Learning Outcomes
By the end of this section, you should be able to:
- 38.2.1 Identify the characteristics of anti-inflammatory and anti-infective drugs used to treat eye disorders.
- 38.2.2 Explain the indications, actions, adverse reactions, and interactions of anti-inflammatory and anti-infective drugs used to treat eye disorders.
- 38.2.3 Describe the nursing implications of anti-inflammatory and anti-infective drugs used to treat eye disorders.
- 38.2.4 Explain the client education related to anti-inflammatory and anti-infective drugs used to treat eye disorders.
Ocular Nonsteroidal Anti-inflammatories
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to prevent and treat eye inflammation. They can help relieve symptoms of pain and swelling from eye conditions or injuries or after eye surgery. Diclofenac sodium and ketorolac tromethamine are both used to treat postoperative ocular inflammation after cataract extraction. They are also used to treat ocular pain and photophobia in clients undergoing corneal refractive surgery. To manage these conditions, drugs are administered directly into the affected eye(s).
Table 38.1 lists common ocular nonsteroidal anti-inflammatory drugs and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Diclofenac sodium (Voltaren Ophthalmic) |
For postoperative ocular inflammation after cataract extraction: 0.1% ophthalmic solution: 1 drop to the affected eye(s) 4 times daily, starting 24 hours after cataract surgery and continuing for 2 weeks after the postoperative period. For ocular pain and photophobia in clients undergoing corneal refractive surgery: 0.1% ophthalmic solution: 1–2 drops to the operative eye(s) within 1 hour before surgery. Within 15 minutes after surgery, apply 1–2 drops to the operative eye(s). Instill 1–2 drops 4 times daily for up to 3 days. |
| Ketorolac tromethamine (Acular) |
For reduction of postoperative ocular inflammation and ocular pain after cataract surgery or corneal refractive surgery: 0.5% ophthalmic solution: 1 drop into the affected eye(s) 4 times daily beginning 24 hours after cataract surgery; continue through the first 2 weeks after surgery. For the treatment of ocular pruritus due to seasonal allergic conjunctivitis: 0.5% ophthalmic solution: 1 drop in the affected eye(s) 4 times daily. |
Safety Alert
Similarly Named Drugs
Do not confuse ketorolac (ocular NSAID) with Ketalar (nonbarbiturate anesthetic).
(Source: Institute for Safe Medication Practices, 2023)
Adverse Effects and Contraindications
Adverse effects are essentially identical for both drugs. Although administering drugs using the ophthalmic route causes minimal systemic effects, they still can occur. The potential exists for prolonged bleeding due to interference with the aggregation (clumping) of thrombocytes (platelets). Blood can enter the aqueous humor, resulting in a hyphema (a collection of blood in the anterior chamber of the eye). The blood usually will dissipate on its own over time. In some susceptible clients, such as those with corneal denervation, dry eye syndrome, diabetes mellitus, or rheumatoid arthritis, continued use of topical NSAIDs over 14 days may result in epithelial breakdown, corneal thinning, erosion, ulceration, or perforation. If any of these occur, they can impair vision. Clients who exhibit evidence of corneal epithelial breakdown should immediately discontinue use of the topical NSAIDs and must be closely monitored to ensure proper healing of the cornea.
All ophthalmic NSAIDs and corticosteroids may slow or delay healing. Concurrent use of these drugs may increase the potential for further healing difficulties. Combining any ophthalmic NSAID with latanoprost will diminish the therapeutic effect of latanoprost.
Ocular NSAIDs are contraindicated for clients with a history of severe NSAID or acetylsalicylic acid (aspirin) hypersensitivity.
