Communicate with the attending physician, e.g., family physician, internist,
or endocrinologist, regarding eye findings. (A:III)
Provide patients whose conditions fail to respond to surgery and for whom
treatment is unavailable with proper professional support and offer referral
for counseling, rehabilitative, or social services as appropriate. (A:III)
Refer patients with reduced visual function for vision rehabilitation (see
www,aao.org/smartsight) and social services (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 23
Diabetic Retinopathy
(Management Recommendations)
Management Recommendations for Patients with Diabetes
Severity of
Retinopathy
Normal or
minimal NPDR
Mild to moderate
NPDR
Presence FollowPanretinal
Focal
Fluorescein
of
up
Photocoagulation
and/or
Angiography
CSME* (Months)
(Scatter) Laser
Laser†
No
12
No
No
No
No
Yes
6-12
2-4
No
No
No
Usually
No
Usually*^
No
Yes
Non-high-risk
No
PDR
Yes
High-risk PDR
No
Yes
Inactive/involuted No
PDR
Yes
2-4
2-4
2-4
2-4
2-4
2-4
6-12
2-4
Sometimes‡
Sometimes‡
Sometimes‡
Sometimes‡
Usually
Usually
No
No
Rarely
Usually
Rarely
Usually
Rarely
Usually
No
Usually
No
Usually**
No
Usually^
No
Usually**
Usually
Usually
Severe NPDR
CSME = clinically significant macular edema; NPDR = nonproliferative diabetic
retinopathy; PDR = proliferative diabetic retinopathy
* Exceptions include: hypertension or fluid retention associated with heart failure,
renal failure, pregnancy, or any other causes that may aggravate macular edema.
Deferral of photocoagulation for a brief period of medical treatment may be
considered in these cases. Also, deferral of CSME treatment is an option when the
center of the macula is not involved, visual acuity is excellent, and the patient
understands the risks.
† Adjunctive treatment that may be considered include intravitreal corticosteroids
or anti-vascular endothelial growth factor agents (off-label use). Data from the
Diabetic Retinopathy Clinical Research Network in 2010 demonstrated that, at one
year of follow-up, intravitreal ranibizumab with prompt or deferred laser resulted in
greater visual acuity gain and intravitreal triamcinolone acetonide plus laser also
resulted in greater visual gain in pseudophakic eyes compared with laser alone.
Individuals receiving the intravitreal injections of anti-vascular endothelial growth
factor agents may be examined one month following injection.
^ Deferring focal photocoagulation for CSME is an option when the center of the
macula is not involved, visual acuity is excellent, close follow-up is possible, and
the patient understands the risks. However, initiation of treatment with focal
photocoagulation should also be considered because although treatment with focal
photocoagulation is less likely to improve the vision, it is more likely to stabilize the
current visual acuity. Treatment of lesions close to the foveal avascular zone may
ICO International Clinical Guidelines, 2010
Page 24
result in damage to central vision and with time, such laser scars may expand and
cause further vision deterioration. Future studies may help guide the use of
intravitreal therapies including corticosteroids and anti-vascular endothelial growth
factor agents in these cases in which laser photocoagulation cannot be
administered safely. Closer follow-up may be necessary for macular edema that is
not clinically significant.
‡ Panretinal photocoagulation surgery may be considered as patients approach
high-risk PDR. The benefit of early panretinal photocoagulation at the severe
nonproliferative or worse stage of retinopathy is greater in patients with type 2
diabetes than in those with type 1. Treatment should be considered for patients
with severe NPDR and type 2 diabetes. Other factors, such as poor compliance
with follow-up, impending cataract extraction or pregnancy, and status of fellow
eye will help in determining the timing of the panretinal photocoagulation.
** It is preferable to perform the focal photocoagulation first, prior to panretinal
photocoagulation laser-induced exacerbation of the macular edema.
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 25
Dry Eye Syndrome (Initial Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History






Ocular symptoms and signs (A:III)
Exacerbating conditions (B:III)
Duration of symptoms (A:III)
Topical medications used and their effect on symptoms (A:III)
Ocular history, including
o Contact lens wear, schedule and care (A:III)
o Allergic conjunctivitis (B:III)
o Ocular surgical history (A:III) (prior keratoplasty, cataract surgery,
keratorefractive surgery)
o Punctal surgery (A:III)
o Ocular surface disease (A:III) (e.g., herpes simplex virus, varicella
zoster virus, ocular mucous membrane pemphigoid, StevensJohnson syndrome, aniridia, graft-versus-host disease)
o Punctal surgery (A:III)
o Eyelid surgery (A:III) (e.g. prior ptosis repair, blepharoplasty,
entropion/ectropion repair)
o Bell palsy (A:III)
Systemic history, including
o Smoking or exposure to second-hand smoke (A:III)
o Dermatological diseases (A:III) (e.g., rosacea)
o Technique and frequency of facial washing including eyelid and
eyelash hygiene (A:III)
o Atopy (A:III)
o Menopause (A:III)
o Systemic inflammatory diseases (A:III) (e.g., Sjogren’s syndrome,
graft-versus- host disease, rheumatoid arthritis, systemic lupus
erythematosus, scleroderma)
o Other systemic conditions (A:III) (e.g., lymphoma, sarcoidosis)
o Systemic medications (A:III) (e.g., antihistamines, diuretics,
hormones and hormonal antagonists, antidepressants, cardiac
antiarrhythmic drugs, isotretinoin, diphenoxylate/atropine, betaadrenergic antagonists, chemotherapy agents, any other drug with
anticholinergic effects)
o Trauma (A:III) (e.g., chemical)
o Chronic viral infections (B:III) (e.g., hepatitis C, human
immunodeficiency virus)
o Nonocular surgery (B:III) (e.g., bone marrow transplant, head and
neck surgery, trigeminal neuralgia surgery)
o Radiation of orbit (B:III)
o Neurological conditions (B:III) (e.g., Parkinson’s disease, Bell palsy,
ICO International Clinical Guidelines, 2010
Page 26
Riley-Day syndrome, trigeminal neuralgia)
o Dry mouth, dental cavities, oral ulcers (B:III)
Initial Physical Exam



Visual acuity (A:III)
External examination
o Skin (A:III)
o Eyelids (A:I)
o Adnexae (A:III)
o Proptosis (B:III)
o Cranial nerve function (A:III)
o Hands (B:III)
Slit-lamp biomicroscopy
o Tear film (A:III)
o Eyelashes (A:III)
o Anterior and posterior eyelid margins (A:III)
o Puncta (A:III)
o Inferior fornix and tarsal conjunctiva (A:III)
o Bulbar conjunctiva (A:III)
o Cornea (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 27
Dry Eye Syndrome
(Management Recommendations)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Care Management

Treat any causative factors that are amenable to treatment as patients with
dry eye symptoms often have many contributory factors (A:III)

Sequence and combination of therapies is determined based on the
patient’s needs and preferences and the treating ophthalmologist’s medical
judgment (A:III)
For mild dry eye, the following measures are appropriate:
o Education and environmental modifications (A:III)
o Elimination of offending topical or systemic medications (A:III)
o Aqueous enhancement using artificial tear substitutes, gels/ointments
(A:III)
o Eyelid therapy (warm compresses and eyelid hygiene) (A:III)
o Treatment of contributing ocular factors such as blepharitis or
meibomianitis (A:III)
For moderate dry eye, in addition to above treatments, the following
measures are appropriate:
o
Anti-inflammatory agents (topical cyclosporine (A:I) and
corticosteroids, (A:II) systemic omega-3 fatty acids supplements
(A:II))
o
Punctal plugs (A:III)
o
Spectacle side shields and moisture chambers (A:III)
For severe dry eye, in addition to above treatments, the following measures
are appropriate:
o Systemic cholinergic agonists (A:I)
o Systemic anti-inflammatory agents (A:III)
o Mucolytic agents (A:III)
o Autologous serum tears (A:III)
o Contact lenses (A:III)
o Correction of eyelid abnormalities (A:III)
o Permanent punctal occlusion (A:III)
Monitor patients prescribed corticosteroids for adverse effects such as
increased intraocular pressure, corneal melting, and cataract formation
(A:III)




Patient Education


Counsel patients about the chronic nature of dry eye and its natural history.
(A:III)
Provide specific instructions for therapeutic regimens. (A:III)
ICO International Clinical Guidelines, 2010
Page 28



Reassess periodically the patient's compliance and understanding of the
disease, risks for associated structural changes and realistic expectations
for effective management, and reinforce education. (A:III)
Refer patients with manifestation of a systemic disease to an appropriate
medical specialist. (A:III)
Caution patients with pre-existing dry eye that keratorefractive surgery may
worsen their dry eye condition. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 29
Esotropia (Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)




Ocular symptoms and signs (A:III)
Ocular history (date of onset and frequency of the deviation, presence or
absence of diplopia) (A:III)
Systemic history (review of prenatal, perinatal and postnatal medical
factors) (A:III)
Family history, including presence of strabismus, amblyopia, extraocular
muscle surgery, genetic diseases. (A:III)
Initial Physical Exam (Key elements)







Visual acuity (A:III)
Ocular alignment (at distance and near) and motility (A:III)
Extraocular muscle function (A:III)
Detection of nystagmus (A:III)
Sensory testing (A:III)
Cycloplegic retinoscopy/refraction (A:III)
Fundoscopic examination (A:III)
Care Management




Consider all forms of esotropia for treatment and re-establish ocular
alignment promptly (A:III)
Prescribe corrective lenses for any clinically significant refractive error (A:I)
If optical correction does not align the eyes, then surgical correction is
indicated (A:III)
Start amblyopia treatment before surgery to reduce angle of strabismus or
increase likelihood of binocularity (A:III)
Follow-up Evaluation




Periodic evaluations necessary until visual maturity reached (A:II)
Hyperopia should be assessed every 1 to 2 years (A:III)
More frequent cycloplegic examinations are indicated in cases with changes
in acuity, amblyopia, or unstable alignment (A:III)
If the examination has been stable, follow-up evaluations are appropriate
every 1 to 2 years during teenage years (A:I)
ICO International Clinical Guidelines, 2010
Page 30
Esotropia Follow-up Evaluation Intervals (A:III)
Age (years) Interval (months)
0-1
3-6
1-5
6-12
5
12-24
Note: More frequent visits may be necessary if amblyopia is present or if there is
a recent deterioration of alignment.
Patient Education


