Ophthalmic Disorders



Ophthalmic Disorders


Joshua J. Spooner



There are many conditions and disorders of the eye, but only a few, such as blepharitis and conjunctivitis, should be diagnosed and treated by a primary care provider. The remaining ocular conditions are usually treated by eye care specialists. Nonetheless, prescribers should be familiar with drug therapy for the more common ophthalmic conditions (glaucoma, keratoconjunctivitis sicca), as they are likely to encounter patients being treated for these disorders.


EYELID MARGIN INFECTIONS: BLEPHARITIS

The eye is well protected externally by the eyebrow, eyelashes, and eyelids. If these protective mechanisms are compromised, the eye becomes predisposed to disease. Externally, the eyelid structures are composed of skin with a high degree of elasticity, muscles that elevate the upper eyelid and close the eyelids, and the tarsal plate, which contains the meibomian glands. Through frequent blinking, the eyelids maintain an even flow of tears over the cornea. Internally, the eyelid structure is lined by the palpebral conjunctiva, which folds upon itself and then covers the sclera of the eyeball up to the corneoscleral junction. Located at the lid margins are the openings to the long sebaceous meibomian glands; these glands secrete the oily film that prevents tears from evaporating. At the base of the eyelash, hair follicles are the superficial modified sebaceous glands of Zeis and the sweat glands of Moll. Any of these glands may become functionally disrupted.

Blepharitis is an inflammation of the eyelid margin. Although it is a common eye disorder in the United States, epidemiologic information on its incidence or prevalence is not robust.


CAUSES

Blepharitis can be caused by a bacterial infection (staphylococcal blepharitis), inflammation or hypersecretion of the sebaceous glands (seborrheic blepharitis), meibomian gland dysfunction (MGD blepharitis), or a combination of these (American Academy of Ophthalmology [AAO], 2013a). Staphylococcal and seborrheic blepharitis primarily involve the anterior eyelid; both have also been referred to as anterior blepharitis.



PATHOPHYSIOLOGY

Although the gram-positive organisms Staphylococcus epidermidis and Staphylococcus aureus are found on the eyelids of a high proportion of healthy subjects, S. aureus is observed more frequently among patients with staphylococcal blepharitis. While S. epidermidis and S. aureus are thought to play a role in the development of staphylococcal blepharitis, their role in disease production remains unclear. Toxin production, immunologic mechanisms, Demodex folliculorum mite infestation, and antigen-induced inflammatory reactions have all been reported with blepharitis (AAO, 2013a; Zhao et al., 2012).

Seborrheic blepharitis typically occurs as part of the more comprehensive condition of seborrheic dermatitis, with dandruff of the scalp, eyebrows, eyelashes, nasolabial folds, and external ears. Seborrheic blepharitis is more commonly found in the geriatric population because of its association with rosacea.

Manifestations of MGD blepharitis include thickening of the eyelid margin, plugging of the meibomian orifices, prominent blood vessels crossing the mucocutaneous junction, and formation of chalazia (painless firm lumps on the eyelid). These changes may lead to atrophy of the meibomian glands (AAO, 2013a). Compared to healthy patients, meibomian
gland secretions are more turbid among patients with MGD blepharitis. These secretions block the gland orifices and become a growth medium for bacteria. Patients with MGD blepharitis frequently have coexisting rosacea or seborrheic dermatitis.


DIAGNOSTIC CRITERIA

There are no specific diagnostic tests for blepharitis; the diagnosis is often based upon patient history and characteristic symptoms. Patients with blepharitis frequently present with irritated red eyes and report a burning sensation. Increases in tearing, blinking, and photophobia are frequently reported, as is eyelid sticking and contact lens intolerance. Upon close inspection, the eyelid margins appear red, greasy, and crusted, with eyelid deposits that cling to the eyelashes. The eyelid margins may be ulcerated and thickened, and eyelashes may be missing.

Although the clinical features of staphylococcal, seborrheic, and MGD blepharitis are similar, there are differences that can aid in the differential diagnosis of these conditions. Eyelash loss and eyelash misdirection frequently occur in staphylococcal blepharitis but are rare in seborrheic blepharitis. The eyelid deposits are matted and scaly in staphylococcal blepharitis, oily or greasy in seborrheic blepharitis, and fatty and possibly foamy in MGD blepharitis. Chalazia are most likely to occur in MGD blepharitis.


