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Home , Blepharitis, Herpes simplex keratitis, Neonatal conjunctivitis, Onchocerciasis

Practical Therapeutics

Drugs 15: 310-316 (1978) © ADIS Press 1978

Eye and : Treatment and Prevention

Francis P. Furgiue/e

University of Pennsylvania Medical School. Scheie Eye Institute. Philadelphia

The scope of ocular and lid infections is too wide the scalp and often, but not always, treatment of the to permit a discussion of all existing entities. This ar­ scalp with antiseborrhoeic shampoos (e.g. selenium ticle places emphasis on the common ocular problems sulphide or other keratolytics) will ameliorate the and their treatment in the geographic area and ex­ eyelid . Treatment for the lids them­ perience of the author. It will not discuss some rare as selves can be accomplished by the use of a mild sham­ well as widespread and important causes of blindness, poo, such as Johnson's baby shampoo, once daily, de­ such as (river blindness), pending on severity. Copious warm soaks are also and leprosy. helpful. Staphylococcal contamination is common. Staphylococcal presents with lid hy­ peraemia and frequent ulcerations of the lid margin 1. Inflammation of the Lids (Blepharitis) from staphylococcal toxins. The lids are matted together on awakening and symptoms of burning, Inflammation of the is known as watering and are common. Underlying blepharitis, which may have a variety of causes. The seborrhoea is usually an associated fmding and cor­ most common forms are: seborrhoeic, staphylococcal neal complications include marginal infiltrates or and angular. Acute, tender, localised swellings are ulcers. Treatment with IS % sodium sulphacetamide generally the result of either chalazions or sties. Un­ drops 4 times daily or 0.5 % solu­ commonly, parasitic by lice or tion instilled 4 or 5 times daily is helpful. Local cor­ folliculorum may be encountered. ticosteroids such as dexamethasone or prednisolone, 2 to 4 times daily, may be added if corneal complica­ tions due to hypersensitivity are present. 1.1 Common Forms of Blepharitis Angular blepharitis is characterised by inflamma­ tion of the outer angles, redness, oedema and fissures. Seborrhoeic blepharitis is characterised by large, The agent often responsible is the Morax-Axenfeld greasy scales at the base of the cilia and represents a Gram-negative rod which responds to sulph­ dysfunction of meibomian secretion. The condition is onamides, zinc sulphate, or gentamicin, topically ap­ frequently associated with seborrhoeic of plied several times daily. Eye and Eyelid Infections 311

1.2 Other Types of Blepharitis cated deeper and away from the lid margins. Chalazions generally do not respond to Viral blepharitis is caused by , therapy. They should be incised and curetted under herpes roster, and . local anaesthesia with 1 % lignocaine. Herpes simplex produces a vesicular eruption which Parasitic by the pubic louse Phthirus breaks down and forms yellow crusts. Herpes zoster pubis is characterised by itching, redness and excoria­ presents a similar picture but follows the distribution tions of lid margins. Usually nits and adult lice are of the first and second division of the trigeminal visible with magnification. It is associated nerve. Molluscum contagiosum forms a small skin with infestation of the skin or pubic area. is nodule with an umbilicated centre and secondarily often by sexual contact or fmger transmissions. produces a follicular . Parasitic infections respond to the application of gam­ Treatment of herpes simplex blepharitis is ma benzene hexachloride cream to the lid margins. generally supportive as it tends to heal within 10 days Repeat in S to 7 days. The shampoo of the same drug and is apt to recur. Herpes zoster has no specific should be used for the pubic and abdominal skin therapy except that concentrated gamma globulin areas. Application of 1 % physostigmine or 3 % may be helpful if and are also present. amoniated mercury to the lid margins 2 or 3 times Molluscum skin nodules may be expressed daily is also effective, but the former will produce un­ mechanically or treated with light application of comfortable side-efTects due to ciliary spasm and electric cautery. . Cryoapplication has also been recommended. Vaccinia involvement of the lids is usually due to Demodex folliculorum also produces itching, pri­ auto-innoculation following , generally marily at night. The organisms can be expressed from within the first week. If the is involved, treat­ meibomian glands where they reside. They can be ment should consist of hyperimmune gamma seen under microscopic examination. Treatment is as globulin administered systemically. Prevention of for pubic louse infection. local secondary infection with a topical antibiotic is also indicated. Hordeolum is an infection due to Staphylococcus 2. Conjunctivitis aureus of the lid margin involving the glands of Moll or Zeiss. It presents as an acute swelling, markedly 2.1 General Considerations tender with a point of suppuration. Treatment should be aimed at promoting drainage. Hordeola or sties Conjunctivitis has a myriad of causes. Aetiological should be incised and drained if treatment with hot and epidemiological patterns of conjunctivitis vary in water applications fails to promote drainage. Local different parts of the world. For example, adenovirus are probably of little value. Systemic anti­ type 8 is in and children in Japan, biotics such as ampicillin (SOOmg 4 times daily) or while in North America the virus causes epidemic (SOOmg every 8 hours) are warranted , primarily in adults. The causes when multiple, large hordeola or sties are recurrent of conjunctival inflammation are mechanical, bac­ or they have not responded to local measures to pro­ terial, viral, rarely fungal, and uncommonly, self-in­ mote drainage. Staphylococci harboured in the nose duced in neurotic individuals. Anatomical predisposi­ may be a source of reinfection. Underlying diabetes tion includes eyes with pronounced vasculature, pro­ should be ruled out. minent globes, and vasomotor disorders, which cause is an annoying, chronic, granulomatous a hyperaemic response of the to minimal inflammation of meibomian glands. It may be present stimuli, environmental dust or pollution, lack of sleep for many weeks or several months. Usually, it is 10- and fatigue. These eyes are often subjected to anti- Eye and Eyelid Infections 312