Table 38.2 is a drug prototype table for ocular nonsteroidal anti-inflammatories featuring diclofenac. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ocular nonsteroidal anti-inflammatory Mechanism of Action Inhibits the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins |
Drug Dosage Postoperative ocular inflammation after cataract surgery: 1 drop to affected eye(s) 4 times daily, starting 24 hours after cataract surgery; continue for 2 weeks after the postoperative period. Ocular pain and photophobia in clients undergoing corneal refractive surgery: 1–2 drops to operative eye(s) within 1 hour before surgery. Within 15 minutes after surgery, apply 1–2 drops to the operative eye(s). Continue to instill 1–2 drops 4 times daily for 3 days. |
| Indications Postoperative ocular inflammation after cataract surgery Ocular pain and photophobia in clients undergoing corneal refractive surgery Therapeutic Effects Reduces inflammation Reduce intensity of photophobia Relieves symptoms of ocular pain postoperatively |
Drug Interactions Anticoagulants Antiplatelet aggregators Corticosteroids Latanoprost Food Interactions No significant interactions |
| Adverse Effects Delay in wound healing Keratitis Increased bleeding of ocular tissues from ocular surgery Hyphema Facial edema Fever Dizziness Headache Burning or stinging of the eyes Itchy eyes Blurred vision Fever Lacrimation Corneal opacities or lesions |
Contraindications Hypersensitivity to NSAIDs or aspirin Pregnancy Breastfeeding Caution: Bleeding conditions (e.g., hemophilia, vitamin K deficiency) Thrombocytopenia Renal insufficiency |
Nursing Implications
The nurse should do the following for clients who are taking ocular nonsteroidal anti-inflammatories:
- Assess client’s visual acuity periodically.
- Monitor for any signs or symptoms of bleeding, especially in the eye.
- Have the client return-demonstrate the application of the drops and/or ointment to ensure they are using the proper technique.
- Encourage the client to get assistance from others or use adaptive devices to minimize the risk of fall or injury until their vision improves.
- Assess for tearing, eye discharge, irritation, and/or facial swelling.
- Monitor severity of pain.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ocular nonsteroidal anti-inflammatory should:
- Notify the provider of any signs or symptoms of keratitis: red eye, sensation of a foreign substance in the eye, eye pain, decreased vision, or sensitivity to light.
- Read the medication label before using; eye medications and ear medications are similarly packaged.
- Avoid contamination of the prescribed product because this can cause infection or damage vision.
The client taking an ocular nonsteroidal anti-inflammatory should not:
- Drive or operate machinery until vision clears.
Ocular Immunosuppressants
In ocular inflammation, immunosuppressants are used as steroid-sparing agents to control the inflammation, with a goal of long-lasting remission and prevention of the threat to vision. Likewise, these agents are utilized to “reprogram” the immune system to alleviate or reduce the lymphocytes from attacking and causing recurrent autoimmune destruction of healthy ocular tissue (Liu et al., 2023). Although several drugs could be used, cyclosporine is the predominant one.
Systemic immunosuppressants are used in some cases for inflammatory eye diseases because they can prevent potential permanent vision loss. This treatment strategy is deployed often for uveitis and other ocular conditions when other treatments have failed (Kopplin, 2020).
Adverse Effects and Contraindications
Because there is minimal systemic absorption, most of the adverse effects are local. Hypersensitivity reactions such as ocular redness, blurry vision, and lid swelling can occur; therefore, the client should be aware and observed for signs of this (College of Optometrists, 2023). It is rare for the drug to cause an anaphylactic reaction.
No true contraindications exist when giving this drug via the ophthalmic route. If a client is already immunocompromised from a different condition, it is important for them to contact their provider if they begin to experience signs of infection. If topical corticosteroids are given concurrently with cyclosporine, this can increase the chances of infection because both drugs can decrease the immune response.