INITIATING DRUG THERAPY

The underlying cause of the blepharitis must be treated, particularly if it is due to seborrheic dermatitis or rosacea. Treatment for all types of blepharitis includes strict eyelid hygiene and warm compresses. The use of warm compresses with a clean washcloth can soften adherent encrustations; once-daily use of compresses is generally sufficient (AAO, 2013a). Patients with MGD blepharitis often benefit from eyelid massage following warm compress use to remove excess oil. Following warm compress use, eyelid cleaning is performed by having the patient rub the base of the eyelashes with a commercially available eyelid cleaner (EyeScrub, OCuSOFT) or a diluted mixture of baby shampoo (e.g., Johnson & Johnson) and water on a cotton swab, cotton ball, or gauze pad. Performing eyelid hygiene daily or several times a week often blunts the symptoms of chronic blepharitis (Guillon et al., 2012). Patients should be advised that eyelid hygiene may be required for life because symptoms frequently recur if eyelid hygiene is discontinued.

Patients suspected of having a new case of seborrheic or MGD blepharitis should be referred to an eye care specialist for a workup. Patients with staphylococcal blepharitis need a topical antibiotic.


Goals of Drug Therapy

The goals of drug therapy are to eradicate the pathogens causing the blepharitis and to reduce the signs and symptoms of blepharitis.


Topical Ophthalmic Antimicrobials

Topical ophthalmic antimicrobials are used for the treatment of and prophylaxis against external bacterial infections (Table 17.1). They kill the offending pathogen and other susceptible organisms.









TABLE 17.1 Overview of Antimicrobial Ophthalmic Agents



































































































































Generic (Trade) Name and Dosage

Selected Adverse Events

Contraindications

Special Considerations


Single-Agent Products


sulfacetamide sodium 10% solution (Bleph-10)

Local irritation, itching, stinging, burning, periorbital edema

Allergy to sulfa drugs


Do not use in infants less than age 2 mo.

A significant percentage of Staphylococcus species are resistant to sulfa drugs.


Do not use in patients with purulent exudates.

Dosing


Solution: 1-2 drops every 2-3 h initially according to the severity of infection


Dosing may be tapered as the condition responds. Usual duration of therapy is 7-10 d.


bacitracin 500 units/g ointment

Blurred vision, redness, burning, eyelid edema


Ointments may blur vision and retard corneal wound healing.

Dosing: apply one to three times a day


erythromycin 0.5% ointment

Redness, ocular irritation


Ointments may blur vision and retard corneal wound healing.

Dosing: apply up to 1 cm to the affected eye(s) up to six times a day


gentamicin 0.3% solution or ointment (Gentak)

Ocular burning and irritation, nonspecific conjunctivitis, conjunctival epithelial defects, conjunctival hyperemia, bacterial and fungal corneal ulcers


In severe infections, dosage of the solution may be increased to as much as 2 drops every hour.


Ointments may blur vision and retard corneal wound healing.

Dosing


Solution: 1-2 drops in the affected eye(s) every 4 h


Ointment: ½ inch to the affected eye two or three times a day


tobramycin 0.3% solution or ointment (Tobrex)

Lid itching, lid swelling, conjunctival hyperemia, nonspecific conjunctivitis, bacterial and fungal corneal ulcers


Ointments may blur vision and retard corneal wound healing.


For more severe infections, the initial dose may be increased to 2 drops every 60 min (solution) or 1 inch every 3-4 h (ointment).

Dosing


Solution: 1-2 drops into the infected eye every 4 h


Ointment: ½ inch every 8-12 h


besifloxacin 0.6% suspension (Besivance)

Conjunctival redness, blurred vision, eye irritation, eye pain, pruritus

Dosing: 1 drop in the affected eye(s) three times a day for 7 d


ciprofloxacin 0.3% solution or ointment (Ciloxan)

Local burning and discomfort, white crystalline precipitate formation, conjunctival hyperemia, altered taste


Ointments may blur vision and retard corneal wound healing.


This is the only ophthalmic fluoroquinolone available as an ointment.

