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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