Pharmacotherapeutics for
Advanced Practice
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Chapter 16:
Ophthalmic Disorders
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Learning Objectives
Describe the pathophysiology of common
ophthalmic disorders routinely presenting in primary
care practice.
Evaluate signs and symptoms of these common
ophthalmic disorders and interpret these signs and
symptoms in order to diagnose subtypes of
blepharitis and conjunctivitis.
Present nonpharmacologic and first- and second-line
treatment options for these common ophthalmic
disorders.
Discuss key patient counseling points for ophthalmic
disorder and treatment options.
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Eyelid Margin Infections: Blepharitis #1
Definition: eyelid margin infection.
Causes: bacterial infection (staphylococcal
blepharitis), inflammation or hypersecretion of the
sebaceous glands (seborrheic blepharitis),
meibomian gland dysfunction (blepharitis), or a
combination of these.
Pathophysiology: toxin production, immunologic
mechanisms, Demodex folliculorum mite infestation,
and antigen-induced inflammatory reactions have all
been reported with blepharitis.
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Eyelid Margin Infections: Blepharitis #2
Manifestations: thickening of the eyelid margin,
plugging of the meibomian orifices, prominent blood
vessels crossing the mucocutaneous junction, and
formation of chalazia (painless firm lumps on the
eyelid).
Diagnostic criteria: based on symptoms: irritated
red eyes and burning sensation; increases in
tearing, blinking, photophobia, eyelid sticking, and
contact lens intolerance.
Treatment: strict eyelid hygiene and warm
compresses.
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Drug Therapy for Blepharitis: SingleAgent Products #1
Sulfacetamide sodium 10% solution (Bleph-10)
Bacitracin 500 units/g ointment
Erythromycin 0.5% ointment
Gentamicin 0.3% solution or ointment (Gentak)
Tobramycin 0.3% solution or ointment (Tobrex)
Besifloxacin 0.6% suspension (Besivance)
Ciprofloxacin 0.3% solution or ointment (Ciloxan)
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Drug Therapy for Blepharitis: SingleAgent Products #2
Gatifloxacin 0.3% solution (Zymaxid)
Levofloxacin 0.5% solution (Quixin)
Moxifloxacin 0.5% solution (Moxeza, Vigamox)
Ofloxacin 0.3% solution (Ocuflox)
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Drug Therapy for Blepharitis: Combination
Products
Polymyxin B sulfate, bacitracin ointment: apply
every 3 to 4 hours for 7 to 10 days.
Polymyxin B sulfate, trimethoprim sulfate solution
(Polytrim): 1 drop in the affected eye(s) every 3
hours (maximum 6 doses a day) for 7 to 10 days.
Polymyxin B sulfate, gramicidin, neomycin solution
(Neosporin): 1 to 2 drops in the affected eye(s)
every 4 hours for 7 to 10 days.
Polymyxin B sulfate, bacitracin zinc, and neomycin
ointment: apply every 3 to 4 hours for 7 to 10 days.
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Recommended Order of Treatment for
Blepharitis
First line:
o Erythromycin 0.5% ophthalmic ointment or
o Bacitracin 500 units/g ointment or
o An ophthalmic fluoroquinolone solution
(besifloxacin, gatifloxacin, levofloxacin, or
moxifloxacin)
Second line: referral to an ophthalmologist
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Question #1
A practitioner prescribes polymyxin B sulfate
gramicidin, neomycin solution (Neosporin) for a
patient with blepharitis. What would be the
appropriate dosage?
A. 1 to 2 drops in the affected eye(s) every 4 hours
for 7 to 10 days
B. 1 drop twice daily for 2 days
C. 1 drop in the affected eye(s) every 3 hours for 7 to
10 days
D. 1 drop in the affected eye(s) twice daily for 2 days
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Answer to Question #1
A. 1 to 2 drops in the affected eye(s) every 4 hours
for 7 to 10 days
Rationale: Polymyxin B sulfate, gramicidin, neomycin
solution (Neosporin) is dosed: 1 to 2 drops into the
affected eye(s) every 4 hours for 7 to 10 days.
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Patient Education for Blepharitis
Educate about chronic nature.
Teach eyelid hygiene, warm compresses, and
occasional antibiotic use.
Counsel contact wears to refrain from wearing
contacts during acute cases.
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External Surface Ocular Infections:
Conjunctivitis
Most common cause of a red, painful eye in the
United States
Common causes
o Gram-positive Staphylococcus and
Streptococcus species and the gram-negative
Moraxella and Haemophilus species; the
adenovirus causes the majority of conjunctivitis
cases in adults.
o Allergic conjunctivitis: seasonal, vernal, and
atopic.
o Mechanical or chemical irritants.
