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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5200_Библиотеки_им_академика_М_И_Перельмана

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NonsteroidalAntiinflammatoryDrugs
Ketorolac0.5%solution (Acular)Dosing:1dropQID
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.
Vasoconstrictors(Decongestants)
Naphazoline0.0125%or
0.03%solutions(ClearEyes) and0.1%solution(AK-Con) Dosing:1-2dropsinthe affectedeye(s),uptoQID
Stinging,blurredvision,mydriasis, redness,punctatekeratitis,increased IOP
Narrow-angle glaucomaNarrow­anglewithout glaucoma
Useshouldbelimitedto 72h. Containsbenzalkonium chloride;usewith contactlensesnot addressedinlabeling.
0.1%solutionrequiresa prescription.
Tetrahydrozoline0.05% solution(VisineAdvanced Relief,MurineforRedEyes, ClearEyesTripleAction, GoodSense,Opti-Clear) Dosing:1-2dropsuptoQID
Stinging,blurredvision,mydriasis, redness,punctatekeratitis,increased IOP
Narrow-angle glaucomaNarrow­anglewithout glaucoma
Useshouldbelimitedto 72h.Contains benzalkoniumchloride; usewithcontactlenses not addressedinlabeling
TopicalCorticosteroids
Dexamethasone0.1%solution (AK-Dex,Decadron)or0.1% suspension(Maxidex) Dosing Solution:1-2dropseveryhour duringthedayandq2hatnight initially,reducedto1dropq4h withfavorableresponse Suspension:1-2dropslessthan fourtosixtimesadayinmild disease;hourlyinsevere disease
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.
Fluorometholone0.1% ointmentorsuspension(FML, Flarex)or0.25%suspension (FMLForte) Dosing Ointment:0.5inchribbonone toTID; duringinitial24-48h,dosing may beincreasedtoq4h. Suspension:1dropBIDto QID;during
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
initial24-48h,dosingmaybe increasedtoq4h.
Loteprednol0.2%or0.5% suspension (Alrex,Lotemax)Dosing
0.2%solution:1dropinthe affected eye(s)QID
0.5%solution:1-2dropsinthe affectedeye(s)QID
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15min followingadministration beforeinsertingcontact lenses.
Prednisolone0.12%or1% suspension(PredMild, Omnipred,PredForte)or1% solution Dosing Solution:2dropsQID Suspension:1-2dropsBIDto QID;dosemaybeincreased duringthe initial24-48h.
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.
IOP,increasedintraocularpressure.
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16.3).
Antihistamine/MastCellStabilizer
Severalproducts(azelastine,epinastine,ketotifen,andolopatadine)havethecombinedpropertiesofan antihistamineandamastcellstabilizer,providingimmediatereliefofitchingandlong-termsuppression ofhistaminerelease.Ketotifenisavailablewithoutaprescription.Theseagentsaregivenonceortwicea dayandhaveanadverseeffectprofilesimilartotheantihistaminesandmastcellstabilizers(seeTable
16.3).
NonsteroidalAntiinflammatoryOphthalmicDrugs
Theophthalmicnonsteroidalantiinflammatorydrug(NSAID)ketorolacmaybeusefulfortreatingtheitch associated with allergic conjunctivitis. The NSAIDs inhibit the biosynthesis of prostaglandin by decreasingtheactivityoftheenzymecyclooxygenase.Ketorolacisadministered1dropfourtimesaday intotheaffectedeye.Itshouldbeusedwithcautioninpatientswithaspirinsensitivitiesandpatientswho havebleedingdisordersorarereceivinganticoagulanttherapybecauseophthalmicNSAIDsareabsorbed systemically.Adverseeventsincludetransientstingingandburning,irritationandinflammation,corneal
edema,andiritis(seeTable16.3).