Discuss findings with the patient when appropriate and/or
parents/caregivers to enhance understanding of disorder and to recruit them
in a collaborative approach to therapy. (A:III)
Formulate treatment plans in consultation with the patient and/or
family/caregivers. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 31
Exotropia (Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)




Ocular symptoms and signs (A:III)
Ocular history (date of onset and frequency of the deviation, presence or
absence of diplopia) (A:III)
Systemic history (review of prenatal, perinatal and postnatal medical
factors) (A:III)
Family history, including presence of strabismus, amblyopia, extraocular
muscle surgery, genetic diseases (A:III)
Initial Physical Exam (Key elements)







Visual acuity (A:III)
Ocular alignment (at distance and near) and motility (A:III)
Extraocular muscle function (A:III)
Detection of nystagmus (A:III)
Sensory testing (A:III)
Cycloplegic retinoscopy/refraction (A:III)
Fundoscopic examination (A:III)
Care Management



Consider all forms of exotropia for treatment and re-establish ocular
alignment as soon as possible if deviation is manifest a large percentage of
the time. (A:III)
Prescribe corrective lenses for any clinically significant refractive error.
(A:III)
Optimal modes of therapy are not well established.
Follow-up Evaluation

Periodic evaluations necessary until visual maturity reached (A:III)

Intervals are reduced if strabismus is stable (A:III)

Includes interval history, tolerance to treatment (if any), and routine
examination and testing of ocular motility (A:III)
ICO International Clinical Guidelines, 2010
Page 32
Exotropia Follow-up Evaluation Intervals (A:III)
Age (years) Interval (months)
0-1
3-6
1-5
6-12
5
12-24
Note: More frequent visits may be necessary if patching therapy is being administered, or
if there is a recent deterioration of alignment.
Patient Education

Discuss findings with the patient when appropriate and/or parents/caregivers to
enhance understanding of disorder and recruit them in a collaborative approach to
therapy. (A:III)

Formulate treatment plans in consultation with the patient and/or
family/caregivers. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 33
Eye Disease in Leprosy
(Initial Evaluation and Management)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History






Ocular symptoms (decreased vision, epiphora, symptoms of irritation) (A:III)
Duration of lagophthalmos (<or>6 months) (A:III)
Duration of leprosy (usually from date of diagnosis) (B:III)
Type of leprosy (A:III)
MDT treatment; what drugs and for how long (A:III)
History of leprosy reactions (B:III)
Initial Physical Exam








Visual acuity (A:III)
Eyelids and lid closure (A:III)
Corneal sensation (A:III)
Conjunctiva (A:III)
Sclera (A:III)
Pupil (A:III)
Nasolacrimal apparatus (A:III)
Slit lamp biomicroscopy
o Corneal epithelial integrity (A:III)
o Corneal nerve beading, stromal opacity (B:III)
o Anterior chamber (A:III)
o Iris atrophy (A:III)
o Iris "pearls" (B:III)
o Posterior synechiae (A:III)
o Cataract (A:III)
Care Management
The main important conditions (cataract, lagophthalmos, anterior uveitis) are
managed as for any patient, and people with leprosy should be integrated into the
normal eye care service, specifically:




Cataract should be removed when it adversely affects patient's visual
function (A:III)
IOL is not contraindicated as long as quality of surgery is good and eye is
quiet (A:III)
Chronic lagophthalmos should be treated surgically if cornea is
compromised or cosmesis is a problem, regardless of severity of
lagophthalmos, by whatever procedure the surgeon does best (A:III)
Special considerations in a person afflicted with leprosy include:
o New onset lagophthalmos (duration <6 months) should be treated
ICO International Clinical Guidelines, 2010
Page 34
with oral prednisolone 25-30 mg per day tapered over 6 months.
(A:III)
o Acute uveitis should be treated with intensive topical steroid;
associated systemic leprosy reaction must be ruled out or treated if
present with systemic steroid give dose) (A:III)
Patient Education




At the end of MDT all patients should be warned that lagophthalmos could
develop and understand the risks associated with this. (A:III)
Patients with residual lagophthalmos must be told about the risk form
exposure and specifically warned about development of red eye and
decreased vision. (A:III)
Patients should understand risks to eye during reaction and given explicit
instructions on where to report if reaction develops. (A:III)
All patients should be informed of significance of decreased vision and told
to report this to case worker for referral to higher level. (A:III)
ICO International Clinical Guidelines, 2010
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Idiopathic Macular Hole
(Initial Evaluation and Therapy)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)



Duration of symptoms (A:III)
Ocular history: glaucoma or other prior eye diseases, injuries, surgery, or
other treatments; prolonged gazing at the sun (A:III)
Medications that may be related to macular cysts (A:III)
Initial Physical Exam (Key elements)


Visual acuity (A:III)
Slit-lamp biomicroscopic examination of the macula and the vitreoretinal
interface (A:III)
Management Recommendations for Macular Hole
Stage
1-A
Management
Observation
Follow-up [A:III]
Prompt return if new symptoms
[A:II]
Every 4 to 6 months in the absence of symptoms
1-B
Observation
Prompt return if new symptoms
[A:II]
Every 4 to 6 months in the absence of symptoms
2
Surgery [A:II] *
1 to 2 days postoperatively, then 1 to 2 weeks
Frequency and timing of subsequent visits varies depending
on the outcome of surgery and the patient’s symptoms
If no surgery, every 4 to 8 months
3
Surgery [A:I]
1 to 2 days postoperatively, then 1 to 2 weeks
Frequency and timing of subsequent visits varies depending
on the outcome of surgery and the patient’s symptoms
4
Surgery [A:I]
1 to 2 days postoperatively, then 1 to 2 weeks
Frequency and timing of subsequent visits varies depending
on the outcome of surgery and the patient’s symptoms
* Although surgery is usually performed, observation is also appropriate.
ICO International Clinical Guidelines, 2010
Page 36
Surgical and Postoperative Care if Patient Receives Treatment




Inform the patient about relative risks, benefits, and alternatives to surgery,
and the need for use of expansile intraocular gas or special patient
positioning postoperatively (A:III)
Formulate a postoperative care plan and inform the patient of these
arrangements (A:III)
Inform patients with glaucoma of possible perioperative increase in IOP
(A:III)
Examine postoperatively within 1 or 2 days and again 1 to 2 weeks after
surgery (A:III)
Patient Education




Inform patients to notify their ophthalmologist promptly if they have
symptoms such as increase in floaters, a loss of visual field, or a decrease
in visual acuity (A:II)
Inform patients that air travel, high altitudes, or general anesthesia with
nitrous oxide should be avoided until the gas tamponade is nearly
completely gone (A:III)
Inform patients who have had a macular hole in one eye that they have a
10% to 20% chance of macular hole formation in the fellow eye, especially if
the hyaloid remains attached (A:III)
Refer patients with functionally limiting postoperative visual impairment for
vision rehabilitation (see www.aao.org/smartsight) and social services (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 37
Keratorefractive Surgery
(Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History




Present status of visual function (A:III)
Ocular history (A:III)
Systemic history (A:III)
Medications (A:III)
Initial Physical Exam






Visual acuity without correction (A:III)
Manifest, and where appropriate, cycloplegic refraction (A:III)
Computerized corneal topography (A:III)
Central corneal thickness measurement (A:III)
Evaluation of tear film (A:III)
Evaluation of ocular motility and alignment (A:III)
Care Management






Discontinue contact lenses before preoperative exam and procedure (A:III)
Inform patient of the potential risks, benefits, and alternatives to and among
the different refractive procedures (A:III)
Document informed consent process; patient should be given an
opportunity to have all questions answered before surgery (A:III)
For LASIK, residual stromal bed thickness should not be less than 250 um
(A:III)
Check and calibrate instrumentation before the procedure (A:III)
Surgeon confirms the identity of the patient, the operative eye, and that the
parameters are correctly entered into the excimer laser’s computer (A:III)
Postoperative Care



Operating surgeon is responsible for postoperative management (A:III)
For surface ablation techniques, examine on the day following surgery and
every 2 to 3 days thereafter until the epithelium is healed (A:III)
For uncomplicated LASIK, examine within 48 hours following surgery, a
second visit 1 to 4 weeks postoperatively, and further visits thereafter as
appropriate (A:III)
ICO International Clinical Guidelines, 2010
Page 38
Patient Education
Discuss the risks and benefits of the planned procedure with the patient. (A:III)
Elements of the discussion include the following:
 Range of expected refractive outcomes
 Residual refractive error
 Reading and/or distance correction postoperatively
 Loss of best-corrected visual acuity
 Side effects and complications (e.g., microbial keratitis, sterile keratitis,
keratectasia
 Changes in visual function not necessarily measured by Snellen acuity,
including glare and function under low-light conditions
 Night vision symptoms (e.g., glare, haloes) developing or worsening; careful
consideration should be given to this issue for patients with high degrees of
ametropia or for individuals who require a high level of visual function in
low-light conditions
 Effect on ocular alignment
 Dry eye symptoms developing or worsening
 Monovision advantages and disadvantages (for patients of presbyopic age)
 Conventional and wavefront-guided ablations advantages and
disadvantages
 Advantages and disadvantages of same-day bilateral keratorefractive
surgery versus sequential surgery. Because vision might be poor for some
time after bilateral same-day photorefractive keratectomy, the patient should
be informed that activities such as driving might not be possible for weeks
 Postoperative care plans (setting of care, providers of care)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines, 2010
Page 39
Ocular HIV/AIDS Related Diseases
(Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
General - Initial Exam History

















Age (B:III)
Ocular symptoms including laterality (A:III)
Systemic symptoms (A:III)
Complete review of systems (A:III)
Prior ocular history (A:III)
Prior medical history (A:III)
Prior surgical history (B:III)
History of other sexually transmitted diseases (A:III)
History of AIDS-defining illnesses or complications (A:III)
Method of HIV acquisition (B:III)
Duration of HIV infection (A:III)
Past and current risk factors – sexual behavior, intravenous drug abuse,
transfusion history (A:III)
Current anti-HIV regimen – duration and compliance (A:III)
Current medications (A:II)
Current CD4 count (A:II)
Current viral load (A:II)
Medication allergies (B:III)
General - Initial Physical Exam











