Oral Pharmaceutical Agents for the Treatment of Anterior Segment Pathologies
Greg Caldwell, OD, FAAO
225 Terrace Drive
Lilly, PA 15938
814-931-2030 mobile
Grubc@aol.com
Abstract
This course will review the usage of oral antibiotics and oral anti-virals for ocular
infections and oral analgesics/narcotics for ocular pain management. Practical
information regarding the identification of adverse/allergic reaction, dialysis, pregnancy
and maximum daily doses will be discussed, which are prerequisites before prescribing
oral pharmaceutical agents.
Course Objectives
 To review adverse/allergic reactions to oral medications
 To review the FDA Pregnancy Categories for medications
 To discuss renal impairment and its impact on prescribing oral medications
 To identify and review the most appropriate oral antibiotics or anti-virals for usage in
ocular infections, so one can implement a timely and effective treatment
 To review oral analgesics/narcotics for ocular pain management to ensure proper and
effective treatment
 To furnish the clinician with pearls, therapeutic options and guidance around pitfalls.
Outline
I.
Medical History
 Chief complaint
 History of the present illness
 Review of systems
 Dialysis
 Past, Family and Social history
 Current medications
 Allergies/Adverse reactions
 Pregnancy
II.
Adverse Reaction/Allergic Reaction
 Hypersensitivity
 Fever
 Rash
 Photosensitivity
 ANAPHYLAXIS
 Hematologic
 Neutropenia
2





 Eosinophilia
 Increase in PT/PTT
Gastrointestinal
 Nausea
 Vomiting
 Diarrhea
Liver failure
Central nervous system
Ototoxicity
Cardiac
 Dysrrhymia
III.
FDA Pregnancy Categories
 Category A
 Studies in pregnant women
 No risk
 Category B
 Animal studies no risk but human not adequate…or
 Animal toxicity but human studies no risk
 Safe
 Category C
 Animal studies show toxicity human studies inadequate but benefit of use
may exceed risk
 Avoid
 Category D
 Evidence of human risk but benefits may out weigh risks
 Avoid
 Category X
 Fetal abnormalities
 Risks > benefits
 Avoid
IV.
Renal Impairment
 Identify patients on hemodialysis
 Adjustment made by patient’s creatinine clearance (CrCl) ml/min
 Work with patient’s primary care physician or internist
V.
Case 1- Dacryocystitis, Preseptal Cellulitis and Bacterial Conjunctivitis
 58 year old male with red and painful OS
 Visual acuity 20/20 OD, 20/60 OS
 Picture of above conditions
 Patient is allergic to Penicillin and Keflex
 Treatment
 Polytrim gtts QID OS
 Zithromax
 1 Z-pack, use as directed PO
3



Dilation and irrigation
 Contraindication
 Indication
Confirmed nasolacrimal duct blockage, dacryocystorhinostomy DCR
Group discussion on treatment
VI.
Augmentin
 Amoxicillin and potassium clavulanate
 Kills everything, good for everyone
 12 weeks old and older
 Safe in pregnancy, category B
 Watch for Penicillin allergies
 Adults: 500mg BID (875mg BID)
 Children < 100 pounds, oral suspension 25-45 mg/kg divided into two
doses
 Covers Staph, Strep, and Haemophilus influenzae
VII.
Zithromax (azithromycin)
 Macrolide antibiotic
 Like erythromycin
 Drug of choice in Penicillin sensitive patients
 All age groups
 Safe in pregnancy, category B
 No renal adjustment
 Adults: 250mg BID, day 1 and 250mg QD, day 2-5
 Dispense: 1 Z-pack as directed
 Children <16: 10mg/kg, day 1 and 5mg/kg, day 2-5
 Covers Staph, Strep, and Haemophilus influenza
 Better tolerated than erythromycin, little GI upset
 Chlamydia, 1 gram QD
VIII.
Keflex (cephalexin)
 Cross reaction with Penicillin sensitive patients
 First generation, moderately affective against Penicillin-ase
 Good for gram +, not good for Haemophilus which is gram –
 Category B
 Adult: 500mg BID for one week
 Drug of choice for blow out fractures
IX.
Ceftin (cefuroxime)
 Cross reaction with Penicillin sensitive patients
 Second generation
 Better for Haemophilus (-)
 Children: 3 months to 12 years old, oral suspension 20-30mg/kg/day
divided into two doses
 Adults: 250mg BID for 10 days
4

