Optometrists manage more anterior segment disease than anyone, and it’s critical that we have the pharma knowledge to treat these patients appropriately. This month’s annual pharmaceutical issue provides detailed advice to elevate your practice so you can give patients much-needed relieve and recovery. I’d like to preface this article series with a few thoughts from my perspective as both a clinician and an educator.


Just because we haven’t seen a new antibiotic in a few years doesn’t mean we should get complacent in drug selection. Drug resistance, while steady, is incredibly high.1 The most recent ARMOR study—a yearly review of over 3,000 ocular isolates in the United States—found methicillin-resistant Staphylococcus is resistant to 30% to 40% of antibiotics; for coagulase-negative Staph., it’s nearly 50%. Because we don’t typically culture conjunctivitis and it takes so long to get a culture for an infectious keratitis, we have to be knowledgeable and judicious when treating empirically.1 Most bacteria are susceptible to newer agents such as Besivance (besifloxacin, Bausch + Lomb).1

Dry Eye Drugs

Although artificial tears continue to advance with a number of new and increasingly effective options, they still play a palliative role, with little value in addressing inflammation. Both Restasis (cyclosporine, Allergan) and Xiidra (lifitegrast, Shire) have made significant contributions to treating the underlying inflammation of dry eye disease.2 Xiidra may bring symptom improvement in as little as two weeks, and some studies of Restasis show improvement at one month.3 

Topical Steroids

Don’t fear these drugs. For superficial punctate keratitis (SPK), few treatments are more effective.4 There are risks to withholding steroids when managing inflammatory diseases such as corneal neovascularization, synechiae, persistent SPK, progressive dry eye, corneal haze and scarring.   

At the same time, don’t be cavalier with steroids. Although the only absolute contraindication is epithelial herpetic disease, there are times when you should apply caution in their use. For example, be wary of steroids when treating an early infectious keratitis (especially without a confirmed diagnosis), an abrasion or when using a bandage contact lens. There still may be a role for steroids in such cases, but exercise greater caution. Always check intraocular pressure within three to five weeks for any patient on a corticosteroid. To help ensure the patient returns for the check, I often provide no refills on steroid-containing drops in new patients.

Systemic Medications

An optometrist without access to systemic meds is in a difficult position to effectively care for patients. Many cases necessitate systemic therapy, and in today’s healthcare system, a referral before treatment leaves the patient vulnerable to significant morbidity. Soft tissue infections such as dacryocystitis, hordeola, canaliculitis and preseptal cellulitis are just one category that comes to mind (orbital cellulitis requires referral to an emergency room for intravenous antibiotics). 

Systemic medications are also required to fully control chronic conditions such as ocular rosacea, multiple or repeat hordeola and chalazia, and chronic ocular surface disease. Severe allergies, dermatological disorders and immune responses may require a short course of oral prednisone. One cannot manage most cases of ocular herpes simplex virus without oral antivirals, and even over-the-counter oral nonsteroidals can greatly aid a patient with a corneal abrasion. 

It’s nearly impossible to effectively manage ocular disease without occasionally having to reach into the bag for an oral medication. Give this hard-won legal right the recognition—and use—it deserves.

Note: Dr. Karpecki is a consultant for many companies discussed here.

1. Asbell PA, Sanfilippo CM, Pillar CM, et al. Antibiotic resistance among ocular pathogens in the United States: five-year results from the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) Surveillance Study. JAMA Ophthalmol. 2015;133(12):1445-54.
2. Stern ME, Gao J, Schwalb TA, et al. Conjunctival T-cell subpopulations in Sjögren’s and non-Sjögren’s patients with dry eye. Invest Ophthalmol Vis Sci. 2002;43(8):2609-14.
3. Deveci H, Kobak S. The efficacy of topical 0.05 % cyclosporine A in patients with dry eye disease associated with Sjogren’s syndrome. Int Ophthalmol. 2014;34(5):1043-8.
4. Coursey TG, de Paiva CS. Managing Sjögren’s syndrome and non-Sjögren syndrome dry eye with anti-inflammatory therapy. Clin Ophthalmol. 2014;8:1447-58.