Table 38.3 is a drug prototype table for ocular immunosuppressants featuring cyclosporine. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ocular immunosuppressant Mechanism of Action Acts as a partial immunomodulator; exact mechanism of action is unknown |
Drug Dosage For keratoconjunctivitis sicca: 1 drop in each eye twice daily, approximately 12 hours apart. Artificial tears may be used concurrently, allowing a 15-minute interval between administration of products. |
| Indications Treatment of dry eye syndrome due to keratoconjunctivitis sicca Therapeutic Effects Increases tear production in clients whose tears are suppressed due to ocular inflammation |
Drug Interactions Topical corticosteroids Food Interactions No significant interactions |
| Adverse Effects Ocular burning or stinging Blurry vision Hyperemia (redness) of the conjunctiva Eye pain Foreign body sensation Pruritus of eyes Excessive watering of the eyes (epiphora) Hypersensitivity reaction (urticaria, periorbital edema, tongue and pharyngeal edema, along with dyspnea) |
Contraindications Allergy to any of the ingredients in the drug Caution: Immunocompromised clients Contact lens wearers: Remove contact lens prior to administration |
Nursing Implications
The nurse should do the following for clients who are taking ocular immunosuppressants:
- Monitor for signs/symptoms of hypersensitivity, such as facial swelling, inflamed tongue, or shortness of breath.
- Ensure the client understands the proper technique for instilling the drop by having them return-demonstrate the procedure.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ocular immunosuppressant should:
- Invert the unit dose vial several times until there is a uniform, white emulsion.
- Use the medication immediately upon opening and discard the remaining solution straightaway.
- Be careful not to touch the tip of the vial to their eye or other surface to avoid the potential for eye injury or contamination.
- Notify the provider of any possible allergic reactions, such as a swollen face, throat, eyes, and/or tongue or shortness of breath.
- Remove their contact lenses prior to instilling the drops. Client can reinsert contacts 15 minutes after administration.
- Wait at least 15 minutes to instill other drops or apply ointments.
Ocular Corticosteroids
Ophthalmic steroids are applied topically for a variety of inflammatory conditions, such as allergic conjunctivitis, uveitis, iritis, and herpes zoster keratitis. In addition, they are beneficial in the treatment of chemical and thermal burns along with foreign body injury. Ophthalmic steroids are also useful in postocular surgery to decrease inflammation and scar tissue formation. It is best these drugs are used on a short-term basis to minimize adverse effects (Fung et al., 2020). Dexamethasone and prednisolone are the two main drugs used to decrease ocular inflammation.
Dexamethasone
Dexamethasone is a more potent ocular corticosteroid and has a longer duration of action than prednisolone. For ocular use, this drug is available in ophthalmic drops and ophthalmic ointment. It can be used as monotherapy (alone) or in combination with other medications, such as antibiotics. Some dexamethasone dosage forms contain a sulfite that may cause an asthmatic episode or an allergic reaction ranging from urticaria to life-threatening anaphylaxis in those who have a sensitivity to sulfites (DailyMed, Maxidex, 2006).
Prednisolone Sodium Phosphate
For ocular use, this drug is available in ophthalmic drops.
Table 38.4 lists common ocular corticosteroids and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Dexamethasone sodium phosphate (Maxidex, Dextenza) |
Ophthalmic dosage for 0.05%, 0.1%, 9%, 0.4 mg, or 0.7 mg: 1–2 drops into affected eye(s) every hour during the day and every 2 hours during the night as initial therapy. When a favorable response is observed, reduce dosage to 1 drop every 4 hours. Further reduction in dosage to 1 drop 3–4 times daily may suffice to control symptoms. |
| Prednisolone sodium phosphate (Omnipred) |
Ophthalmic dosage (prednisolone sodium phosphate 1% ophthalmic solution): 1–2 drops into affected eye(s) every hour while awake and every 2 hours at night. When a favorable response is observed, reduce dosage to 1 drop every 4 hours; thereafter, 1 drop 3–4 times daily to control symptoms. Dosage and duration vary with condition and may extend from a few days to several weeks, according to therapeutic response. |
Adverse Effects and Contraindications
Most of the serious adverse effects occur when the drug is being used for a prolonged period of time. Extended use may cause increased IOP, which may result in glaucoma. Anyone using these products for more than 10 days should routinely have their intraocular pressure checked. In addition, the optic nerve may become damaged, which will cause visual acuity defects and loss of vision in certain fields. Subcapsular cataract formation is also a potential adverse effect. Many viral, bacterial, and fungal infections of the cornea or conjunctiva may be exacerbated; therefore, corticosteroids are contraindicated in those with an active infection (DailyMed, Prednisolone, 2023).
