Empirical Therapy for Microbial Keratitis: A Contemporary Update for General Ophthalmologists

Abstract Purpose: To summarize updated protocols and evidence for empirical therapy of microbial keratitis in India, contextualized for general ophthalmologists and emphasizing local epidemiology and resistance trends. Materials and Methods: This review synthesizes published and recent data from peer-reviewed studies, relevant clinical trials, and surveillance reports concerning empirical antibiotic and antifungal therapy for microbial keratitis, with particular focus on pathogens prevalent in India. Results: Bacterial keratitis remains the most common cause of corneal ulcers, with growing antimicrobial resistance (notably to fluoroquinolones and aminoglycosides) among Indian isolates. Filamentous fungal keratitis is disproportionately prevalent in tropical regions, with natamycin as the agent of choice per the Mycotic Ulcer Treatment Trials. Fortified antibiotics and tailored empirical therapy remain crucial for vision-threatening or resistant infections, while emerging techniques—such as intrastromal injections and corneal cross-linking—show promise for recalcitrant cases. Acanthamoeba and viral keratitis require diagnosis-driven combinational or antiviral therapy, respectively. Conclusion: An agile, evidence-based, regionally adapted approach to empirical therapy is vital for optimizing outcomes in microbial keratitis in India. Surveillance-guided regimen adjustments, timely escalation, and the integration of novel modalities are recommended for primary and secondary eyecare settings.