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Young Ophthalmologists
Ophthalmic Drops 101
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“Numb the patient, dilate, start IOP-lowering drops … make sure they’re not allergic, then call me back,” said my senior resident. It was July, and my pockets were filled with a rainbow of eyedrops. Which one was I to avoid in babies? Why did I need to check sickle cell prep? And as my patients always asked, “What are the side effects? Why are my eyes still dilated?”

To help you get a quicker start to understanding the eyedrops you need while on call, here is a list of the most common drops and some clinical pearls. This is not a comprehensive list, nor should these descriptions substitute for medical advice or training. Eyedrops have multiple indications and side effects beyond what is listed here. This is an introduction to the most common drops encountered while in your first few months of residency. 

In the charts below, the brand name is listed in parenthesis if it has not yet become generic.

Anesthetic Drops

Drug Lid Color
Duration Indication Cautions
Proparicaine
(Alcaine)

Tetracaine

(Pontocaine)
White
10–30 min Topical anesthesia

Breaks down corneal epithelium ulcers

Speeds absorption of subsequent drops
Long-term use causes corneal ulcers

Check corneal sensation before use in setting of ulcers
Fluress
(Benoxinate + fluorescein)
n/a
white dropper 
10–20 min
Applanation tonometry

Stains defects on corneal/conjunctival surface 

Topical anesthesia
Not for Seidel tests (use fluorescein paper strips)

Patients may see yellow when they blow their nose

Dilation Drops

Drug Lid Color
Duration Indication Cautions
Phenylephrine
2.5%, 10%
(Neosynephrine)
Red 3 hours
Use with tropicamide for adult dilation Avoid 10% in hypertensive crisis, pediatrics and the elderly
Tropicamide 1%
(Mydriacil)
Red 4–6 hours
Use with phenylephrine for adult dilation
 
Cyclopentolate
1%, 2% (Cyclogyl)
Red 24 hours
Cycloplegic refractions  
Homatropine 2%
Red 1–2 days
No longer manufactured  
Atropine 1%
Red 7–10 days
Break posterior synechiae

Decrease ache from ocular inflammation

Fogging for amblyopia treatment
Avoid in angle-closure glaucoma

Glaucoma Drops

Drug Lid Color
Dosing Class Cautions
Timolol 0.5%
(Timoptic)
Yellow BID Beta blocker
Avoid in patients with asthma, COPD, CHF and bradycardia
Brimonidine 0.1%, 0.15%, 0.25%
(Alphagan)
Purple TID Alpha agonist
Avoid in patients under age of 3

Avoid in nursing women (only class B med)
Dorzolamide
(Trusopt)
Orange TID Carbonic anhydrase inhibitor
Avoid in sulfa allergy

Avoid in sickle cell patients with hyphema (can induce sickling in anterior chamber)

Patients may complain of bitter or metallic taste
Bimatoprost 0.01%, 0.03%
(Lumigan)

Travoprost 0.004%
(Travatan Z) 

Latanoprost 0.005%
(Xalatan)

Teal green
Qhs Prostaglandin agonist
May reactivate herpes simplex virus keratitis

Darkens hazel irides

Conjunctival hyperemia common

Avoid in uveitic glaucoma and pregnancy
Cosopt
White or Dark blue
BID Combo of
Dark blue timolol +
dorzolamide
 
Combigan
Dark blue
BID Combo of
timolol +
brimonidine
 
Acetazolamide
250mg tabs,
500 mg sequel (caps)
slow release
(Diamox)  
n/a PO
BID
Carbonic anhydrase inhibitor
Avoid in sulfa allergy

Avoid in sickle cell patients with hyphema (can induce sickling in anterior chamber)

Beware with potassium-losing diuretics or digitalis

Common side effects: peripheral limb tingling/weakness; bad taste with carbonated beverages; diarrhea
Methazolamide
25mg tabs
(Neptazane)
n/a PO
BID – TID
Carbonic anhydrase inhibitor
Same as above but less severe

Steroid Drops

Drug Lid Color
Indication Cautions
Prednisolone acetate
1% (PredForte)
White or Pink
Postoperative inflammation

Iritis
Can cause elevated IOP and cataracts
Fluorometholone
0.1% (FML)
White Ocular surface inflammation/dry eye Can cause elevated IOP and cataracts, but to a much lesser extent than above

Antibiotic Drops

Drug Lid Color
Indication Cautions
Moxifloxacin
(Vigamox)

Gatifloxacin

(Zymaxid)
Tan 4th generation fluoroquinolone

Postoperative

Corneal ulcers
 
Ofloxacin
(Ocuflox)
Tan 3rd generation fluoroquinolone

Postoperative
 
Erythromycin ointment
(Emycin)
n/a
tube
Bacterial conjunctivitis

Sterile cornea defects to prevent infection

Prevent ophthalmia neonatorum
 
Bacitracin ointment
(Bacitracin)
n/a
tube
Methicillin-resistant Staphylococcus aureus  
Tobramycin Dexamethasone ointment (Tobradex)
n/a
tube
Gram negatives (Pseudomonas)  
Neomycin, Polymyxin Dexamethasone ointment (Maxitrol)
n/a
tube
Postoperative

Common gram positives
Neomycin is the most common cause of contact dermatitis

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About the author: Janice C. Law, MD, is an assistant professor at the Vanderbilt Eye Institute in Nashville. She received her ophthalmology training at the Kresge Eye Institute in Detroit, where she also served as chief resident. After a two-year medical and surgical retina fellowship at the Vanderbilt Eye Institute, Dr. Law joined the retina faculty as assistant professor in vitreoretinal diseases and surgery. Dr. Law is also the associate program director for residency education in ophthalmology and plays a very active role in developing curricula and assessing teaching and learning within ophthalmic education. Janice Law, MD 
 
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