CASE REPORT: DISCOMFORT HAS OD SEEING RED

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Fluoroquinolones helped treat this patient’s bacterial keratoconjunctivitis.

A 23-year-old Asian male presented with bilateral redness and irritation as well as thick, sticky discharge. He reported that his lids were “glued shut” upon awakening. The symptoms, he said, began several days earlier—first in the right eye, then the left—and had been worsening.

Visual acuity was 20/30 in both eyes. Both eyes had conjunctival injection with mild diffuse epitheliopathy and papillary hypertrophy.

The patient had bacterial keratoconjunctivitis for which I prescribed Novartis’ Ciloxan (ciprofloxacin 0.3%). I instructed him to instill one drop every hour and to use a saline lavage as needed. Twenty-four hours later, the discharge was gone.

DEFENSE BREAKDOWN
Bacterial keratoconjunctivitis is the result of a breakdown in the ocular defense system. An antigen-antibody reaction causes an inflammatory response to bacteria and exotoxins, which may alter corneal metabolism. Common causes include Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae and Pseudomonas aeruginosa.

The resulting discharge can be toxic to the cornea. Epithelial breakdown and erosion can occur in bacterial conjunctivitis, and when this happens it is then termed bacterial keratoconjunctivitis. Punctate keratitis comes from mucopurulent discharge.

Signs include conjunctival injection (inferior greater than superior) that may extend to the episclera, sticky mucopurulent discharge. Tarsal papillae are common, and the cornea may show punctate epithelial erosion. Symptoms include generalized ocular discomfort. When the cornea is involved, the patient may experience foreign-body sensation and decreased acuity. Heavy loads or virulent organisms may be hard to eradicate without ocular damage.

MANAGEMENT
Bacterial conjunctivitis is largely a benign, self-limiting disease, and treatment is not mandatory. Studies have shown that past three days of infection, the use of topical antibiotics shows no additional benefit.

Culture and sensitivity testing is usually time-consuming and expensive, so we reserve this only for hyperacute or unresponsive presentations. Instead, many clinicians begin treatment with broad-spectrum antibiotic therapy immediately.

Fluoroquinolones represent the best option today, particularly the fourth-generation fluoroquinolones. These include Bausch + Lomb’s Besivance (besifloxacin 0.6%), Novartis’ Moxeza (moxifloxacin 0.5%) and Allergan’s Zymaxid (gatifloxacin 0.5%).

Dosing is every two hours to four times daily depending upon the clinical presentation. Instruct the patient not to go below the recommended minimum dosing or taper off antibiotics, because this might promote resistance.

However, fourth-generation fluoroquinolones are very expensive. If the patient’s finances or insurance coverage are considerations, older-generation generic fluoroquinolones— Ciloxan, Allergan’s Ocuflox (ofloxacin 0.3%) and Santen’s Quixen (levofloxacin 0.5%)—are very effective and inexpensive. Other agents, such as Allergan’s Polytrim (polymyxin B sulfate and trimethoprim ophthalmic solution) and Alcon’s Tobrex (tobramycin), remain viable options.

Joseph Sowka, OD, FAAO, Dipl, is a professor at Nova Southeastern University in Fort Lauderdale, FL. He is chief, Advanced Ocular Care; director, The Glaucoma Service; and chair, Department of Optometric Clinical Sciences.

WHERE TO FIND IT
Alcon Laboratories
800.451.3937 | Alcon.com
Allergan
800.347.4500 | Allergan.com
Bausch + Lomb
800.828.9030 | Bausch.com
Novartis
888.669.6682 | Pharma.US.Novartis.com
Santen Inc.
855.772.6836 | SantenUSA.com

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