Dosing


Solution: 1-2 drops every 2 h while awake for 2 d and then 1-2 drops every 4 h while awake for 5 d


Ointment: ½ inch three times a day for 2 d and then ½ inch twice a day for 5 d


gatifloxacin 0.3% solution (Zymaxid)

Conjunctival irritation, tearing, papillary conjunctivitis, eyelid edema, ocular itching, dry eye

Dosing: 1 drop in the affected eye every 2 h while awake for 1 d and then 1 drop in the affected eye up to four times daily while awake for 6 d


levofloxacin 0.5% solution (Quixin)

Temporarily decreased or blurred vision, eye irritation, itching, dry eye

Dosing: 1 drop in the affected eye every 2 h while awake for 2 d and then 1 drop in the affected eye up to four times daily while awake for 5 d


moxifloxacin 0.5% solution (Moxeza, Vigamox)

Decreased visual acuity, dry eye, ocular itching and discomfort, ocular hyperemia

Dosing:


Moxeza: 1 drop in the affected eye two times a day for 7 d


Vigamox: 1 drop in the affected eye three times a day for 7 d


ofloxacin 0.3% solution (Ocuflox)

Ocular burning and stinging, itching, redness, edema, blurred vision, photophobia


Rare reports of dizziness and nausea with use

Dosing: 1-2 drops in the affected eye every 2-4 h for 2 d and then 1-2 drops four times a day


azithromycin 1% solution (AzaSite)

Eye irritation, dry eye, ocular discharge


Refrigerate bottle; once opened, discard after 14 d.

Dosing: 1 drop in affected eye(s) twice daily for 2 d and then 1 drop once daily for 5 d


Combination Products


polymyxin B sulfate, bacitracin ointment

Local irritation (burning, stinging, itching, redness), lid edema, tearing, rash


Ointments may blur vision and retard corneal wound healing.

Dosing: apply every 3-4 h for 7-10 d, depending upon the severity of infection.


polymyxin B sulfate, trimethoprim sulfate solution (Polytrim)

Local irritation (burning, stinging, itching, redness), lid edema, tearing, rash

Dosing: 1 drop in the affected eye(s) every 3 h (maximum six doses a day) for 7-10 d


polymyxin B sulfate, gramicidin, neomycin solution (Neosporin)

Itching, swelling, conjunctival erythema, local irritation


Dosage of the solution may be increased to as much as 2 drops every hour for severe infections.

Dosing: 1-2 drops into the affected eye(s) every 4 h for 7-10 d


polymyxin B sulfate, bacitracin zinc, and neomycin ointment

Itching, swelling, conjunctival erythema, local irritation


Acute infections may require dosing every 30 min.


Ointments may blur vision and retard corneal wound healing.

Dosage: apply every 3-4 h for 7-10 d, depending upon the severity of infection.










TABLE 17.2 Recommended Order of Treatment for Blepharitis





























Order

Agent

Comments


First line

Erythromycin 0.5% ophthalmic ointment

Ointments tend to cause a greater degree of blurry vision than solutions.

or

Bacitracin 500 units/g ointment

Erythromycin and bacitracin are available as inexpensive generic products.

or

An ophthalmic fluoroquinolone solution (besifloxacin, gatifloxacin, levofloxacin, or moxifloxacin)

The remaining ophthalmic fluoroquinolones do not provide good staphylococcal coverage.


Second line

Referral to an ophthalmologist



Selecting the Most Appropriate Agent

Topical antimicrobials that are effective against staphylococci are listed in Table 17.2.


First-Line Therapy

Topical antibiotics such as bacitracin ointment or erythromycin 0.5% ophthalmic ointment are used first line for staphylococcal blepharitis and should be applied to the eyelid margins one or more times daily or at bedtime for a few weeks. Therapy selection is based on allergies and patient preference for ointment or solution (drops). Ointments tend to cause a greater degree of blurry vision than the solutions; if a patient prefers a solution, a fluoroquinolone (besifloxacin, gatifloxacin, levofloxacin, or moxifloxacin) would be suitable. The AAO (2013a) recommends that the frequency and duration of treatment should be guided by the severity of the condition and the response to treatment.


Second-Line Therapy

If the blepharitis fails to respond to the first-line therapy after several weeks or the condition appears to worsen at any time (including any vision loss or corneal involvement), the patient should be referred to an ophthalmologist for a complete evaluation.


PATIENT EDUCATION

Patients should be educated about the chronic nature of blepharitis. While chronic blepharitis is rarely cured, improved eyelid hygiene, warm massages, and occasional antibiotic use (for staphylococcal blepharitis) can improve symptoms. Counsel contact lens wearers to refrain from wearing contact lenses during an acute case of blepharitis, especially if antibiotic therapy has been initiated. Contact lens wearers with chronic blepharitis should consult with their eye care professional to determine whether contact lens use is safe.


