and Randall Thomas, O.D.
When Oregon passed its orals and injectables bill in late June, it became the 37th state to allow optometrists some measure of oral therapeutic prescriptive authority. Now, more than ever, we need to understand how to use all the weapons in our treatment arsenal, including oral medications.
Our job as optometric physicians is to help patients in need. In most cases we can meet these needs with topical medicines, but with some uncommon clinical conditions, optimum patient care requires an oral medication.
These medications include antibiotics, analgesics, antivirals, anti-allergy drugs, corticosteroids and carbonic anhydrase inhibitors. Here, we’ll explain how and when to use them.
Antibiotics
Doctors commonly use oral antibiotics for the following conditions:
- Internal hordeolum. Most internal hordeola respond to aggressive applications of warm soaks (10 minutes at a time, repeated at least qid). For those larger, more tender and painful hordeola, supplement heat therapy with oral antibiotics. We suggest Keflex (cephalexin) 500mg bid for patients who are not allergic to penicillin or cephalosporins.
When the patient has a penicillin or cephalosporin allergy, Zithromax (azithromycin) in a Z-pak (500mg on day one, followed by 250mg for the next four days) is a good alternative. If the patient also has allergies to macrolides, we recommend the oral fluoroquinolone Levaquin (levofloxacin) at 500mg once daily. Patients usually take oral antibiotics for seven days. - Severe external infections/preseptal cellulitis. You can use the same approach with severe bacterial infections or preseptal cellulitis. However, a Neisseria gonorrhoeae infection that causes a hyperactive conjuncti- vitis is best treated with Rocephin I.M. (ceftriaxone sodium).
- Chlamydial conjunctivitis. This form of conjunctivitis, also known as adult inclusion conjunctivitis, is a unique presentation often characterized by a unilateral, mild to moderately injected eye, with giant follicles in the inferior forniceal conjunctiva and marked papillary hypertrophy of the superior palpebral conjunctiva. Most of these patients are sexually active, between the ages of 15 and 35, and are asymptomatic. Another management measure: Suggest the patient’s sexual partner be tested and/or treated.
Since chlamydial (adult inclusion) conjunctivitis fails to respond to topical antibiotics, treat with a macrolide antibiotic, such as Zithromax 1,000mg in a single dose. - Chronic meibomianitis. Blepharitis can be subdivided into anterior and posterior varieties. Posterior blepharitis is synonymous with meibomianitis, a common cause of tear film dysfunction. Oral doxycycline can be helpful for those patients with “evaporative” dry eye disease and chronic, inspissated (plugged) meibomian glands. Prescribe it at 200mg for one month, then 100mg for about 6-8 months.
Analgesics
Corneal abrasion and recurrent epithelial erosions are by far the most common conditions that cause pain. You can manage most ocular surface pain with cycloplegics and pressure patching, or bandage soft contact lens. However, patients with extensive surface damage and/or low pain tolerance thresholds may require supplemental oral analgesics for 1-2 days until epithelial healing occurs. Such analgesia can range from OTC products to Schedule II narcotics.
In these circumstances, we generally advise patients to take what they usually do for headache or dental pain. When patients ask us specifically, we usually recommend 400mg of ibuprofen qid, taken with meals.
We occasionally prescribe Ultram (tramadol hydrochloride) or Vioxx (rofecoxib). On rare occasions, we may prescribe Schedule III narcotics such as Lortab or Vicodin (hydrocodone/acetaminophen combinations) or stronger Schedule II narcotics such as Tylox or Percocet (oxycodone/acetaminophen combinations) for very severe pain. Prescribe all these analgesics for three days at the most, or about 12 tablets. With such short-term use, you should have no concerns about their addictive potential.
Antivirals
These drugs are mandatory for treating varicella-zoster disease, and can be immensely helpful in cases of herpes simplex disease. There are three antivirals: Zovirax and generics (acyclovir), Valtrex (valacyclovir) and Famvir (famciclovir). All are safer than aspirin; their most common side effect is occasional mild nausea.
Since these drugs are activated only by virally infected cells, they have extremely low toxicity, which explains their enhanced safety profile. These medications are most effective when taken within three days of the onset of disease. However, prescribe a therapeutic course even if the patient has gone a week or so without care.