Category B
X.
Cipro (ciprofloxacin), Levoquin (levofloxacin)
 End of the line antibiotic
 Really effective
 Category C
 Avoid during pregnancy
 Only use if 18 years old or older
 500mg BID for one week, Cipro
 500mg QD for one week, Levoquin
XI.
Sulfa Drugs
 Bactrim (sulfamethoxazole/trimethoprim)
 Limited use…last line of defense
 High incidence of Steven-Johnsons
 Avoid in pregnancy
 Category C
 Avoid in sickle cell disease
 Cross reaction with:
 Oral hypoglycemics
 Carbonic anhydrase inhibitors
 Celebrex
 Thiazide diuretics
 All are sulfa based
 Bactrim BID for ten days
 Bactrim DS BID for ten days
XII.
Summary
 Adults
 Augmentin
 Zithromax
 Keflex
 Cipro
 Bactrim
 Children
 Augmentin
 Zithromax
 Ceftin
 Avoid Cipro
 Bactrim
XIII.
Case 2- Rosacea Blepharitis
 48 year old male both eyes are red, gritty, sandy and dry
 Visual acuity 20/20 OU
 Show multiple pictures of rosacea, lid margins and conjunctiva
 Treatment
5






Warm compresses
Lid hygiene
Artificial tears
Doxycycline 100mg QD for at least one month
Dermatological consult
Group discussion on treatment
XIV. Vibramycin (doxycycline)
 Drug of choice for marginal inflammatory blepharitis
 Antibiotic, anti-inflammatory and anti-collagenase
 Inhibits the lipase enzyme
 Avoid in children
 Category D
 Avoid in pregnancy
 No renal adjustment
 Can enhance coumadin
 50-100mg QD for 2-12 weeks
XV.
Final Thoughts
 Penicillin, Ampicillin and Amoxicillin are of no benefit for treating ocular
infections
 Popular Penicillin derivative, Dicloxacillin 250mg QID for a week
XVI. Case 3- Varicella Zoster Virus, Herpes Zoster Ophthalmicus
 52 year old male with red and painful OD
 Visual acuity 20/30 OD, 20/20 OS
 Show multiple pictures of lids and conjunctiva
 Group discussion on treatment
XVII. Oral Anti-Virals
 Third generation, go into every cell but only activate in viral infected cells
 First generation were mutogenic
 Can be used prophalactically prior to PKP, LASIK or PTK
XVIII. Zovirax (acyclovir)
 Good for simplex
 Poor absorption
 Dosage: 800mg 5 times per day
 Maintenance dose: 200-400mg BID
 Category B
XIX. Famvir (famcyclovir)
 Proven to reduce post-herpetic trigeminal neuralgia
 Drug of choice for zoster patients 50 years old and older
 Dosage:
 Zoster 500mg TID
6

XX.
 Recurrent simplex 125-250mg BID
Category B
Valtrex (valacyclovir)
 Pro-drug of acyclovir
 GI upset
 HSV-1, HSV-2 and VZV
 Dosage: 1 g TID for one week
 Category B
XXI. Case 4- Recurrent Herpes Simplex Keratitis
 47 year old female with a red and painful OD
 Visual acuity 20/30 OD, 20/20 OS
 First episode
 Group discussion on treatment
 Second episode
 Group discussion on treatment
 Third episode
 Group discussion on treatment
XXII. Herpetic Eye Disease Study
 HEDS I
 Benefit from steroids in stromal keratitis
 No benefit from oral acyclovir in stromal keratitis
 Benefit from steroids if iritis present

HEDS II
 No benefit from acyclovir to stop progression to stromal or iridocyclitis
 Maintenance dose 400mg BID, decreases recurrence by 41% within first year
XXIII. Questions
XXIV. Thank-you