JRSM >
Volume 98, Number 6 >
Pp. 274-275
Department of Ophthalmology, Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury SY3 8XQ, UK
Correspondence to: Mr A Patwardhan E-mail: apatwa{at}hotmail.com
If prescribed for a viral ocular infection, topical ciprofloxacin is more likely to do harm than good.
CASE HISTORY
A previously fit and healthy man of 27 attended with painful red eyes. He also reported general malaise and sore throat. For the past week he had been treating his eyes with ciprofloxacin 0.3% ophthalmic solution every two hours on the advice of his general practitioner, and it was a worsening of his eye symptoms that caused him to come to eye casualty. There was no previous history of eye disorder and he was using no other medications. On examination, visual acuities were 6/60 in the right eye and 6/36 in the left eye. Both conjunctivae showed a severe follicular reaction, and fluffy white precipitates were seen adhering to the surface of both corneas (Figure 1). There was mild pharyngitis but lymphadenopathy was absent. The clinical evidence was suggestive of pharyngo-conjunctival fever. When the infiltrates were scraped under local anaesthesia, subepithelial infiltrates typical of adenoviral keratoconjunctivitis were clearly visible (Figure 2). The patient was asked to stop topical ciprofloxacin and was treated with only tear substitute. Six weeks later visual acuities were 6/6 and ocular examination revealed nothing abnormal. On electronmicroscopy the corneal scrapings showed needle-shaped crystals and viral cultures grew adenovirus type 3; the bacterial cultures were negative.
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COMMENT
The formation of white crystalline precipitates is a well known property of ciprofloxacin when it is used for treatment of bacterial ulcer.1-3 These precipitates, though sometimes troublesome, have the advantage of yielding high local concentrations of the drug and their presence is beneficial in bacterial keratitis.4 The reason for their appearance is that topical ciprofloxacin is made up at low pH to discourage precipitation, and the pH rises when the solution meets the tear film. This is not true of topical ofloxacin. Sometimes ciprofloxacin crystals develop even in the original container, blocking the nozzle track.5 Adenoviral keratoconjunctivitis, as seen in the present patient, resolves spontaneously within 10–14 days.6 Topical lubricants, and in some cases topical corticosteroids, may be useful, but antibiotic therapy has no role.6 The irregular surface formed by precipitates of ciprofloxacin causes discomfort, reduces visual acuity and delays recovery.
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