Ocular infections and stewardship practices for Ophthalmologists: The RED EYE AMSP model

Ocular infections, ranging from conjunctivitis and keratitis to postoperative and device-associated endophthalmitis, remain a significant cause of preventable visual morbidity worldwide. In India and other low- and middle-income countries, the irrational use of topical and systemic antimicrobials, often without microbiological confirmation, has contributed to the emergence of multidrug-resistant ocular pathogens. Fluoroquinolone-resistant Pseudomonas aeruginosa , methicillin-resistant Staphylococcus aureus , and resistant Fusarium and Candida species are now major challenges in ophthalmic practice. The widespread availability of over-the-counter ophthalmic drops, empirical perioperative prophylaxis, and the use of steroid-antibiotic combinations exacerbate this problem. Antimicrobial stewardship (AMS) in ophthalmology, though relatively underdeveloped, is now a global priority. The Society of Antimicrobial Stewardship PractIce (SASPI) in India advocates an integrated AMS model linking diagnostic, preventive, therapeutic, and administrative strategies. For ophthalmologists, this translates into culture-guided therapy for recalcitrant or postsurgical infections, restricting the use of broad-spectrum or prolonged topical antimicrobials, enforcing asepsis during surgeries, and adopting antimicrobial auditing systems. The RED EYE AMSP model presented in this perspective provides a ten-point, ophthalmology-specific adaptation of the SASPI framework focusing on rational prescribing, evidence-based diagnostics, environmental safety, and interprofessional partnership. By embracing stewardship, ophthalmologists can preserve antimicrobial efficacy, minimize iatrogenic resistance, and contribute to the broader One Health goal of antimicrobial resistance containment.