The FDA has approved Dextenza (Ocular Therapeutix), a dexamethasone ophthalmic insert, for treatment of ocular itching associated with allergic conjunctivitis. Dextenza was approved earlier for treatment of ocular inflammation and pain following ophthalmic surgery.

The ophthalmic H1-antihistamine alcaftadine 0.25%, which has been available by prescription since 2011 for use in patients with allergic conjunctivitis, is now available without a prescription as Lastacaft Once Daily Relief (Allergan) for temporary relief of itchy eyes due to pollen, ragweed, grass, animal hair, and dander in adults and children ≥2 years old. It is the third ophthalmic antihistamine to be approved for over-the-counter (OTC) use (see Table 1).

The FDA has approved Acuvue Theravision with Ketotifen (Johnson & Johnson Vision Care), a daily-wear, disposable, vision-correcting soft contact lens that releases the H₁-antihistamine ketotifen, for prevention of ocular itch due to allergic conjunctivitis in contact lens users. This is the first approval for a drug-eluting contact lens. Ketotifen eye drops (Alaway, Zaditor, and others) are available over the counter.

The choice of drugs for treatment of allergic rhinitis depends on the severity of symptoms and whether they are intermittent or persistent (see Table 1).

A 0.24% ophthalmic solution of the second-generation H₁-antihistamine cetirizine (Zerviate – Eyevance) is now available by prescription for treatment of ocular itching associated with allergic conjunctivitis in patients ≥2 years old. Oral cetirizine (Zyrtec, and others), which is used for treatment of allergic conjunctivitis and rhinitis, has been available over the counter (OTC) for years.

This issue includes reviews of drugs for glaucoma, age-related macular degeneration (AMD), bacterial conjunctivitis, and dry eye disease. Allergic conjunctivitis is reviewed in a separate issue.

The FDA has approved Odactra (ALK), a sublingual allergen extract, for immunotherapy in adults 18-65 years old with house dust mite (HDM)-induced allergic rhinitis, with or without conjunctivitis. Odactra is the first sublingual allergen extract to be approved in the US for this indication. Three other sublingual allergen extracts were approved earlier (see Table 1).

Allergic rhinitis can be classified as seasonal, perennial, or episodic. It is often associated with allergic conjunctivitis, rhinosinusitis, and asthma.

H₁-ANTIHISTAMINES — Oral – Oral second-generation H₁-antihistamines are the preferred first-line treatment for relief of the itching, sneezing, and rhinorrhea that characterize mild-to-moderate allergic rhinitis. They are less effective for nasal congestion.

Allergic rhinitis, allergic conjunctivitis, atopic dermatitis, urticaria, anaphylaxis and asthma (not included here; reviewed in Treatment Guidelines 2008; 6:83) are prevalent worldwide, especially in industrialized countries. Pharmacologic treatment of these disorders continues to improve in efficacy and safety. In addition to using drugs to prevent and control these allergic diseases, patients should be instructed to avoid, if possible, specific allergens and/or environmental conditions that trigger or worsen their symptoms. Allergen-specific immunotherapy may be useful for treatment of allergic rhinitis and allergic conjunctivitis, and in preventing severe insect venom-triggered reactions.

Drugs for glaucoma, age-related macular degeneration, bacterial conjunctivitis, and dry eyes are reviewed here. Ophthalmic drugs can have local and systemic adverse effects. In addition, for some elderly patients, the complexity of self-administering numerous ophthalmic drugs may be the limiting factor in their ability to care for themselves. Drugs for the treatment of allergic conjunctivitis will be reviewed in a future issue of Treatment Guidelines on Drugs for Allergic Disorders.

Drugs for glaucoma, age-related macular degeneration, bacterial and allergic conjunctivitis, and dry eyes are reviewed here. Ophthalmic drugs can have local and systemic adverse effects. In addition, for some elderly patients, the complexity of self-administering numerous ophthalmic drugs may be the limiting factor in their ability to care for themselves.

Epinastine HCl, an H₁-receptor antagonist and mast cell stabilizer, has been approved by the FDA for use in a 0.05% ophthalmic solution (Elestat - Allergan/Inspire) for prevention of itching associated with allergic conjunctivitis. The drug is available orally in Europe and Asia.

Two new fluoroquinolone solutions, moxifloxacin 0.5% (Vigamox - Alcon) and gatifloxacin 0.3% (Zymar - Allergan) are now available in the US for ophthalmic use in treatment of bacterial conjunctivitis.

Olopatadine hydrochloride (Patanol - Alcon), a propilidinedibenzoxypin derivative, has recently been marketed in a 0.1% ophthalmic solution for prevention of itching due to allergic conjunctivitis in adults and children more than three years old. It is the first drug for this indication that both inhibits mast cell degranulation and is a selective histamine H1 receptor antagonist (NA Sharif et al, J Pharmacol Exp Ther, 278:1252, 1996).

A 0.05% ophthalmic solution of levocabastine hydrochloride (Livostin - Iolab), a histamine H 1 -receptor antagonist, has been approved by the US Food and Drug Administration for treatment of seasonal allergic conjunctivitis. The new drug is a cyclohexylpiperidine derivative with no structural relationship to any other antihistamine.

Lodoxamide, a mast cell stabilizer, has been marketed in a 0.1% ophthalmic solution (Alomide - Alcon) for treatment of vernal keratoconjunctivitis.

Ketorolac (kee' toe role ak) tromethamine 0.5%, a nonsteroidal anti-inflammatory drug (NSAID) previously available for parenteral and oral administration (Toradol - Medical Letter, 32:79, 1990), has now been approved for ophthalmic use (Acular - Allergan, Fisons) to relieve itching in seasonal allergic conjunctivitis. NSAIDs decrease prostaglandin concentrations in the eye, which theoretically might contribute to a decrease in itching. Several other NSAIDs are available for ophthalmic use in the USA, but none is marketed for this indication. Flurbiprofen (Ocufen) and suprofen (Profenal) are promoted for use in ophthalmic surgery to prevent miosis. Diclofenac (Voltaren) is available in an ophthalmic solution for treatment of post-operative inflammation after cataract extraction.

An ophthalmic formulation of ciprofloxacin hydrochloride (Ciloxan - Alcon), a fluoroquinolone antibiotic, was recently marketed in the USA for treatment of bacterial keratitis and conjunctivitis. Ciprofloxacin has been used orally (Cipro) to treat a variety of serious infections (Medical Letter, 30:11, 1988) and recently was approved for intravenous administration.

Bacterial infections of the conjunctivae are usually self-limited, but topical antimicrobial therapy can be helpful. A solution of trimethoprim sulfate 0.1% with polymyxin B sulfate 10,000 units/ml (Polytrim - Burroughs Wellcome, distributed by Allergan) was recently marketed in the USA for treatment of superficial ocular bacterial infections.