E-Doc Interactive - Eye Infections And The Use Of Ocular Antibiotics, Spersanicol


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Highly effective preparations are available for the treatment of common eye infections and these drugs can play an important role in everyday patient care. Most of these drugs are administered as drops or ointments and act topically on the conjunctiva or eyelid.

Mandi Schultz B. Sc (Micro), B. Pharm

The eye is a complex and sensitive organ and is therefore also more vulnerable to trauma and infections. It is important for the nurse to have a thorough knowledge of the eye so that she can advise patients on the protection of the eye, correct use of eye medication and can recognise any condition that might require expert medical attention.

EXAMINATION OF THE EYE The recognition of medical emergencies and injuries to the eye, also the occurrence of infections and less serious problems, necessitate a measure of proficiency on the part of the nurse to examine the eye.

After taking a complete and pertinent health history from the patient the following must be established during the examination:

Is there any discharge?

When and how did the symptoms start?

What is the nature of the pain and has it spread?

It is important to test the patient?s sight; i. e. can he see at all as well as previouslyIt is important to test both the good and the injured eye as this can indicate bleeding, a foreign object or a detached retina. If the eyes are damaged in any way, medical attention must be sought immediately..

In the clinic or hospital the nurse should look for:

Any signs of inflammation

Any wound or bleeding

Colour changes on the cornea and membrane ? e. g. the membrane may be red as a result of dilation or damage to blood vessels with haemorrhaging.

Irregularities in the continuity of any of the structures

Haemorrhaging or foreign objects behind the cornea.

Any signs of bleeding or trauma to the eye must be referred immediately.

The nurse must also examine the eyelid for any signs of inflammation or infection. When examining the eyelid, the patient should look down and the upper lid should be peeled upwards. This is done by pulling the eyelashes downwards and exerting pressure on the centre of the eyelid using a cottonwool bud, match or thumb. Then the lid is lifted upwards by pulling on the eyelashes. In this way the eyelid can be properly examined. The lower lid is easily pulled away from the eye.

COMMON EYE PROBLEMS

Eye infections, which may present in the clinic or hospital, include:

Bacterial conjunctivitis

Viral conjunctivitis

Trachoma (Chlamydial Keratoconjunctivitis)

Dacrocystitis

Bacterial conjunctivitis occurs as a result of infection of one or both eyes, usually by Staphylococcus aureus or Streptococcus pneumoniae, resulting in a copious purulent discharge making the eye sticky but not affecting the patient?s vision. Other causative organisms include Haemophilus aegyptius and Moraxella lacumata. Babies may contract Gonococcal conjunctivitis during birth due to an infected mother.

Bacterial conjunctivitis is self-limiting and usually lasts about 10 days without treat-ment. A baby with Gonococcal conjunc-tivitis should be referred for treatment with systemic antibiotics and is regarded as a medical emergency as the cornea may be affected. Bacterial conjunctivitis is usually treated with an antibiotic ointment, which should be applied three times daily. The eye should be bathed in warm water to remove the discharge and care should be taken not to infect the other eye.

Viral conjunctivitis may be as a result of Adenovirus or as a result of the Herpes simplex virus. Adenovirus conjunctivitis is usually associated with pharyngitis, fever and swelling of the lymph glands. The conjunctiva is red and there is a watery discharge. The Herpes simplex virus produces a follicular conjunctivitis with the formation of a dendritic lesion. More extensive ulcers may also occur in a chronic infection. There is not specific treatment for Adenovirus conjunctivitis, although antibioticointments may be used to prevent any secondary bacterial infections. Herpes simplex virus conjunctivitis may be treated with antivirals, such as acyclovir, although if suspected the patient must be referred for proper diagnosis using fluorescein.

Trachoma is an eye disease caused by Chlamydia trochomatis and is characterised by follicles, papillary hyperplasia and vascularisation of the cornea. This leads to the formation of lesions and consequent blindness. In the acute stage the eye is red and itchy and lacrimation is excessive. The patient usually presents with visual disturbances although it is often acquired during childhood when it is more difficult to diagnose. The condition is usually associated with poor living conditions and poor hygiene and is spread via direct contact. Any patient presenting with signs of trachoma must be referred immediately as early treatment can prevent the onset of blindness.

