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Table of Contents
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1.0 Treatment of ocular infections
o 1.1 Bacterial conjunctivitis
o 1.2 Chlamydia trachomatis conjunctivitis
o 1.3 Viral conjunctivitis
o 1.4 Herpes simplex keratitis
o 1.5 Ophthalmic herpes zoster
o 1.6 Topical antimicrobials
 1.6.1 Aciclovir (Zovirax)
 1.6.2 Chloramphenicol (e.g. Chloromycetin)
 1.6.3 Ciprofloxacin (e.g. Ciloxan)
 1.6.4 Framycetin (e.g. Soframycin)
 1.6.5 Sulfacetamide (e.g. Acetopt)
 1.6.6 Tetracycline (e.g. Latycin)
 1.6.7 Tobramycin (Tobrex)
 1.6.8 Combination polymyxin B sulphate, neomycin sulphate,
gramicidin / bacitracin sulphate (Neosporin)
2.0 Treatment of allergic and vernal conjunctivitis
3.0 Fluorescein dye
4.0 Mydriatic agents
5.0 Topical local anaesthetics
References
1.0 Treatment of ocular infections
This section details the current recommended treatments of various ocular infections based
on the recommendations in Therapeutic Guidelines: Antibiotic (version 11). [1]
Golden Rule!
There is no place for the use of a combination of antimicrobials and steroids in the
treatment of ocular infection.
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1.1 Bacterial conjunctivitis
Bacterial conjunctivitis should respond to therapy within 3 days. If there is no significant
improvement after three days of treatment, either the diagnosis is wrong or the wrong drug
has been chosen. Common pathogens include Strep. spp., Staph. spp. and Haemophilus
influenzae. Suggested treatment is either chloramphenicol 0.5% eye drops or combination
drops polymyxin B sulfate + neomycin sulfate + gramicidin (Neosporin), in a dose of 1 to 2
drops hourly decreasing to 6-hourly as the infection improves. Ointment can be used instead
of drops at bedtime. Propamidine drops 0.1% (Brolene) can be used for very mild cases, in a
dose of 1 to 2 drops, 3 to 4 times daily for 5 to 7 days.
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1.2 Chlamydia trachomatis conjunctivitis
Chlamydia trachomatis conjunctivitis or trachoma requires systemic treatment with
azithromycin (1 gm orally as a single dose; child: 20 mg/kg up to 1 gm) in adults and children
over 6 kg or erythromycin (10 mg/kg orally, 6-hourly) in neonates and children under 6 kg.
Treatment for three weeks is recommended for both the patient and the other persons sharing
the dwelling.
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1.3 Viral conjunctivitis
Viral conjunctivitis (usually caused by adenovirus) has no effective treatment. Symptomatic
management is advised, using lubricating eye drops to relieve discomfort. Most cases are
self-limiting and last 14-21 days. In cases where it may be impossible to distinguish between
viral and bacterial conjunctivitis, empirical treatment with antibiotic therapy is appropriate.
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1.4 Herpes simplex keratitis
Herpes simplex keratitis should be treated with aciclovir 3% eye ointment, 5 times daily for at
least 14 days or until 3 days after healing. Note that referral to an ophthalmologist should be
made if there is no apparent healing within 3 days or if there is any opacity of the cornea.
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1.5 Ophthalmic herpes zoster
Ophthalmic herpes zoster should be treated early and aggressively with famciclovir 250mg
orally, 8-hourly or valaciclovir 1 gm orally, 8-hourly or aciclovir 800 mg orally, 5 times a day for
7 days. Aciclovir 3% eye ointment 5 times daily can be used to supplement this treatment. If
sight is threatened, parenteral aciclovir should be used at a dose of 10 mg/kg, 8-hourly for 7
days. Due to the risk of serious complications, an ophthalmologist should be consulted when
treating ophthalmic herpes zoster.
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1.6 Topical antimicrobials
This section deals specifically with the antimicrobial drops and ointments used in ophthalmic
therapy. Agents are considered in alphabetical order.