Vasoconstrictors(Decongestants)
Vasoconstrictoreyedrops (naphazolineandtetrahydrozo-line)mayofferrelieftopatientswithallergic conjunctivitis. With the exception of the higher-strength (0.1%) naphazoline solution, these agents are available without a prescription. Adverse effects include stinging, blurred vision, mydriasis, and increased redness; punctate keratitis and increased intraocular pressure (IOP) may also occur. These agentsarecontraindicatedinpatientswithnarrow-angleglaucomaoranarrowanglewithoutglaucoma. Reboundcongestionmayoccurwithextendeduseoftheseagents;useshouldbelimitedtoamaximumof 72hours(seeTable16.3).
TopicalCorticosteroids
Topical corticosteroids have been shown to reduce inflammation in allergic conjunctivitis. Low-dose corticosteroid therapy can be used at infrequent intervals for short-term periods (1–2 weeks) (AAO, 2018b). Long-term use of topical corticosteroids is associated with severe adverse effects including ocularinfection,cataractformation,andglaucoma(Orayetal.,2016)(seeTable16.3).
SelectingtheMostAppropriateAgent
Treatment of bacterial conjunctivitis is aimed at eradicating the offending organism. Cultures are not indicatedunlesstheinfectiondoesnotresolvewithfirst-linetherapy(Table16.4andFigure16.1).
There is conflicting information about the use of soft contact lenses while taking ophthalmic medicationsthatcontainthepreservativebenzalkoniumchloride.Thispreservative,whichisinmanyof the ophthalmic antihistamines, mast cell stabilizers, NSAIDs, vasoconstrictors, and topical steroids reviewedinthissection,maybeabsorbedbycontactlenses.Whilenoproductsidentifycontactlensuse as an absolute contraindication to therapy, some (e.g., cromolyn, lodoxamide, and nedocromil) have warningsadvisingagainsttheuseofcontactlensesduringtherapy;othersadvisepatientstowait10to15 minutesafteradministeringthemedicationbeforereinsertingcontactlenses(seeTable16.3).Regardless oftheetiology,contactlenswearersshouldrefrainfromwearingcontactlensesduringanacutecaseof conjunctivitis.
BacterialConjunctivitis
The treatmentof bacterial conjunctivitis is aimed at theorganisms S. aureus, S. pneumoniae, and H. influenzae.First-linetreatmentsinclude5to7daysoftherapywitherythromycinointment(twiceorthree
timesdaily)orpolymyxinB–trimethoprimsolution(1dropevery3–4hours).Therapyselectioncanbe basedonpatientpreferenceforointmentorsolution.Ifbacterialconjunctivitisdoesnotresolvewithfirst­linetherapy,thepatientshouldbereferredtoaneyecareprofessionalsothatculturesmaybetakentorule outC.trachomatis.The ophthalmic fluoroquinolones withimproved gram-positive organism coverage (besifloxacin,gatifloxacin,levofloxacin,ormoxifloxacin)canbeusedassecond-linetherapy.
Gonococcalinfectionrequiresimmediatetreatment.Ceftriaxoneplusazithromycinisrecommendedfor adultsandchildrenwhoweighatleast45kg;childrenwhoweighlessthan45kgandneonatesshould receiveareduceddoseofceftriaxone.Inadultsandchildrenatleast8yearsold,C.trachomatisinfection
istreatedwithazithromycinordoxycycline.Azithromycinshouldbeusedinchildrenwhoweighatleast 45kgbutarelessthan8yearsold,whileneonatesandchildrenwhoweighlessthan45kgshouldreceive erythromycinbaseorerythromycinethylsuccinate.
Seasonal(HayFever)Conjunctivitis
Steps should be taken to minimize exposure to the offending allergen. The ophthalmic antihistamines alcaftadineoremed-astinecanbeusedasfirst-linetherapyformildseasonalconjunctivitis.Ifsymptom controlisinadequate,abriefcourse(1–2weeks)ofalow-potencytopicalcorticosteroidcanbeaddedto theregimen.Iftheconditionispersistent,amastcellstabilizeror,preferably,anagentwithantihistamine andmast cell stabilizer properties (azelastine, epinastine, ketotifen, or olopatadine) can be used. The ophthalmicNSAIDketorolacshouldbe reserved forthird-linetherapy, as itisgenerallyless effective than the ophthalmic antihistamines (Abelson et al., 2015). Many of these agents can be stored in the refrigeratorandprovide acoolingsensationandsymptomaticreliefuponinstillation.Patientsmayalso benefit from the use of cool compresses and artificial tears (which dilute allergens and help manage coexistingteardeficiency).