If too much drug enters the system, clients on antidiabetic agents or warfarin will need to have their dose adjusted.
Table 38.5 is a drug prototype table for ocular corticosteroids featuring prednisolone. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ocular corticosteroid Mechanism of Action Inhibits inflammatory response to inciting agents of a mechanical, chemical, or immunological nature |
Drug Dosage Ophthalmic dosage (prednisolone sodium phosphate 1% ophthalmic solution): 1–2 drops into affected eye(s) every hour while awake and every 2 hours at night. When a favorable response is observed, reduce dosage to 1 drop every 4 hours; thereafter, 1 drop 3–4 times daily to control symptoms. Dosage and duration vary with condition and may extend from a few days to several weeks, according to therapeutic response. |
| Indications To decrease inflammation in allergic conjunctivitis, iritis, uveitis, chemical and thermal burns, or deeply penetrated foreign bodies Therapeutic Effects Inhibits edema, fibrin deposition, capillary dilation, and leukocyte migration |
Drug Interactions No significant interactions Food Interactions No significant interactions |
| Adverse Effects Blurred vision Photophobia Eye dryness and/or irritation Cataract formation Glaucoma Optic nerve damage Secondary infection |
Contraindications Acute superficial herpes simplex keratitis Fungal ocular diseases Acute infectious stages of ocular varicella Viral diseases of the cornea and conjunctiva Tuberculosis of the eye Advanced glaucoma |
Nursing Implications
The nurse should do the following for clients who are taking ocular corticosteroids:
- Teach the client the proper way to administer the medication and to avoid contamination.
- Assess for therapeutic effects, including decreased eye pain, redness, and irritation.
- Make the environment safe for ambulation because the drug can cause transient blurry vision. Ensure adequate lighting and a clear path to the bathroom.
- Assess for increased eye pain, drainage, headache, prolonged blurred vision or changes in visual acuity, and sensitivity to light.
- Apply warm, wet compresses over affected eye(s) to help reduce inflammation and/or discomfort.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ocular corticosteroid should:
- Follow the tapering instructions given by the prescriber to avoid adrenal gland insufficiency. Usually tapering occurs over a few weeks or months depending on how long steroids were taken.
- Notify their health care provider immediately if they experience excess fatigue, weight loss, increased urine output, confusion, irregular heart rhythm, or dizziness during titration. This may indicate the drug is being stopped too quickly.
- Immediately contact their health care provider if they develop any sudden visual changes, undergo trauma, or develop an infection.
- Wear sunglasses when outside to reduce the sensitivity to light.
The client taking an ocular corticosteroid should not:
- Wear contact lenses for at least 15 minutes after instillation of the drug because one of the preservatives in dexamethasone could be absorbed by soft contact lenses, making the drug less effective.
- Drive or participate in hazardous activities until their vision is clear.
Ocular Antibacterials
Topical antibacterials are used to treat ophthalmic infections and to prevent infection after ocular surgery. Bacterial infections are and will remain contagious until treated for 24–48 hours. There are various antibacterials that have ophthalmic uses. These agents are active against numerous gram-positive and gram-negative organisms. They are generally used to treat infections involving the conjunctiva or cornea, such as conjunctivitis, keratitis, corneal ulcers, and blepharitis. The choice of antibiotic depends on the pathogen causing the infection. Additionally, many different combination preparations are available. Caution should be exercised when administering these products with regard to the select agent, strength, and formulation. Unfortunately, the risk of superinfection is high when using ophthalmic antibiotics due to contamination of the eyedropper or tube. Counseling on the proper technique of administration is a critical teaching point to help reduce the risk of superinfection.
