PHRM 541 Dry Eyes and Conjunctivitis

Define conjunctivitis

Inflammation of the transparent membrane that lines your eyelids and eyeball

What are symptoms of conjunctivitis?

Redness, irritation, itching, discharge or mild pain

What can cause conjunctivitis?

Allergies, viruses, bacteria, and other secondary causes like toxic conjunctivitis or systemic infection

What is the onset of acute bacterial conjunctivitis?

Hours to days

What are gram positive bacteria that can cause acute bacterial conjunctivitis?

Staphylococcus aureus and streptococcus pneumoniae

What are gram negative bacteria that can cause acute bacterial conjunctivitis?

Haemophilus influenzae

What are clinical signs and symptoms of acute bacterial conjunctivitis?

Red uncomfortable eyes

Lid adhesion in the morning

Purulent discharge

What is the only infectious conjunctivitis that is not self limiting?

Gonococcal conjunctivitis (Neisseria gonorrhea)

What agents are used for the treatment of hyperacute bacterial conjunctivitis (gonococcal)?

SYSTEMIC TREATMENT

Ceftriaxone IM

Topical FQ or bacitracin

Doxycycline PO

Azithromycin PO

What is the general approach to bacterial conjunctivitis treatment?

EMPIRIC APPROACH = broad spectrum antibiotics

Self limited

Treatment reduces spread of disease and recovery time

What are broad spectrum agents used for bacterial conjunctivitis?

Polytrim solution

Polysporin ointment

Erythromycin or bacitracin ointment (G+)

Tobramycin/Gentamicin

Fluoroquinolones

What are pros of eye drops?

Little impact on vision

Work effectively

Easy to instill

What are cons of eye drops?

Crying can wash them out

May sting

Some people just can't do it

What are pros of eye ointment?

Effective

Long contact time

Can instill while kids sleep

What are cons of eye ointment?

Can blur vision

Uncomfortable and sticky

Hard for some to instill themselves

What are indications for polymyxin B combination antibiotics?

Polymyxin B = gram (-)

TMP/gramicidin/neomycin = broad spectrum

Bacitracin = gram (+)

What are indications for aminoglycoside antibiotics?

S. aureus/S. epidermidis

Tobramycin = more effective against P. aeruginosa

What are indications for fluoroquinolone antibiotics?

Pseudomonas coverage

Describe the relationship between fluoroquinolone generation and gram positive and pseudomonas coverage

4th gen = more gram (+) coverage

Later the generation, the more pseudomonas coverage

What are indications for macrolide antibiotics?

Gram (+) and some gram (-)

What is notable about acute bacterial conjunctivitis treatment with sulfonamides?

Significant resistance exists

What usually causes viral conjunctivitis?

An adenovirus

What are clinical signs and symptoms of viral conjunctivitis?

Lymphadenopathy

Pinkish/purplish red conjunctiva

Mild-severe discomfort

May have associated corneal infiltrates of fever/sore throat

PROFUSE tearing = risk of infection spreading

What is critical for preventing the spread of viral conjunctivitis?

Nonpharmacologic measures

What is the general approach to treatment of viral conjunctivitis?

PALLIATIVE TREATMENT = cool compresses, artificial tears

Control the spread of infection

What pharmacologic therapy is available for viral conjunctivitis?

NONE

What type of hypersensitivity is allergic conjunctivitis?

Type 1

What causes itching and hyperemia associated with allergic conjunctivitis?

H1 and H2

What causes cellular infiltration, vasodilation, and mucous secretion associated with allergic conjunctivitis?

Prostaglandins and leukotrienes

What is the hallmark symptom of allergic conjunctivitis?

Itching

What is the general approach to allergic conjunctivitis treatment?

STEP TREATMENT for symptom relief

Block and/or stabilize histamine receptors

Prevention of exposure to allergens

What are pharmacologic therapy options for allergic conjunctivitis?

Antihistamines

Antihistamine/mast cell stabilizer

Topical NSAIDs or steroids

Cool compresses and dilution of allergens with artificial tears

Describe treatment for allergic conjunctivitis with minimal symptoms

Artificial tears

Describe treatment for allergic conjunctivitis with mild symptoms

Topical antihistamine or antihistamine/decongestant

Describe treatment for allergic conjunctivitis with mild-moderate symptoms

Mast cell stabilizer or antihistamine/mast cell stabilizer combination

Describe treatment for allergic conjunctivitis with moderate-severe symptoms

Short term corticosteroids or immunotherapy that may be used in conjunction with antihistamine/stabilizing drops

How often are mast cell stabilizers administered?

BID to QID depending on the agent

Nedocromil sodium = BID

Lodoxamide trimothomene = BID to QID

Cromolyn sodium = QID

Which antihistamines also have mast cell stabilizer activity?

Ketotifen

Epinastine

Olopatadine

Cetirizine

What are side effects of medications for allergic conjunctivitis?

Stinging

Burning

Dryness

Blurred vision

Dysgeusia

What are topical steroids used for in allergic conjunctivitis?

Inflammation

Pain

What are risk factors for dry eyes?

Increasing age

Female gender

Environment

Hormones

LASIK surgery

Eyelid disease

Connective tissue/autoimmune disease

What is the general approach to treatment of dry eyes?

STEP TREATMENT

What is the mainstay of treatment for dry eye?

TEAR REPLACEMENT = drops, ointments

TEAR RETENTION = punctal occlusion

Describe treatment for dry eye with mild symptoms

Emollient or solution artificial tears PRN to QID

Describe treatment for dry eye with moderate s/sx

Non preserved artificial tear preparations QID or more

Qhs gel drops or ointment

Consider environmental factors and humidity control

Describe treatment for dry eye with moderate to severe s/sx

Above plus punctal occlusion

Immunomodulators/steroids

Autologous serum

Amniotic membrane

What is the dosing frequency of cyclosporine for dry eye?

BID (0.05% and 0.09%)

What is the dosing frequency of lifitegrast 5% for dry eye?

BID

What is the dosing frequency of loteprednol etabonate 0.05% for dry eye?

QID dosing

What are nonpharmacologic therapies for dry eye?

Environmental modifications

Lid hygiene and warm compress

Smoking cessation

Medication review

Punctal occlusion