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16
OphthalmicDisorders
JoshuaJ.Spooner
LearningObjective
1.Describethepathophysiologyofcommonophthalmicdisordersroutinelypresentinginprimarycare
practice.
2. Evaluatesignsandsymptomsofthesecommonophthalmicdisordersandinterpretthesesignsand
symptomsinordertodiagnosesubtypesofblepharitisandconjunctivitis.
3.Presentnonpharmacologicandfirst-andsecond-linetreatmentoptionsforthesecommonophthalmic
disorders.
4.Discusskeypatientcounselingpointsforophthalmicdisorderandtreatmentoptions.
INTRODUCTION
Therearemanyconditionsanddisordersoftheeye,butonlyafew,suchasblepharitisandconjunctivitis,
shouldbediagnosedandtreatedbyaprimarycareprovider.Theremainingocularconditionsareusually
treated byeyecare specialists. Nonetheless, prescribers should be familiar withdrugtherapyfor the
morecommonophthalmicconditions(glaucoma,dryeyedisease[DED]),astheyarelikelytoencounter
patientsbeingtreatedforthesedisorders.
EYELIDMARGININFECTIONS:BLEPHARITIS
The eye is well protected externally by the eyebrow, eyelashes, and eyelids. If these protective
mechanismsarecompromised,theeyebecomespredisposedtodisease.Externally,theeyelidstructures
arecomposedofskinwithahighdegreeofelasticity,musclesthatelevatetheuppereyelidandclosethe
eyelids,andthetarsalplate,whichcontainsthemeibomianglands.Throughfrequentblinking,theeyelids
maintainanevenflowoftearsoverthecornea.Internally,theeyelid structureislinedbythepalpebral
conjunctiva, whichfolds upon itself and then covers the sclera ofthe 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 are the
superficial modifiedsebaceousglands ofZeisandthesweatglandsofMoll. Anyoftheseglandsmay
becomefunctionallydisrupted.
Blepharitisisaninflammationoftheeyelidmargin.AlthoughitisacommoneyedisorderintheUnited
States,epidemiologicinformationonitsincidenceorprevalenceisnotrobust.
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], 2018a).
Staphylococcal and seborrheic blepharitis primarily involve the anterior eyelid; both have also been
referredtoasanteriorblepharitis.
Pathophysiology
Although the gram-positive organism Staphylococcus aureus and coagulase-negative species such as
Staphylococcusepidermidisarefoundontheeyelidsofahighproportionofhealthysubjects,S.aureusis
observed more frequentlyamongpatientswithstaphylococcal blepharitis. While S.epidermidis andS.
aureusarethoughttoplayaroleinthedevelopmentofstaphylococcalblepharitis,theirroleindisease
production remains unclear. Toxin production, immunologic mechanisms, Demodex folliculorum mite
infestation,andantigen-induced inflammatoryreactionshave all beenreportedwithblepharitis (AAO,
2018a; Fromstein et al., 2018). Isotretinoin use is also associated with an increase in S. aureus
conjunctivalcolonizationandblepharitis.
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.
Seborrheicblepharitisismorecommonlyfoundinthegeriatricpopulationbecauseofitsassociationwith
rosacea.
ManifestationsofMGDblepharitisincludethickeningoftheeyelidmargin,pluggingofthemeibomian
orifices, prominent blood vessels crossing the mucocutaneous junction, and formation of chalazia
(painlessfirmlumpsontheeyelid).Thesechangesmayleadtoatrophyofthemeibomianglands(AAO,
2018a).Comparedtohealthypatients,meibomianglandsecretionsaremoreturbidamongpatientswith
MGDblepharitis.Thesesecretionsblocktheglandorifices andbecomeagrowthmediumforbacteria.
PatientswithMGDblepharitisfrequentlyhavecoexistingrosaceaorseborrheicdermatitis.