biotics and/or vasoconstrictors without permanent Chemical conjunctivitis may result from reaction benefit from either , as the condition is to silver nitrate instillation for prevention of gonor­ neither infectious nor an expression of disease. These rhoeal ophthalmia. Smears and cultures of the con­ patients require simple reassurance and the advice junctiva are negative. The condition is mild and self­ that topical will not cure the 'bloodshot limited. appearance' .

2.3 Conjunctivitis in Children and Adults 2.2 Bacterial conjunctivitis: In children and adults, Smears and conjunctival cultures are mandatory bacterial causes are usually due to staphylococci, in cases of neonatal conjunctivitis. streptococci, and pneumococci, uncommonly Koch­ Gonococcal infection: This is a hyperacute con­ Weeks bacillus (Haemophilus aegyptius), and rarely junctivitis with marked lid hyperaemia and purulent Corynebacterium (diphtheria), Mycobacterium and discharge, which usually occurs within the first 24 to Neisseria species. Aetiological diagnoses are made by 72 hours postpartum. A Gram stain of conjunctival smears and cultures. Most cases of bacterial con­ tissue scraping will reveal Gram-negative intracellu­ junctivitis usually respond to topical treatment by one lar diplococci, even before the discharge is positive. or more of the following: sulphafurazole (sulflsox­ Numerous pus cells are found in the exudate. Corneal azole); 15 % sodium sulphacetamide; 0.5 % chlor­ ulceration and perforation are dangerous complica­ amphenicol; or combinations of or gra­ tions. micidin and polymyxin and . Usually, the Treatment should include drops (10,000 resistant or persistent cases of inflammation are then units/mt) every I to 2 hours, or ointment subjected to laboratory investigation by smears and instilled every 2 hours combined with systemic cultures. Bacterial conjunctivitis is usually purulent penicillin G given intramuscularly. Ampicillin or and in the case of infection due to ~-haemolytic strep­ amoxycillin may be used as an alternative to penicillin tococci and Corynebacterium organisms, produces a G. Gonorrhoeal ophthalmia is prevented by the use of membranous and pseudomembranous conjunctivitis. I % silver nitrate in the eyes of the newborn im­ Viral causes of conjunctivitis are usually those as­ mediately after birth. sociated with the viruses, which pro­ Inclusion conjunctivitis is now known to be due to duce a watery or catarrhal mucoid discharge. These chlamydia oculogenitalis (TRIC) agent but is difficult are self-limited and may be treated with a topical to isolate on culture. There is purulent discharge with sulphonamide to prevent secondary infection. In­ less severe inflammatory signs. Onset is usually 5 to fluenza and Newcastle viruses may produce associ­ 12 days postpartum. Smears show cytoplasmatic in­ ated conjunctivitis with negative cultures and a self­ clusion bodies in cells stained with Giemsa; no bac­ limited course. teria are seen. Topical sulphonamides or tetracycline Adenoviruses produce a follicular conjunctivitis. ointment, 4 or 5 times daily, is usually sufficient Associated corneal involvement occurs with type 8 treatment. EKC (epidemic keratoconjunctivitis). Infection may Staphylococcal and Pseudomonas organisms are be unilateral with preauricular adenopathy, corneal causes of conjunctivitis in newborn and prematures inflltrates and a purulent sterile discharge. Rising which may result in and death. Diagnosis serum antibody titres assist in the laboratory diag­ is established by eye cultures. Pseudomonas may pro­ nosis. The eye discharge from adenoviral infections duce an , panophthalmitis, sep­ are highly contagious and spread by fingers and tox­ ticaemia and death. ometers contaminated by contact with the infected pa- Eye and Eyelid Infections 313