EXTERNAL SURFACE OCULAR INFECTIONS: CONJUNCTIVITIS

Conjunctivitis is the most common cause of a red, painful eye in the United States (Horton, 2015). Conjunctivitis is an inflammation of the bulbar conjunctiva (the clear membrane that covers the white part of the eye) or the palpebral conjunctiva (the lining of the inner surfaces of the eyelids). Conjunctivitis is commonly referred to as pink eye.


CAUSES

The most common organisms seen in acute bacterial conjunctivitis are the gram-positive Staphylococcus and Streptococcus species and the gram-negative Moraxella and Haemophilus species; less common organisms include Neisseria gonorrhoeae and Chlamydia trachomatis (CDC, 2014). In children, up to 50% of conjunctivitis cases are of bacterial origin. The most common pathogens in neonates are N. gonorrhoeae and C. trachomatis, while S. aureus, Haemophilus influenzae, Streptococcus pneumoniae, and Pseudomonas aeruginosa are the most commonly isolated organisms in children with bacterial conjunctivitis (Sethuraman & Kamat, 2009).

Viruses account for the majority of conjunctivitis cases in adults. The most common viral etiology is adenovirus infection (Horton, 2015); conjunctivitis due to an adenovirus is highly contagious. Other viruses associated with conjunctivitis include the herpes simplex virus, the varicella-zoster virus, and molluscum contagiosum (AAO, 2013b).

Allergic conjunctivitis is fairly common and is frequently mistaken for bacterial conjunctivitis. There are three common types of allergic conjunctivitis: seasonal (hay fever) conjunctivitis, due to seasonal release of plant allergens; vernal conjunctivitis, which is of unknown origin but is thought to be due to seasonal airborne antigens; and atopic conjunctivitis, which occurs in people with atopic dermatitis or asthma.

Conjunctivitis can also be caused by mechanical or chemical irritants. A foreign body on the eye (typically a contact lens) can lead to giant papillary conjunctivitis.



PATHOPHYSIOLOGY

General mechanisms of infection are at work in bacterial and viral conjunctivitis. In bacterial conjunctivitis, the infecting organism is obtained via contact with an infected individual and transmitted to the eye by fingertips. Neonates with conjunctivitis may have become inoculated during childbirth by their infected mother. Transmission of viral conjunctivitis is usually through direct contact with infected persons, contact with contaminated surfaces, or contaminated swimming pool water (Cronau et al., 2010; Wong & Anninger, 2014). In both bacterial and viral conjunctivitis, the infectious agent causes the inflammation of the conjunctiva. Mechanical and chemical irritants that cause conjunctivitis operate in the same manner.


In allergic conjunctivitis, symptoms are caused by the immunoglobulin (Ig)E-mediated release of mast cells in the conjunctiva (Kari & Saari, 2012).


DIAGNOSTIC CRITERIA

In addition to the hallmark red or pink eye, classic patient complaints that occur in conjunctivitis include itching or burning sensations of the eyes, ocular discharge (“leaky eye”), eyelids that are stuck together in the morning, and a sensation that a foreign body is lodged in the eye. Patients may also report a feeling of fullness around the eye. Moderate to severe pain and light sensitivity are not typical features of a primary conjunctival inflammatory process (Azari & Barney, 2013). If these symptoms are present, or if the patient reports blurred vision that does not improve with blinking, the patient should be referred to an eye care professional, as a more serious ocular disease process (such as a corneal abrasion or keratoconjunctivitis) may be occurring. Neonates with signs of conjunctivitis should be referred to an eye care professional for immediate examination, as bacterial conjunctivitis due to C. trachomatis or N. gonorrhoeae can lead to serious eye damage.

Although many symptoms of conjunctivitis are nonspecific (tearing, irritation, stinging, burning, and conjunctival swelling), inspection and patient history can help determine the cause of illness. Patients who report that their eyelids were stuck together upon awakening most likely have bacterial conjunctivitis (Deibel et al., 2013); this sticking is caused by a purulent ocular discharge. Because gonococcal conjunctivitis produces a copiously purulent discharge, the cause of any copiously purulent conjunctivitis should be suspected as N. gonorrhoeae until Gram-stain testing proves otherwise. Bacterial conjunctivitis usually starts in one eye and can become bilateral a few days later.