DiagnosticCriteria
Therearenospecificdiagnostictestsforblepharitis;thediagnosisisoftenbaseduponpatienthistoryand
characteristicsymptoms.Patientswithblepharitisfrequentlypresentwithirritatedredeyesandreporta
burningsensation.Increases intearing,blinking,andphotophobiaarefrequentlyreported,as are eyelid
stickingandcontactlensintolerance.Symptomsaretypicallyworseinthemorning(worseningsymptoms
later in the day are more indicative of keratoconjunctivitis sicca). Upon close inspection, the eyelid
margins appear red, greasy, and crusted, with eyelid deposits that cling to the eyelashes. The eyelid
marginsmaybeulceratedandthickened,andeyelashesmaybemissing.
Althoughtheclinicalfeaturesofstaphylococcal,seborrheic,andMGDblepharitisaresimilar,thereare
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 foamy in MGD blepharitis. Chalazia are most likely to occur in MGD
blepharitis.
InitiatingDrugTherapy
Theunderlyingcauseoftheblepharitismustbetreated,particularlyifitisduetoseborrheicdermatitisor
rosacea.Treatmentforalltypesofblepharitisincludesstricteyelidhygieneandwarmcompresses.The
use of warm compresses with a clean washcloth can soften adherent encrustations; once-daily use of
compresses is generally sufficient (AAO, 2018a). Patients with MGD blepharitis often benefit from
eyelid massage following warm compress use to remove excess oil. Following warm compress use,
eyelid cleaningis performed byhaving the patient rubthebase ofthe eyelashes withacommercially
availableeyelidcleaner(EyeScrub,OCuSOFT)oradilutedmixtureofbabyshampoo(e.g.,Johnson&
Johnson) and water on a cotton swab, cotton ball, or gauze pad. Performing eyelid hygiene daily or
severaltimesaweekoftenbluntsthesymptomsofchronicblepharitis (Duncan&Jeng,2017). Patients
shouldbeadvisedthatwarmcompressesandeyelidcleansingmayberequiredforlifebecausesymptoms
frequentlyrecurifeyelidhygieneisdiscontinued.
PatientssuspectedofhavinganewcaseofseborrheicorMGDblepharitisshouldbereferredtoaneye
carespecialistforaworkup.Patientswithstaphylococcalblepharitisneedatopicalantibiotic.
GoalsofDrugTherapy
Thegoals ofdrugtherapyaretoeradicatethepathogenscausingthe staphylococcal blepharitis andto
reducethesignsandsymptomsofblepharitis.
TopicalOphthalmicAntimicrobials
Topicalophthalmicantimicrobialsareusedforthetreatmentofandprophylaxisagainstexternalbacterial
infections(Table16.1).Theykilltheoffendingpathogenandothersusceptibleorganisms.
SelectingtheMostAppropriateAgent
TopicalantimicrobialsthatareeffectiveagainststaphylococciarelistedinTable16.2.
First-LineTherapy
Topicalantibioticssuchasbacitracinointmentorerythromy-cin0.5%ophthalmicointmentareusedfirst
lineforstaphylo-coccalblepharitisandshouldbeappliedtotheeyelidmarginsoneormoretimesdaily
oratbedtimeforafewweeks.Therapyselectionisbasedonallergiesandpatientpreferenceforointment
or solution (drops). Ointmentstend to cause a greater degree of blurry vision thanthe solutions; if a
patientprefersasolution,azithromycinorafluoroquinolone(besifloxacin,gatifloxacin,levofloxacin,or
moxifloxacin) would be suitable. The AAO (2018a) recommends that the frequency and duration of
treatmentshouldbeguidedbytheseverityoftheconditionandtheresponsetotreatment.
Second-LineTherapy
Iftheblepharitisfailstorespondtothefirst-linetherapyafterseveralweeksortheconditionappearsto
worsenatanytime(includinganyvisionlossorcornealinvolvement),thepatientshouldbereferredtoan
ophthalmologistforacompleteevaluation.
TABLE16.1
OverviewofAntimicrobialOphthalmicAgents
Generic(Trade)NameandDosage SelectedAdverseEvents Contraindications Special
Considerations
Single-AgentProducts
Sulfacetamidesodium10%solution
(Bleph-10)Dosing
Solution:1-2dropsq2-3hinitially
accordingtotheseverityofinfection
Dosingmaybetaperedasthecondition
responds.Usualdurationoftherapyis710d.
