Download Tox-ICK!

The AOA’s CLCS Newsletter, May 2013
Tox-ICK!
Jordan Jones, O.D.
Toxicity is described as damage to the structure of tissue or disturbance of
function with or without an accompanying inflammatory response (1). Ocular
tissue damage may be a direct result of a drug itself, an accompanying
preservative, or from the breakdown of a drug (1). Often, toxic conjunctivitis
can be confused with allergic conjunctivitis, especially when considering
topical medication use (2-6).
Toxic Conjunctivitis (1, 2, 6)
 Can occur after one exposure
 Mixed papillary/follicular response
 Corneal involvement from punctate keratitis to severe ulcerative keratopathy
 Associated dermatitis
 Often inferior (due to Bell’s Phenomenon when applying drops)
Allergic Conjunctivitis (1, 2, 6)
 Tends to be chronic
 Papillary response
 Cornea typically unaffected
 Primary symptom of itching
Preservatives such as BAK, chlorobutanol and thimerosal are often found in topical medications
and can cause adverse effects even when the drug itself is well tolerated. Frequent and
extended use can cause edema, hyperemia, and punctate keratitis (2,7,8).
Anesthetic use can also cause varying degrees of toxic effects. Even a single use for diagnostic
purposes may cause stinging and punctate keratitis (2). Anesthetic abuse can cause detrimental
effects to the ocular tissue, including corneal epithelial defects and edema as well as stromal
edema and infiltrates (9, 10).
Other causes of toxic conjunctivitis include, but are not limited to:
 Cosmetics and skin care products (11)
 Hair care products (12)
 Tear gas weapons and lacrimating agents (13)
As with all ocular examinations, a thorough history is important when trying to identify the
offending substance. Removal of the offending agent is the first step in managing toxic
conjunctivitis as repeated exposures could lead to worsening of the condition. In instances
where a topical medication cannot be discontinued, preservative-free or oral preparations
should be considered when applicable. Once the culprit is removed, non-preserved lubricants
may be helpful with aiding symptomatic relief.
References:
1.
2.
3.
4.
5.
6.
Wilson FM II. Adverse external ocular effects of topical ophthalmic therapy: an epidemiologic, laboratory, and clinical
study. Trans Am Ophthalmol Soc. 1983;81:854–965.
Wilson FM II. Adverse external ocular effects of topical ophthalmic medications. Surv Ophthalmol. 1979;24(2):57–88.
Schwab IR, Abbott RL. Toxic ulcerative keratopathy. An unrecognized problem. Ophthalmology. 1989;96:1187.
Burstein NL. Corneal cytotoxicity of topically applied drugs, vehicles and preservatives. Surv Ophthalmol. 1980;25(1):15–
30
Katz LJ. Twelve-month evaluation of brimonidine-purite versus brimonidine in patients with glaucoma or ocular
hypertension. J Glaucoma. 2002;11(2):119–126.
Jerstad KM, Warshaw E. Allergic contact dermatitis to latanoprost. Contact Dermat. 2002;13(1):39–41.
The AOA’s CLCS Newsletter, May 2013
7.
8.
9.
10.
11.
12.
13.
Neville R, Dennis P, Sens D, et al. Preservative cytotoxicity to cultured corneal epithelial cells. Curr Eye Res.
1986;5:367–372.
Wilson WS, Duncan AJ, Jay JL. Effect of benzalkonium on the stability of the precorneal tear film in rabbit and man. Br J
Ophthalmol. 1975;59:667–669.
Rossenwasser GOD, Holland S, Pflugfelder SC, et al. Topical anesthetic abuse. Ophthalmology. 1990;97:967–972
Higbee RG, Hazlett LD. Topical ocular anesthetics affect epithelial cytoskeletal proteins of wounded cornea. J Ocular
Pharmacol. 1989;5:241
MacLean AL. Spray keratitis: a common epithelial keratitis from noncorrosive household sprays. Trans Am Acad
Ophthalmol Otol. 1967;71:330–339.
Laibson PR, Oconor J. Explosive tear gas injuries of the eye. Trans Am Acad Ophthalmol Otol. 1970;74:811–819.
Zollman TM, Bragg RM, Harrison DA. Clinical effects of oleoresin capsicum (pepper spray) on the human cornea and
conjunctiva. Ophthalmology. 2000;107 (12):2186–2189.
Dr. Jordan Jones is a graduate of the UMSL College of Optometry and recently completed a
cornea and contact lens residency at NSU Oklahoma College of Optometry. Dr. Jones currently
lives in St. Louis, Mo.
Please close this browser window to return to the CLCS Newsletter