Various drug classifications are used to treat ocular infections. Some of these include fluoroquinolones (ciprofloxacin), aminoglycosides (gentamycin, neomycin), macrolides (erythromycin), and a combination drug that includes neomycin. Ocular neomycin can be prescribed in several ways: neomycin, polymyxin B, and bacitracin; neomycin, polymyxin B, and hydrocortisone; neomycin, polymyxin B, and dexamethasone; or neomycin, polymyxin B, and gramicidin. Polymyxin is considered a polypeptide bactericidal antibiotic, while bacitracin is a bactericidal and bacteriostatic polypeptide antibiotic. Dexamethasone and hydrocortisone are corticosteroids (discussed in the previous section). The choice of the medication may depend on many factors. One important factor to consider is whether the client wears contact lenses.
Gentamicin Sulfate
Gentamicin sulfate has bactericidal effects that interfere with bacterial synthesis. This class of medication is used primarily against aerobic gram-negative bacilli, such as Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. The drug has no effects on anaerobic bacteria. In addition to the uses of ciprofloxacin, gentamicin can be used for blepharitis, acute meibomianitis (inflammation of the meibomian gland), and dacryocystitis (inflammation of the lacrimal sac) (DailyMed, Gentamicin, 2022).
Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin
This combination antibiotic product has multiple mechanisms of action. First, it works similar to gentamicin by interfering with bacterial synthesis. This drug is mainly used in the treatment of bacterial conjunctivitis and blepharitis. Sometimes it is necessary to administer both a corticosteroid and an antibacterial, such as for inflammatory ocular infections or traumas. Even if there is no active infection, corticosteroids reduce the body’s immune response, and if this is clinically concerning based on the client’s health, an antibacterial may be added as a prophylactic measure.
Erythromycin
This drug is the first-line agent in treating simple cases of bacterial conjunctivitis. It prevents the further growth of bacteria rather than directly destroying them. Interestingly, because this drug is administered via ointment form, even if it stays on the eyelid and eyelashes, it still provides a therapeutic effect despite the medication not being directly on the conjunctiva (DailyMed, Erythromycin, 2023).
In newborns born to someone with active disease, 1 cm of ointment is administered one time right after delivery to prevent eye infections, especially gonococcal ophthalmia neonatorum (GON) and chlamydial ophthalmia. If left untreated, these infections can cause serious eye problems, including corneal scarring, ocular perforation, and blindness as early as 24 hours after birth. Erythromycin is the only FDA-approved drug for this purpose.
Table 38.6 lists common ocular antibacterials and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Ciprofloxacin hydrochloride 0.3% (Ciloxan) |
For bacterial conjunctivitis: Ophthalmic dosage (ointment): ½-inch strip of ointment in the affected eye(s) 3 times a day for the first 2 days, then a ½-inch strip in the affected eye(s) 2 times a day for the next 5 days. Ophthalmic dosage (solution): 1–2 drops in the affected eye(s) every 2 hours, while awake, for 2 days. Then 1–2 drops in the affected eye(s) every 4 hours, while awake, for the next 5 days. For corneal ulcers: Ophthalmic dosage (solution): Day 1: 2 drops in the affected eye(s) every 15 minutes for the first 6 hours, and then 2 drops in the affected eye(s) every 30 minutes for the rest of the day, while awake. Day 2: 2 drops in the affected eye(s) every hour, while awake. Days 3–14: 2 drops in the affected eye(s) every 4 hours, while awake. |
| Erythromycin 0.5% (Ilotycin) |
Ophthalmic ointment: Approximately 1 cm (less than ½ inch) of erythromycin ophthalmic ointment directly in the affected eye(s) up to 6 times a day, depending on the severity of the infection Neonatal dosing: 1 cm of ointment applied to both eyes 1 time following delivery. |
| Gentamicin sulfate 0.3% (Garamycin) |
Ophthalmic dosage (ointment): A 1.27-cm ribbon applied to the affected eye(s) 2–3 times a day. Ophthalmic dosage (solution): 1–2 drops in the affected eye(s) every 4 hours. For severe infections, use up to 2 drops into the affected eye(s) every hour. |