Localirritation,itching,
stinging,burning,periorbital
edema
Allergytosulfa
drugsDonotuse
ininfantslessthan
age2mo.
Asignificant
percentageof
Staphylococcus
speciesare
completelyresistant
tosulfadrugs.
Bacitracin500units/gointmentDosing:
applyBIDandHS
Blurredvision,redness,
burning,eyelidedema
Ointmentsmayblur
visionandretard
cornealwound
healing.
Erythromycin0.5%ointmentDosing:
applyupto1cmtothe
affectedeye(s)uptosixtimes
daily
Redness,ocularirritation Ointmentsmayblur
visionandretard
cornealwound
healing.
Gentamicinsulfate0.3%solutionor
ointment(Gentak)Dosing
Solution:1-2dropsintheaffected
eye(s)q4hOintment:0.5inchtothe
affected
eye(s)BIDorTID
Ocularburningandirritation,
nonspecificconjunctivitis,
conjunctivalepithelialdefects,
conjunctivalhyperemia,
bacterialandfungalcorneal
ulcers
Insevereinfections,
dosageofthe
solutionmaybe
increasedtoas
muchas2drops
everyhour.
Ointmentsmayblur
visionandretard
cornealwound
healing.
Tobramycin0.3%solutionor
ointment(Tobrex)Dosing
Solution:1-2dropsintothe
infectedeyeq4hOintment:0.5inchBID
orTID
Liditching,lidswelling,
conjunc-tivalhyperemia,
nonspecificconjunctivitis,
bacterialandfungalcorneal
ulcers
Ointmentsmayblur
visionandretard
cornealwound
healing.
Formoresevere
infections,theinitial
dosemaybe
increasedto2drops
q60min(solution)or
0.5inchq3–4h
(ointment).
Besifloxacin0.6%suspension
(Besivance)Dosing:1dropinthe
affected
eye(s)TIDfor7d
Conjunctivalredness,blurred
vision,eyeirritation,eyepain,
pruritus
Ciprofloxacin0.3%solutionor
ointment(Ciloxan)Dosing
Solution:1-2dropsq2hwhileawakefor
2dandthen1-2dropsq4hwhileawake
for5d
Ointment:0.5inchTIDfor2dand
then0.5inchBIDfor5d
Localburninganddiscomfort,
whitecrystallineprecipitate
formation,conjunctival
hyperemia,alteredtaste
Ointmentsmayblur
visionandretard
cornealwound
healing.
Thisistheonly
ophthalmic
fluoroquinolone
availableasan
ointment.
Gatifloxacin0.3%solution(Zymaxid)
Dosing:1dropintheaffectedeye(s)
q2hwhileawakefor1d(upto8times
daily)andthen1dropintheaffected
eye(s)uptoQIDwhileawakefor6d
Conjunctivalirritation,tearing,
papillaryconjunctivitis,eyelid
edema,ocularitching,dryeye
Levofloxacin0.5%solution(Quixin)
Dosing:1dropintheaffectedeye(s)
q2hwhileawakefor2d(upto8times
daily)andthen1dropintheaffected
eye(s)uptoQIDwhileawakefor5d
Temporarilydecreasedor
blurredvision,eyeirritation,
itching,dryeye
Moxifloxacin0.5%solution
(Moxeza,Vigamox)Dosing:
Moxeza:1dropintheaffected
eye(s)BIDfor7d
Vigamox:1dropintheaffected
eye(s)TIDfor7d
Decreasedvisualacuity,dry
eye,ocularitchingand
discomfort,ocularhyperemia
Ofloxacin0.3%solution(Ocuflox)
Dosing:1-2dropsintheaffectedeye(s)
q2-4hfor2dandthen
1-2dropsQIDfor5d
Ocularburningandstinging,
itching,redness,edema,
blurredvision,photophobia
Rarereportsof
dizzinessand
nauseawithuse
Azithromycin1%solution(AzaSite,
Klarity-A)
Dosing:1dropinaffectedeye(s)BID
for2dandthen1droponcedailyfor5
d
Eyeirritation,dryeye,ocular
discharge
Refrigeratebottle;
onceopened,
discardafter14d.
