Pharmacological Management of Ocular Infection

Question 1

What are the common antibacterials and types?

Answer 1

• Aminoglycosides:
  o Gentamicin
  o Tobramycin
  o Neomycin
• Cephalosporins, 2nd gen
  o Cefruroxime
• Macrolides
  o Azithryomycin
• Quinolones
  o Ciprofloxacin
  o Levofloxacin
  o Moxifloxacin
  o Ofloxacin
• Other
  o Chloramphenicol
  o Fusidic acid

Question 2

What are antimicrobial agents?

Answer 2

• An agent, either natural or synthetic, that kills or inhibits growth of susceptible microorganisms – could be bacteria, viral or fungal
• Antibiotic substance is produced by natural metabolic processes of some microorganisms that can inhibit or kill other microorganisms
  o Always derived from natural process
• Antimicrobials may be further classified as antibacterial, antiviral or antiprotozoal, depending on type of organism against which they exert an effect

Question 3

What are the main microorganisms associated with ocular infections?

Answer 3

Bacteria:
Staph aureus, streptococcus pneumoniae, neisseria gonorrhaea, pseudomonas aeruginosa*
Viruses:
Adenovirus, enterovirus, herpes simplex virus
Fungi:
Candida species
Protozoa:
Acanthamoeba species, naegleria species
* = particularly associated with CL use

Question 4

What is bacteria?

Answer 4

• Prokaryotic cells – does not have nucleus or membrane-bound organelles
• Classification:
  o Many methodologies
  o Gram staining particularly important for classification of bacteria for purposes of using effective tx regimes

Question 5

What is the action of antibactrial drugs?

Answer 5

• Site of action of antibacterial agents is commonly:
  o The cell membrane (or more selectively the cell wall) - allows uptake of nutrients by passive diffusion – if disrupt function of cell wall then it cannot replicate
  o The ribosomes - the site of protein synthesis
  o DNA gyrase – replication of genetic material of bacterial cells  essential for bacterial replication – so if disrupt activities of DNA gyrase then that will hinder replication of bacterial cells

Question 6

What is the mechanism, medicinal forms, indications and important points to note about aminoglycosides?

Answer 6

• Mechanism
  o Interfere w/ ribosome function affecting protein synthesis
   By combining mRNA to produce an abnormal codon
  o Bacteriocidal – kills bacteria
  o Broad spectrum antibiotics, affecting protein synthesis taking place at ribosomes
   Mechanism is slightly different to chloramphenicol or fusidic acid. The aminoglycosides inhibit protein synthesis by disruption of the function of the 30S ribosomes causes a misreading of the peptidyl tRNA identities
• This results in incorrect peptides & proteins being produced
   They have bacteriostatic effects as well as a slow bactericidal effect (esp. in gram negative bacteria) as it works on the bacterial cell membrane and may exert weak inhibitory effects on bacterial DNA replication
  o Generic is listed in BNF as non-proprietary
• Medicinal Forms: available topical presentations
  o Gentamicin (0.3% Generic) (PoM)
  o (Tobramycin) – not currently available
  o Neomycin in combo w/ steroid product (PoM)
• Indications:
  o Bacterial eye infections
• TO NOTE:
  o Typically, not used as 1st line tx for bacterial conjunctivitis or bacterial keratitis as better for gram negative than gram positive bacteria
  o Gentamicin (and Tobramycin) used to treat P. Aeruginosa
   May be used in 2ndary care for pxs w/ CL associated keratitis
   Gentamicin 0.3% 3mg per 1ml 10ml
  o Neomycin – broader spectrum but not effective against P. Aeruginosa, currently only available in combination drops with dexamethasome and polymixicin B (Maxitrol)
  o Neomycin used in combo with steroids to treat post operative inflammation
   BUT becoming less commonly used for this purpose as now listed as “less suitable for prescribing” in BNF
  o Aminoglycosides can be toxic to OCULAR surface, typically response occurs after 1-2 weeks of use & is not serious typical undesirable effects as a result of ocular toxicity are punctate keratitis, injection of inferior cul de sac, and a weepy erythema with oedema of eyelid tissues

Question 7

What are the cautions, interactions, contraindications, undesirable effects, info on pregnancy/breastfeeding for gentamicin (aminoglycoside)?