Trachoma is treated with oral tetracyclines or erythromycin for three to five weeks. Topical tetracycline ointment can be applied at the same time or a solution of 1 ? 3% tetracycline can be used to bath the eye twice a day for three months. Good personal hygiene is essential to prevent reinfection.

Dacrocystitis is an infection of the tearducts and glands and the patient usually complains of pain in the eye, particularly in the corner and a watery or tacky discharge. The corner of the eye is usually swollen and pressure will cause the emission of pus from the puncture. Topical and systemic antibiotics are used to treat the condition.

The following eyelid problems may present in the clinic or hospital:

Stye (Hordeolum)

Blepharitis

Chalazion

Cellulitis

Entropion and Ectropion

A Stye (Hordeolum) is a small swollen abscess on the eyelid caused by bacterial infection, usually Staphylococcus. The infection occurs in the sebaceous gland on the margin of the eyelid. It is red, swollen and very painful and it often has a head containing yellow pus. Should this head or point be on the inside of the lid, it is an abscess of the Meibomian gland. If the point is on the outside, it is smaller and on the edge of the eyelid and regarded as a Stye.

Styes are treated with an antibiotic cream or eyedrops administered every two hours and a warm compress. It may sometimes be necessary to lance and drain the abscess.

Blepharitis is an infection of the eyelid edge and is usually chronic. Patients complain of painful eyelids, which are worse in the mornings. The edges of the eyelids are crusty and the eyes are red. This sometimes follows repeated Styes on the eyelids. This condition is more common in elderly patients and they often present with seborrhoeic dermatitis as well.

Blepharitis may be classified as either Anterior blepharitis or Posterior blepharitis. Both types present with the same symptoms of eye irritation, burning, swelling and a stick morning discharge. This infection is as a result of heavy colo-nisation by Staphylococcus aureus and may never be controlled once it has been allowed to set in. Lidhygiene is absolutely essential and the patient must be made aware of the need for total commitment to the eradication of the infection.

The lashes should be cleaned regularly using cottonwool dipped in a bicarb solution or baby shampoo. Warm compresses can be used to soften the crusts for easier removal. The application of antibiotic eye ointment should follow the lid washing and then be applied three times a day. Ointments, generally chloramphenicol or sulphonamides must be used so as to coat the eyelid and lashes adequately. Systemic antibiotics may sometimes be of value if the topical applications have failed. Artificial tears can be used to provide symptomatic relief.

Chalazion is a firm swelling of the eyelid often found together with Blepharitis and is a cyst of the meibomian gland and is the result of inflammation and granulation.

Cellulitis usually results from sepsis in the vicinity of the eye and is characterised by extensive swelling and redness of the eyelid, usually only on one side. If it were to spread to the eye socket, it may cause meningitis and even blindness. Cellulitis should be referred to a medical practitioner as systemic antibiotics are indicated.

Entropion and Ectropion is usually a problem in the elderly and is the inward or outward turning or folding of the eyelid. Sulphonamides can be administered to prevent infection, but the patient should be referred to an ophthalmologist for surgery.

Bacteria are the cause of most eye infections, whereas viral and fungal infections are much less common. Superficial infections such as Blepharitis and conjunctivitis are generally treated with topical agents. More serious infections may require subconjunctival injections. Acute and chronic trachoma may require 1 to 2 months of continued treatment with concurrent use of appropriate oral anti-chlamydial therapy.

The same precautions applying to the indiscriminate use of systemic antibiotics hold for those used topically. The widespread prescription of these agents may result in the emergence of resistant strains.

Chloramphenicol is usually the drug of choice due to the fact that ocular toxicity is low, penetration is excellent and thedrug is active against a wide spectrum of organisms. Only if there is not an adequate response or if resistance can be demonstrated, should an alternate preparation or combinations of agents be resorted to.

Chloramphenicol preparations available in South Africa include Chloromex Ophthalmic Ointment?, Chlornicol?, Chlo-romycetin?, Chloroptic? and Spersanicol?.

Sulphacetamide is a non-antibiotic, anti-microbial agent that is very useful in treating superficial infections such as Bacterial conjunctivitis and Blepharitis. The ophthalmic dose for an infection is usually ?instil every 2 to 6 hours?. Itis considered useful to use Sulphacetamide prophylactically to prevent infection after an eye injury.

