As a practicing pediatrician, I find Pediatric Annals a useful and interesting publication. Overall, the edition on eye infections was up to your usual high standards. I am writing about one small point. In his article, "Chronic Conjunctivitis in Infants and Children," [Pediatric Annals. 1993;22:366-374] Dr Weiss repeatedly referred to the use of Optichrom (4% cromolyn, Fisons Corp, Rochester, New York), a medication that I have been unable to get for years. Does he compound this himself from inhaled cromolyn? If he has some source for this, please let us all know. If not, one strike against your issue editor for letting this through.
Edward C. Lamon, MD
Albuquerque, New Mexico
The author responds.
Dr Lamon correctly points out that Optichrom, a mast cell stabilizer, is no longer routinely available for the treatment of allergic eye disease. According to Fisons, there were manufacturing problems that led to its withdrawal but they plan to reintroduce it in the future. I was told that it is available for emergency treatment of individual cases but this involves considerable paperwork. Some pharmacists have made 4% cromolyn from Nasalcrom (cromolyn nasal solution, Fisons Corp, Rochester, New York) but its safety for use on the eye and its sterility cannot be guaranteed. Alomide (lodoxamide, Alcon Laboratories Ine, Fort Worth, Texas) is a mast cell stabilizer that has been found to be efficacious but its use is awaiting Food and Drug Administration (FDA) approval. Thus, I would suggest two alternative medications in the meantime:
* Acular (ketorolac tromethamine) is a 0.5% ophthalmic solution that has been approved recently by the FDA for the acute treatment of hay fever conjunctivitis. It is a nonsteroidal anti- inflammatory drug (NSAID) whose mechanism of action is the inhibition of prostaglandin synthesis. However, its safety and efficacy beyond 7 days has not been established. Because it does not inhibit leukotriene synthesis, it is probably indicated for short-term treatment only and should be used with caution in patients with aspirinsensitive asthma. Other topical NSAIDs such as Ocufen (flurbiprofen, Allergan Medical Optics, Irvine, California), Voltaren (diclofenac, Geigy Pharmaceuticals, Ardsley, New York), and Suprofen (profenal) are available but these have not received FDA approval for the treatment of allergic conjunctivitis.
* Prednisolone 0.125% comes in three topical forms: AK-Pred Ophthalmic (Akorn Ine, Abita Springs, Louisiana), Êconopred Ophthalmic (Alcon Laboratories Ine, Fort Worth, Texas), and Pred Mild ( Allergan Pharmaceuticals, Irvine, California). It can be used for the treatment of hay fever, vernal, and atopic conjunctivitis. Assuming the adverse ocular effects are dosage-related, this weak corticosteroid should not be associated with cataracts, elevations of intraocular pressure, or other side effects.
In sum, acular and prednisolone 0.125% are recommended for the short-term treatment of allergic conjunctivitis. Mast cell stabilizers will probably be the drug of choice for long-term treatment but prednisolone 0.125% can be used until they become available. In severe or recalcitrant cases, the judicious use of a stronger topical corticosteroid preparation is sometimes necessary.
Avery H. Weiss, MD