Answer 7

IP OPTOMS
* Cautions:
o Nephrotoxicity – kidneys
o Ototoxicity – damage to inner ear
 No evidence of above 2 when gentamicin used topically
o Neuromuscular blocking effects – can block neuromuscular transmission at the neuromuscular junction which can cause paralysis of effected the skeletal muscles – unlikely to happen in topical use
* Interactions:
o Concurrent use with other potentially nephrotoxic or ototoxic drugs should be avoided (unless considered essential)
 Potent diuretics such as ethacrynic acid & frusemide are believed to enhance any risk of ototoxicity whilst amphotericin B, cisplatin & cyclosporin & cephalosporins are potential enhancers of nephrotoxicity.
* Contraindications:
o In cases of known allergy to aminoglycosides
o Due to neuromuscular blocking effects contraindicated in myasthenia gravis & related conditions
* Undesirable effects:
o Local sensitivity; blurred vision, eye irritation, burning sensation, stinging sensation, itching
* Pregnancy & Breastfeeding:
o Usage in pregnancy should only be considered in life-threatening situations where expected benefits outweigh possible risks
o Amount of gentamicin ingested from milk is unlikely to result in significant blood levels in breast-fed infants – so is relatively safe to use gentamicin in mothers who are breast-feeding

Question 8

Describe mechanism, medicinal forms, indications, cautions, interactions and pregnancy/breastfeeding info for cephalosporins?

Answer 8

None available topically but one available for use as intracameral injection
* Mechanism:
o Interferes with cell wall synthesis
o Bateriocidal
* Medicinal forms:
o Available for use as intracameral injection
o Cefuroxime (Aprokam intracameral injection) (PoM)
 Cefuroxime brand name APROKAM 1mg injected into the anterior vitreous at the end of cataract surgery
* Indications:
o Prophylaxis of endophthalmitis after cataract surgery
 Advocated for this purpose by the Scottish Medicines Consortium
* Cautions:
o Combined operations with cataract surgery – e.g. combined trabeculectomy with cataract surgery – use it with caution due to increased risks associated with that surgery
o Complicated cataract surgery – may wish not to use cefuroxime
o Reduced endothelial cell count
o Severe risk of infection
o Severe thyroid eye disease
* Interactions:
o More likely to cause nephrotoxicity if combined w/ other preparations such as aminoglycosides, methotrexate, acyclovir, ganciclovir, ketorolac
 More likely if these drugs are administered systemically
* Pregnancy & Breastfeeding:
o Safe to use in pregnancy, present in breastmilk in low concs (but still safe for use) – but unlikely for female who is of fertile age to be having cataract surgery

Question 9

What is the mechanism, medicinal forms, indications, off label uses by opthalmology and resistance of macrolides?

Answer 9

IP OPTOMS
* Mechanism:
o Inhibits translocation during protein synthesis taking place at ribosomes
o Bacteriostatic effect by disrupting protein synthesis which involves binding to ribosomes – same site of action as chloramphenicol so if both agents are used simultaneously some competition at drug site may occur
o Reasonably broad spectrum
* Medicinal Forms:
o Available topic preparations
 Azithromycin (Azyter 1.5% SDU eye drops) (PoM) – 15mg per gram unit dose, bds for 3 days for both children & adults
 (Erythromycin) – only available in US
* Indications:
o Chlamydia trachomatis tx
 Macrolide antibiotic drugs block protein synthesis in bacteria, including Chlamydia (mechanism is slightly different from chloramphenicol, aminoglycosides, tetracyclines or fusidic acid) and they reduce the replication rate of bacteria.
o Bacterial conjunctivitis
o Also used off licensed in stubborn blepharitis
* Erythromycin most useful against gram +ve organisms & a few gram -ve organisms (such as N. Gonorrheae)
* Azithromycin commonly used for the treatment of blepharitis by ophthalmologists
o Use in blepharitis is off label
 Azyter has demonstrated notable additional anti-inflammatory activities when compared to standard eyelid care ie. Lid hygiene and hot compresses
 Some evidence that topical azithromycin gives a superior result to systemic azithromycin for blepharitis
* Other off label uses by ophthalmology:
o Topical erythromycin and systemic penicillin to treat neonatal N. Gonorrheae conjunctivitis
o Systemic erythromycin and topical azithromycin to treat neonatal chlamydial conjunctivitis
* Resistance to macrolides (not as much of a consideration when using topically, more so when systemically) is brought by modification of ribosomes & can occur when used widely as a prophylactic
o Has been shown to be case in group of children where erythromicin resistant staphylocci were found when these children had been administered erythromycin to prevent ophthalmia neonatorum
o That’s why it is never used prophylactically – only used in active infections

Question 10

What are the cautions, interactions, contraindications, undesirable effects and info on pregnancy/breastfeeding for azithromycin (type of macrolide)?