General appearance (A:III)
External examination – face, ocular adnexa (A:III)
Lymphatics – preauricular and submandibular nodes (A:III)
Visual acuity (A:III)
Extraocular motility (A:III)
Confrontation visual fields (A:III)
Eyelids – lid closure, interpalpebral fissure height (B:III)
Lacrimal gland (B:III)
Evaluation of tear film – Schirmer, rose bengal and fluorescein staining
(A:III)
Nasolacrimal function (B:III)
Slit-lamp examination
o Eyelid margins (A:III)
o Conjunctiva (A:III)
o Sclera (A:III)
o Cornea (A:III)
o Anterior chamber (A:III)
ICO International Clinical Guidelines, 2010
Page 40

o Iris (A:III)
o Lens (A:III)
o Anterior vitreous (A:III)
Dilated ophthalmoscopic examination
o Vitreous – cell/flare, blood, condensations (A:III)
o Optic disc (A:III)
o Retinal vasculature (A:III)
o Macula/fovea (A:III)
o Peripheral retina with scleral depression (A:III)
o Choroid (A:III)
General - Diagnostic Tests



HIV infection – for increased risk populations and/or suspected infection
o Anti-HIV ELISA to screen for infection, followed by confirmation with
Western blot (A:II)
AIDS
o Presence of AIDS-defining illness(es) (A:III)
o CD4 (< 200 cells/µl, per CDC criteria) (A:II)
Known HIV/AIDS patient
o CD4 count (A:II)
o Viral load (A:II)
General - Care Management




Management of HIV/AIDS should involve a multidisciplinary team, including
an infectious disease specialist and an ophthalmologist (A:III)
Anti-Retroviral Therapy (ART) or Highly Active Anti-Retroviral Therapy
(HAART), where available (A:II)
Emphasis on prevention of disease transmission (A:III)
Identification and treatment of HIV/AIDS associated illnesses/infections
(particularly tuberculosis and syphilis) (A:II)
HIV Retinopathy – Initial Exam History


CD4 count (A:II)
Ocular symptoms – usually asymptomatic (B:III)
HIV Retinopathy – Initial Physical Exam




Visual acuity (A:III)
Slit lamp examination (B:III)
Dilated ophthalmoscopic examination (A:II)
Screen for other HIV/AIDS related illnesses/infections (B:III)
HIV Retinopathy - Care Management


Treat immune compromise with HAART (A:II)
Consider corticosteroids (B:III) or focal laser (A:II) for macular edema
ICO International Clinical Guidelines, 2010
Page 41
HIV Retinopathy – Follow-up Evaluation


Lesions usually resolve over weeks to months (A:II)
Dilated ophthalmoscopic examination every 3 months for CD4 counts
persistently below 50 cells/µl (A:II)
Cytomegalovirus (CMV) Retinitis – Initial Exam History



Interval since AIDS diagnosis (A:II)
History of CMV related systemic complications (A:II)
Ocular symptoms –blurred vision, floaters, photopsias, scotomata (A:II)
Cytomegalovirus (CMV) Retinitis – Initial Physical Exam




Visual acuity (A:II)
Cornea for small endothelial deposits (B:III)
Anterior chamber for signs of inflammation (A:II)
Dilated ophthalmoscopic examination of both eyes – including optic disc,
macula, and retinal periphery. The choroid should be examined to rule out
co-infection with other agents (A:II)
Cytomegalovirus Retinitis – Diagnostic Tests

CD4 count – typically less than 50 cells/µl (A:II)
Cytomegalovirus Retinitis – Ancillary Testing


Fundus photography may be useful to document disease progression or
response to treatment and fluorescein angiography as indicated to evaluate
for the presence of macular edema or ischemia (A:III)
Test for syphilis and vitreous biopsy for other causes of necrotizing retinitis
(varicella zoster virus, herpes simplex virus, toxoplasmosis) when diagnosis
uncertain (A:II)
Cytomegalovirus – Care Management






Main objectives include direct treatment of CMV retinitis with anti-CMV
medications, and improvement of immune status with initiation/optimization
of HAART if not already taking anti-retroviral therapy (A:II)
To reduce the possibility of immune recovery uveitis, patients with newly
diagnosed CMV retinitis who are not on HAART should be treated with antiCMV medications until the retinitis is inactive, or at least less active. HAART
should then be initiated (A:II)
Also, in cases with expected persistent immune suppression, e.g. poor
response to or unavailability of ART, immediate treatment is indicated (A:II)
Local anti-CMV therapy, as might be achieved using intravitreal injection of
ganciclovir or foscarnet, may be used immediately when active CMV retinitis
either involves or threatens the optic disc or macula (A:II)
Induction followed by indefinite maintenance therapy in cases of persistent
immune suppression (A:II)
Ganciclovir
o Intravenous – 5 mg/kg every 12 hours for 2 to 3 weeks, then 5
mg/kg/day 5 to 7 times per week indefinitely. (A:I) Monitor for
ICO International Clinical Guidelines, 2010
Page 42


leukopenia, the risk of which may be lessened by administering
leukocyte-stimulating factors such as granulocyte colony-stimulating
factor (A:II)
o Intraocular – 2 to 2.5 mg/0.1 ml intravitreal injection twice per week
until inactive, then weekly (A:I)
o Intravitreal sustained-release implant (Vitrasert) – 4.5 mg implant that
releases 1 µg/hr for eight months. This should be combined with oral
valganciclovir therapy for systemic coverage (A:I)
Foscarnet
o Intravenous – 60 mg/kg every 8 hours or 90 mg/kg every 12 hours for
14 days, then 90 to 120 mg/kg/day. Monitor for renal toxicity (A:I)
o Intraocular – 1.2 mg/0.05 ml (or 2.4 mg/0.1 ml) (A:I)
Valganciclovir
o Oral – 900 mg twice daily for 2 weeks, (A:I) then 900 mg daily
indefinitely. (A:II) Monitor for leukopenia (A:II)
Cytomegalovirus – Follow-up Evaluation





Recurrence is very common, and patients being treated with anti-CMV
medications should be evaluated monthly (A:II)
Intervals may be extended when CD4 counts are elevated, anti-CMV
medications are discontinued, and the disease remains inactive in the
setting of immune recovery (A:II)
Visual symptoms (A:II)
CD4 count and HIV viral load (A:II)
Review of systems for CMV related systemic complications or drug-induced
side effects (A:II)
Cytomegalovirus – Follow-up Examination




Visual acuity (A:II)
Slit lamp examination (B:II)
Ophthalmoscopic examination – including the macula and peripheral retina
(A:II)
Serial fundus photography (B:II)
Cytomegalovirus – Follow-up Management






No treatment can eliminate CMV from the eye (A:II)
Patient education about the symptoms of CMV retinitis is crucial (A:III)
For recurrences, first line is re-induction with the same therapy in the
absence of side effects or evidence of drug resistance (A:II)
Persistent or progressive retinitis after 6 weeks of induction-level therapy
implies resistance or incorrect diagnosis (A:II)
UL97 and UL54 mutations in CMV DNA are associated with relative
ganciclovir resistance (A:II)
Anti-CMV drugs may be discontinued in patients on HAART with no signs of
active CMV retinitis in whom CD4 counts are above 100 to 150 cells/µl for at
least three to six months (A:II)
ICO International Clinical Guidelines, 2010
Page 43
Tuberculosis – Initial Exam History



CD4 count (typically < 200 cells/µl) (A:II)
Visual and ocular symptoms (A:II)
History M. Tuberculosis infection, systemic complications, or exposure (A:II)
Tuberculosis – Initial Physical Exam





Visual acuity (A:III)
External examination – including eyelids and adnexa (B:III)
Slit lamp examination (B:III)
Intraocular pressure (B:III)
Dilated ophthalmoscopic examination - optic disc, macula, retinal periphery,
and choroid (A:II)
Tuberculosis – Diagnostic Tests



Presumptive diagnosis by clinical examination combined with PPD skin
testing and chest x-ray (A:II)
Requires a high index of clinical suspicion (B:III)
Consider leukocyte stimulation based assays where available, particularly
®
when PPD skin testing is unreliable (QuantiFERON -TB Gold Test;
®

T.SPOT-TB test) (A:II)
Definitive diagnosis requires biopsy with histopathologic examination (A:III)
Tuberculosis – Ancillary Testing



Fluorescein angiography to evaluate suspected retinal vasculitis (A:III)
Indocyanine green angiography may be helpful to detect subclinical
choroidal involvement (A:III)
Optical coherence tomography to diagnose and monitor for cystoid macular
edema (A:III)
Tuberculosis – Care Management




Systemic treatment is indicated with rifampin (500 mg/day for weight > 50
kg and 600 mg/day for weight < 50 kg), isoniazid (5 mg/kg/day),
pyrimethamine (25 to 30 mg/kg/day, and ethambutol (15 mg/kg/day) for 2
months then rifampin and isoniazid for another 4 to 7 months (A:II)
Oral prednisone (1 mg/kg/day), taper as directed by clinical response (A:II)
Initiate/optimize HAART if not already taking anti-retroviral therapy (A:II)
Coordinate care with an infectious disease specialist (A:III)
Tuberculosis – Follow-up Evaluation


Monitor all patients for medication toxicity (A:II)
Examine patients monthly until there is significant clinical improvement
(A:III)
Toxoplasmosis (T. gondii) – Initial Exam History

CD4 count (typically < 200 cells/µl) (A:II)
ICO International Clinical Guidelines, 2010
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

Visual and ocular symptoms (A:III)
History of T. gondii infection, systemic complications, or exposure (A:III)
Toxoplasmosis – Initial Physical Exam




Visual acuity (A:II)
Intraocular pressure (B:II)
Slit lamp examination (C:II)
Dilated ophthalmoscopic examination (A:II)
Toxoplasmosis – Diagnostic Tests



Primarily a clinical diagnosis (A:III)
Serologic testing for anti-T. gondii IgM/IgG antibodies (A:II)
In unclear cases, can perform PCR on aqueous or vitreous for T. gondii
DNA (B:II)
Toxoplasmosis – Care Management