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Diagnostic Criteria for Conjunctivitis
Hallmark: red or pink eye
Itching or burning sensation of eyes
Ocular discharge (“leaky eye”)
o Viral: profuse watery
o Bacterial: sticky purulent
Eyelids stuck together in the morning
Sensation that a foreign body is lodged in the eye;
fullness around the eye
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Initiating Drug Therapy for Conjunctivitis
Highly contagious: good handwashing and
instrument-cleansing techniques are imperative.
Etiology must be determined, as treatment is
different for bacterial, viral, and allergic
conjunctivitis.
The goals of drug therapy are to eradicate the
offending organism (for bacterial conjunctivitis), to
relieve symptoms, and to quicken the resolution of
the disease.
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Use of Antibiotics for Treating
Conjunctivitis #1
Justified because it can shorten the course of the
disease, which reduces person-to-person spread,
and lowers the risk of sight-threatening
complications.
Five to seven days of therapy with agents such as
erythromycin ointment or bacitracin–polymyxin B
ointment, or solution is usually effective.
Sulfacetamide has weak-to-moderate activity
against many organisms.
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Use of Antibiotics for Treating
Conjunctivitis #2
The aminoglycosides have good gram-negative
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; the older fluoroquinolones (ciprofloxacin,
norfloxacin, and ofloxacin) have poor coverage of
Streptococcus species, while the newer
fluoroquinolones (besifloxacin, gatifloxacin,
levofloxacin, and moxifloxacin) offer improved
gram-positive coverage.
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Use of Antibiotics for Treating
Conjunctivitis #3
 Neisseria gonorrhoeae: 250-mg intramuscular (IM) injection of
ceftriaxone (Rocephin) plus a single 1-g dose of oral
azithromycin for adults and children who weigh at least 45 kg.
Children who weigh less than 45 kg: a single 125-mg IM
injection of ceftriaxone; 25 to 50 mg/kg of ceftriaxone
intravenous or IM for neonates.
 Chlamydia trachomatis: single 1-g dose of azithromycin or 7
days of doxycycline 100 mg twice daily. Children who weigh at
least 45 kg but are less than 8 years old: single dose of
azithromycin 1 g. Neonates and children who weigh less than
45 kg: 50 mg/kg/d of erythromycin base or erythromycin
ethylsuccinate (4 doses/day for 14 days).
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Drug Therapy for Conjunctivitis
Antibiotics
Antihistamines
Mast cell stabilizers
Antihistamine/mast cell stabilizer
Nonsteroidal anti-inflammatory ophthalmic drugs
Vasoconstrictors (decongestants)
Topical corticosteroids
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Question #2
A patient presents with conjunctivitis. What is the
recommended third line of therapy for the condition?
A. Topical antihistamine
B. Low-potency topical corticosteroid
C. Ophthalmic ketorolac
D. Antihistamine/mast cell stabilizer
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Answer to Question #2
C. Ophthalmic ketorolac
Rationale: Ophthalmic ketorolac is used as a third line
of therapy for patients with conjunctivitis. Topical
antihistamines are first-line therapy. Addition of a
brief course of low-potency topical corticosteroid to
the first-line agent or for recurrent or persistent
disease: a product with antihistamine/mast cell
stabilizer properties is second-line therapy.
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Bacterial Conjunctivitis
The treatment of bacterial conjunctivitis is aimed at
the organisms Staphylococcus aureus,
Streptococcus pneumoniae, and Haemophilus
influenzae.
First-line treatments include 5 to 7 days of therapy
with erythromycin ointment (two or three times
daily) or polymyxin B–trimethoprim solution (1 drop
every 3 to 4 hours).
Therapy selection can be based on patient
preference for ointment or solution.
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Seasonal (Hay Fever) Conjunctivitis
Steps should be taken to minimize exposure to the
offending allergen.
The ophthalmic antihistamines alcaftadine or
emedastine 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.
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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.
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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.
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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.
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Dry Eye Syndrome: Keratoconjunctivitis
Sicca
Commonly called dry eye syndrome.
Can occur intermittently or chronically.
Causes: decreased tear production, increased tear
evaporation, or a combination of these factors can
initiate an inflammatory response on the ocular
surface.
Risk factors: advanced age, female gender, and a
history of LASIK surgery.
