EEM Rewind: The Wonderful World of Eye Drops

Emergency eye drops fall into four practical buckets: antibiotics, anesthetics, steroids, and pressure-lowering agents for acute angle-closure glaucoma. A few choices matter disproportionately in the ED, including drops over ointment for tolerance, steroids only with ophthalmology input, and a multimodal approach when intraocular pressure is high.

ED Eye Drops That Matter

• Antibiotic workhorse choices: Polymyxin B/trimethoprim and ofloxacin are the reliable first-line drops: safe, inexpensive, and usually better tolerated than ointment for routine ED ocular infections and epithelial defects.
• When ointment helps most: Erythromycin or bacitracin ointment earns its place when lubrication is part of the treatment plan, especially with corneal abrasion or severe dry eye, not because ointment treats infection better.
• Agents to avoid: Sulfacetamide and gentamicin are poor ED choices because they can be caustic or toxic to the ocular surface, a useful distinction we get into in the episode.
• Topical steroid boundary: Prednisolone, dexamethasone, and difluprednate should not be started independently in the ED; topical steroids belong behind an ophthalmology recommendation because the wrong eye gets harmed fast.
• Limited topical anesthetics: Topical anesthetics can be reasonable for a simple traumatic corneal abrasion, but only in a tightly limited 24-hour quantity and only when the diagnosis is absolutely secure.

Corneal Defects and Red Eye

• Epithelial defect infection risk: Any epithelial defect, from corneal abrasion to exposure keratopathy, loses the cornea's protective barrier and needs a topical antibiotic to prevent secondary bacterial infection.
• Herpetic lesion pairing: Suspected herpetic dendrites call for an oral antiviral plus a topical antibiotic, because the viral process and the bacterial superinfection risk are separate problems.
• Bacterial conjunctivitis clues: Purulent copious discharge in children or nursing-facility patients points toward bacterial conjunctivitis; drops are usually preferable because these eyes are already goopy enough.
• Viral conjunctivitis reality: Viral conjunctivitis often looks worse than bacterial disease, with pain, watery discharge, and swollen lids, yet usually does not need antibiotics; the bedside distinction is worth hearing in the chapter.
• Corneal ulcer risk split: Ulcer size and location drive urgency: small peripheral ulcers are less vision-threatening, while central ulcers can jeopardize the visual axis and demand more aggressive therapy plus ophthalmology follow-up.

Acute Angle-Closure Glaucoma Drops

• Multimodal pressure strategy: Acute angle-closure glaucoma is not a one-drop problem; acetazolamide plus dorzolamide/timolol and brimonidine targets aqueous production and outflow from multiple angles.
• Timolol airway caution: Timolol is useful for mild glaucoma, but a history of reactive airways should make you pause because beta-blockade can create trouble outside the eye.
• Cosopt severe disease role: Dorzolamide/timolol is a strong ED option for severe glaucoma because it suppresses aqueous humor production with two mechanisms rather than one.
• Brimonidine as adjunct: Brimonidine is the classic add-on when timolol/dorzolamide is already running, contributing both reduced aqueous production and improved outflow.
• Acetazolamide sickle caution: Oral acetazolamide is a key severe-glaucoma medication, but sickle cell anemia is an important contraindication. We walk through the practical regimen in the episode.