Caution!
Penetrating eye injuries require the use of parenteral antibiotics. Drops and ointments
should not be used.
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1.6.1 Aciclovir (Zovirax)
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indications - treatment of herpes simplex keratitis, herpes zoster ophthalmicus
contraindications - hypersensitivity.
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1.6.2 Chloramphenicol (e.g. Chloromycetin)
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broad spectrum antibiotic effective against Gram positive and negative species
contraindications - hypersensitivity
side effects - bone marrow hypoplasia leading to aplastic anaemia is a rare but
potentially fatal side effect which has been reported after topical use.
Caution!
Treatment with chloramphenicol longer than a few days is not advised because of the
risk of blood dyscrasias.
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1.6.3 Ciprofloxacin (e.g. Ciloxan)
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ciprofloxacin is a fluroquinolone based antibiotic effective against Staph. aureus,
Staph. epidermidis, Strep. pneumoniae, Streptococci (viridans group), Haemophilus
influenzae, Pseudomonas aeruginosa and Serratia marcescens
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contraindications - hypersensitivity. Note that its safety in children under 12 months
has not been proven
side effects - burning, stinging, taste abnormality, (rarely) white crystalline precipitates
in the eye.
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1.6.4 Framycetin (e.g. Soframycin)
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well tolerated by eye tissue
effective against Staphylococci, Pseudomonas aeruginosa, coliforms and
Pneumococci
contraindications - hypersensitivity.
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1.6.5 Sulfacetamide (e.g. Acetopt)
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effective against E. coli, Staph. aureus, Strep. pneumoniae, Streptococci (viridans
group), Haemophilus influenzae, Klebsiella spp. and Enterobacter spp. Significant
incidence of Staph. resistance
contraindications - hypersensitivity to sulphurs
side effects - conjunctival irritation, burning, stinging.
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1.6.6 Tetracycline (e.g. Latycin)
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indications - superficial ocular infections and blepharitis
side effects - overgrowth of resistant organisms (such as Staph., Pseudomonas,
Proteus, fungi).
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1.6.7 Tobramycin (Tobrex)
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effective against Staph. aureus, Staph. epidermidis, Streptococci including Strep.
pneumoniae, Pseudomonas aeruginosa, E. coli, Klebsiella pneumoniae, Enterobacter
aerogenes and Proteus mirabilis (indole negative). Bacterial resistance may develop
in prolonged use
indications - treatment of external infections of the eye and its adnexa caused by
susceptible bacteria
contraindications - hypersensitivity
side effects - ocular toxicity and hypersensitivity (approx 3%).
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1.6.8 Combination polymyxin B sulphate, neomycin sulphate, gramicidin
/ bacitracin sulphate (Neosporin)
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broad spectrum
indications - bacterial conjunctivitis, corneal ulcer due to susceptible organisms,
styes, keratitis, blepharitis, scleritis
contraindications - hypersensitivity to polymyxins, gramicidin, bacitracin or neomycin
groups of antibiotics.
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2.0 Treatment of allergic and vernal conjunctivitis
Simple allergic conjunctivitis can be treated with cold compresses or astringent drops.
Combinations of naphazoline and antazoline or pheniramine drops are available over the
counter and provide some remedy for the seasonal allergic conjunctivitis. These preparations
provide decongestant action as well as antihistamine effects. Systemic antihistamines are
sometimes necessary. In a severe acute attack, vasoconstrictors (e.g. 1/8% phenylephrine)
and ice packs may be necessary.
Olopatadine is a new drug used for both the treatment of acute seasonal allergic conjunctivitis
and prevention of further episodes of acute seasonal allergic conjunctivitis. It has a dual
action, being a selective H1 receptor-antagonist and a mast cell stabiliser. This translates to a
rapid onset as well as a long duration of action (up to 12 hours). It is well tolerated. Results of
an unpublished study [2] have suggested the superior efficacy and safety profile of
olopatadine as compared with a topical steroid, loteprednol, for the treatment of seasonal
allergic conjunctivitis.