Viral conjunctivitis produces a profuse watery discharge. Similar to bacterial conjunctivitis, viral conjunctivitis usually starts in one eye and can become bilateral within a few days. While unlikely, photophobia and a foreign body sensation may be reported. Examination may reveal a tender preauricular node. A rapid, in-office immunodiagnostic test with high sensitivity and specificity for adenovirus is available (Sambursky et al., 2013).

In allergic conjunctivitis, itching is the hallmark symptom; it can be mild to severe and may manifest as excessive blinking. A history of recurrent itching or a personal or family history of hay fever, asthma, atopic dermatitis, or allergic rhinitis is suggestive of allergic conjunctivitis. In general, a patient with conjunctivitis who does not report an itchy eye does not have allergic conjunctivitis. Unlike bacterial or viral conjunctivitis, allergic conjunctivitis usually presents with bilateral symptoms. An ocular discharge may or may not be present; if present, it may be watery or mucoid. Aggressive forms of allergic conjunctivitis are vernal conjunctivitis in children and atopic conjunctivitis in adults. Atopic and vernal conjunctivitis are associated with shield corneal ulcers and perilimbal accumulation of eosinophils (Horner-Trantas dots) (Nijm et al., 2011). Atopic conjunctivitis is associated with eyelid thickening, conjunctival scarring, blepharitis, and corneal scarring (AAO, 2013b).

Giant papillary conjunctivitis occurs mainly in contact lens wearers. These patients report excessive itching, mucus production and discharge, and increasing intolerance to contact lens use. Upon examination, the upper tarsal conjunctiva may show inflammation and papillae greater than 0.3 mm (Donshik et al., 2008). Ptosis may occur in severe cases (AAO, 2013b).


INITIATING DRUG THERAPY

Before drug therapy is prescribed, both the patient and the practitioner should be aware that bacterial and viral conjunctivitis are highly contagious and are spread by contact. Therefore, good hand-washing and instrument-cleansing techniques are imperative. The etiology of illness should be determined, as treatment is different for bacterial, viral, and allergic conjunctivitis.


Goals of Drug Therapy

The goals of drug therapy are to eradicate the offending organism (for bacterial conjunctivitis), to relieve symptoms and to quicken the resolution of the disease. A patient with bacterial conjunctivitis should experience improvement in symptoms a few days after the start of antibiotic therapy; the organisms remain active (and contagious) for 24 to 48 hours after therapy begins. With viral conjunctivitis, the disease is contagious for at least 7 days after symptoms appear; it may be contagious for up to 14 days.


Antibiotics

Although bacterial conjunctivitis caused by typical pathogens (Staphylococcus, Streptococcus, Pneumococcus, Moraxella, and Haemophilus species) is usually self-limiting, antibiotic therapy is justified because it can shorten the course of the disease, which reduces person-to-person spread, and lowers the risk of sight-threatening complications. The choice of antibiotic is usually empirical. Five to seven days of therapy with agents such as erythromycin ointment or bacitracin-polymyxin B ointment or solution is usually effective. While well tolerated, sulfacetamide has weak to moderate activity against many organisms. The aminoglycosides have good gram-negative coverage but incomplete coverage of Streptococcus and Staphylococcus species and a relatively high incidence of corneal toxicity. The fluoroquinolones also have good gram-negative coverage; the older fluoroquinolones (ciprofloxacin, norfloxacin, and ofloxacin) have poor coverage of Streptococcus species, while the newer fluoroquinolones (besifloxacin, gatifloxacin, levofloxacin, and moxifloxacin) offer improved gram-positive coverage.

Because gonococcal infection is serious, immediate treatment of conjunctivitis due to N. gonorrhoeae with a 250-mg intramuscular (IM) injection of ceftriaxone (Rocephin) plus a single 1-g dose of oral azithromycin is recommended for adults
and children who weigh at least 45 kg. Children who weigh less than 45 kg should receive a single 125-mg IM injection of ceftriaxone, while 25 to 50 mg/kg of ceftriaxone intravenous or IM (not to exceed 125 mg) is the appropriate dose for neonates. Cephalosporin-allergic patients should be referred to an infectious disease specialist. Topical antibiotic therapy is not necessary but is often initiated to prevent secondary infection (AAO, 2013b).

