What is the recommended treatment, including eye drops, for a dog bite to the eye in a patient?

Dog Bite to the Eye: Treatment Protocol

Immediate copious irrigation with tap water or sterile saline is the critical first intervention for any dog bite involving the eye, followed by systemic antibiotics (amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days), prophylactic topical ophthalmic antibiotics, and urgent ophthalmology consultation for surgical repair of ocular adnexal injuries. 1, 2, 3

Immediate Wound Management

Irrigation Protocol

• Perform aggressive saline lavage immediately with large volumes of sterile normal saline or tap water to minimize bacterial contamination and rabies risk. 1, 3
• The American Heart Association and American Red Cross recommend irrigation of bite wounds with copious amounts of fluid (water or saline) to minimize risks of bacterial and rabies infections. 1
• Continue irrigation until all visible debris and contaminants are removed from the ocular surface and periocular tissues. 3

Wound Debridement

• Perform selective debridement of devitalized tissue only, preserving as much viable tissue as possible given the functional and cosmetic importance of periocular structures. 3, 4
• Avoid aggressive debridement in the periocular region due to limited tissue availability for reconstruction. 3

Systemic Antibiotic Therapy

First-Line Treatment

• Start oral amoxicillin-clavulanate 875/125 mg twice daily immediately for 7-10 days to cover the polymicrobial flora of dog bites, including Pasteurella species (present in 50% of dog bites). 2, 5
• Dog bite wounds contain an average of 5 bacterial species, with 60% harboring mixed aerobic and anaerobic organisms. 2

Alternative Regimens

• For penicillin-allergic patients, use doxycycline (excellent activity against Pasteurella multocida) or fluoroquinolones with additional anaerobic coverage. 5
• For severe infections requiring hospitalization, IV options include ampicillin-sulbactam, piperacillin-tazobactam, second-generation cephalosporins, or carbapenems. 5

Topical Ophthalmic Antibiotics

Eye Drop Selection

While guidelines do not specify exact ophthalmic formulations for dog bite injuries, prophylactic topical antibiotics are warranted given the high infection risk:

• Moxifloxacin 0.5% ophthalmic solution: instill one drop in the affected eye 3 times daily for 7 days. 6
• Gatifloxacin 0.3% ophthalmic solution: Day 1 - one drop every 2 hours while awake (up to 8 times); Days 2-7 - one drop 2-4 times daily. 7
• Fluoroquinolone eye drops provide broad-spectrum coverage against common ocular pathogens and are appropriate for traumatic injuries with high contamination risk. 6, 7

Surgical Considerations

Periocular Wound Repair

• Facial and eyelid dog bite wounds should receive primary closure after copious irrigation and cautious debridement for optimal cosmetic and functional results. 5, 4
• Full-thickness eyelid lacerations involving the lacrimal drainage system (present in approximately two-thirds of cases) require meticulous surgical repair with canalicular intubation. 8, 9
• Urgent ophthalmology or oculoplastic surgery consultation is mandatory for all ocular adnexal injuries. 3, 8

Globe Examination

• Perform systematic examination to rule out globe rupture, intraocular foreign bodies, or penetrating injury before proceeding with repair. 3, 8
• Even seemingly superficial periocular bites can mask serious underlying injuries including occult facial fractures or intracranial penetration, particularly in young children. 8

Tetanus and Rabies Prophylaxis

Tetanus Management

• Administer tetanus toxoid if the patient has not received vaccination within 10 years, with Tdap preferred over Td if not previously given. 2, 5

Rabies Assessment

• If the dog is healthy and available, confine and observe for 10 days without administering rabies vaccine during observation. 2, 5
• If the dog is stray, unwanted, or cannot be observed, initiate rabies post-exposure prophylaxis immediately (both rabies immunoglobulin and vaccine for previously unvaccinated individuals). 5
• Consult local health officials regarding rabies risk assessment and reporting requirements. 2, 10

Mandatory Follow-Up

• Schedule follow-up within 48-72 hours to assess response to antibiotics, wound healing, and development of complications. 2, 5
• Monitor for warning signs requiring hospitalization: fever, systemic symptoms, rapidly spreading erythema, lymphangitis, abscess formation, or failure to improve within 48 hours. 2
• Children under 3 years with levator muscle damage require monitoring for reversible amblyopia. 8

Common Pitfalls to Avoid

• Do not delay irrigation while waiting for specialized solutions—tap water is immediately beneficial and superior to delayed treatment. 1
• Do not apply povidone-iodine to bite wounds, as there is no evidence supporting its benefit despite common clinical practice. 1
• Do not withhold antibiotics in periocular dog bites—the infection rate is significant (approximately 16% overall) and consequences of ocular infection are severe. 2, 9
• Do not miss lacrimal system involvement, which occurs in the majority of eyelid dog bites and requires specialized repair. 8, 9