Initial treatment involves oral antimicrobials for 4 to 6 weeks. Options
include:
o Trimethoprim/sulfamethoxazole (800/160) 500 mg PO twice daily
(A:II)
o Pyrimethamine (100 mg loading dose given over 24 hours, followed
by 25 to 50 mg daily) and sulfadiazine (1 g given four times daily) for
4 to 6 weeks. Should be given concurrently with folinic acid (3 to 5
mg twice weekly) to prevent leukopenia and thrombocytopenia (B:II)
o Clindamycin (300 mg orally every 6 hours) for 3 or more weeks (B:II)
o Atovaquone (750 mg orally four times daily) for 3 months (B:II)
o Consider use of Azithromycin in patients with sulfa-related allergy
(B:III)
Maintenance therapy with at least one of the above medications is
recommended for patients with ocular toxoplasmosis who remain severely
immunodeficient (A:III)
Oral corticosteroids may be considered when inflammation contributes to
vision loss (vitritis, vasculitis, serous retinal detachment, lesion involving or
threatening the optic disc or macula) - 0.5 mg/kg/day with taper, initiated
and ended concurrent with antimicrobial therapy (A:III)
Topical corticosteroids may be considered for significant anterior chamber
inflammation (A:III)
Toxoplasmosis – Follow-up Evaluation


Initial follow-up should be one week after initiation of treatment, then as
indicated by examination and treatment response (A:III)
Lesions typically take several months to resolve (A:III)
Syphilis – Initial Exam History


CD4 count (often less than 200 cells/µl). However, ocular syphilis in the
setting of HIV/AIDS may occur at any CD4 count. (A:II)
Visual symptoms and rapidity of onset (A:III)
ICO International Clinical Guidelines, 2010
Page 45


Previous syphilis infection, related complications, or exposure (A:III)
History of other sexually-transmitted diseases (B:III)
Syphilis – Initial Physical Exam




Visual acuity (A:II)
Intraocular pressure (B:II)
Slit lamp examination (B:III)
Dilated ophthalmoscopic examination (A:II)
Syphilis – Diagnostic Tests



Both non-treponemal (RPR or VDRL) and treponemal (MHA-TP or FTAABS) testing should be obtained (up to one-third of patients with syphilitic
uveitis have a negative non-treponemal test) (A:II)
Patients with profound immune suppression may present with seronegative
syphilis (A:II)
CSF examination (RPR or VDRL) in all HIV/AIDS patients with ocular
syphilis (A:II)
Syphilis – Care Management




Treat as neurosyphilis (A:II)
Involve an infectious disease specialist in coordinating systemic
management (A:III)
First-line treatment is with IV penicillin G, 18 to 24 million units for 14 days
(A:II)
Worsening ocular inflammation following the initiation of penicillin may be
indicative of a Jarish-Herxheimer reaction (A:II)
Syphilis – Follow-up Evaluation



Serial serum and CSF antibody levels every month for 3 months, then every
6 months until CSF cell count normalizes and CSF VDRL/RPR becomes
non-reactive (A:III)
Serum quantitative nontreponemal testing every 3 months for one year,
then yearly (A:III)
Maintenance therapy is not necessary or recommended (B:II)
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Table 1. Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
CD4
count
History
Examination
Key Findings
Diagnostic
workup
Management
Follow-up
 IV acyclovir 10 mg/kg every 8 hours for 7 days (A:II)
 Alternatives: valacyclovir (1 gram PO 3 times daily) or
oral acyclovir (800 mg PO 5 times daily); close follow-up
for signs of disseminated infection including cerebritis
(A:II)
 Patient receiving high doses of valacyclovir should be
monitored for TTP/HUS (A:II)
 Maintain on oral acyclovir 800 mg, 3 to 5 times daily
indefinitely (A:II)
 Alternatively, can maintain on oral famciclovir or
valacyclovir
 Topical corticosteroids for iridocyclitis and/or stromal
keratitis (A:II)
 Immune reconstitution (A:II)
 Indications for treatment: 1) loss of normal lid function,
2) discomfort, 3) cosmesis
 Treatment depends on the size and location of lesions
(A:II)
 Treatment options include intralesional vinblastine or
interferon-alpha, local radiation therapy, excision, and
cryotherapy (A:II)
 Systemic chemotherapy if disseminated disease (A:II)
 Reduce size of large lesions prior to excision
 Observe for
post-herpetic
neuralgia
 Serial DOE
 Eyelid lesions
commonly
recur within
6 to 8 weeks
(A:II)
 Routine preand postoperative
examinations
Herpes Zoster
Ophthalmicus
< 200
cells/µ
l (A:II)
 Prior zoster
infection (A:II)
 Age






Periorbita
Eyelids
SLE
Sclera
AC
DOE
 Vesiculobullous dermatitis in
CN V1 distribution (A:II)
 Complications include
keratitis, uveitis, scleritis,
retinitis, and optic neuritis
(A:II)
 Hemorrhagic hypopyon
(B:II)
 Clinical
examination
 Can confirm
diagnosis
with viral
culture,
Tzanck
smear, PCR
(A:II)
Kaposi’s Sarcoma
< 200
cells/µ
l (A:II)
 Manner of HIV
acquisition (sexual
more common)
(B:II)
 Dry eye symptoms
(B:II)
 Pain (rare) (B:II)
 Reduced vision
(rare) (C:II)
 Highly vascularized tumor
of the skin or mucous
membranes (A:II)
 May involve eyelids and/or
conjunctiva (A:II)
 Eyelid lesions may appear as
a purplish nodule (A:II)
 Conjunctival lesions can
mimic SCH (B:II)
 Clinical
examination
 Biopsy with
histopatholog
y of
suspicious
lesions (A:II)
Molluscum
Contagiosum
Any
(A:II)
 History of
molluscum
exposure (A:II)
 Immune reconstitution (A:II)
 Topical agents: liquid nitrogen, trichloracetic acid,
cantharadin (A:II)
 Incision with curettage, excision, or cryotherapy (A:II)
Any
(A:II)
 Geographic
location – higher
risk in Africa (A:II)
 History of HPV
infection (B:II)
 Papulonodular dermatitis of
the skin and mucous
membranes (A:II)
 Multiple small umbilicated
lesions (A:II)
 Papilliform, gelatinous, or
leukoplakic lesion at the
interpalpebral limbus (A:II)
 SCC: lesion is more
extensive, feeder vessels
more common (A:II)
 Erythematous lesion of the
eyelid or conjunctiva (A:II)
 Clinical
examination
Squamous Cell
Carcinoma (SCC)
and Conjunctival
Intraepithelial
Neoplasia (CIN)
 External
examination
 Lymphatics
 Oral cavity
 SLE
 Eyelids
 Lacrimal
gland
 Skin of face
and upper
body
 Periorbita
 SLE
 Trunk and
genitalia
(B:III)
 VA
 External
examination
 SLE
 Gonioscopy
 Biopsy with
histopatholog
ic
examination
(A:II)
 Wide excision with cryotherapy for non-invasive lesions
(A:II)
 Frozen section pathologic examination (A:II)
 Alternatives include MMC, 5-FU, and interferon (A:II)
 Biopsy (A:II)
 Systemic
evaluation
(A:II)
 Radiation (A:II)
 Chemotherapy (A:II)
 Involve an oncologist
 As directed
by treatment
in
coordination
with
oncologist
SLE = slit lamp examination, AC = anterior chamber, DOE = dilated ophthalmoscopic examination, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, TTP/HUS = thrombotic
thrombocytopenic purpura/hemolytic uremic syndrome, HIV = human immunodeficiency virus, SCH = subconjunctival hemorrhage, HPV = human papilloma virus, VA = visual acuity, MMC = mitomycin C, 5-FU
= 5-fluorouracil, FBS = foreign body sensation = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation
Cutaneous or
Conjunctival
Lymphoma
Any
(A:II)
 Presence/history
of systemic
lymphoma (A:II)
 Ocular symptoms
 VA
 External
examination
 SLE
 DOE (C:III)
 Recurrences
are common
(A:II)
Table 1. (continued) Adnexal Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
CD4
count
Conjunctival
Microvasculopathy
Any
(A:II)
 Typically
asymptomatic
(B:II)
 SLE
 DOE (B:III)
Conjunctivitis
Any
(A:II)
 Symptoms of
irritation,
discharge (A:II)
 VA
 SLE
Atopic dermatitis
Any
(A:II)
 History of atopic
triad: dermatitis,
rhinitis, asthma
 Typical
symptomatology
(B:II)
 Triggers (A:II)
 Use of Indonavir
(B:II)
 Itching, FBS,
redness
 External
examination
 Eyelids
History
Examination
Key Findings
 Inferior perilimbus (A:II)
 Segmental vascular dilation
and narrowing (A:II)
 Comma-shaped vascular
fragments (A:II)
 Microaneurysms (A:II)
 Blood column granularity
(A:II)
 Conjunctival erythema (A:II)
 Watery, mucoid, or purulent
discharge (A:II)
 Pruritis and excematous
changes of the periorbital
skin (A:II)
Diagnostic
workup
Management
Follow-up
 Clinical
examination
 Not indicated
 Unnecessary
 Clinical
examination
 Culture and
gram stain of
discharge
(A:II)
 Clinical
examination
 Guided by results of gram stain and culture
 Clinical examination should be used to initiate empiric
treatment
 Every 5 to 7
days until
resolution
 Topical corticosteroids (i.e. hydrocortisone 0.5% cream)
(A:II)
 Topical calcineurin inhibitors, Elidel (pimecrolimus) and
Protopic (tacrolimus) are contraindicated in
immunosuppressed patients (B:II)
 Serial
examination
s until
resolution
 External
 Crusting and erythema of
 Clinical
 Lid hygiene
 Every 4
examination
eyelid margins (A:II)
examination
weeks
 Consider culture in high-risk patients
 Eyelids
 SLE –
including tear
film and
cornea
SLE = slit lamp examination, AC = anterior chamber, DOE = dilated ophthalmoscopic examination, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, TTP/HUS = thrombotic
thrombocytopenic purpura/hemolytic uremic syndrome, HIV = human immunodeficiency virus, SCH = subconjunctival hemorrhage, HPV = human papilloma virus, VA = visual acuity, MMC = mitomycin C, 5FU = 5-fluorouracil, FBS = foreign body sensation = visual acuity, MMC = mitomycin C, 5-FU = 5-fluorouracil, FBS = foreign body sensation
Blepharitis
Any
(A:II)
ICO International Clinical Guidelines, 2010
Page 48
Table 2. Corneal and Anterior Segment Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
CD
4
cou
nt
History
Examination
Key Findings
 Lagophthalmos
and reduced blink
rate (B:II)
 Diminished tear
meniscus (B:III)
 Rapid TBUT (A:II)
 Interpalpebral
staining with rose
bengal or
fluorescein (A:II)
 Dendritic epithelial
keratitis (A:II)
 Decreased corneal
sensation (A:II)
 Elevated IOP (B:II)
 Iris atrophy (B:II)
 May present with a
mild conjunctivitis
or anterior uveitis
(B:II)
 1/3 develop
stromal
involvement (B:II)
 Dendritic epithelial
keratitis, which
may be larger in
HIV+ patients
(A:II)
 Limbal
involvement (B:II)
Keratoconjunctivitis sicca
Any
(A:I
I)
 Typical history
 History of HIV
encephalopathy (B:III)
 Duration of infection with
HIV (B:III)
 VA
 Periorbita
(B:III)
 Lacrimal
gland (C:III)
 Eyelids
(A:II)
 SLE with
fluorescein
Viral
keratitis
Any
(B:I
I)
 Reduced vision
 Ocular symptoms
 Presence or recent history
of zoster dermatitis (A:II)
 Prior history of zoster or
herpes infection (A:II)