TABLE16.4
RecommendedOrderofTreatmentforConjunctivitis
Order Agent Comments
BacterialConjunctivitis(nongonococcal,nonchlamydial)
Firstline Erythromycinointmentor
Bacitracin-polymyxinBointment
Ointmentstendtocausea greaterdegreeofblurry visionthansolutions.
Second line
Ophthalmicfluoroquinolone(besifloxacin,gatifloxacin,levofloxacin,or moxifloxacin)solution
Theremainingophthalmic fluoroquinolonesdonot providegoodstaphylococcal coverage.
Seasonal(HayFever)Conjunctivitis
Firstline Topicalantihistamine(alcaftadineoremedastine) Minimizationofexposureto
theoffendingallergen,cool compresses,andartificial tearsmayalsobehelpful.
Second line
Additionofabriefcourseoflow-potencytopicalcorticosteroidtothefirst­lineagent
or
Forrecurrentorpersistentdisease:aproductwithantihistamine/mastcell stabilizerproperties(azelastine,epinastine,ketotifen,orolopatadine)
Third line
Ophthalmicketorolac
Vernal/AtopicConjunctivitis
Firstline Topicalantihistamineororalantihistamineormastcellstabilizer Minimizationofexposureto
theoffendingallergen,cool compresses,andartificial tearsmayalsobehelpful.
Second Foracuteexacerbations:additionofabriefcourseoflow-potencytopical
line corticosteroidtothefirst-lineagent
ViralConjunctivitis
Firstline Topicalantihistaminesor
Artificialtearsor Coldcompresses
Thereisnoeffective treatmentforviral conjunctivitis;treatmentis forsymptommitigation.
Second line
Inseverecases:alow-potencytopicalcorticosteroid Useofthetopical
corticosteroidsshouldnot exceed2wk.
GiantPapillaryConjunctivitis
Mild disease
Oneormoreofthefollowing:replacecontactlensesmorefrequently, decreasecontactlenswearingtime,increasethefrequencyofenzyme treatment,usepreservative-freelenscaresystems,switchtodisposable lenses,administermastcellstabilizer,changethecontactlenspolymer
Moderate orsevere disease
Sameasmilddiseaseand Discontinuationofcontact
lenswearforseveralweeks orabriefcourseoftopical corticosteroidtreatment
Vernal/AtopicConjunctivitis
Similar to seasonal conjunctivitis, general treatment measures for vernal/atopic conjunctivitis include minimizingexposuretotheoffendingallergenanduseofcoolcompressesandartificialtears.Thetopical antihistamines (alcaftadine or emedastine), oral antihistamines, or mast cell stabilizers (bepotastine, cromolyn, lodoxamide, or nedocromil) can be used as first-line agents for the treatment of vernal or atopicconjunctivitis.Forpatientswithacuteexacerbations,atopicalcorticosteroidcanbeaddedtothe first-lineagentforcontrolofseveresymptoms.
FIGURE16-1Treatmentalgorithmforconjunctivitis.
IOPincreasedintraocularpressure
ViralConjunctivitis
There is no effective treatment for viral conjunctivitis; patients should be informed of the risk of spreadingtheinfectiontotheothereye(inunilateralinfection)ortootherpeople.Topicalantihistamines, artificial tears, or cool compresses can be used to relieve symptoms. In severe cases of adenoviral keratoconjunctivitis with marked chemosis or lid swelling, epithelial sloughing, or membranous conjunctivitis,topicalcorticosteroidscanbehelpfulinreducingsymptomsandpreventingscarring.