Answer 10

IP OPTOMS
* Cautions:
o Pxs should be informed that tx should cease at end of 3 day course even if residual sxs remain
* Interactions:
o Many varied interactions – consult BNF – particularly problematic when prescribing systemic erythromycin
* Contraindications:
o Hypersensitivity to azithromycin, to any other macrolide (e.g. erythromycin) or to excipient Triglyceride – would not use Azyter if allergic to either of these
* Undesirable effects:
o Common:
 Eye discomfort
 Blurred vision
o Uncommon:
 Eye allergy
 Angioedema –area of swelling of lower layer of skin & tissue just under skin or mucous membranes.
* Swelling may occur in face, tongue, larynx, abdomen, or arms and legs. Often associated with hives, which are swelling within upper skin – can occur to periorbital skin when using topical agent
* Pregnancy & Breastfeeding:
o Listed as safe for use during pregnancy & breastfeeding
Need to discuss the frequency of undesirable effects with pxs when prescribing

Question 11

Describe mechanism, medicinal forms, and indications of quinolones?

Answer 11

IP OPTOMS
* Extremely effective topical antibacterials
* Mechanism:
o Interferes with the production of DNA by inhibiting the enzyme (DNA gyrase) responsible for producing the coils of nucleic acid in the bacterial cells – inhibits protein metabolism
o Bacteriostatic
o Effective against gram +ve and gram -ve – broad spectrum
* Medicinal Forms:
o Available topical preparations
 Ciprofloxacin (Ciloxan 0.3% eyedrops) (PoM) – next cheapest drug in this class £4.70 per 5ml bottle
 Levofloxacin (Levofloxacin generic 5mg/ml eyedrops)(PoM) – there is a preservative free version of this available
 Moxifloxacin (Moxivig 0.5% eyedrops) (PoM)
 Ofloxacin (Exocin 0.3% eyedrops) (PoM) – v commonly used in practice – most cost-effective drug in this class £2.15 per 5ml bottle
* Indications:
o Ciprofloxacin indicated for superficial bacterial eye infections, severe superficial eye infections, and corneal ulcers
o The other drugs in this class are indicated for eye infections

Question 12

What are the cautions, interactions, contraindications, undesirable effects, info on pregnancy/breastfeeding for ofloxacin (type of quinolone)?

Answer 12

IP OPTOMS
* Cautions:
o Safety & effectiveness in infants below age of 1 year have not been established – so should be used with EXTREME caution in this age group
o Caution should be taken in patients w/ known risk factors for prolongation of QT interval such as, for example:
 Concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III anti-arrhythmics, tricyclic antidepressants, macrolides (systemic), antipsychotics)
 Cardiac disease (e.g. heart failure, myocardial infarction, bradycardia)
 Elderly patients & women may be more sensitive to QTc-prolonging medications. Therefore, caution should be taken when using fluoroquinolones, including EXOCIN® (topical quinolone), in these populations
 Use with caution in pxs with uncorrected electrolyte imbalance (e.g. hypokalaemia, hypomagnesaemia)
 The above 4 points apply more to systemic application rather than topical application (except point 3)
* Interactions:
o As per above
* Contraindications:
o In those with known allergy to drug or excipients in formulation
* Undesirable effects:
o Eye irritation & ocular discomfort
o Ventricular arrhythmia – reported predominantly in pxs w/ risk factors for QT prolongation
* Pregnancy & Breastfeeding:
o Not suitable for use during pregnancy & breastfeeding
Use in pregnancy: There have been no adequate & well-controlled studies performed in pregnant women. Since systemic quinolones have been shown to cause arthropathy in immature animals, it is recommended that EXOCIN® not be used in pregnant women.
Use during lactation: Because ofloxacin and other quinolones taken systemically are excreted in breast milk, and there is potential for harm to nursing infants, a decision should be made whether to temporarily discontinue nursing or not to administer the drug, taking into account the importance of the drug to the mother

Question 13

What is the mechanism, medicinal forms, indications, dose, cautions, interactions, contraindications, undesirable effect and pregnancy/breastfeeding info for chloramphenicol?

