effects side ocular induced-Drug  • PART7  

Generic names: 1. Gatifloxacin; 2. levofloxacin; 3. moxifloxacin; 4. norfloxacin; 5. ofloxacin.

Proprietary names: 1. Tequin, Zymar; 2. Iquix, Levaquin, Quixin; 3. Avelox, Vigamox 4. Noroxin; 5. Floxin, Ocuflox.

Primary use

These quinolone antibacterial agents are used primarily against most Gram-negative aerobic and many Gram-positive aerobic bacteria.

Ocular side effects

Systemic administration

Probable

1. Eyelids

a.Hyperpigmentation

b.Angioedema

c.Urticaria

2. Conjunctiva

a.Hyperemia

b.Hypersensitivity 3. Visual sensations

a.Blurred vision

b.Glare phenomenon (norfloxacin)

c.Lacrimation

4. Photosensitivity (ofloxacin)

5. Ocular pain

Possible

1. Visual hallucinations (ofloxacin)

2. Nystagmus (ofloxacin)

3. Papilledema secondary to intracranial hypertension

4. Eyelids or conjunctiva

a.Erythema multiforme

b.Erythema nodosum

c.Exfoliative dermatitis

d.Lyell’s syndrome

e.Stevens-Johnson syndrome

Conditional/Unclassified

1. Toxic optic neuropathy (moxifloxacin)

2. Uveitis (moxifloxacin)

Local ophthalmic use or exposure – topical application

Certain

1. Irritation

a.Pain

b.Burning sensation

c.Lacrimation

d.Foreign body sensation 2. Eyelids

a.Edema

b.Allergic reactions

c.Itching 3. Cornea

a.Precipitates – white (rare)

b.Keratitis

c.Infiltrates

d.Superficial punctate keratitis 4. Conjunctiva

a.Hyperemia

b.Chemosis

c.Papillary conjunctivitis

5. Decreased vision

6. Photophobia

7. Miosis (moxifloxacin)

Systemic reactions from topical ocular medication

Certain

1. Dermatitis

2. Nausea

Possible

1. Pediatric warning: arthropathy (theoretically under age 12)

Clinical significance

There are surprisingly few and seldom severe adverse systemic effects from these quinolones. While hypersensitivity reactions occur, they are uncommon. Photosensitivity may occur rarely, but appears to be seen most frequently with ofloxacin. Visual sensations are more common with ciprofloxacin and occasionally with norfloxacin. Rare reports of uveitis (Bringas-Clavo and Iglesias-Cortinas 2004; Cano-Parra and Diaz-Llopis 2005) or drug-related optic neuropathy (Gallelli et al 2004) have been reported along with a few cases in the National Registry with moxifloxacin. This data is patchy at best.

Topical ocular quinolones are generally well tolerated. Ocular pain, erythema, pruritis, photophobia and epiphora occur in a small percentage of patients. Seldom is corneal precipitation of these drugs seen as with ciprofloxacin; however, there are reports with ofloxacin (Desai et al 1999; Claerhout et al 2003) and norfloxacin (Castillo et al 1997). Awwad et al (2004) reported corneal intrastromal gatifloxacin crystal deposits after pentrating keratoplasty, with follow-up discussion of pro and cons by ­Wittpenn (2005) and by Cavanaugh (2005). Donnenfeld et al (2004) reported that topical ocular moxifloxacin can cause pupillary miosis, possibly due to prostaglandin release into the anterior chamber. Since moxifloxacin does not contain the preservative benzalkonium chloride, topical ocular toxicity may be less overall. The Medical Letter still does not generally recommend quinolones in the pediatric age group or in pregnancy.

References and Further Reading

Awwad ST, Haddad W, Wang MX, et al. Corneal intrastromal gatifloxacin crystal deposits after penetrating keratoplasty. Eye Contact Lens 30: 169–172, 2004.

Bringas-Calva R, Iglesias-Cortinas D. Acute and bilateral uveitis secondary to moxifloxacin. Arch Soc Esp Oftalmol (Spain) 79: 357–359, 2004.

Burka JM, Bower KS, Vanroekel C, et al. The effect of fourth-generation fluoroquinolones gatifloxacin and moxifloxacin on epithelial healing following photorefractive keratectomy. Am J Ophthalmol 140: 83–87, 2005.

Cano-Parra J, Diaz-Llopis M. Drug induced uveitis. Arch Soc Esp Oftalmol (Spain) 80: 137–149, 2005.

Castillo A, Benitez del Castillo JM, Toledano N, et al. Deposits of topical norfloxacin in the treatment of bacterial keratitis. Cornea 16: 420–423, 1997.

Cavanagh HD. Response: crystallization of gatifloxacin after penetrating keratoplasty. Eye Contact Lens 31: 93, 2005.

Claerhout I, Kestelyn PH, Meire F, et al. Corneal deposits after the topical use of ofloxacin in two children with vernal keratoconjunctivitis. Br J Ophthalmol 87: 646, 2003.

Desai C, Desai KJ, Shah UH. Ofloxacin induced hypersensitivity reaction. J Assoc Physicians India 47: 349, 1999.

Donnenfeld EP, Chruscicki DA, Bitterman A, et al. A comparison of fourthgeneration fluoroquinolones gatifloxacin 0.3% and moxifloxacin 0.5% in terms of ocular tolerability. Curr Med Res Opin 20: 1753–1758, 2004.

Gallelli L, Del Negro S, Naty S, et al. Levofloxacin-induced taste perversion, blurred vision and dyspnoea in a young woman. Clin Drug Invest 24: 487–489, 2004.

Konishi M, Yamada M, Mashima Y. Corneal ulcer associated with deposits of norfloxacin. Am J Ophthalmol 125(2): 258–260, 1998.