CombinationProducts
PolymyxinBsulfate,bacitracinointment
(AK-Poly-Bac)
Dosing:applyq3-4hfor7-10d,
dependingupontheseverityofinfection.
Localirritation(burning,
stinging,itching,redness),lid
edema,tearing,rash
Ointmentsmayblur
visionandretard
cornealwound
healing.
PolymyxinBsulfate,trimethoprim
sulfatesolution(Polytrim)
Localirritation(burning,
stinging,itching,redness),lid
Dosing:1dropintheaffectedeye(s)
q3h(maximumsixdosesdaily)for7-10
d
edema,tearing,rash
PolymyxinBsulfate,gramicidin,
neomycinsolution(Neosporin)
Dosing:1-2dropsintotheaffected
eye(s)q4hfor7-10d
Itching,swelling,conjunctival
erythema,localirritation
Dosageofthe
solutionmaybe
increasedtoas
muchas2drops
everyhourfor
severeinfections.
PolymyxinBsulfate,bacitracin
zinc,andneomycinointment
(Neo-Polycin)Dosage:applyq3-4hfor
7-10d,
dependingupontheseverityof
infection.
Itching,swelling,conjunctival
erythema,localirritation
Ointmentsmayblur
visionandretard
cornealwound
healing.
PatientEducation
Patientsshouldbeeducatedaboutthechronicnatureofblepharitis. While chronicblepharitis israrely
cured, improved eyelid hygiene, warm massages, and occasional antibiotic use (for staphylococcal
blepharitis)canimprovesymptoms.Counselcontactlenswearerstorefrainfromwearingcontactlenses
during an acute case of blepharitis, especially if antibiotic therapy has been initiated. Contact lens
wearers withchronicblepharitisshould consultwith their eye care professional todetermine whether
contactlensuseissafe.
TABLE16.2
RecommendedOrderofTreatmentforBlepharitis
Order Agent Comments
First
line
Erythromycin0.5%ophthalmicointment
or
Bacitracin500units/gointment
or
Azithromycin1%solutionor
Anophthalmicfluoroquinolonesolution
(besifloxacin,gatifloxacin,levofloxacin,or
moxifloxacin)
Ointmentstendtocauseagreaterdegreeofblurryvisionthan
solutions.
Erythromycinandbacitracinareavailableasinexpensive
genericproducts.
Theremainingophthalmicfluoroquinolonesdonotprovide
goodstaphylococcalcoverage.SecondlineReferraltoan
ophthalmologist
Second
line
Referraltoanophthalmologist
EXTERNALSURFACEOCULARINFECTIONS:CONJUNCTIVITIS
Conjunctivitis is the most common cause of a painful red eye in the United States (Horton, 2015).
Conjunctivitisisaninflammationofthebulbarconjunctiva(theclearmembranethatcoversthewhitepart
oftheeye)orthepalpebralconjunctiva(theliningoftheinnersurfacesoftheeyelids).Conjunctivitisis
commonlyreferredtoaspinkeye.
Causes
Themostcommonorganismsseeninacutebacterialconjunctivitisarethegram-positiveStaphylococcus
andStreptococcus species and the gram-negative Moraxella and Haemophilus species; less common
organismsincludeNeisseriagonorrhoeaeandChlamydiatrachomatis(CentersforDiseaseControland
Prevention[CDC],2020).Inchildren,upto50%ofconjunctivitiscasesareofbacterialorigin.Themost
commonpathogensinneonatesareN.gonorrhoeaeandC.trachomatis,while S.aureus,Haemophilus
influenzae,Streptococcuspneumoniae, andPseudomonasaeruginosaarethemostcommonlyisolated
organismsinchildrenwithbacterialconjunctivitis,withH.influenzaemostfrequentlyfoundinchildren
below7yearsofageandS.aureusmostfrequentlyfoundinchildren7yearsofageandolder(Chenet
al.,2018;Sethuraman&Kamat,2009).