GiantPapillaryConjunctivitis
Management of giant papillary conjunctivitis centers around identifying and modifying the causative entity.Treatmentofmildgiantpapillaryconjunctivitisduetocontactlensusecanconsistofoneormore ofthe following:more frequentreplacementof contactlenses, reduction incontactlenswearingtime, increase inthefrequencyofenzyme treatment,use ofpreservative-free lenscaresystems,switching to disposable daily-wear lenses, administration of a mast cell stabilizer, and change of the contact lens polymer (AAO, 2018b). In moderate or severe giant papillary conjunctivitis due to contact lens use, discontinuationofcontactlensuseforseveralweeksorabriefcourseoftopicalcorticosteroidtherapy maybenecessary.
MonitoringPatientResponse
Ifsymptomsbegintoimprovewithin48hours,nofollow-upisneeded.Ifthereis noimprovement,the patientshouldbereferredtoaneyecareprofessionalforevaluation.
PatientEducation
Itisimportanttoinstructpatientswithbacterialorviralconjunctivitis towashtheir handscarefullyto preventspreadinginfection.Organismsinbacterialconjunctivitisremainactive(andcontagious)for24 to48hoursaftertherapybegins,whilepatientswithviralconjunctivitiscanremaincontagiousforupto 14days.Patientsshouldbetaughthowtoapplythemedicationintheinneraspectofthelowereyelid.The tip ofthe container should nottouchthe eyelashes,asit maycontaminatethemedicationandresultin therapy failure or reinfection. Patients should not share eye medications because this can spread the infection. To improve the effectiveness of an ophthalmic antibiotic, crusted eyelids should be gently cleansedbeforeinstillingmedication.Regardlessoftheetiology,contactlenswearersshouldrefrainfrom wearingcontactlensesduringanacutecaseofconjunctivitis.
DRYEYEDISEASE:KERATOCONJUNCTIVITISSICCA
Keratoconjunctivitis sicca,commonlyreferred toasdryeyedisease(DED)or dry eye syndrome,isa common ophthalmologic abnormality involving bilateral disruption of tear film on the ocular surface. EstimatesoftheprevalenceofdryeyeintheUnitedStatesrangefrom10%to20%,withtheprevalence markedlyhigherforindividualsovertheageof80yearscomparedtothoseyoungerthan60yearsofage (19.0% vs. 8.4%) (Moss et al., 2000). DED can occur intermittently or as a chronic condition that becomes a self-perpetuatingsyndrome.While themajorityofpatientswithDEDexperiencenon-sight­threatening ocular irritationandintermittentlyblurred vision,patients withsevereDEDare atriskfor severe visionloss duetoocular surfacekeratinization,cornealscarring,andcornealulceration(AAO, 2018c).
Causes
DED is a multifactorial disease. It can be the result of decreased tear production, increased tear evaporation,oracombinationofthesefactors(Craigetal.,2017).Inaddition,decreasedtearsecretion andclearance initiate an inflammatory response on theocular surface, and research suggests thatthis
inflammationplaysaroleinthepathogenesisofDED(Leeetal.,2018).
Risk factors for DED include advanced age, female gender, and a history of laser-assisted in situ keratomileusis surgery. Individuals with concomitant inflammatory conditions (rosacea, lupus, sarcoidosis, or rheumatoid arthritis), systemic viral infections (hepatitis C, human immunodeficiency virus/ acquired immunodeficiency syndrome, or Epstein-Barr virus), or conditions such as MGD blepharitis, Sjögrensyndrome,Parkinson’sdisease,andBell palsyarealso atincreased riskforDED. Symptoms caused by dry eye may be exacerbated by environmental factors such as wind, reduced humidity,cigarettesmoke,andheatingandair-conditioning(Calogneetal.,2017).Systemicmedications such as antihistamines, diuretics, anticho-linergics, antidepressants, beta blockers, antipsychotics, menopausalhormonetherapy,oralcontraceptives,andisotretinoincanalsoexacerbatedryeyesymptoms (AAO,2018c;Clayton,2018).
