Corneal Ulcer and Ulcerative Keratitis in Emergency Medicine Medication

Updated: Aug 05, 2019
  • Author: Jesse Borke, MD, FACEP, FAAEM; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

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Anesthetics

Class Summary

Anesthetics are indicated for pain relief and for conjunctival and corneal scrapings. Local anesthetics stabilize the neuronal membrane and prevent the initiation and transmission of nerve impulses, thereby producing the local anesthetic action.

Proparacaine

Has a rapid onset of anesthesia that begins within 13-30 sec after instillation. Short duration of action (about 15-20 min). Since prolonged eye anesthesia can eliminate the patient's awareness of mechanical damage to the cornea, do not use outside of the ED. Frequent use of anesthetics may retard healing.

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Antibiotics

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Cefazolin

First-generation cephalosporin antibiotic for gram-positive bacterial coverage. Commonly used in combination with an aminoglycoside to achieve broad-spectrum coverage.

This 50-133 mg/mL solution must be compounded.

Gentamicin (Gentak)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with a first-generation cephalosporin.

Erythromycin (PCE, Ery-Tab, Erythrocin Lactobionate, E.E.S.)

Indicated for treatment of infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Ciprofloxacin ophthalmic (Ciloxan)

Bactericidal antibiotic that inhibits bacterial DNA synthesis, and consequently growth, by inhibiting DNA gyrase in susceptible organisms.

Indicated for pseudomonal infections and those due to multidrug-resistant gram-negative organisms.

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Antirheumatic, disease-modifying agents

Class Summary

These agents are used in the treatment of rheumatoid arthritis associated corneal ulcer.

Infliximab (Remicade, Inflectra, Renflexis)

Chimeric anti-tumor necrosis factor alpha monoclonal antibody. Neutralizes cytokine TNF-alpha and inhibits its binding to TNF-alpha receptor. Mix in 250-mL normal saline for infusion over 2 h. Must use with low-protein-binding filter (1.2 micron or less). Indicated to reduce signs and symptoms of active ankylosing spondylitis.

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Cycloplegics

Class Summary

Instillation of a long-acting cycloplegic agent can relax any ciliary muscle spasm that can cause a deep aching pain and photophobia.

Cyclopentolate (Cyclogyl)

Blocks the action of acetylcholine at parasympathetic sites in the smooth muscle, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).

Atropine ophthalmic

Blocks the action of acetylcholine at parasympathetic sites in the smooth muscle, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).

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Antifungals

Class Summary

Broad-spectrum antifungal agents that cause minimal pain and corneal irritation are recommended. Natamycin is the first-line treatment in fungal infections of the cornea. Candidal infections refractory to natamycin may respond to voriconazole, amphotericin B, miconazole, fluconazole, and ketoconazole. Topical application of these drugs, however, is somewhat limited because most of them must be compounded.

Natamycin (Natacyn)

Predominantly fungicidal tetraene polyene antibiotic, derived from Streptomyces natalensis that possesses in vitro activity against a variety of yeast and filamentous fungi, including Candida, Aspergillus, Cephalosporium, Fusarium, and Penicillium species. Binds fungal cell membrane forming a polyene sterol complex that alters membrane permeability and depleting essential cellular constituents. Activity against fungi is dose related, but it is not effective in vitro against gram-negative or gram-positive bacteria. Generally, therapy should be continued for 14-21 d or until the fungal keratitis has resolved. In many cases, reducing the dosage gradually at 4-7 d intervals may help ensure that the organism has been eliminated.

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Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

Mechanism of action is believed to be through inhibition of the cyclooxygenase enzyme that is essential in the biosynthesis of prostaglandins. Inhibition of prostaglandin synthesis results in vasoconstriction and decreases in vascular permeability, leukocytosis, and intraocular pressure (IOP). These agents, however, have no significant effect on IOP.

Ibuprofen (Addaprin, Caldolor, Genpril, Dyspel, Motrin, Advil)

Usually the DOC for treatment of mild to moderate pain, if no contraindications exist.

Inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.

Naproxen (Aleve, Naprosyn, Naprelan, Flanax Pain Relief, Anaprox DS)

Used for relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing activity of the enzyme cyclooxygenase, resulting in prostaglandin synthesis.

Ketoprofen

Used for the relief of mild-to-moderate pain and inflammation. Small doses are initially indicated in small and elderly patients and in those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.

Diclofenac (Cambia, Dyloject, Zipsor, Zorvolex)

Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase, which in turn decreases formation of prostaglandin precursors. Has anti-inflammatory, antipyretic, and analgesic properties.

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Analgesics

Class Summary

Pain control is essential to quality patient care, ensuring patient comfort, promoting pulmonary toilet, and containing sedating properties that benefit patients who experience mild or severe pain.

Oxycodone and acetaminophen (Percocet, Endocet, Primlev, Xartemis XR)

Drug combination indicated for the relief of moderate to severe pain. Oxycodone inhibits ascending pain pathways by binding to the opiate receptor. Alters the response and perception of pain and produces generalized CNS depression. Acetaminophen inhibits prostaglandin synthesis in the CNS and blocks pain impulse generation peripherally.

Oxycodone and aspirin (Percodan)

This drug combination is indicated for the relief of moderate to severe pain. Oxycodone binds to opiate receptors in the central nervous system (CNS), inhibiting the ascending pain pathways, altering pain response and perception. Aspirin inhibits platelet aggregation; has analgesic and ant-inflammatory properties.

Morphine (Arymo ER, Duramorph, Kadian, MS Contin)

An opioid analgesic, morphine interacts with endorphin receptors in the CNS, inhibiting the pain pathways, altering pain response and perception.

Codeine and acetaminophen (Tylenol with Codeine #3, Tylenol with Codeine #4)

Acetaminophen and codeine combination is used for the treatment of mild to moderate pain.

Hydrocodone and acetaminophen (Hycet, Lorcet, Norco, Vicodin, Zamicet)

This combination is used for the relief of moderate to severe pain. Analgesics alter the perception of and response to pain.

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Antivirals, Ophthalmic

Class Summary

Therapy of viral infections begins with mechanical debridement of the involved rim along with a rim of normal epithelium. This is followed by the topical instillation of antiviral medications.

Trifluridine ophthalmic (Viroptic)

A structural analogue of thymidine, this agent inhibits viral DNA polymerase. Viroptic has better penetration through the cornea and greater efficacy (95% heal rate) than other topical agents.

Ganciclovir ophthalmic (Zirgan)

Acyclic nucleoside analogue of 2'deoxyguanasine. Phosphorylates first to monophosphate form by viral-encoded protein kinase homologue, then to diphosphate and triphosphate forms by cellular kinases, allowing for greater concentration of ganciclovir in virus-infected cells, possibly due to preferential phosphorylation of ganciclovir in virus-infected cells. Thought to inhibit HSV replication by competitive inhibition of viral DNA polymerases and by incorporating itself into viral DNA, causing termination of viral DNA elongation. Like acyclovir, ganciclovir is virostatic and exerts its effect only on replicating virus.

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