Virusesaccountforthemajorityofconjunctivitiscases inadults.Themostcommonviraletiologyis
adenovirus infection (Horton, 2015); conjunctivitis due to an adenovirus is highly contagious. Other
viruses associated withconjunctivitis include the herpes simplexvirus, the varicella-zoster virus, and
molluscumcontagiosum(AAO,2018b).
Allergicconjunctivitisisfairlycommonandisfrequentlymistakenforbacterialconjunctivitis.There
are threecommontypes ofallergic conjunctivitis:seasonal/perennial(hay fever) conjunctivitis, dueto
seasonalreleaseofplantallergens,outdoorairpollution,andexposuretopetsandfarmanimals;vernal
conjunctivitis,whichisofunknownoriginbutisthoughttobeduetohot,dryenvironmentsandairborne
environmental 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
(typicallyacontactlens)canleadtogiantpapillaryconjunctivitis.
Pathophysiology
General mechanisms of infection are at work in bacterial and viral conjunctivitis. In bacterial
conjunctivitis,theinfectingorganismisobtainedviacontactwithaninfectedindividualandtransmittedto
theeyebyfingertips.Neonateswithconjunctivitismayhavebecomeinoculatedduringchildbirthbytheir
infected mother. Transmission of viral conjunctivitis is usually through direct contact with infected
persons,contaminatedsurfaces,orcontaminatedswimmingpoolwater(Fredrick,2018).Inbothbacterial
andviralconjunctivitis,theinfectiousagentcausestheinflammationoftheconjunctiva.Mechanicaland
chemicalirritantsthatcauseconjunctivitisoperateinthesamemanner.
Inallergicconjunctivitis,symptomsarecausedbytheimmunoglobulin(Ig)E-mediatedreleaseofmast
cellsintheconjunctiva(Leonardietal.,2017).
DiagnosticCriteria
Inadditiontothehallmarkredorpinkeye,classicpatientcomplaintsthatoccurinconjunctivitisinclude
itchingorburningsensationsoftheeyes,oculardischarge(“leakyeye”),eyelidsthatarestucktogetherin
themorning,andasensationthataforeignbodyislodgedintheeye.Patientsmayalsoreportafeelingof
fullnessaroundtheeye.Moderatetoseverepainandlightsensitivityarenottypicalfeaturesofaprimary
conjunctivalinflammatoryprocess(Azari&Barney,2013;Narayana&McGee,2015).Ifthesesymptoms
arepresent,orifthepatientreportsblurredvisionthatdoesnotimprovewithblinking,thepatientshould
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.
trachomatisorN.gonorrhoeaecanleadtoseriouseyedamage.
Althoughmany symptoms of conjunctivitis are nonspecific (tearing, irritation, stinging, burning,and
conjunctival swelling), inspection andpatienthistorycanhelp determine the cause of illness. Patients
whoreportthattheireyelidswerestucktogetheruponawakeningmostlikelyhavebacterialconjunctivitis
(Garcia-Ferreretal.,2018);thisstickingiscausedbyapurulentoculardischarge.Becausegonococcal
conjunctivitisproducesacopiouslypurulentdischarge,thecauseofanycopiouslypurulentconjunctivitis
shouldbesuspectedasN.gonorrhoeaeuntilGramstaintestingprovesotherwise.
Bacterialconjunctivitisusuallystartsinoneeyeandcanbecomebilateralafewdayslater.
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,
photophobiaandaforeignbodysensationmaybereported.Examinationmayrevealatenderpreauricular
node.Arapid,in-officeimmunodiagnostictestwithhighspecificityforadenovirusisavailable(Holtzet
al.,2017;Kametal.,2015).
Inallergicconjunctivitis,itchingisthehallmarksymptom;itcanbemildtosevereandmaymanifestas
excessive blinking.A historyof recurrentitchingora personal or familyhistoryofhayfever,asthma,
atopic dermatitis, or allergic rhinitis is suggestive of allergicconjunctivitis. In general, a patientwith
conjunctivitiswhodoesnotreportanitchyeyedoesnothaveallergicconjunctivitis.Unlikebacterialor
viralconjunctivitis,allergicconjunctivitisusuallypresentswithbilateralsymptoms.Anoculardischarge
may or may not be present; if present, it may be watery or mucoid. Aggressive forms of allergic
conjunctivitisarevernalconjunctivitisinchildrenandatopicconjunctivitisinadults.Atopicandvernal
conjunctivitis are associated with shield corneal ulcers and perilimbal accumulation of eosinophils
(Garcia-Ferrer et al., 2018). Atopic conjunctivitis is associated with eyelid thickening, conjunctival
scarring,blepharitis,andcornealscarring(AAO,2018b).