Pathophysiology
Tears are composedofthree layers: a mucuslayer produced bygobletcells, whichcoats thecornea, allowingthetear toadheretotheeye;amiddle aqueouslayerproducedbythelacrimalglands,which providesmoistureandsuppliesoxygenandnutrientstothecornea;andanouterlipidfilmlayerproduced bythemeibomianglands,whichsealsthetearfilmontheeyeandpreventsevaporation.Theouterlipid filmlayerisreplenishedbyeyelidblinking,whichrelubricatesandredistributesthelipidlayeracrossthe ocularsurface.Theocularsurfaceandtear-secretingglandsfunctionasanintegratedunittomaintainthe tear supply and to clear used tears. Aging, ocular surface diseases (such as herpes simplex virus keratitis), surgeriesthatdisruptthetrigeminalafferentsensorynerves,systemicinflammatorydiseases, and systemic diseases and medications that disrupt the efferent cholinergic nerves that stimulate tear secretioncandisruptthisfunctionalunitandresultinanunstableandpoorlymaintainedtearfilm(AAO, 2018c;Pfulgfelder&dePaiva,2017).Decreasedtearsecretionandclearanceleadstoaninflammatory responseontheocularsurface,whichisalsobelievedtoplayaroleinDED.
DiagnosticCriteria
Family practitioners should always refer patients reporting dry eye to an ophthalmologist if there is moderatetoseverepain,visionloss,cornealinfiltrationorulceration,ornoresponsetotherapy(AAO, 2018c). Making the diagnosis of DED, particularly the mild form, can be difficult because of the unpredictable correlation between reported symptoms and clinical signs and the relatively poor sensitivity/specificity of existing diagnostic tests (AAO,2018c). Because mostdry eyeconditions are chronic,repeatobservationwillallowamoreaccurateclinicaldiagnosisofDED.
SignsandsymptomsofDEDincludeadryeyesensation,ocularirritation,redness,burning,stinging,a foreign body or gritty sensation, blurred vision, photophobia, contact lens intolerance, an increased frequencyofblinking,and,paradoxically,increasedtearing(AAO,2018c;NationalEyeInstitute[NEI],
2019). DED symptoms tend to worsenin dry climates, in the wind, duringair travel, withprolonged visualefforts(e.g.,readingorcomputeruse),andtowardtheendoftheday(AAO,2018c).
A physical examination (including a test of visual acuity, an external examination, and slit-lamp biomicroscopy)shouldbeperformedtodocumentthesignsofDED;toassessthequality, quantity, and stabilityofthetearfilm;andtoruleoutothercausesofocularirritation(AAO,2018c).Evaluativetools (the Dry Eye Questionnaire 5 or Ocular Surface Disease Index) can be utilized to screen for DED; positivesymptomscoresshouldtriggeramoredetailedexamination,whichmayincludefluoresceintear
break-uptime,tear osmolaritytesting, or ocular surfacestaining (Craiget al.,2017).Individuals with moderate to severe dry eye who have a family history of autoimmune disorders and/or signs and symptomsofanautoimmunedisordershouldbeevaluatedforanunderlyingautoimmunedisorder.
InitiatingDrugTherapy
Beforestartingdrugtherapy,thepatientshouldtrynonpharma-cologicinterventionssuchasenvironmental control (increasing air humidity, avoiding drafts and cigarette smoke) and scheduling regular breaks during computer use and reading. Unfortunately, these interventions result in limitedeffectiveness and producefew lastingimprovements inDED symptoms.Exogenous medicalfactors that cancause DED (i.e., blepharitis, meibomianitis)shouldbeaddressed,andprescriptionmedicationsthatcanexacerbate DEDsymptomsshouldbediscontinuedwhenpossible.
IfthenonpharmacologicinterventionsfailtoeliminateDED symptoms,drugtherapyis appropriate.
Table16.5givesinformationaboutthedrugsusedtotreatDED.
GoalsofDrugTherapy
ThegoalsoftherapyinDEDaretorelievediscomfort,maintainandimprovevisualfunction,andreduce or prevent structural damage (AAO, 2018c). Therapy should attempt to normalize tear volume and composition so that the eye tissues are properly lubricated, nourished, and protected, resulting in improvedpatientsatisfactionandclinicaloutcomes.