VZV
VA
IOP
Periorbita
Eyelids/lash
es
 Corneal
sensation
 SLE with
fluorescein
 DOE with
scleral
depression
Diagnostic
workup
Management
Follow-up
 Clinical
examination
 Schirmer
testing (A:II)
 TBUT (B:II)
 Rose bengal or
fluorescein
staining (A:II)
 Artificial tears
 Long-acting lubricants
 Consider punctual occlusion in
resistant cases
 As dictated by examination
 Clinical
examination
 Corneal
sensation
(A:II)
 May confirm
with viral
culture, DFA,
PCR (B:II)
 Acyclovir 800 mg PO 5 times
daily or 10 mg/kg IV tid (A:II)
 Foscarnet IV for resistant cases
(A:II)
 Consider maintenance dose of
acyclovir (600 mg PO tid) (A:II)
 Infectious dendrites can be
treated with oral (as described
above) or topical antiviral
medications (trifluridine 1% 9
times daily) (A:II)
 Every 1 to 7 days until
resolution, then every 6 months
 Observe for stromal and/or
neurotrophic keratitis and
postherpetic neuralgia (B:III)
 Topical trifluridine 1% 9 times
 Every 1 to 7 days until resolution
daily or Acyclovir ointment 5
 HSV appears to recur more
times daily (A:II)
frequently in HIV/AIDS patients
(A:II)
 May treat with oral acyclovir
(400-800 mg PO 5 times daily)
alone (A:II)
 Consider lesion debridement
(B:III)
 Long term suppression with
acyclovir 400 mg PO bid for 1
year (A:I)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, TBUT = tear film breakup time, VZV = varicella zoster virus, HSV = herpes zoster virus, IOP = intraocular pressure, DOE =
dilated ophthalmoscopic examination, DFA = direct fluorescent antibody, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, AIDS = acquired immunodeficiency syndrome, FBS = foreign
body sensation, AC = anterior chamber, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus
HSV
ICO International Clinical Guidelines, 2010
Page 49
Table 2. (continued) Corneal and Anterior Segment Manifestations of HIV/AIDS (A:III unless otherwise indicated)
CD4
count
Entity
History
Examination
Key Findings
Diagnostic
workup
Management
Follow-up
 Reduced
 VA
 Epithelial defect
 Clinical
 Guided by culture results (B:II)
 Daily follow-up until
vision
with stromal
examination
substantial improvement
 SLE with
 Aggressive treatment with topical
infiltrate (A:II)
 Discharge
fluorescein
 Culture and
fortified antibiotics and/or antifungal
 High risk for corneal
 Tend to be more
gram stain
agents (A:II)
perforation (A:II)
 Timing of
 DOE (C:III)
(A:II)
severe and bilateral
symptom
in HIV+ patients
onset
(A:II)
(B:III)
Microsporidial keratitis
< 100
 Reduced
 VA
 Punctate epithelial
 Scraping or
 Immune reconstitution (A:II)
 Serial examinations until
cells/µl
vision
keratopathy (A:II)
biopsy of
resolution
 SLE with
 Directed treatment options include:
(A:II)
suspicious
 Ocular
fluorescein
 Mild papillary
topical propamidine isethionate, topical
corneal and
symptoms
conjunctivitis (A:II)
fumagillin, oral albendazole, oral
conjunctival
– FBS,
itraconazole (A:II)
 Mild AC
lesions (A:II)
irritation,
inflammation (A:II)
 Consider debulking (B:III)
photophobi
 Giemsa stain
(A:II)
a
Vortex keratopathy
Any
 FBS
 VA
 Characteristic
 History and
 Reduce or discontinue offending
 Lesions resolve slowly
(B:II)
(Phospholipidosis)
whorl-like pattern
clinical
medication, if possible (A:II)
 Medication
 SLE
of gray-white
examination
history (eg.
subepithelial
amiodaron
corneal deposits
e,
(A:II)
chloroquin
e,
chlorproma
zine,
ganciclovir,
acyclovir)
(A:II)
Drug-associated uveitis
Any
 Reduced
 VA
 AC inflammation
 History and
 Topical corticosteroids with or without
 Serial every 1 to 2 weeks
(A:II)
 Cidofovir
vision
(A:II)
clinical
dose reduction of offending medication
examinations until
 SLE
(A:II)
examination
resolution
 Rifabutin
 Medication
 Rifabutin IOP (B:III)
 Usually unnecessary to discontinue
history,
associated
 Terbinafine
 DOE (B:III)
offending medication (B:III)
including
hypopyon (A:II)
daily doses
 Mydriatic agent
(A:II)
 Immune
status
(B:III)
 Duration
on HAART
(B:III)
 History of
CMV
retinitis
(A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, TBUT = tear film breakup time, VZV = varicella zoster virus, HSV = herpes zoster virus, IOP = intraocular pressure, DOE
= dilated ophthalmoscopic examination, DFA = direct fluorescent antibody, PCR = polymerase chain reaction, PO = per os (by mouth), IV = intravenous, AIDS = acquired immunodeficiency syndrome, FBS =
foreign body sensation, AC = anterior chamber, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus
Bacterial or fungal
keratitis
Gonorrhea
Syphilis
Tuberculosis
Cryptococcus
Any
(B:II)
ICO International Clinical Guidelines, 2010
Page 50
Table 3. Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
HIV
retinopathy
CD4 count
< 50
cells/µl
(A:II)
History
Examination
 Visual and
ocular
symptoms
(typically
asymptomatic)
(B:III)
 VA
 SLE (B:III)
 DOE (A:II)
 Duration of
AIDS (A:II)
 History of
systemic CMV
infection (A:II)
 Ocular
symptoms
including
blurred vision,
gradual visual
field loss,
photopsia, and
floaters (A:II)
 VA (A:II)
 SLE (B:II)
 DOE (A:II)
Key Findings
 Conjunctival
microvascular changes
(B:II)
 CWS (A:II)
 IRH (A:II)
 MAs (A:II)
 Retinal ischemia (A:II)
 CME (A:II)
 Geographic thickening
and opacification of the
retina (A:II)
 Mild anterior chamber
and vitreous
inflammation (B:II)
 Characteristic linear or
stellate KP (B:II)
 3 main types: granular
retinitis with satellite
lesions, hemorrhagic
retinitis with prominent
edema, or perivascular
retinitis (A:II)
Diagnostic workup
 Clinical diagnosis
Management
 Improve immune status with
HAART (A:II)
 Screen for other infections/illnesses
 Consider corticosteroids (B:III) or
focal laser (A:II) for macular edema
Follow-up
 Lesions spontaneously resolve
over weeks to months (A:II)
 DOE every 3 months for CD4
counts persistently < 50 cells/µl
(A:II)
 Improve immune status, although
 CMV cannot be eliminated from
consider delay of HAART in
the eye (A:II); patient education
HAART-naïve patients until
for recurrences is crucial
retinitis is improved to reduce the
 Reevaluate patients monthly
risk of IRU (A:II)
while treating with anti-CMV
 Immediate treatment if persistent
medications (A:II)
immune suppression is expected
 Extend visit intervals when CD4
(A:II)
counts are elevated, anti-CMV
 Induction followed by maintenance
medications are discontinued,
(A:II)
and the disease remains inactive
 Ganciclovir: IV (5 mg/kg every 12
in the setting of immune recovery
hours for 3 weeks, then 5
(A:II)
mg/kg/day) (A:I); IO (2 Consider serial fundus
2.5mg/0.1ml twice weekly until
photography (B:II)
inactive) (A:I); intraocular implant
 Treat recurrences with re(A:I), combine with oral anti-CMV
induction of same therapy, unless
medications for systemic coverage
contraindicated due to side effects
(A:II)
or resistance (A:II)
 Foscarnet: IV (60 mg/kg every 8
 May discontinue maintenance
hours or 90 mg/kg every 12 hours
therapy in patients without active
for 14 days, then 90 to 120
CMV retinitis and at least 6
mg/kg/day) (A:I); IO (1.2 mg/0.05
months of CD4 cell counts above
ml) (A:I)
150 cells/µl (A:II)
 Valganciclovir: PO (900 mg bid for
2 weeks, then 900 mg daily).
Monitor for leukopenia (A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA =
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune
recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified
protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma
reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN =
progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome,
PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular
motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable
CMV
retinitis
< 50
cells/µl
(A:II)
 Primarily a clinical
diagnosis
 CD4 count (A:II)
 Rule out syphilis and
other causes of
retinitis (A:II)
 Consider vitreous
biopsy in challenging
cases
ICO International Clinical Guidelines, 2010
Page 51
Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
CD4
count
History
< 200
cells/µl
(A:II)