Sulphacetamide preparations available in South Africa include Covosulf?, Spersamide ? and Sulphacetamide Eye Ointment ?. Sulphacetamide is sometimes available in a 10% and 30% solution. The 30% solution may initially be irritating, but this is usually followed by an analgesic effect.

Tetracyclines are also indicated for super-ficial eye infections caused by susceptible organisms. It is used for Trachoma with concurrent oral treatment and for chlamydial infections. It is however ineffective against pseudomonas. The only preparation readily available in South Africa contains both oxytetracyline and polymyxin B (Terramycin?). Some patients complain of stinging or burning of the eyes after tetracycline instillation, but it is usually well tolerated and seldom leads to sensitisation.

Aminoglycosides, such as Gentamycin (Garamycin Eye Drops?) and Tobramycin (Tobrex?) are highly effective in the treatment of most eye infections, but because of the risk of sensitisation it is recommended that their use be restricted to serious sight-threatening infections.

ADMINISTRATION OF OCULAR ANTIBIOTICS

Eye drops are easily instilled; rapidly effective and best used when the eyes are to remain uncovered. They need to be instilled frequently because of the rapid elimination from the conjunctival sac. The volume of the conjunctival sac is less than that of one drop, so it is wasteful to instil more than one drop at a time. If two or more different eye drops are required at the same time of day, the patient should wait for approximately 10 ? 15 minutes between instillation to prevent dilution and overflow. It is important that the patient does not squeeze the eye shut after administration of the drop, as this will eliminate the fluid from the conjunctival sac. If necessary the lid should be gently held open for 1 to 2 minutes after a drop has been administered.

Other combination antibiotic preparations available in South Africa include:

The general use of Neomycin is discouraged because of the risk of sensitivityreactions.

Eye ointments are easier to apply and are retained for a longer period in the conjunctival sac, resulting in a more sustained absorption. A common disadvantage of eye ointments is blurring of vision for 10 ? 15 minutes after application. If this is a problem the ointment should be used overnight or when the eye is to be covered with an eye patch.

Subconjunctival injection is a useful form of drug delivery, particularly in serious corneal and intraocular infections. The drug diffuses mainly through the cornea of the eye and higher intraocular concentrations may be achieved than with topical drops or ointments. The maximum volume of injected drug is usually restric-ted to 1ml.

Ophthalmic solutions are generally sterile, but once bottles are open there is always the risk of contamination. Whether in plastic or glass bottles, eye solutions should not remain in use for longer than four weeks after opening. Preservative free preparations should be kept refrigerated and discarded within 1 week after opening.

The following guidelines must be followed when administering eye drops or ointments:

If microbial contamination is pre-vented, preparations can be used for four weeks after opening and should then be discarded.

Eye drops or ointments should notbe administered to different patients from the same container, particularly if there is any indication of an eye infection.

It is important that the container does not touch the eyelashes or any other part of the eye since this may lead to contamination and possible reinfection.

Some practical hints

When bathing the eye, massage the corners of the eyes firmly with down-ward movements to press any matter from the tear ducts. Bathe the eye thoroughly using a solution of 0.5-tsp salt to 500ml warm water. For babies, cottonwool swabs can be dipped into the solution and used to wipe the eye clean.

Eyedrops should be administered with the patient sitting and looking upwards. Pull the lower lid down, drop the liquid in between the eyelid and eyeball and let the patient look down while the lower lid is still held firmly.

For the administration of eye ointment, pull the lower lid as explained above and let the patient look up. Squeeze about 1cm of ointment onto the inside of the lower lid. Let the patient close the eye while rolling the eyeball in all directions.

Eye bandages can be used to keep the eye closed and protected. These bandages should be oval in shape and about 0.5cm thick cottonwool with gauze on either side. They should be placed firmly on the eye to press the eyelid against the cornea and secured with adhesive tape from the forehead to the cheek at a 45? angle.

A warm compress, such as a warm facecloth or towel may be used to reduce pain.

Eye care is extremely important and with the appropriate pharmaceutical care many minor eye conditions need not progress to more serious problems. It is however important the patients are educated about eye infections, instructed in precise techniques for drug instillation and made aware of any possible adverse effects.

Posted on Wednesday, October 16 @ 16:32:26 SAST by E-Doc