Since shingles is the main disease for which doctors prescribe oral antivirals, the standard doses are set for treating zoster disease. Herpes simplex is a weaker virus and about twice as easy to kill as zoster. So, there are two dosing protocols for these drugs. Prescribe acyclovir, because of its relatively short half-life, five times a day; use the remaining two antivirals tid. Prescribe all for seven days. Refer to the table above for dosing.
In cases of herpes simplex disease, topical Viroptic (trifluridine) remains the standard and accepted drug of choice for epithelial keratitis. However, if the patient is allergic to Viroptic, you can use either Vira-A (vidarabine) ophthalmic ointment or an oral antiviral effectively.
Anti-Allergy Medications
Most patients who present with a chief complaint of “itchy eyes” have pure allergic conjunctivitis. But some have concurrent allergic sinusitis and/or rhinitis. Here’s where oral antihistamines can help.
We rarely prescribe this class of drugs, but there are patients who will occasionally require oral therapy to subdue their allergic disease expression. The three drugs we would consider in these situations:
- Zyrtec (cetirizine) 5mg or 10mg qd.
- Claritin (loratadine) 10mg qd.
- Allegra (fexofenadine) 180mg qd.
Corticosteroids
While the side-effect potential for this class of drugs is notorious, these concerns are minimal for short-term use. Occasionally, patients need oral steroids just to regain tissue normality.
Conditions to consider the use of corticosteroids are:
- Facial/periocular poison oak/ivy exposure.
- Orbital pseudotumor.
- Hyperacute allergic blepharodermatitis.
- Contact blepharodermatitis that does not respond to a topical ophthalmic steroid.
- Recalcitrant anterior uveitis.
- Recalcitrant episcleritis.
Before you prescribe oral corticosteroids, ask the patient three straightforward questions:
Consult with the patient’s primary-care physician or obstetrician if he or she answers yes to one or more of these questions. If the answers are negative, prescribe 40-60mg of prednisone.
Corticosteroids are almost always dispensed as 10mg tablets. A typical dosing schedule is four tablets po for two days, then two tablets po for two days, then one tablet po for two days. When you prescribe 60mg or less per day, the patient can take the total dose at one time. At 80mg a day or more, divide the dosage to bid.
There is a current trend in general medicine to do short-term, corticosteroid pulse therapy without taper. For example, a patient who was exposed to a noxious substance presents to your office. Her right eyelid is swelling shut, and there is periorbital and facial swelling on the right side. After you confirm allergic disease, prescribe a corticosteroid at 60mg for one day, then 40mg for one day, then discontinue medication to address acute swelling (along with the use of cold compresses). As with all diseases, individualize therapy to the patient. Carbonic Anhydrase Inhibitors If the patient is not sulfa-allergic, give two 250mg tablets of Diamox (acetazolamide) as your first step in reducing IOP in angle closure, or any other form of acute IOP increase. (Since Diamox 500mg Sequels are time released, don’t use them for acute situations when you need rapid drug loading.) If (and only if) the patient is sulfa-allergic, employ an orally administered hyperosmotic agent such as Osmoglyn (50% glycerin) to treat acute angle closure.
If achieving target IOP requires oral therapy for chronic glaucoma patients, consider Neptazane (methazolamide) 25mg bid. Neptazane has a relatively enhanced safety profile for chronic care compared with other oral CAIs.
If your state law prohibits your use of these oral agents, simply get written “standing orders” from the patient’s primary care physician or consulting ophthalmologist for managing angle closure.
Every eye physician in the world should have acetazolamide 250mg tablets in the office. Just as we would not embark on an automobile trip without a spare tire, we would not be in our practices without acetazolamide tablets.
There are many instances in which we can enhance patient care through the use of oral medications. Of course, topicals are the mainstay for managing ocular disease, but we occasionally need orals for some of the challenging cases in clinical care. We must be as prepared as possible to meet the needs of our patients, and oral medications are another important weapon in our disease-management arsenal.
Drs. Melton and Thomas lecture extensively on eye disease and ocular pharmacology. They are the authors of Review of Optometry’s Clinical Guide to Ophthalmic Drugs.
We rarely use this class of medicines in chronic care, but they can be tremendously helpful in managing acute IOP spikes of any origin. Doctors most commonly use CAIs for acute angle-closure glaucoma.
Like many oral hypoglycemic (anti-diabetic) medications, these drugs are sulfonamide derivatives. So, always ask patients before using or prescribing these agents if they’re allergic to sulfa drugs.