Key Findings
VA (A:II)
IOP (B:II)
SLE (C:II)
DOE (A:II)
 Moderate-to-severe AC
and vitreous
inflammation (B:II)
 Retinochoroiditis with a
relative lack of retinal
hemorrhage (A:II)
 Smooth leading edge
without satellite lesions
(B:II)
 A rare cause of isolated
anterior uveitis(C:II)
 Vitritis (A:II)
 Choroidal tubercles and
tuberculomas (A:II)
 Overlying exudative
retinal detachment (B:II)
 Retinal periphlebitis
(A:II)
Diagnostic workup
Management
Follow-up
 Trimethoprim/sulfamethoxazole
 Initially every 3 to 5 days, then as
(800/160) 500 mg PO bid for 4 to 6
indicated by examination
weeks (A:II)
 Maintenance therapy with at least
 Pyrimethamine and
one medication is recommended
sulfamethoxazole for 4 to 6 weeks
for all patients with persistent
(option of combination with
severe immune deficiency
azithromycin) (B:II)
 Clindamycin (300 mg PO every 6
hours) for 3 or more weeks (B:II)
 Atovaquone (750 mg PO qid) for 3
months (B:II)
Tuberculosis
< 200
 Visual
 VA
 Presumptive
 Systemic treatment with rifampin
 Monitor all patients for drug
cells/µl
symptoms (A:II)  External
diagnosis combined
(500 mg/day for weight > 50 kg
toxicity (A:II)
(A:II)
with PPD skin testing
and 600 mg/day for weight < 50
 History of M.
examination
 Examine patients monthly until a
and CXR (A:II)
kg), isoniazid (5 mg/kg/day),
Tuberculosis
(B:III)
significant improvement
infection,
pyrimethamine (25 to 30
 SLE (B:III)
 Consider IGRAs (eg.
systemic
mg/kg/day, and ethambutol (15
QuantiFERON®-TB
 IOP (B:III)
complications,
mg/kg/day) for 2 months then
Gold; T.SPOT-TB®)
 DOE (A:II)
rifampin and isoniazid for another 4
or exposure
(B:II)
(A:II)
to 7 months (A:II)
 FA, ICG, and OCT
 PO prednisone (1 mg/kg/day),
when indicated (see
taper as directed by clinical
text) (B:III)
response (A:II)
 Immune reconstitution (A:II)
 Involve an infectious disease
specialist
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA =
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune
recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified
protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma
reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN =
progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome,
PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular
motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable
Toxoplasmosis
 Visual
symptoms (A:II)
 Exposure to
undercooked
meat or cats
(A:II)
Examination
 Clinical diagnosis
 Anti-Toxoplasma
IgM/IgG (A:II)
 PCR of aqueous in
unclear cases (B:II)
ICO International Clinical Guidelines, 2010
Page 52
Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
Syphilis
CD4 count
History
Examination
Often < 200
cells/µl, but
can vary
(A:II)
 Visual
symptoms (A:II)
 Sexual history
(B:II)




VA (A:II)
IOP (B:II)
SLE (B:II)
DOE (A:II)
 History of HZO
or dermatitis
(A:II)
 History of
herpes
encephalitis
(B:II)
 Visual
symptoms
(pain, vision
loss, new
floaters or
scotomata)
(A:II)




VA (A:II)
IOP (B:III)
SLE (B:III)
DOE (A:II)
Key Findings
Diagnostic workup
 Iridocyclitis or diffuse
inflammation (A:II)
 Necrotizing retinitis
(A:II)
 Subretinal plaque (B:II)
 Papillitis, optic neuritis,
or neuroretinitis (A:II)
 RPR or VDRL (A:II)
 FTA-ABS or MHATP (A:II)
 Consider
seronegative syphilis
(B:II)
 CSF examination
(A:II)
 Retinal whitening with
occasional hemorrhages
(A:II)
 Multiple large confluent
areas of retinitis (A:II)
 Rapid progression (A:II)
 Prominent (ARN) or
minimal (PORN) vitreal
inflammation (B:II)
 Clinical diagnosis
 Aqueous or vitreous
biopsy for PCR-based
analysis can aid in
diagnosis (B:II)
 Note location and
extent of involved
retina
Management
 Treat as neurosyphilis (A:II)
 Involve an infectious disease
specialist
 IV penicillin G, 18 to 24 million
units for 14 days (A:II)
Follow-up
 Serial serum and CSF antibody
levels – every month for 3 months,
then every 6 months until CSF cell
count normalizes and CSF VDRL
becomes non-reactive (A:III)
 Maintenance therapy not
recommended (B:II)
 Monitor patients for a JarishHerxheimer reaction (A:II)
 Can progress rapidly (A:II)
 Daily until significant
improvement, then weekly
 Induction with high-dose
intravenous acyclovir (15 mg/kg q
8 hours) (A:II)
 Intraocular ganciclovir (2 to
2.5mg/0.1ml twice weekly) or
foscarnet (1.2 mg/0.05ml) as
indicated (A:II)
 Maintenance with long term oral
valacyclovir or valganciclovir may
be considered (B:II)
 Patients receiving high doses of
valacyclovir should be monitored
for TTP/HUS (A:II)
 Patients receiving valganciclovir
should be monitored for leukopenia
(A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA =
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU =
Immune recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD =
purified protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid
plasma reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN
= progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction
syndrome, PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM
= extraocular motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable
Non-CMV
necrotizing
herpetic
retinitis
PORN: < 50
cells/µl
(A:II)
ARN: >
50cells/µl
(A:II)
ICO International Clinical Guidelines, 2010
Page 53
Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
CD4 count
Immune
recovery
uveitis
>100
cells/µl or
50 cell/µl
increase
(A:II)
Pneumocystis
choroiditis
< 200
cells/µl
(A:II)
History
 History/extent
of CMV retinitis
(A:II)
 History of
cidofovir use
(B:II)
 History of
aerosolized
pentamidine use
(A:II)




 Visual
symptoms
including vision
loss, diplopia,
and new
scotomata (A:II)
 Headache/
meningismus
(A:II)




Examination
Key Findings
VA (A:II)
IOP (B:II)
SLE (A:II)
DOE (A:II)
 Panuveitis with vitreous
predominance (A:II)
 May be complicated by
TRD, RNV, ERM
formation, or CME (A:II)
 Diagnosis based on
history and clinical
examination
 Consider FA to rule
out CME (B:III)
 Topical, periocular, or intraocular
corticosteroids (A:II)
 PPV for VMTS, ERM, cataract, PVR
(A:II)
 Weekly until resolution
 Multiple welldemarcated yellowish
choroidal lesions in the
posterior pole (A:II)
 Lack of iritis, vitritis, or
vasculitis (A:II)
 Clinical diagnosis
 Consider workup for
systemic disease,
including CXR, ABG
analysis, abdominal
CT, and liver
function testing
 Clinical diagnosis
 CNS symptoms –
think of cryptococcal
meningitis (A:II)
 Skin lesions – biopsy
(B:II)
 TMP-SMX or pentamidine
(4 mg/kg/day) (A:II)
 Monthly until resolution – usually
1 to 3 months
 Following a 3 week IV induction
regimen, maintain on oral
prophylactic treatment until
immune system recovers (CD4
count above 200 cells/µl) (A:II)
 Weekly until resolution
 VA (A:II)
 SLE (C:III)
 DOE OU
(A:II)
Diagnostic workup
Management
Follow-up
Isolated choroiditis:
 Signs and symptoms of
central nervous system
 IV fluconazole, 400 mg/day and IV
infection (A:II)
flucytosine, 100 to 150 mg/kg/day
for 10 weeks (A:II)
 Papilledema (A:II)
Associated with meningitis:
 Retrobulbar optic
 IV amphotericin B, 0.7 to 1
neuritis (B:II)
mg/kg/day and IV flucytosine 100
 Multifocal choroiditis
mg/kg/day for 2 weeks followed
(A:II)
by IV fluconazole for at least 10
 Other findings may
weeks (A:II)
include iritis, iris mass,
vitritis, necrotizing
retinitis, and eyelid or
conjunctival mass (B:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA =
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune
recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified
protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma
reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN =
progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome,
PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular
motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable
Cryptococcus
< 50
cells/µl
(A:II)
VA
SLE (B:II)
EOM (A:II)
DOE (A:II)
ICO International Clinical Guidelines, 2010
Page 54
Table 3. (continued) Posterior Manifestations of HIV/AIDS (A:III unless otherwise indicated)
Entity
CD4 count
History
Examination
HIVassociated
retinitis
> 120
cells/µl
(A:II)
 Visual
symptoms (A:II)




Intraocular
lymphoma
< 500
cells/µl
(A:II)
 Floaters (A:II)
 Vision loss
(A:II)
 VA (A:II)
 DOE (A:II)
 History/extent
of necrotizing
retinitis (A:II)
 History of
trauma (B:II)
 History of
myopia (B:II)
 VA (A:II)
 SLE (B:II)
 DOE (A:II)
VA
IOP (C:II)
SLE (C:III)
DOE (A:II)
Key Findings
 Peripheral multifocal
retinitis (A:II)
 Retinal vasculitis (A:II)
 Mild vitreous
inflammation (B:II)
 Lack of retinal
hemorrhage (B:II)
 Slow progression (B:II)
 Necrotizing retinitis
(A:II)
 Retinal vasculitis (B:II)
 Subretinal mass (A:II)
 Vitritis (A:II)
 Multifocal choroiditis
(A:II)
 Poor response to
treatment (A:II)
 CNS symptoms (A:II)
Diagnostic workup
Management
Follow-up
 Clinical diagnosis
 Rule out other
entities, particularly
syphilis (A:II)
 Antiretroviral therapy should lead
to regression (A:II)
 Weekly until resolution
 Workup and
treatment for
infectious processes
(A:II)
 AC tap for IL-10
(B:II)
 Vitreous biopsy with
cytologic
examination (A:II)
 Consider retinal
biopsy
 MRI for CNS
lymphoma (A:II)
 Clinical diagnosis
 B-scan ultrasound if
visualization is poor
 Radiation and chemotherapy (A:II)
 Involve Oncology
 Immune reconstitution (B:II)
 Monthly DOE
 Poor prognosis (A:II)
 Rhegmatogenous retinal
 PPV with long-term silicone oil
 Routine post-operative follow-up
detachment (A:II)
tamponade and scleral buckling
 As directed by other disorders
(A:II)
 Holes or microholes in
areas of areas of atrophic
retina or chronic retinitis
(A:II)
 Note extent of
detachment, number,
size, and location of
retinal holes, and
involvement of the
macula (A:II)
HIV = human immunodeficiency virus, VA = visual acuity, SLE = slit lamp examination, DOE = dilated ophthalmoscopic examination, CWS = cotton wool spots, IRH = intraretinal hemorrhages, MA =
microaneurysms, CME = cystoid macular edema, HAART = highly active antiretroviral therapy, CMV = cytomegalovirus, AIDS = acquired immunodeficiency syndrome, KP = keratic precipitates, IRU = Immune
recovery uveitis, IV = intravenous, IO = intraocular, PO = per os (by mouth), IOP = intraocular pressure, AC = anterior chamber, PCR = polymerase chain reaction, IOP = intraocular pressure, PPD = purified
protein derivative, CXR = chest X-ray, IGRA = Interferon-gamma release assay, FA = fluorescein angiography, ICG = indocyanine green angiography, OCT = optical coherence tomography, RPR = rapid plasma
reagin, VDRL = venereal disease research laboratory, FTA-ABS = fluorescent treponemal antibody absorption, MHA-TP = microhemagluttination-Treponema pallidum, CSF = cerebrospinal fluid, PORN =
progressive outer retinal necrosis, ARN = acute retinal necrosis, HZO = herpes zoster ophthalmicus, TTP/HUS = thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, TRD = tractional retinal
detachment, RNV = retinal neovascularization, ERM = epiretinal membrane, CME = cystoid macular edema, FA = fluoroscein angiography, PPV = pars plana vitrectomy, VMTS = vitreomacular traction syndrome,
PVR = proliferative vitreoretinopathy, OU = oculus uterque (both eyes), CXR = chest X-ray, ABG = arterial blood gas, CT = computed tomography, TMP-SMX = trimethoprim sulfamethoxazole, EOM = extraocular
motility, CNS = central nervous system, MRI = magnetic resonance imaging, N/A = not applicable
Retinal
detachment
N/A
ICO International Clinical Guidelines, 2010
Page 55
Posterior Vitreous Detachment, Retinal Breaks
and Lattice Degeneration
(Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)