tient. Medical personnel tend to transmit the disease. diagnosis by laboratory methods; stains, scrapings, Thus, disposable cotton applicators to examine the and smears of conjunctiva and cultures. eyes followed by thorough washing of the examiner's hands, with sterilisation of instruments making con­ tact with the eye, are important measures in preven­ 3. Corneal Infections tion and spread of this disabling disease. There is no specific cure. Topical antibiotics prevent secondary 3.1 Treatment of Corneal Infection infection and low dose tend to control the subepithelial corneal inflltrates. For example: Keratitis and may arise from trauma 10% sulphacetamide, 0.2 % prednisolone, 0.12 % to the eye following fmgemail scratches, abrasions, phenylephrine (Blephamide) or 4 % sulphafurazole foreign bodies, contact lenses, and so on. combined with 0.125 % prednisolone, either used 4 Bacterial keratitis: The most virulent bacteria pro­ times daily, may be helpful but should be tapered off ducing corneal ulcer and leading to perforation are: as the disease abates. Pseudomonas aeruginosa, ~-haemolytic streptococci, Viral follicular conjunctivitis must be differenti­ gonococci, pneumococci and Staph. aureus. There is ated from other TRIC agents. Trachoma involves an associated purulent exudate (hypopym) in the an­ follicular changes of the upper lid, primarily with in­ terior chamber. Scrapings of the ulcer margin should volvement of the superior cornea which contains in­ be obtained for smears and cultures on appropriate filtrates and micropanus. Smears of the expressed media (blood agar, thioglycolate and beef heart infu­ follicle material show characteristic cellular inclusion sion broth and Sobauraud's). bodies. Adult inclusion conjunctivitis is spread by Immediate treatment necessitates use of a com­ contact of contaminated genital secretion with the bination of drugs aimed at the most frequent causa­ eye. The disease is less severe and corneal complica­ tive organisms mentioned above. The highest antibac­ tions less frequent. Treatment consists in topical and terial ocular tissue levels are obtained by subcon­ systemic sulphonamides and tetracycline antibiotics. junctival or subtenon injection administered daily. A The ointment forms may be applied 4 times daily to 27 gauge needle on a tuberculin syringe is used to the eyes and I to 1.5g systemic tetracycline daily for draw up 0.5ml of the antibiotic and the conjunctiva periods of 3 to 6 weeks or longer in the case of anaesthetised with a local anaesthetic such as 8 or I 0 trachoma. drops of amethocaine (tetracaine), piperocaine or Chronic conjunctivitis is often the aftermath of as­ proxymetacaine (proparacaine). While the patient sociated chronic staphylococcal blepharitis and fre­ looks up, the needle point is engaged just beneath the quently the result of over-medication in an attempt to bulbar conjunctiva near the cul-de-sac where it is relieve 'bloodshot eyes', which are not the result of in­ loosely bound. The injection is made slowly, as rapid fection (section 1.1). Many chronically inflamed eyes distension of the tissues causes marked pain. The are due to toxic or rebound effects of the tissues in doses for this route (table I) are administered daily response to preservatives, vasoconstrictors or vehicles over a period of 7 to 10 days. contained in eye medications, if not the antibiotic it­ Topical antibiotic drops are also given, such as self. Chief offenders are the aminoglycosides, chloramphenicol 0.5 %; gramicidin, polymyxin, neo­ neomycin and gentamicin; benzalkonium chloride; mycin; sodium sulphacetamide, etc. One or more of adrenaline (epinephrine) derivatives; and dispersing these may be given 2 drops every hour or two. Cyclo­ agents such as methylcellulose and polyvinyl alcohol. plegics such as I % or 0.25 % hyoscine are It is best to stop all medication for several days when given I drop 4 times daily to control uveitis and pre­ progress is lacking and symptoms persist. Efforts vent adhesions (). I 0 % acetyl cysteine or should then be directed to established aetiological 0.5 % calcium or sodium edetate may also be used to Eye and Eyelid Infections 314