ArtificialTearsandLubricants
ArtificialtearsandlubricantscanbeusedaspalliativetherapiestorelieveDEDsymptoms.Designedto mimic the composition of natural tears, artificial tears contain lipids, water with dissolved salts and proteins,andmucin.Artificialtearsandlubricantsareover-the-counterproducts,availableinavarietyof formulations(emulsions,gels,ointments).Ointmentsandgelsmaymaketheeyelidsstickyandblurvision andareoftenusedonlyatbedtime.
For patients with mild DED, use of artificial tears four times daily plus a lubricating ointment at bedtimemaybeuseful.Astheseverityofdryeyeincreases,administrationofartificialtearscanincrease tohourly.Preservative-freepreparationsshouldbeusedifthepatientappliestearsmorethanfourtimesa day(AAO,2018c).
CholinergicAgonists
The cholinergic agonists pilocarpine and cevimeline are indicated for the treatment of dry mouth in patientswithSjögrensyndrome. Theseagentsbindtomuscarinicreceptors,stimulatingsecretionofthe salivaryandsweatglands and improvingtear function. However, these agents are more effective for treatingdrymouthcomparedtodryeye.Themainadverseeventwiththeseagentsisexcessivesweating, reported in 18% to 40% of patients. The use of these agents is contraindicated in patients with uncontrolledasthmaandwhenmiosisisundesirable(acuteiritis,narrow-angleglaucoma).
FattyAcidSupplements
Supplementation with n-3 fatty acids has been reported to provide benefits in DED due to their antiinflammatoryactivityandhasbeenrecommendedbyclinicians(Serhanetal.,2008).However,there isnodefinitiveevidencesupportingfattyacidsupplementationinthemanagementofDED,andalarge, multicenter, double-blind clinical trial failed to demonstrate the effectiveness of n-3 fatty acid supplementationinpatientswithmoderatetosevereDED(Asbelletal.,2018).
TopicalCyclosporine
Cyclosporineophthalmicemulsionhasbeenreportedtoincrease aqueoustearproductionanddecrease ocular irritation symptoms in patients with DED. It prevents T cells from activating and releasing cytokines that incite the inflammatory component of dry eye. Adverse effects include ocular burning, conjunctivalhyperemia,discharge,itching,andblurredvision.
Lifitegrast
Lifitegrast is a lymphocyte function-associated antigen-1 (LFA-1) antagonist. The exact mechanism of actionoflifitegrastinDEDisnotknown,thoughlifitegrastblockstheinteractionofcellsurfaceproteins LFA-1 and intercellular adhesion molecule-1 and may inhibit T cell–related inflammation in DED. Adverseeffectsincludetastealterationanddecreasedvisualacuity.
TopicalCorticosteroids
TopicalcorticosteroidshavebeenshowntoreduceinflammationinDEDbyreducingcytokinelevelsin theconjunctivalepithelium.Low-dosecorticosteroidtherapycanbeusedatinfrequentintervalsforshort­term (2 weeks) suppression of irritation secondary to inflammation (AAO, 2018c). Long-term use of topical corticosteroids is associated with severe adverse effects, including ocular infection, cataract formation,andglaucoma(Cutoloetal.,2019).
SelectingtheMostAppropriateAgent
AgentselectionisdeterminedbytheseverityofDEDandtheunderlyingpathophysiology(Table16.6).
First-LineTherapy
ForpatientswithmildDED,theuseofatearsubstitutefourtimesadayisappropriate.Formoderateor severeDED,artificialtearscanbeusedasoftenashourly,althoughadministrationthatfrequentlymaybe cumbersome.Preservative-freepreparationsshouldbeusedifthepatientusestearsmorethanfourtimes aday.Alubricatingointmentappliedatbedtimemayalsobeuseful.
ApatientwithDEDandunderlyingSjögrensyndromemaybenefitfromtherapywithoralpilocarpine5 mgfourtimesdailyororalcevimeline30mgthreetimesdaily.
TABLE16.5
OverviewofDryEyeDiseaseAgents
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