Giantpapillaryconjunctivitisoccursmainlyincontactlenswearers. Thesepatientsreportexcessive
itching, mucus production and discharge, and increasing intolerance to contact lens use–symptoms
resemble those of vernal conjunctivitis. Upon examination, the upper tarsal conjunctiva may show
inflammationandpapillaegreaterthan1mm(Ackermanetal.,2016).Ptosismayoccurinseverecases
(AAO,2018b).
InitiatingDrugTherapy
Beforedrugtherapyisprescribed,boththepatientandthepractitionershouldbeawarethatbacterialand
viralconjunctivitis arehighlycontagiousandare spreadbycontact.Therefore, goodhandwashingand
instrument-cleansingtechniquesareimperative.Theetiologyofillnessshouldbedeterminedastreatment
isdifferentforbacterial,viral,andallergicconjunctivitis.
GoalsofDrugTherapy
Thegoalsofdrugtherapyaretoeradicatetheoffendingorganism(forbacterialconjunctivitis),torelieve
symptoms, and to quicken theresolution of the disease. A patient with bacterial conjunctivitis should
experienceimprovementinsymptomsafewdaysafterthestartofantibiotictherapy;theorganismsremain
active(andcontagious)for24 to48hoursaftertherapybegins.Withviralconjunctivitis,thediseaseis
contagiousforatleast7daysaftersymptomsappear;itmaybecontagiousforupto14days.
Antibiotics
Althoughbacterialconjunctivitiscausedbytypicalpathogens
Haemophilus species) isusuallyself-limiting,antibiotic therapyisjustified becauseitcanshortenthe
course ofthedisease, whichreduces person-to-personspread andlowers the risk ofsight-threatening
complications.Thechoiceofantibioticisusuallyempirical;clinicalevidenceindicatingthesuperiority
of any particular antibiotic is lacking (AAO, 2018b). Five to 7 days of therapy with agents such as
erythromycin ointment or bacitracin–polymyxin B ointment is usually effective. While well tolerated,
sulfacetamide hasweakto moderate activityagainst many organisms. Theaminoglycosideshave good
gramnegative 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;theolder fluoroquinolones(ciprofloxacin,norfloxacin,andofloxacin)havepoor coverageof
Streptococcus species,whilethenewer fluoroquinolones (besifloxacin,gatifloxacin,levofloxacin,and
moxifloxacin)offerimprovedgram-positivecoverageandareavailableinasolution.
Becausegonococcalinfectionisserious,immediatetreatmentofconjunctivitisduetoN.gonorrhoeae
with a 250-mg intramuscular (IM) injection of ceftriaxone (Rocephin) plus a single 1-g dose of oral
azithromycinisrecommendedforadultsandchildrenwhoweighatleast45kg.Childrenwhoweighless
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-allergicpatientsshouldbereferredtoaninfectiousdiseasespecialist.Topicalantibiotic
therapyisnotnecessarybutisofteninitiatedtopreventsecondaryinfection
(AAO,2018b).
AsC.trachomatisisnowthemostcommoncauseofconjunctivitisinneonatesintheUnitedStates,the
long-time standard prophylactic agent for neonates, topical 1% silver nitrate solution, is no longer
recommended(norcommerciallyavailable)intheUnitedStates.Topicaltreatmentofneonatalchlamydial
conjunctivitis is ineffective and unnecessary (American Academy of Pediatrics, 2015). In adults and
childrenatleast8yearsold,C.trachomatisinfectionistreatedwithasingle1-gdoseofazithromycinor
7daysoftherapywithdoxycycline100mgtwicedaily.Childrenwhoweighatleast45kgbutareless
than8yearsoldshouldreceivethesingledoseofazithromycin1g.Neonatesandchildrenwhoweigh
lessthan45kgshouldreceive50mg/kg/doferythromycinbaseorerythromycinethylsuccinate,divided
intofourdosesadayfor14days(AAO,2018b).IdentificationofeitherChlamydiaorN.gonorrhoeae
conjunctivitisrequiresthatthepatient’ssexualpartneralsobetreated.
