- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
Contents
Aetiology
Chemical irritation of ocular and/or adnexal tissues by a topically applied drug or cosmetic, or by environmental or occupational substances
or
Delayed hypersensitivity (cell-mediated) response to a topically applied drug, preservative or other excipient, or cosmetic
Some drugs and preservatives may be both toxic and capable of inducing a delayed hypersensitivity response
Whatever the mechanism, there may be a delay in onset of weeks or months following a symptom-free period
Predisposing factors
Topical ophthalmic medication (either prescribed or over the counter)
Cosmetics applied to lids or lashes
Related to dose and frequency
If due to a delayed hypersensitivity response, takes at least two weeks to develop
Some drugs and preservatives are more likely to produce the problem:
- brimonidine
- atropine
- neomycin
- benzalkonium chloride
- phenylmercuric nitrate
- lanolin (component of some eye ointments)
Patients may use preserved topical medications for long periods of time, for example in glaucoma and in tear deficiency, but individual susceptibility to conjunctivitis medicamentosa varies widely
Symptoms of conjunctivitis medicamentosa
Initial improvement in the original condition requiring treatment
Then apparent deterioration despite proper compliance with regimen
Irritation, ocular pain, stinging, burning, photophobia
Ocular redness
Lid swelling
Blurred vision
Signs of conjunctivitis medicamentosa
Diffuse punctate staining of cornea and/or conjunctiva
Chronic epithelial defects (due to toxic inhibition of epithelial healing)
Tear film instability
Sometimes:
- corneal oedema
- pseudodendrites
- disciform stromal infiltrates
Differential diagnosis
Contact lens related staining or oedema
Corneal erosion, abrasion or ulcer
Corneal endothelial dysfunction
Ocular rosacea
Viral keratoconjunctivitis
Dry eye, exposure keratitis
Some topical medications (e.g. some prostaglandin analogues) cause hyperaemia as a known side effect
Rebound hyperaemia related to topical decongestants
Management by optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere
Non pharmacological
Withdrawal of the offending medication or preservative
Cold compress (symptomatic relief)
Advise patient to avoid any future use of causative drug or preservative
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Non-prescribed (over the counter) medications:
- decide whether original condition still requires treatment
- prescribe unpreserved alternative if necessary
Prescribed medications:
- where unpreserved formulation of the same medication available, switch to that
- do not discontinue a medication when the consequences of interruption could be more serious than the conjunctivitis medicamentosa (e.g. glaucoma medications)
- refer back to original prescriber for consideration of alternative medication
- unpreserved tear supplements / ocular lubricants (for symptomatic relief)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
- If severe, and in consultation with original prescriber, consider a short course of topical steroid,e.g. gutt. FML 0.1% qds for up to a week
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Antihistamines and mast cell stabilizers are not recommended for the treatment of conjunctivitis medicamentosa because they are ineffective in controlling inflammation in type IV hypersensitivity reactions
Management category
B2: Alleviation or palliation; normally no referral, but always inform and be advised by the original prescriber
Possible management by ophthalmologist
As above
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and Evaluation (see www.gradeworkinggroup.org)
Sources of evidence
Baudouin C, Labbé A, Liang H, Pauly A, Brignole-Baudouin F. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res. 2010;29(4):312-34
Gomes JAP, Azar DT, Baudouin C, Efron N, Hirayama M, Horwath-Winter J, Kim T, Mehta JS, Messmer EM, Pepose JS, Sangwan VS, Weiner AL, Wilson SE, Wolffsohn JS. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511-538
Hosten LO, Snyder C. Over-the-Counter Ocular Decongestants in the United States - Mechanisms of Action and Clinical Utility for Management of Ocular Redness. Clin Optom (Auckl). 2020;12:95-105
Spector SL, Raizman MB. Conjunctivitis medicamentosa. J Allergy Clin Immunol. 1994;94(1):134-6
Thygesen J. Glaucoma therapy: preservative-free for all? Clin Ophthalmol. 2018;12:707-717
Summary
What is Conjunctivitis medicamentosa?
Conjunctivitis medicamentosa is a condition in which a drug applied to the eye as drops or ointment, or a cosmetic, or some other substance reaching the eye surface, causes an irritative or allergic reaction. Some drugs are more likely than others to create this problem, including some anti-glaucoma agents and antibiotics. It can also be caused by preservatives in the medication. The patient notices redness, stinging or burning and possibly eyelid swelling and/or blurred vision.
How is Conjunctivitis medicamentosa managed?
Once recognised, the remedy involves withdrawing the offending medication and prescribing a substitute if necessary. If a preservative is the cause, it may be possible to obtain drops without preservative.
Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
Version 9
Date of search 10.12.20
Date of revision 18.12.20
Date of publication 06.08.21
Date for review 09.12.22
© College of Optometrists
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
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