Table I. Dosage of antibiotics in corneal infections 60mg of prednisone in 4 divided doses daily, tapering off rapidly as improvement is noted). Antibiotic Subcon- Intra· Parenteral Syphilitic keratitis is generally congenital and oc­ junctival vitreal curs in acquired syphilis only in abo?t 3 % of cases or Ampicillin 100mg 2-4g q 4h less. The clinical picture is that of a deep inflamma­ ( 150-200mg/ tion involving the major part of the corneal kg/day) parenchyma. Uveitis is invariably associated. There Bacitracin 10,OOOu 500- 25,OOOuq 6h are other stigma of congenital syphilis (Hutchinson's (1mg) 1000u teeth, deafness, depressed saddle-shaped bridge of the Carbenicillin 100mg 2mg 2-6g q 4h nose) that help differentiate it from other types of in­ (400-5OOmg/ terstitial keratitis (viral, lymphopathia venereum, kg/day) , etc.). Treatment requires intramuscular Cephaloridine 100mg 0.25mg 0.5-1g q 6h penicillin G 1 mega u daily over a week to 10 days. Topical corticosteroids every hour or by daily subcon­ Chloram- 1mg 1-2mg 0.25-0.75g q 6h phenicol (5Omg/kg/ day) junctival injection must be given in addition to cycloplegics to control the severe keratitis and associ­ Colistin 25mg O.lmg 1.5-5.0mg/ kg/day ated uveitis. Ocular therapy may extend for many weeks or months. 20-4Omg O.4mg 3-5mg/kg/day Gentamicin Fungus keratitis is usually a chronic, indolent, Methicillin 100mg 1-2mg 1-2g q 4h corneal infection generally following trauma to the Neomycin 250-500mg 2.5g eye by plant or vegetable matter. Characteristically,

Penicillin G 0.5- 1000- Usual dose- the ulcer appears dry with irregular borders, elevated 1megau 4000u 600,OOOu margins, and satellite lesions. Diabetics and patients to 1.2mega u/ who have had immunosuppression are likely candi­ day dates for fungus infection. It may also arise from Large dose - pretreatment of an ocular infection with prolonged 1O-12mega u use of antibiotic- combinations which Polymyxin B 5-10mg O.lmg 1.5-2.5mg/ allow opportunistic organisms to become invasive. kg/day Species of fungi encountered vary but include Tobramycin 20-4Omg 0.5mg 3-5mg/kg/day Asperigillus, Candida, Furarium, Penicillium, Vancomycin 15-25mg 0.5-1g/12h Volutella, and others. The generally available systemic antifungal agents such as amphotericin B are highly toxic, and topical application to the eye is generally poorly penetrating: inhibit collagenase enzymes which destroy corneal The topical agents available are collagen and lead to perforation. (pimaricin), 1 % clotrimazole, and amphotericin B While treatment seems drastic, the corneal and are usually given every 2 hours. Recent reports pathology is rapidly destructive, often leading to per­ show that and amphotericin B act syn­ foration and loss of sight, despite intensive therapy. ergistically against Candida infection. At present, Systemic antibiotic therapy requires maximum therapy of fungus keratitis is disappointing due to the dosage and when instituted, it is necessary to watch limited availability of effective systemic agents which for toxic side-effects. The destructive tissue damage are fungicidal and non-toxic. by toxins elaborated during the inflammatory course Viral keratitis: Treatment is aimed at the offending may be prevented by systemic or oral steroids (e.g. virus agent. will respond to Eye and Eyelid Infections 315