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
symptomsofallergicconjunctivitis.Ocularadverseeventswiththeseagentsincludetransientstingingor
burning uponinstillation,dryeyes, redeyes, andblurred vision. Oral antihistamines can also help to
relievesymptomsinpatientswithvernal/atopicconjunctivitis(seeTable16.3).
TABLE16.3
OverviewofAntiallergyOphthalmicAgents
Generic(Trade)Nameand
Dosage
SelectedAdverseEvents Contraindications SpecialConsiderations
Antihistamines
Alcaftadine0.25%solution
(Lastacaft)Dosing:1dropin
theaffectedeye(s)oncedaily
Eyeirritation,burningandstinging,
itching
Labeling:wait10min
followingadministration
beforeinsertingcontact
lenses.
Emedastine0.05%solution
(Emadine)Dosing:1dropin
theaffectedeye(s)uptoQID
Blurredvision,burningandstinging,
dryeyes,foreignbodysensation,
hyperemia,itching
Labeling:wait10min
followingadministration
beforeinsertingcontact
lenses.
MastCellStabilizers
Bepotastine1.5%solution
(Bepreve)Dosing:1dropinto
theaffected
eye(s)BID
Mildtastefollowinginstillation,eye
irritation
Labeling:wait10min
followingadministration
beforeinsertingcontact
lenses.
Cromolyn4%solution
(Crolom)Dosing:1-2dropsin
eacheyefourtosixtimesdaily
atregularintervals
Burningandstinging,conjunctival
injection,wateryeyes,itching,dry
eye,styes
Labeling:refrainfrom
contactlensusewhile
undertreatment.
Lodoxamide0.1%solution
(Alomide)Dosing:1-2dropsin
eacheyeQID
Burningandstinging,ocularitching,
blurredvision,dryeye,tearing,
hyperemia,foreignbodysensation
Labeling:refrainfrom
contactlensusewhile
undertreatment.
Nedocromil2%solution
(Alocril)Dosing:1-2dropsin
eacheyeBID
Ocularburningandstinging,
unpleasanttaste,redness,
photophobia
Labeling:refrainfrom
contactlensusewhile
exhibitingthesignsand
symptomsofallergic
conjunctivitis.
Antihistamine/MastCellStabilizer
Azelastine0.05%solution
(Optivar)
Dosing:1dropintoeach
affectedeyeBID
Ocularburningandstinging,
headache,bittertaste,eyepain,
blurredvision
Labeling:wait10min
followingadministration
beforeinsertingcontact
lenses.
Epinastine0.05%solution
(Elestat)Dosing:1dropineach
eyeBID
Burningsensation,folliculosis(hair
follicleinflammation),hyperemia,
itching
Labeling:wait10min
followingadministration
beforeinsertingcontact
lenses.
Ketotifen0.025%solution
(Alaway,ClaritinEye,Zaditor,
TheraTearsAllergy)
Dosing:1dropintheaffected
eye(s)q8-12h,oncedailyor
BID
Headache,conjunctivalinjection,
burningandstinging,conjunctivitis,
dryeye,itching,photophobia
Labeling:wait10min
followingadministration
beforeinsertingcontact
lenses.
Olopatadine0.1%(Patanol),
0.2%(Pataday),or0.7%
(Pazeo)solutionDosing
0.1%:1dropineachaffected
eyeBID
atanintervalof6-8h0.2%,
0.7%:1dropintheaffected
eye(s)oncedaily
Ocularburningandstinging,dryeye,
headache,foreignbodysensation,
hyperemia,lidedema,itching
Labeling:wait5-10min
followingadministration
beforeinsertingcontact
lenses.
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