| Neomycin sulfate (available only in combination with other drugs for ophthalmic use; specific combination product listed where relevant) |
Neomycin, polymyxin B, and bacitracin: Ophthalmic dosage (ointment): A thin strip of ointment in the affected eye(s) every 3–4 hours for 7–10 days. Neomycin, polymyxin B, and dexamethasone: Ophthalmic dosage (drops): 1–2 drops in the affected eye(s) 4–6 times a day. Ophthalmic dosage (ointment): A small amount (about ½ inch) in the affected eye(s) 3–4 times a day. Neomycin, polymyxin B, and gramicidin: Ophthalmic dosage (eye drops): 1–2 drops in the affected eye(s) every 4 hours for 7–10 days. For a more serious infection, dosage may be increased to as much as 2 drops per hour. Neomycin, polymyxin B, and hydrocortisone: Ophthalmic suspension dosage: 1–2 drops in the affected eye(s) every 3–4 hours. |
Adverse Effects and Contraindications
Ocular antibacterials can cause blurred vision; therefore, safety factors must be in place to prevent falls (uncluttered environment, adequate lighting, walking devices in reach). Hypersensitivity reactions to these drugs or any of their components can occur even with the first dose, so the nurse must make clients aware of this and tell them to seek treatment immediately. The drug should be discontinued at the first appearance of a skin rash.
Use of antibacterials over a prolonged period can deplete the normal flora, causing a superinfection. If this occurs, the treatment plan may need to be modified to add an antifungal agent. If the superinfection is bacterial, the overgrowth of this new organism may be resistant to the antibiotic’s activity, and another appropriate antibacterial will need to be initiated.
Because they have a broad spectrum of activity against multiple organisms, ocular antibacterials are often overused, which can lead to the development of bacterial resistance. If purulent discharge, inflammation, or pain becomes worse, the client should discontinue the drug and contact a health care provider.
During the first 7 days of treating a corneal ulcer with ciprofloxacin drops, a nonharmful white crystalline precipitate commonly forms on the corneal defect. This precipitate will resolve on its own and causes no corneal damage (DailyMed, Ciprofloxacin, 2022).
If ciprofloxacin is concurrently given with a systemic fluoroquinolone, arthropathy (tendon inflammation and tendon rupture) can occur. This usually occurs in young and older populations.
Table 38.7 is a drug prototype table for ocular antibacterials featuring ciprofloxacin. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ocular antibacterial Mechanism of Action Inhibits bacterial DNA synthesis |
Drug Dosage For bacterial conjunctivitis: Ophthalmic dosage (ointment): ½-inch strip of ointment in the affected eye(s) 3 times a day for the first 2 days, then a ½-inch strip in the affected eye(s) 2 times a day for the next 5 days. Ophthalmic dosage (solution): 1–2 drops in the affected eye(s) every 2 hours, while awake, for 2 days. Then 1–2 drops in the affected eye(s) every 4 hours, while awake, for the next 5 days. For corneal ulcers: Ophthalmic dosage (solution): Day 1: 2 drops in the affected eye(s) every 15 minutes for the first 6 hours, and then 2 drops in the affected eye(s) every 30 minutes for the rest of the day, while awake. Day 2: 2 drops in the affected eye(s) every hour, while awake. Days 3–14: 2 drops in the affected eye(s) every 4 hours, while awake. |
| Indications Bacterial conjunctivitis Corneal ulcers Therapeutic Effects Bactericidal effects on a broad range of gram-negative and gram-positive organisms Decreased conjunctival redness and edema Reduced eye drainage and pain |
Drug Interactions Systemic quinolones Food Interactions No significant interactions |
| Adverse Effects Eye burning or discomfort Foreign body sensation White precipitate on cornea Photophobia Blurred vision/decreased vision Hypersensitivity Superinfection |
Contraindications Hypersensitivity to any of the ingredients in ciprofloxacin or any quinolone |
Nursing Implications
The nurse should do the following for clients who are taking ocular antibacterials:
- Consistently use aseptic techniques when giving the drug to prevent further infection (Iskandar et al., 2022).
