When A Condition Does Not Respond to Topicals, Oral Medications May Be Key

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Classes of oral antibiotics, corticosteroids, carbonic anhydrase inhibitors, and antivirals add vital options for treatment.

The following article is a part of Ophthalmology Advisor’s conference coverage of the Southeastern Educational Congress of Optometry (SECO) 2021, held in Atlanta and virtually from April 28 to May 2, 2021. The team at Ophthalmology Advisor will be reporting on the presentations offered by these leading experts in optometry and ophthalmology. Check back for more from the SECO 2021 Meeting.


Medications taken orally affect the entire body, so clinicians often start off conservatively, prescribing topicals first. Justin Schweitzer, OD, does not shy away from recommending oral drugs when needed, though. “We are the primary eye care provider,” he writes. “Practice at the highest level allowed within your scope.” In Dr Schweitzer’s course at the Southeastern Educational Congress of Optometry (SECO) 2021 Conference, held April 28 to May 2 in Atlanta, attendees will benefit from an in-depth rundown of studies on, and suggested dosages for several medicines.

During the course “When Topical Just Isn’t Enough,” Schweitzer will present challenging diagnoses, such as a case of cellulitis, looking at differential signs that could indicate either preseptal or orbital cellulitis. He will list appropriate oral antibiotic options to help resolve the condition, along with persistent redness and swelling. Further, different generations of antibiotics, allergies, and cross-reactivity will be addressed. Prior research indicates patients who react to penicillin may have an 80% likelihood of becoming less sensitive in about 10 years.

In cases of meibomian gland dysfunction, patients sometimes do not respond to conservative management, and then oral doxycycline or azithromycin may improve symptoms, the course explains. Schweitzer adds that a number of conditions are more responsive than others to systemic medicines. In episcleritis, oral medications are seldom needed, while in anterior scleritis, four types of oral NSAIDs are first-line treatment. However, if there is no improvement in scleritis at 2 weeks, he believes it is time to bring out the “big guns;” oral corticosteroids. 

Regarding corticosteroids, clinicians should be aware that oral doses of 40 mg or more have been shown to cause a 5% to 18% greater risk of side effects, such as mood swings, insomnia, personality changes, and depression, as well as increased intraocular pressure (IOP), cataract formation, and increased blood sugar in those with diabetes. It is contraindicated in pregnancy. Encouragingly, there are typically few ocular side effects with short term use.

Schweitzer will discuss the effectiveness of carbonic anhydrase inhibitors for glaucoma. Acetazolamide can lower IOP 40% to 60% by blocking aqueous humor production. Side effects can include fatigue or tingling in extremities, and use of this drug is not indicated in patients with severe COPD, and liver or kidney disease. For patients without contraindications, this medication can buy time during IOP spikes when surgery is not possible or topical absorption is not reliable. Methazolamide is another option, he adds.

Course attendees will learn more about the challenging diagnoses of epithelial and stromal herpes simplex virus (HSV) infections. In addition, for neurotrophic keratitis a recombinant human nerve growth factor, cenegermin-bkbj, has been shown to stimulate corneal healing. Antivirals, such as acyclovir may be used as prophylaxis or therapy for HSV keratitis. Also, herpes zoster virus — chickenpox and shingles — has a 15% chance of affecting the ophthalmic branch of trigeminal cranial nerve V. Therapy for postherpetic neuropathic pain includes cold compresses, analgesics, gabapentin, amitriptyline, or antivirals.

Schweitzer adds that systemic treatment is sometimes indicated for acute ocular conditions; “oral medications are necessary at times to put out fires.”

Disclosure: The presenter declared affiliations with the biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.  

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Schweitzer, Justin. When topical is not enough: oral medications. Presented at: Southeastern Educational Congress of Optometry (SECO) 2021 Annual Meeting; April 28-May 2, 2021; Atlanta, GA. Course 145.