As C. trachomatis is now the most common cause of conjunctivitis in neonates in the United States, the long-time standard prophylactic agent for neonates, topical 1% silver nitrate solution, is no longer recommended or commercially available in the United States. Topical treatment of neonatal chlamydial conjunctivitis is ineffective and unnecessary (American Academy of Pediatrics, 2012). In adults and children at least 8 years old, C. trachomatis infection is treated with a single 1-g dose of azithromycin or 7 days of therapy with doxycycline 100 mg twice daily. Children who weigh at least 45 kg but are less than 8 years old should receive the single dose of azithromycin 1 g. Neonates and children who weigh less than 45 kg should receive 50 mg/kg/d of erythromycin base or erythromycin ethylsuccinate, divided into four doses a day for 14 days (AAO, 2013b). Identification of either Chlamydia or N. gonorrhoeae conjunctivitis requires that the patient’s sexual partner also be treated.


Antihistamines

The ophthalmic antihistamines alcaftadine and emedastine prevent the histamine response in blood vessels by preventing histamine from binding with its receptor site and are useful in reducing the symptoms of allergic conjunctivitis. Ocular adverse events with these agents include transient stinging or burning upon instillation, dry eyes, red eyes, and blurred vision. Oral antihistamines can also help to relieve symptoms in many patients (see Table 17.3).


Mast Cell Stabilizers

The mast cell stabilizers (bepotastine, cromolyn, lodoxamide, and nedocromil) inhibit hypersensitivity reactions and prevent the increase in cutaneous vascular permeability that accompanies allergic reactions. These agents may be helpful for patients with allergic conjunctivitis. Ocular adverse events include transient burning, stinging or discomfort, pruritus, blurred vision, dry eyes, taste alteration, and foreign body sensation (see Table 17.3).









TABLE 17.3 Overview of Antiallergy Ophthalmic Agents



































































































































































Generic (Trade) Name and Dosage

Selected Adverse Events

Contraindications

Special Considerations


Antihistamines


alcaftadine 0.25% solution (Lastacaft)

Eye irritation, burning and stinging, itching


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing: 1 drop in the affected eye once daily


emedastine 0.05% solution (Emadine)

Blurred vision, burning and stinging, dry eyes, foreign body sensation, hyperemia, itching


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing: 1 drop in the affected eye up to four times a day


Mast Cell Stabilizers


bepotastine 1.5% solution (Bepreve)

Mild taste following instillation, eye irritation


Labeling: refrain from contact lens use while exhibiting signs and symptoms of allergic conjunctivitis.


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing: 1 drop into the affected eye(s) twice daily


cromolyn 4% solution (Crolom)

Burning and stinging, conjunctival injection, watery eyes, itching, dry eye, styes


Labeling: refrain from contact lens use while under treatment.

Dosing: 1-2 drops in each eye four to six times a day at regular intervals


lodoxamide 0.1% solution (Alomide)

Burning and stinging, ocular itching, blurred vision, dry eye, tearing, hyperemia, foreign body sensation


Labeling: refrain from contact lens use while under treatment.

Dosing: 1-2 drops in each eye four times a day


nedocromil 2% solution (Alocril)

Ocular burning and stinging, unpleasant taste, redness, photophobia


Labeling: refrain from contact lens use while exhibiting the signs and symptoms of allergic conjunctivitis.

Dosing: 1-2 drops in each eye twice a day


Antihistamine/Mast Cell Stabilizer


azelastine 0.05% solution (Optivar)

Ocular burning and stinging, headache, bitter taste, eye pain, blurred vision


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing: 1 drop into each affected eye twice daily


epinastine 0.05% solution (Elestat)

Burning sensation, folliculosis (hair follicle inflammation), hyperemia, itching


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing: 1 drop in each eye twice a day


ketotifen 0.025% solution (Alaway, Zaditor, Thera Tears Allergy)

Conjunctival injection, burning and stinging, conjunctivitis, dry eye, itching, photophobia


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing: 1 drop in the affected eye(s) every 8-12 h, no more than twice daily


olopatadine 0.1% (Patanol), 0.2% (Pataday), or 0.7% (Pazeo) solution

Ocular burning and stinging, dry eye, headache, foreign body sensation, hyperemia, lid edema, itching


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing


0.1%: 1-2 drops in each affected eye twice daily


0.2%, 0.7%: 1 drop in the affected eye(s) once daily


Nonsteroidal Anti-inflammatory Drugs


ketorolac 0.5% solution (Acular)

Stinging and burning, corneal edema, iritis, ocular irritation or inflammation


Use with caution in patients with aspirin sensitivities and patients with bleeding disorders or those receiving anticoagulant therapy.