- Teach the client the proper techniques for administering and storing the medication (Iskandar et al., 2022).
- Encourage the client not to wear contact lenses until treatment is completed and the bacteria eradicated.
- Evaluate for therapeutic effectiveness: decreased conjunctival erythema, drainage, and eye discomfort.
- Assess for hypersensitive reactions, such as hives, pruritus, facial/tongue/pharyngeal swelling, or difficulty breathing.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ocular antibacterial should:
- Wash off any eye makeup and wash hands thoroughly prior to medication administration.
- Understand that they are still contagious until they have been receiving medication for 24–48 hours.
- Seek immediate attention if experiencing any hypersensitivity reactions such as severe eye redness or irritation of the eye, eyelids, lips, or face.
- Notify their health care provider if symptoms are not improving or are worsening.
- Protect eyes by wearing sunglasses when outside.
The client taking an ocular antibacterial should not:
- Drive or operate machinery with blurred vision.
- Wear contact lenses during the course of treatment.
Ocular Antivirals
Antiviral agents are used to treat herpes simplex ocular infections and primary keratoconjunctivitis. Trifluridine (Viroptic) is the most commonly administered antiviral ophthalmic drug. This is a locally active drug and is available in solution form. Systemic absorption is negligible, which reduces the risk of systemic adverse effects. This drug does not affect liver or kidney function. The overall action of this drug is to suppress viral replication. If there are no signs of improvement after 7 days of therapy or if there is incomplete re-epithelialization, continued use of this drug is not recommended and another therapy should be considered (DailyMed, Trifluridine, 2021).
Adverse Effects and Contraindications
Because this drug is locally acting, it causes very few adverse effects. Most of them are ocular-related. Continuous administration of trifluridine for periods exceeding 21 days should be avoided because of potential ocular toxicity. Rare adverse effects include keratitis sicca, hyperemia, epithelial keratopathy, and increased IOP. This drug is considered carcinogenic and can be extremely harmful if it enters the bloodstream; therefore, safety precautions such as handwashing and wearing gloves must be in place.
There are no true contraindications except for hypersensitivity to the drug’s active and nonactive ingredients. If a client has a known sensitivity to any of the ingredients, the drug should be avoided (DailyMed, Trifluridine, 2021).
Table 38.8 is a drug prototype table for ocular antivirals featuring trifluridine. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ocular antiviral Mechanism of Action Interferes with DNA synthesis in cultured mammalian cells; antiviral mechanism of action is not completely known |
Drug Dosage 1 drop on cornea of affected eye(s) every 2 hours while awake; maximum dose: 9 drops daily until corneal ulcer has completely re-epithelialized. Following re-epithelialization: 1 drop every 4 hours while awake for an additional 7 days; minimum daily dose: 5 drops. |
| Indications Primary keratoconjunctivitis Recurrent epithelial keratitis due to herpes simplex virus, types 1 and 2 Therapeutic Effects Inhibits viral replication by causing formation of defective viral proteins |
Drug Interactions No significant interactions Food Interactions No significant interactions |
| Adverse Effects Mild, transient burning or stinging upon administration Palpebral conjunctival edema Ocular toxicity Retinal detachment |
Contraindications Hypersensitivity to drug |
Nursing Implications
The nurse should do the following for clients who are taking ocular antivirals:
- Dispose of the drug or container by adhering to the biohazard procedures of the facility.
- Refrigerate the solution at 36°F–48°F.
- Teach the client proper handling, administration, and disposal of the drug.
- Assess for a decrease in conjunctival erythema and potential adverse effects.
- Assess for manifestations of retinal detachment, such as floaters, flashes of light, or a shadow falling over their vision.