ODU) given as drop~ every 2 to 3 hours Table 11. Summary of the prevention and treatment of lid over a period of 1 week. If there is no improvement, inflammation (adenine arabinoside, ARA A, Vira A) can Prevention of lid inflammation be used 5 times daily and gradually tapered ofT after 2 1. Improve general hygiene. weeks or more, depending on clinical improvement. 2. Mechanical removal of oily scales from lid margin in cases Triflorothymidine 4 or 5 times daily may be of chronic seborrhoeic blepharitis. substituted if previous treatment fails. If drug therapy 3. Avoid rubbing lids with dirty fingers. is unavailable, one may instil topical piperocaine or 4. Shampoo scalp and lid margins. 5. Correct refractive errors in chronic recurring chalazions. amethocaine anaesthetic drops, and mechanically 6. Treat sexual contacts in cases of pubic lice infestations. swab the affected area with half strength tincture of iodine which is then neutralised with 4 % Treatment of lid inflammation cocaine. 1. Seborrhoeic blepharitis: Selenium sulphide shampoo to Topical corticosteroids should be avoided when scalp and lid margins daily or bi-weekly depending on severity. treating dendritic keratitis due to herpes simplex. 2. Angular and staphylococcal blepharitis: Bacitracin, They act to spread the disease and allow stromal inva­ chloramphenicol or erythromycin ointment applied 4 times sion. Only in chronic recurrent cases of deep herpetic a day and warm water compresses twice daily. keratitis, when severe iritis and inflammation cannot be controlled, should low dose steroids be used and then only a drop or two daily of 0.125 % pred­ nisolone or 0.05 % dexamethasone. The steroid should be employed in addition to antiviral agents Early diagnosis is important. Aqueous and such as idoxuridine or vidarabine. vitreous tap is mandatory for smear and culture in Herpes zoster keratitis has no known specific most, if not all, cases of suspected . treatment. Control of inflammation with 0.125 % Direct intravitreal injection of antiobiotic (as well as prednisolone 3 or 4 times daily may be combined subconjunctival in desperate cases) may be made im­ with cycloplegics to control uveitis. A topical mediately following vitreous tap. Dosage is listed in sulphonamide helps reduce secondary infection. table I. Daily periocular injections produce higher Corneal infection by or varicella viruses drug levels than the systemic route of administration. have no specific antiviral therapy. Treatment is sup­ Overwhelming intraocular infection may benefit portive. Relief of photophobia and prevention of sec­ from removal of the infected fluid by vitrectomy, ondary bacterial infection depend on severity and where such facilities as a vitrector are available. degree of ocular involvement. Systemic corticosteroids are warranted early (within Endophthalmitis may be endogenous or ex­ the first 48 hours of therapy) to counteract inflam­ ogenous. The latter frequently follows accidental matory damage to the and other tissues. trauma or intraocular , such as ex­ Prevention of endophthalmitis is better than cure. traction. Staph. aureus is the predominant cause Strict asepsis should be attained in the operating room followed by Pseudomonas, Proteus, and Escherichia with meticulous attention to surgical procedure, solu­ coli as less frequent offenders. Treatment is similar to tion and instrument sterility. A subconjunctival injec­ that of the management of bacterial corneal ulcers, tion of antibiotic at the end of the surgical procedure, omitting collagenase inhibitors. Fungal endoph­ followed by daily topical antibiotic medication, will thalmitis usually occurs as a metastatic spread in pa­ reduce the chance of developing endophthalmitis. tients who have been immunosuppressed or in indi­ Sterile cotton and solutions should be used, and the viduals previously treated with antibiotic and corti­ hands washed prior to redressings in the immediate costeroid therapy. postoperative period. Eye and Eyelid Infections 316

3.2 Prevention of Corneal Ulcers solutions to irrigate foreign bodies or remove debris. Do not use topical corticosteroids in suspected viral or Corneal ulcers may be prevented by prophylactic fungal infections and avoid prolonged topical anti­ use of antibacterial agents in cases of minor trauma to biotic-steroid combinations. the eye. Strict attention to aseptic technique is impor­ tant. Use disposable cotton applicators to examine eyes suspected of infection, washing the hands Author's address: Dr Francis P. Furgiuele. 5430 Greene thoroughly before and after examination. Use sterile Street. Philadelphia, Pennsylvania 19144 (USA).