Symptoms of PVD (A:I)
Family history (A:II)
Prior eye trauma (A:III)
Myopia (A:II)
History of ocular surgery including refractive lens exchange and cataract
surgery (A:II)
Initial Physical Exam (Key elements)


Examination of the vitreous for hemorrhage detachment and pigmented
cells (A:III)
Examination of the peripheral fundus with scleral depression (A:III) The
preferred method of evaluating peripheral vitreoretinal pathology is with
indirect ophthalmoscopy combined with scleral depression (A:III)
Ancillary Tests

Perform B-scan ultrasonography if peripheral retina cannot be evaluated.
(A:II) If no abnormalities are found, frequent follow-up examinations are
recommended. (A:III)
Surgical and Postoperative Care if Patient Receives Treatment:



Inform patient about the relative risks, benefits and alternatives to surgery
(A:III)
Formulate a postoperative care plan and inform patient of these
arrangements (A:III)
Advise patient to contact ophthalmologist promptly if they have a substantial
change in symptoms such as new floaters or visual field loss (A:II)
ICO International Clinical Guidelines
Page 56
Care Management
Management Options
Type of Lesion
Acute symptomatic horseshoe tears
Acute symptomatic operculated tears
Traumatic retinal breaks
Asymptomatic horseshoe tears
Asymptomatic operculated tears
Asymptomatic atrophic round holes
Asymptomatic lattice degeneration
without holes
Asymptomatic lattice degeneration with
holes
Asymptomatic dialyses
Fellow eyes atrophic holes, lattice
degeneration, or asymptomatic
horseshoe tears
Treatment
Treat promptly (A:II)
Treatment may not be necessary
(A:III)
Usually treated (A:III)
Usually can be followed without
treatment (A:III)
Treatment is rarely recommended
(A:III)
Treatment is rarely recommended
(A:III)
Not treated unless PVD causes a
horseshoe tear (A:III)
Usually does not require treatment
(A:III)
No consensus on treatment and
insufficient evidence to guide
management
No consensus on treatment and
insufficient evidence to guide
management
PVD = Posterior vitreous detachment
Follow-up History


Visual symptoms (A:I)
Interval history of eye trauma or intraocular surgery (A:II)
Follow-up Physical Exam





Visual acuity (A:III)
Evaluation of the status of the vitreous, with attention to the presence of
pigment, hemorrhage, or syneresis (A:II)
Examination of the peripheral fundus with scleral depression (A:II)
B-scan ultrasonography if the media are opaque (A:II)
Patients who present with vitreous hemorrhage sufficient to obscure retinal
details and a negative B-scan should be followed periodically. For eyes in
which a retinal tear is suspected, a repeat B-scan should be performed
within approximately 4 weeks of the initial examination (A:III)
ICO International Clinical Guidelines
Page 57
Patient Education


Educate patients at high risk of developing retinal detachment about the
symptoms of PVD and retinal detachment and the value of periodic followup exams. (A:II)
Instruct all patients at increased risk of retinal detachment to notify their
ophthalmologist promptly if they have a substantial change in symptoms
such as an increase in floaters, loss of visual field, or decrease in visual
acuity. (A:III)
*Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines
Page 58
Primary Open-Angle Glaucoma (Initial Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)





Ocular history (A:III)
Systemic history (A:III)
Family history (A:II)
Review of pertinent records (A:III)
Assessment of impact of visual function on daily living and activities (A:III)
Initial Physical Exam (Key elements)










Visual acuity (A:III)
Pupils (B:II)
Slit-lamp biomicroscopy of anterior segment (A:III)
Measurement of IOP (A:I)
Central corneal thickness (A:II)
Gonioscopy (A:III)
Evaluation of optic nerve head and retinal nerve fiber layer with magnified
stereoscopic visualization (A:III)
Documentation of optic nerve head appearance by color stereophotography
or computer-based image analysis (A:II)
Evaluation of the fundus (through a dilated pupil whenever feasible) (A:III)
Visual field evaluation, preferably by automated static threshold perimetry
(A:III)
Management Plan for Patients in Whom Therapy is Indicated






Set an initial target pressure of at least 25% lower than pretreatment IOP,
assuming that the measured pretreatment pressure range contributed to
optic nerve damage. (A:I)
Target pressure is an estimate; all treatment decisions must be
individualized according to the needs of the patient. (A:III)
Medical therapy is presently the most common initial intervention to lower
IOP; consider balance between side effects and effectiveness in choosing a
regimen of maximal effectiveness and tolerance to achieve the desired IOP
reduction for each patient. (A:III)
Assess the patient who is being treated with glaucoma medication for local
ocular and systemic side effects and toxicity. (A:III)
Laser trabeculoplasty can be considered as initial therapy in selected
patients (A:I)
Filtering surgery can be considered in selected cases as initial therapy. (A:I)
ICO International Clinical Guidelines
Page 59
Surgery and Postoperative Care for Laser Trabeculoplasty Patients

The ophthalmologist who performs surgery has the following
responsibilities:
o Obtain informed consent. (A:III)
o Ensure that the preoperative evaluation confirms the need for
surgery. (A:III)
o At least one IOP check within 30 minutes to 2 hours of surgery. (A:I)
o Follow-up examination within 6 weeks of surgery or sooner if concern
about IOP-related optic nerve damage. (A:III)
Surgery and Postoperative Care for Incisional Glaucoma Patients

The ophthalmologist who performs surgery has the following
responsibilities:
o Obtain informed consent. (A:III)
o Ensure that the preoperative evaluation accurately documents
findings and indications for surgery. (A:III)
o Prescribe topical corticosteroids in the postoperative period. (A:II)
o Follow-up evaluation on the first postoperative day (12 to 36 hours
after surgery) and at least once during the first 1 to 2 weeks. (A:II)
o In the absence of complications, perform additional postoperative
visits during a 6-week period. (A:III)
o Schedule more frequent visits, as necessary, for patients with
postoperative complications. (A:III)
o Additional treatments as necessary to maximize chances for a
successful long-term result. (A:III)
Patient Education for Patients with Medical Therapy



Discuss diagnosis, severity of the disease, prognosis and management
plan, and likelihood of lifelong therapy. (A:III)
Educate about eyelid closure or nasolacrimal occlusion when applying
topical medications to reduce systemic absorption. (B:II)
Encourage patients to alert their ophthalmologist to physical or emotional
changes that occur when taking glaucoma medications. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines
Page 60
Primary Open-Angle Glaucoma
(Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Exam History




Interval ocular history (A:III)
Interval systemic medical history (B:III)
Side effects of ocular medication (A:III)
Frequency and time of last IOP-lowering medications, and review of use of
medications (B:III)
Physical Exam





Visual acuity (A:III)
Slit-lamp biomicroscopy (A:III)
Measurement of IOP (A:I)
Evaluation of optic nerve head and visual fields (see table below) (A:III)
Measurement of central corneal thickness should be repeated after any
event that may alter it (A:II)
Management Plan for Patients on Medical Therapy:




At each exam, record dosage and frequency of use, discuss adherence to
the therapeutic regimen and patient's response to recommendations for
therapeutic alternatives or diagnostic procedures. (A:III)
Perform gonioscopy if there is a suspicion of angle closure, anteriorchamber shallowing or anterior-chamber angle abnormalities or if there is
an unexplained change in IOP. (A:III) Perform gonioscopy periodically (e.g.,
1-5 years). (A:III)
Reassess treatment regimen if target IOP is not achieved and benefits of a
change in therapy outweighs risks. (A:III)
Adjust target pressure downward if optic disc or visual field change is
progressive. (A:III) Within each of the recommended intervals, factors that
determine frequency of evaluation include the severity of damage, the rate
of progression, the extent to which the IOP exceeds the target pressure and
the number and significance of other risk factors for damage to the optic
nerve. (A:III)
ICO International Clinical Guidelines
Page 61
Follow-Up:
Recommended Guidelines for Follow‐up:
Recommended Guidelines for Follow-up Glaucoma Status Evaluations with
Optic Nerve and Visual Field Assessment (B:III) *
Target IOP
Achieved
Progression of
Damage
Duration of
Control (months)
Approximate
Follow-up Interval
(months)**
Yes
No
≤6
6
Yes
No
>6
12
Yes
Yes
NA
1–2
No
Yes
NA
1–2
No
No
NA
3–6
IOP = intraocular pressure; NA = not applicable
* Evaluations consist of clinical examination of the patient, including optic nerve head
assessment (with periodic color stereophotography or computerized imaging of the optic
nerve and retinal nerve fiber layer structure) and visual field assessment.
** Patients with more advanced damage or greater lifetime risk from POAG may require
more frequent evaluations. These intervals are the maximum recommended time
between evaluations.
Patient Education:


Educate about the disease process, rationale and goals of intervention,
status of their condition, and relative benefits and risks of alternative
interventions so that patients can participate meaningfully in developing an
appropriate plan of action. (A:III)
Refer for or encourage patients with significant visual impairment or
blindness to use appropriate vision rehabilitation and social services. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines
Page 62
Primary Open-Angle Glaucoma Suspect
(Initial and Follow-up Evaluation)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)