Labeling: do not administer while wearing contact lenses.

Dosing: 1 drop four times a day


Vasoconstrictors (Decongestants)


naphazoline 0.012% or 0.03% solutions (Clear Eyes), 0.02% solution (VasoClear), and 0.1% solution (AK-Con)

Stinging, blurred vision, mydriasis, redness, punctate keratitis, increased IOP

Narrow-angle glaucoma


Narrow-angle without glaucoma

Use should be limited to 72 h.


Contains benzalkonium chloride; use with contact lenses not addressed in labeling

Dosing: 1-2 drops in the affected eye(s) every 3-4 h, up to four times a day


oxymetazoline 0.025% solution (Visine L.R.)

Stinging, blurred vision, mydriasis, redness, punctate keratitis, increased IOP

Narrow-angle glaucoma


Narrow-angle without glaucoma

Use should be limited to 72 h.


Contains benzalkonium chloride; use with contact lenses not addressed in labeling

Dosing: 1-2 drops in the affected eye(s) every 6 h


tetrahydrozoline 0.05% solution (Visine, Murine for Red Eyes, Clear Eyes Triple Action)

Stinging, blurred vision, mydriasis, redness, punctate keratitis, increased IOP

Narrow-angle glaucoma


Narrow-angle without glaucoma

Use should be limited to 72 h.


Contains benzalkonium chloride; use with contact lenses not addressed in labeling

Dosing: 1-2 drops up to four times a day


Topical Corticosteroids


dexamethasone 0.1% solution (AK-Dex, Decadron) or 0.1% suspension (Maxidex)

IOP elevation, loss of visual acuity, cataract formation, secondary ocular infection, globe perforation, stinging and burning

Dendritic keratitis


Fungal disease


Viral disease of the cornea and conjunctiva


Mycobacterial eye infection

Labeling: wait 15 min following administration before inserting contact lenses.

Dosing


Solution: 1-2 drops every hour during the day and every 2 h at night initially, reduced to 1 drop every 4 h with favorable response


Suspension: 1-2 drops less than four to six times a day in mild disease; hourly in severe disease


fluorometholone 0.1% ointment or suspension (FML, Flarex) or 0.25% suspension (FML Forte)

IOP elevation, glaucoma, posterior subcapsular cataract formation, delayed wound healing

Dendritic keratitis


Vaccinia and varicella


Fungal disease


Viral disease of the cornea and conjunctiva


Mycobacterial eye infection

Dosing


Ointment: ½ inch ribbon one to three times daily; during initial 24-48 h, dosing may be increased to every 4 h.


Suspension: 1 drop two to four times daily; during initial 24-48 h, dosing may be increased to every 4 h.


loteprednol 0.2% or 0.5% suspension (Alrex, Lotemax)

IOP elevation, loss of visual acuity, cataract formation, secondary ocular infection, globe perforation, stinging and burning, dry eye, itching, photophobia

Dendritic keratitis


Fungal disease


Viral disease of the cornea and conjunctiva


Mycobacterial eye infection

If needed, dosing of the 0.5% solution can be increased to 1 drop every hour during the first week of therapy.


Labeling: wait 10 min following administration before inserting contact lenses.

Dosing


0.2% solution: 1 drop in the affected eye(s) four times a day


0.5% solution: 1-2 drops in the affected eye(s) four times a day


prednisolone 0.12% or 1% suspension (Pred Mild, Omnipred, Pred Forte) or 1% solution

IOP elevation, cataract formation, delayed wound healing, secondary ocular infection, acute uveitis, globe perforation, stinging and burning, conjunctivitis

Dendritic keratitis


Fungal disease


Viral disease of the cornea and conjunctiva


Mycobacterial eye infection


Acute, purulent, untreated eye infections

Labeling: wait 15 min following administration before inserting contact lenses.

Dosing


Solution: 2 drops four times a day


Suspension: 1-2 drops two to four times a day; dose may be increased during the initial 24-48 h

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Nov 11, 2018 | Posted by in PHARMACY | Comments Off on Ophthalmic Disorders

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