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Signs and Symptoms of Dry Eye Syndrome
Dry eye sensation
Ocular irritation
Redness, burning, and stinging
A foreign body or gritty sensation
Blurred vision
Contact lens intolerance
An increased frequency of blinking, and,
paradoxically, increased tearing
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Initiating Drug Therapy #1
Artificial tears and lubricants
Cholinergic agonists
Fatty acid supplements
Topical cyclosporine
Lifitegrast
Topical corticosteroids
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Glaucoma (Primary Open-Angle
Glaucoma)
Definition: Group of eye diseases involving optic
neuropathy characterized by irreversible damage to
the optic nerve and retinal ganglion cells.
Causes/risk factors: increase in intraocular
pressure (IOP), increased age, black race, family
history of glaucoma, thin central cornes, type 2
diabetes; degeneration of the trabecular meshwork
and Schlemm canal; decrease in aqueous humor.
Classifications: primary open-angle glaucoma
(POAG), (70% of cases) acute closed-angle
glaucoma, normal-tension glaucoma, and narrowangle glaucoma.
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Initiating Drug Therapy #2
Beta-blockers
o Betaxolol 0.25% suspension or 0.5% solution
(Betoptic S): 1 to 2 drops in the affected eye(s)
twice daily
o Carteolol 1% solution: 1 drop in the affected eye
BID
o Levobunolol 0.25% or 0.5% solution (Betagan):
1 to 2 drops once daily (0.5%) or twice daily
(0.25%)
o Metipranolol 0.3% solution (OptiPranolol): 1
drop in the affected eye(s) twice daily
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Drug Therapy for POAG #1
Beta-blockers (cont.)
o Timolol 0.25% or 0.5% solution (Timoptic,
Betimol, Istalol) or gel-forming solution
(Timoptic-XE): solution: 1 drop in the affected
eye(s) twice daily; gel-forming solution: 1 drop
in the affected eye(s) once daily
Carbonic anhydrase inhibitors
o Brinzolamide 1% suspension (Azopt): 1 drop in
the affected eye(s) three times daily
o Dorzolamide 1% solution (Trusopt): 1 drop in
the affected eye(s) three times daily
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Drug Therapy for POAG #2
Prostaglandins
o Bimatoprost 0.03% solution (Lumigan): 1 drop
in the affected eye(s) once daily in the evening
o Latanoprost 0.005% solution (Xalatan): 1 drop
in the affected eye(s) once daily in the evening
o Tafluprost 0.0015% solution (Zioptan): 1 drop in
the affected eye(s) once daily in the evening
o Travoprost 0.004% solution (Travatan Z): 1
drop in the affected eye(s) once daily in the
evening
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Drug Therapy for POAG #3
Adrenergic agonists
o Apraclonidine 0.5% solution (Iopidine): 1 to 2
drops in the affected eye(s) three times daily
o Brimonidine 0.1%, 0.15%, or 0.2% solution
(Alphagan P): 1 drop in the affected eye(s) three
times daily, approximately 8 hours apart
Cholinergic agents
o Pilocarpine 1%, 2%, or 4% solution (Isopto
Carpine): 1 to 2 drops three or four times daily
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Drug Therapy for POAG #4
Combination products
o Brimonidine and timolol 0.2% to 0.5% solution
(Combigan): 1 drop in the affected eye(s) every
12 hours
o Dorzolamide and timolol 2% to 0.5% solution
(Cosopt):1 drop in the affected eye(s) twice
daily
o Brinzolamide and brimonidine 1% to 0.2%
solution (Simbrinza): 1 drop in the affected
eye(s) three times daily
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Question #3
A patient diagnosed with glaucoma is not responding
to therapy with bimatoprost. What is the second-line
therapy recommended for this patient?
A. Travoprost
B. Ophthalmic beta-blocker
C. Brimonidine
D. Ophthalmic carbonic anhydrase inhibitor
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Answer to Question #3
B. Ophthalmic beta-blocker
Rationale: The second-line treatment for glaucoma is
substitution of an ophthalmic beta-blocker (if failure
to decrease IOP to a significant extent) or addition of
an ophthalmic beta-blocker (if IOP is significantly
decreased but not to goal). First-line treatment is
prostaglandin ophthalmic solution (bimatoprost,
latanoprost, tafluprost, or travoprost). Third-line
treatment is addition of an ophthalmic carbonic
anhydrase inhibitor or addition of brimonidine.
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Summary
There are many conditions and disorders of the eye,
but only a few, such as blepharitis and
conjunctivitis, should be diagnosed and treated by a
primary care provider.
The remaining ocular conditions are usually treated
by eye care specialists.
Nonetheless, prescribers should be familiar with
drug therapy for the more common ophthalmic
conditions (glaucoma, keratoconjunctivitis sicca), as
they are likely to encounter patients being treated
for these disorders.
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