Ocular history (A:III)
Systemic history (A:III)
Family history (A:III)
Review of pertinent records (A:III)
Assessment of impact of visual function on daily living and activities (A:III)
Initial Physical Exam (Key elements)










Visual acuity (A:III)
Pupils (B:II)
Slit-lamp biomicroscopy of anterior segment (A:III)
Measurement of IOP (A:I)
Central corneal thickness (A:II)
Gonioscopy (A:III)
Evaluation of optic nerve head and retinal nerve fiber layer, with magnified
stereoscopic visualization (A:III)
Documentation of optic nerve head appearance color stereophotography or
computer-based image analysis(A:II)
Evaluation of the fundus (through a dilated pupil whenever feasible) (A:III)
Visual field evaluation, preferably by automated static threshold perimetry
(A:III)
Management Plan for Patients in Whom Therapy is Indicated:


A reasonable initial goal is to set target pressure 20% less than mean of
several baseline IOP measurements. (A:I)
Choose regimen of maximal effectiveness and tolerance to achieve desired
therapeutic response. (A:III)
Follow-Up Exam History




Interval ocular history (A:III)
Interval systemic medical history and any change of systemic medications
(B:III)
Side effects of ocular medications if patient is being treated (A:III)
Frequency and time of last glaucoma medications, and review of use, if
patient is being treated (B:III)
ICO International Clinical Guidelines
Page 63
Follow-Up Physical Exam




Visual acuity (A:III)
Slit-lamp biomicroscopy (A:III)
IOP (A:III)
Gonioscopy is indicated when there is a suspicion of an angle-closure
component, anterior chamber shallowing or unexplained change in IOP
(A:III)
Follow-up Intervals


Visit intervals depend on the interaction between patient and disease, which
is unique for every patient. (A:III)
Frequency of periodic optic nerve head and visual field evaluation is based
on risk assessment. Patients with thinner corneas, higher IOPs, disc
hemorrhage, larger cup-to-disc, larger mean pattern standard deviation, or
family history of glaucoma may warrant closer follow-up.
Patient Education for Patients with Medical Therapy:




Discuss diagnosis, number and severity of risk factors, prognosis,
management plan and likelihood that therapy, once started, will be long
term. (A:III)
Educate about disease process, rationale and goals of intervention, status
of their condition, and relative benefits and risks of alternative interventions.
(A:III)
Educate about eyelid closure and nasolacrimal occlusion when applying
topical medications to reduce systemic absorption. (B:II)
Encourage patients to alert their ophthalmologist to physical or emotional
changes that occur when taking glaucoma medications. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
ICO International Clinical Guidelines
Page 64
Primary Angle Closure
(Initial Evaluation and Therapy)
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History (Key elements)



Ocular history (symptoms suggestive of intermittent angle-closure attacks)
(A:III)
Family history of acute angle-closure glaucoma (B:II)
Systemic history (e.g., use of topical or systemic medications) (A:III)
Initial Physical Exam (Key elements)


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Refractive status (A:III)
Pupils (A:III)
Slit-lamp biomicroscopy (A:III)
o Conjunctival hyperemia (in acute cases)
o Central and peripheral anterior chamber depth narrowing
o Anterior chamber inflammation suggestive of a recent or current
attack
o Corneal swelling with or without microcystic edema (in acute cases)
o Iris abnormalities, including diffuse or focal atrophy, posterior
synechiae, abnormal pupillary function, irregular pupil shape, and a
mid-dilated pupil (suggestive of a recent or current attack)
o Lens changes, including cataract and glaukomflecken
o Corneal endothelial cell loss
Measurement of IOP (A:III)
Gonioscopy of both eyes (A:III)
Evaluation of fundus and optic nerve head using direct ophthalmoscope or
biomicroscope (A:III)
Management Plan for Patients in Whom Iridotomy is Indicated
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Laser iridotomy is the preferred surgical treatment for acute angle-closure
crisis. (A:II)
In acute angle-closure crisis, usually use medical therapy first to lower the
IOP, to reduce pain and clear corneal edema in preparation for iridotomy.
(A:III)
Perform prophylactic iridotomy in fellow eye if chamber angle is
anatomically narrow. (A:II)
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Surgery and Postoperative Care for Iridotomy Patients
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The ophthalmologist who performs surgery has the following
responsibilities:
o Obtain informed consent (A:III)
o Ensure that preoperative evaluation confirms the need for surgery
(A:III)
o Perform at least one IOP check within 30 minutes to 2 hours of
surgery (A:III)
o Prescribe topical corticosteroids in the postoperative period (A:III)
o Ensure that the patient receives adequate postoperative care (A:III)
Follow-up evaluations include:
o Evaluation of patency of iridotomy (A:III)
o Measurement of IOP (A:III)
o Gonioscopy, if not performed immediately after iridotomy (A:III)
o Pupil dilation to reduce risk of posterior synechiae formation (A:III)
o Fundus examination as clinically indicated (A:III)
Use medications perioperatively to avert sudden IOP elevation, particularly
in patients with severe disease. (A:III)
Follow-up of Patients with Iridotomy:
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After iridotomy, follow patients with glaucomatous optic neuropathy as
specified in the Primary Open-Angle Glaucoma PPP. (A:III)
After iridotomy, patients with a residual open angle or a combination of open
angle and some PAS with or without glaucomatous optic neuropathy should
be followed at least annually, with special attention to repeat gonioscopy.
(A:III)
Education for Patients if Iridotomy is Not Performed:

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Inform patients at risk for acute angle closure about symptoms of acute
angle-closure crisis and instruct them to notify immediately if symptoms
occur. (A:III)
Warn patients of medications that could cause pupil dilation and induce an
acute angle-closure crisis. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
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Trachoma
(Ratings: A: Most important, B: Moderately important, C: Relevant but not critical
Strength of Evidence: I: Strong, II: Substantial but lacks some of I, III: consensus
of expert opinion in absence of evidence for I & II)
Initial Exam History
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Living in a trachoma-endemic region (A:I)
Duration of red eye (an acute follicular conjunctivitis may be due to other
organisms) (C:III)
Any previous similar episodes (active trachoma is often recurrent) (C:III)
Household contacts with history of trachoma or chronic conjunctivitis (B:I)
Purulent discharge (although active trachoma is often sub-clinical or
asymptomatic) (C:III)
Duration of trichiasis (C:III)
History of previous lid surgery (A:III)
Initial Physical Exam


Using 2.5x magnification loupes and adequate lighting (daylight or
torchlight) or using a slit lamp, assess signs of trachoma using the WHO
simplified grading scale:
www.who.int/ncd/vision2020_actionplan/documents/Simplifiedgradingoftrac
homa.PDF (A:III)
Briefly, note any trichiasis or corneal opacity. Evert the upper palpebral
conjunctivae and note follicles over the tarsal plate (5 follicles greater than
0.5 mm in the central tarsus constitutes the WHO grade of TF), intense
inflammatory thickening obscuring 50% of the normal, underlying
conjunctival vasculature (TI), and easily visible scarring (TS).
Diagnostic (Laboratory) Tests
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PCR testing for chlamydial DNA—this is the gold standard for identifying
infection but not for diagnosing trachoma (B:I)
Direct Chlamydial Immunofluorescence test +/- chlamydial culture of
conjunctival epithelial cells (C:II)
Chlamydial culture (difficult to perform) (C:II)
Giemsa stain of conjunctival scrape to look for:
o Basophilic intracytoplasmic inclusion bodies in epithelial cells (C:III)
o Polymorphonuclear leucocytes (C:III)
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Management
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Management of trachoma should be community based. The WHO
recommends the integrated SAFE Strategy, surgery for trichiasis,
community wide antibiotic treatment, facial cleanliness education and
environmental improvements (B:III)
Surgical: Trichiasis surgery (bilamellar tarsal rotation or the related Trabut
procedure) should be considered if any of the following are present:
o one or more in-turned eyelashes are abrading the cornea when the
patient is looking straight ahead (A:II)
o pre-existing evidence of corneal damage from trichiasis (B:II)
o severe discomfort from trichiasis (C:III)
o Contra-indications to trichiasis surgery include defective lid closure,
children with trichiasis (may need general anesthetic), and poor
general health. (C:III)
o Epilation is considered an alternative for refusal to have surgery
(B:III)
Community-wide antibiotic treatment is recommended if there is >10%
active trachoma in children aged 1-9 years of age in the community.
Targeted treatment of clinically active cases is recommended for a lower
prevalence. Household contacts, and in particular, siblings, may also be
treated, even if they have no active signs of infection (B:II)
The following antibiotic treatment is recommended by the WHO:
o Single dose azithromycin: in children aged <16 years dosage is
20mg/kg (maximum dose 1g); in adults dosage is 1g (A:I)
o Or, use topical 1% tetracycline eye ointment in pregnant women,
children aged below 6 months and those allergic to macrolides, used
twice daily in both eyes for 6 weeks (A:I)
o It is acceptable to treat follicular conjunctivitis in a trachoma-endemic
area with antibiotics even without laboratory documentation of active
chlamydial infection (A:I)
Facial Cleanliness: promote regular face-washing with clean water. Clean
faces have been associated with clinically active trachoma, but it should be
noted that face-washing interventions have not been shown to reduce
ocular chlamydial infection (B:II)
Environmental Improvements: (improving water supply, latrine provision and
fly control). The face fly Musca sorbens has been implicated as a possible
vector for trachoma and breeds preferentially on human feces. These flies
cannot breed in latrines, so latrine construction is thought to reduce fly
populations and trachoma transmission (B:II)
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Follow-up Evaluation
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WHO recommends annual, community based treatment with
reassessment at three years. (B:II)
Note that follicles can take months to clear even after infection has been
eliminated, and that re-treatment may not be warranted if follicles are slowly
improving depending on the time that has elapsed since the last treatment
was given. (B:II)
For treatment of individual more frequent examinations can be
undertaken. Follow-up 1 month after treatment, with retreatment as
necessary is reasonable.
Re-infection frequently occurs in endemic areas, so patient education
regarding methods that may reduce transmission is useful. (C:III)
After trichiasis surgery, patients should be seen within 2 weeks for suture
removal, and annually to ensure that trichiasis has not returned. (A:III)
* Adapted from the American Academy of Ophthalmology Summary Benchmarks,
November 2010 (www.aao.org)
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