Answer 13

Exempted PoM
* Mechanism:
o Inhibition of protein synthesis by interaction with bacterial ribosomes
 Protein synthesis requires amino acids to be brought to ribosome sites, arranged in correct sequence & linked to the one next to it
 Chloramphenicol blocks this linking of the amino acids resulting in a reduction and eventual halt in the overall rate of cell division.
 However, resistance to chloramphenicol can occur as a result of alterations (mutations) in the ribosome binding sites
* Little evidence of this resistance occurring in topical chloramphenicol
o Bacteriostatic
* Medicinal Forms:
o Available topical preparations
 Chloramphenicol generic 0.5% eyedrops (5ml bottle and SDUs) (PoM)
 Chloramphenicol generic 1% eye ointment (PoM)
* Both available as exempted PoMs for optoms
* Indications:
o Superficial eye infections – when used as PoM
o When used as P med – only indicated for bacterial conjunctivitis
* Dose:
o 0.5% eyedrops: apply one drop into the infected eye every 2 hrs for 48 hours
 After this period, treatment should be every four hours during waking hours. Eye drops may be supplemented by ointment at night.
 The course of treatment should last five days (even if symptoms improve within this time).
o 1% eye ointment: put a small amount into affected eye 4 times a day for 2 days, and then twice a day for 5 days.
* Cautions:
o Risk of aplastic anaemia after topical chloramphenicol use is less than 1 per million tx courses
* Interactions:
o Safety for use during pregnancy & breastfeeding has not been established
o Avoid in pxs taking drugs liable to depress bone marrow function
* Contraindications:
o Hypersensitivity to drug or any of excipients
o Immune system deficits: Hypersensitivity reactions including angioedema, anaphylaxis, urticaria, fever, vesicular and maculopapular dermatitis
o Blood & Lymphatic system disorders: Bone marrow depression and rarely aplastic anaemia has been reported following topical use of chloramphenicol. Whilst the hazard is a rare one, it should be borne in mind when assessing the benefits expected from the use of this compound
 Above 2 points are only theoretical risks when applying chloramphenicol topically
o Known personal or FH of blood dyscarsias, including aplastic anaemia
* Undesirable effect:
o Transient irritation, burning, stinging, itching & dermatitis on skin around eye
* Pregnancy & Breastfeeding:
o Not recommended in either

Question 14

What is other info to know about chloramphenicol?

Answer 14

• Potent broad spectrum (effective against both gram positive and negative)
• Ineffective against pseudomonas aeruginosa (gram -ve bacteria) – so if px CL wearer and has eye infection, chloramphenicol SHOULD NOT BE USED AS 1ST LINE AGENT
• Widely used due to:
  o Broad spectrum
  o Good corneal penetration
  o Little cross resistance – when used topically
• PoM: used in management of bacterial conjunctivitis, hordeolum, staphylococcal and seborrheic blepharitis, nasolacrimal duct obstruction where there is evidence of infection, dacryocystitis, marginal keratitis
• Cost-effective treatment
• Can be used age 2 years + when supplied directly by an entry level optometrist, can write a written order as an exempted PoM for patients from age 1 month +
  o Chloramphenicol has a dual classification. When classified a POM it can be used from 1 month. When as a P medicine for 2 years and over
• Important to note that chloramphenicol is available as various branded eye drops and eye ointments, which are P meds, e.g. Optrex infected eyes, eye drops 0.5% chloramphenicol
• P med: These preparations are only suitable for treatment of acute bacterial conjunctivitis, and can only be used in patients over age 2 and can only be used for a maximum of 5 days
• For details of the latest drug preparations see the BNF, however this may not list all P meds
  More and more toddlers coming to optoms with bacterial conjunctivitis – knowing your rights & knowing way you can use the legislation means can treat 6mth old baby if feel within your competence & so long as used via a signed order.
  If supplying directly to px (without signed order) – can only use it in bacterial conjunctivitis (cannot use it for e.g. hordeolum) & can only use it in children >2yrs.

Question 15

What is the mechanism, medicinal forms, indications, dose, caution, interactions, contraindications, undesirable effects and info on pregnancy/breastfeeding for fusidic acid?