- Take precautions when caring for the client because viral infections are contagious.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ocular antiviral should:
- Immediately notify the health care provider if they experience reduced vision, floaters, flashes of light, or a curtain-like shadow over their field of vision because these could be signs of retinal detachment.
- Use the proper technique when administering and discarding any of the drug or container.
- Store the medication in the refrigerator to maintain its potency.
- Thoroughly wash face, hands, and any exposed skin after handling medication.
- Understand that viral infections are contagious and may remain so until they are completely gone.
The client taking an ocular antiviral should not:
- Instill the eye drops if they are not at room temperature because this can cause injury and pain.
- Assume that the organism has been fully eliminated because herpes lies dormant until something triggers it to become active.
Ocular Antifungals
Topical antifungals are active against a variety of yeast and filamentous fungi. Some of these include candida, aspergillus, cephalosporium, fusarium, and penicillium. The only FDA-approved drug for ocular fungal infections is natamycin (Natacyn). This is a polyene antibiotic. Although the activity against fungi is dose-related, this drug is predominantly fungicidal. Because it is prepared in a suspension formula, it must be shaken well before using. Approximately 2% of this drug enters the body systemically, but this is an insufficient concentration to cause systemic issues. Most of the drug adheres to the cornea for desired periods of time without causing secondary damage. This drug does not enter intraocular fluid; therefore, it does not increase eye pressure. Continuation of therapy is determined by clinical picture and laboratory studies.
It may be helpful to decrease the dosage gradually at 4- to 7-day intervals to ensure the replicating organism has been eliminated. Failure to improve within 10 days indicates that the organism may not be related to a fungus. If true, the organism may be resistant to natamycin, and a different drug may be prescribed.
Adverse Effects and Contraindications
There are no true contraindications except for hypersensitivity to the drug’s active and nonactive ingredients. If one has a known sensitivity to any of the ingredients, the drug should be avoided (DailyMed, Natacyn, 2023).
Table 38.9 is a drug prototype table for ocular antifungals featuring natamycin. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Ocular antifungal Mechanism of Action Binds to sterols on the fungal cell membrane altering cell membrane permeability, causing leakage of essential intracellular contents |
Drug Dosage 1 drop in the affected eye(s) every 1–2 hours for 3–4 days. Then 1 drop 6–8 times a day for 14–21 days. |
| Indications Fungal blepharitis, conjunctivitis, and keratitis caused by susceptible organisms Therapeutic Effects Inhibits reproduction of the organism (fungistatic) or kills the organism (fungicidal) |
Drug Interactions No significant interactions Food Interactions No significant interactions |
| Adverse Effects Allergic reaction Change in vision Corneal opacity Chest pain Dyspnea Paresthesia Eye discomfort/irritation Conjunctival hyperemia Foreign body sensation Excess tearing (lacrimation) |
Contraindications Hypersensitivity to drug |
Nursing Implications
The nurse should do the following for clients who are taking ocular antifungals:
- Shake the medication well so all the particles are evenly mixed.
- Be observant for any manifestations of hypersensitivity (e.g., skin rash, hives, eye pain, or swelling of the face, lips, or tongue), and provide treatment immediately (Cleveland Clinic, 2023b).
- Assess for therapeutic effects (e.g., decreased eye pain, redness, and tearing along with increased visual acuity).
- Be certain the medication is being correctly administered and no doses are missed, because fungal infections are very difficult to treat.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an ocular antifungal should:
- Notify the health care provider if experiencing hives, difficulty breathing, tunnel vision, chest pain, dyspnea, alteration in visual acuity, or paresthesia (“pins and needles” sensation) because these may represent adverse reactions.
The client taking an ocular antifungal should not:
- Use before the suspension has been adequately shaken and there is a uniform mixture.
- Wear contact lenses before treatment is completed. If this is not feasible, contact lenses can be inserted no earlier than 15 minutes after the drug has been administered.