Topical steroids are a first line treatment for acute vernal conjunctivitis. Due to the risks
associated with long term topical steroid use (e.g. glaucoma and cataract), maintenance is
best achieved using mast cell histamine release inhibitors (e.g. cromoglycate or lodoxamide
drops) if possible. Given the risk / benefit profile of the treatment of vernal conjunctivitis,
referral of patients with vernal conjunctivitis to an ophthalmologist is appropriate.
Desensitisation has not been shown to be an effective treatment.
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3.0 Fluorescein dye
Fluorescein is a yellow-green dye, used in the diagnosis of corneal lesions. It has a low
irritability and is highly effective in uncovering lesions on the essentially transparent cornea
and scleral conjunctiva. It is available in dye impregnated strips or single use vials. Note that
stock solutions should not be used as fluorescein is notoriously liable for contamination with
Pseudomonas. The dye is applied to the inside of the lower eyelid, and distributed over the
cornea by asking the patient to blink several times. A cobalt blue light is then used to highlight
any conjunctival or corneal defect.
Caution!
Fluorescein will permanently stain soft contact lenses so they should be removed prior
to application.
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4.0 Mydriatic agents
Mydriasis is an important and necessary part of an ophthalmoscopic examination. Agents
used to achieve mydriasis include cyclopentolate 1% (e.g. Cyclogyl) and tropicamide 0.5% or
1% (e.g. Mydriacyl). Systemic absorption is minimised by applying pressure to the tear duct
for 2 minutes after administration.
As mydriatic agents are anticholinergic preparations, they also cause loss of accommodation,
through paralysis of the ciliary muscle (cycloplegia). For this reason, patients should be
advised not to drive after administration (depending on duration of action of the agent used).
The use of mydriatics is contraindicated in the following circumstances:
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assessment of anterior chamber depth suggests a shallow anterior chamber. In this
case, application of a mydriatic may precipitate an attack of acute angle-closure
glaucoma
if the patient is undergoing an neurologic examination where pupillary signs are being
watched
prior to pupillary reaction testing.
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5.0 Topical local anaesthetics
Local anaesthetics are useful in an ocular examination in procedures where painless surface
manipulation is needed, such as the removal of a corneal foreign body. Proxymetacaine
(Alcaine) and oxybuprocaine (Fluress) are local anaesthetics that have a rapid onset (within
20 seconds) and duration of action that lasts about 15 minutes. Amethocaine (0.5% & 1%) is
also useful but should not be used in patients on current sulphonamide therapy. Patients
should be advised not to rub their eyes for at least 20 minutes after the administration of
anaesthetic.
Local anaesthetic eye drops should be used with caution in patients with known allergies,
cardiac disease or hyperthyroidism. Allergic corneal reactions have been rarely reported.
Local anaesthetic eye drops should never be prescribed to patients for long term use due to
the risk of corneal opacification and scarring.
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References
[1] Therapeutic Guidelines Ltd. Therapeutic Guidelines: Antibiotic, Version 11. Melbourne:
Therapeutic Guidelines Ltd, 2000.
[2] Berdy GJ, Stoppel JO, Epstein AB. Comparison of the clinical efficacy and safety of
olopatadine hydrochloride 0.1% ophthalmic solution and loteprednol etabonate 0.2%
ophthalmic suspension in the conjunctival allergen challenge model (unpublished).
[3] Gole GA. Paediatric ophthalmology notes. Brisbane: Dept of Ophthalmology, Royal
Children's Hospital, May 2001.
[4] Gaston H. Managing the red eye. Practitioner 1989;22: 233(1479):1566-72
[5] Bradford CA. Basic ophthalmology for medical students and primary care residents. 7th
edn. San Francisco, CA: American Academy of Ophthalmology, 1999.
[6.] Keeney AH. Ocular Examination - Basis and Technique. 2nd edn. USA: C.V. Mosby
Company, 1976.
[7.] MIMS Annual. 25th edn. Singapore: MIMS Australia, June 2001.