Answer 15

• Mechanism:
  o Inhibition of protein synthesis taking place at ribosomes by inhibiting DNA translocation but does not bind to ribosomes
  o Chemically related to the cephalosporin antibiotics, but is a protein synthesis inhibitor
  o Mechanism of action of fusidic acid is similar to that of chloramphenicol, tetracyclines and te macrolides
  o Fusidic acid is a translocase inhibitor, indirectly interfering with translocase enzyme (by binding to a protein associated with the enzyme). If the translocase is blocked, the incoming peptidyl tRNA molecules cannot bind and protein synthesis is stopped
  o Bacteriostatic – when used in clinically recommended doses
   But at high doses can exert a slow bactericidal effect
• Medicinal Forms:
  o Available topical preparations
   Fusidic acid 1% viscous eye drops – exempted PoM
• Indications:
  o Staphylococcal eye infections – particularly good for gram +ve bacteria
• Dose:
  o Apply twice daily, tx should be continued for at least 48hrs after the eye returns to normal
• Cautions:
  o Not to be worn w/ CLs – microcrystalline fusidic acid may cause scratches in the contact lens or cornea. Contact lenses are kept out until all symptoms of the infection have gone.
  o Contains BAK which can cause eye irritation & CL discolouration
• Interactions:
  o Systemic interactions are unlikely since systemic exposure after application of Fusidic acid eye drops is negligible
• Contraindications:
  o Hypersensitivity to drug or any excipients – including BAK
• Undesirable Effects:
  o Common: blurred vision (thick preparation), burning, redness & stinging on application
  o Uncommon: hypersensitivity, eyelid oedema, lacrimation, skin rash, angioedema
• Pregnancy & Breastfeeding:
  o Can be used during pregnancy & breastfeeding

Question 16

What is other important info on fusidic acid?

Answer 16

• Potent narrow spectrum antibiotic, effective against gram +ve bacteria, in particular staphylococcus aeureus
• Tx of marginal keratitis, blepharitis, bacterial conjunctivitis when gram +ve bacteria are thought to be causative organism
• V expensive currently, since Fusithalmic viscous eye drops are no longer available only product available is fusidic acid cost £29.06 per 5g tube
• As a result has been removed from many local formularies
  o Now only used in cases of absolute need
• Can be used on children of any age – so occasionally still is a precedent to use it
• Fusidic acid should not be used with quinolones, with which they are antagonistic

Question 17

What is the mechanism, medicinal forms and indications for toptical antiprotazoal/antibacterial?

Answer 17

IP/Entry Level - available as P Med
* Mechanism:
o Aromatic diamidine disinfectant w/ antibacterial, antiprotozoal & antifungal actions
* Medicinal Forms:
o Available topical preparations
 Propamidine isethionate 0.1% eye drops (Brolene eye drops) (P)
 Dibrompropamidine 0.15% eye ointment (GoldenEye ointment)(P)
 Propramidine isethionate 0.1% eye drops (GoldenEye drops) (P)
* Indications:
o It may be used topically for the treatment of minor eye infections such as conjunctivitis and blepharitis
o Used by medics primarily for antiprotozoal and antifungal properties

Question 18

Describe propramidine isetionate and its cautions, interactions, contraindications, undesirable effects and info on pregnancy/breastfeeding?

Answer 18

Available as P Med - antiprotozoal/antibacterial
* Propamidine isetionate is active against Gram +ve non-spore forming organisms, but less active against Gram -ve bacteria & spore forming organisms. It also has antifungal properties.
* It may be used off license in the treatment of acanthamoeba keratitis by specialists only
* Works well even in the presence of copious purulent discharge – e.g. if someone has conjunctivitis with a lot of purulent discharge if it is a gram +ve organism
* Cautions:
o If no significant improvement after 2 days discontinue and consult a physician
o Unsuitable for use with contact lenses – due to preservatives in the preparation
o If vision is disturbed or becomes worse during the treatment regime discontinue and consult a physician – with some urgency
* Interactions:
o None known
* Contraindications:
o Hypersensitivity to the drug or any excipients e.g. the preservative
* Undesirable Effects:
o Eye discomfort, blurred vision, few systemic effects
* Pregnancy and Breastfeeding:
o Not suitable during pregnancy or breastfeeding

Question 19

Describe viruses?

Answer 19

• Simple noncellular structures – lack several characteristics of living things, except ability to replicate which they can accomplish when they are contained within prokaryotic or eukaryotic cells
• Contain nucleic acid (in form of single or double-stranded RNA or DNA – not both) and a capsid (protein coat) – these two together are known as nucleocapsid
• Sometimes an envelope (an additional glycoprotein coat around the capsid) and a tail
  o Viruses without envelope  naked viruses
• Capsids are formed from identical protein subunits, called capsomeres, which assemble into repeating, three-dimensional, symmetrical structures of which there are two major classes:
  o Helical: the protein subunits and the nucleic acid are arranged in a helix;
  o Icosahedral: the protein subunits assemble into a 20-sided symmetric shell that covers the nucleic acid-containing core
• Are considered neither prokaryotes nor eukaryotes as they lack several characteristics of living things, except ability to replicate (which they accomplish only in living cells)
• Pathogenesis of viral infection consists of several different steps
  o Initially virus must enter a host. Entrance may be accomplished through one of the body surfaces, for example skin, respiratory system, gastrointestinal system, urogenital system or conjunctiva of eye.
  o Some viruses enter host by way of needle injuries, blood transfusions and organ transplants, or by means of insect vectors which transmit the virus from one host to another

Question 20

What is the action of antiviral drugs?

Answer 20

• Topical antiviral drugs are active against herpes simplex & herpes zoster
• Block the ability of the virus to replicate DNA
• Topical antivirals (acyclovir and ganciclovir are prodrugs i.e. once biotransformed inside virus infected corneal and conjunctival epithelial cells) are active against the virus
  o The drugs themselves are largely ineffective against the virus, but will be biotransformed inside virus-infected corneal epithelial or conjunctival epithelial cells into the active form of the drug
• The active drug blocks DNA transcription leading to DNA that is fragmented and no longer functional as a template for subsequent mRNA & later protein synthesis
  o As a result, the herpes virus fails to replicate
• These drugs can be toxic to corneal epithelial cells, so needs to be used cautiously

Question 21

Describe the mechanism, medicinal forms and indications of topical antiviral?

Answer 21

IP OPTOMS
* Mechanism:
o Block actions of viral DNA/RNA polymerase enzymes
* Medicinal Forms:
o Available topical preparations
 Aciclovir 3% ophthalmic ointment (Zoviraz) (PoM) – stopped being produced
 Ganciclovir 0.15% eye ointment (Virgan) (PoM) – only one available
* Indications:
o Herpes simplex keratitis – other viral infections are not susceptible to ganciclovir – ganciclovir not effective against adenovirus or enterovirus

Question 22

Describe ganciclovir and cautions, interactions, contraindications, undesirable effects and info on pregnancy/breastfeeding?

Answer 22

Ganciclovir (type of topical antiviral): IP OPTOMS ONLY - PoM
* Available on PGD’s in some local shared care schemes in Scotland
* Can be used by IP optom (& optoms using PGD’s) to treat uncomplicated superficial acute or recurrent herpes simplex keratitis
* Aciclovir may be used in children but use of ganciclovir in children is not recommended (efficacy not been established in children so not recommended under age 18)
* Not effective against other viral organisms which can cause conjunctivitis e.g.not effective against adenovirus
* College Guidance on Tx of HSK:
o When infection is stromal, atypical or diagnosis is in doubt, or px is a CL wearer – then that px is more appropriately managed within ophthalmology
* Cautions:
o Stinging on instillation
o Avoid wearing CLs during treatment regime
o Avoid if known hypersensitivity to acyclovir or valaciclovir (antiviral tx used more systemically)
o Topical antivirals can be toxic to corneal epithelial cells therefore should be used with caution
* Interactions:
o The concomitant administration of Chloramphenicol with other drugs liable to depress bone marrow function should be avoided
* Contraindications:
o Hypersensitivity to the active drug or to any of the excipients – including BAK
o Myelosuprresssion during previous exposure to chloramphenicol
 If someone had aplastic anaemia after using chloramphenicol
o Known personal or family history of blood dyscrasias including aplastic anaemia
* Undesirable Effects:
o Very common SPK (however, this did not necessitate an early termination of treatment and healed without sequaele).
o Common – transient stinging on instillation, conjunctivitis
o Rare – Blepharitis
o Very rare – Immediate hypersensitivity reactions including angioedema and urticaria.
* Pregnancy and Breastfeeding:
o Manufacturer advises avoid unless no suitable alternative – limited information available
o Ganciclovir may be used in pregnancy when benefits outweigh risks
o Safe for use during breastfeeding