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ODReference

Ophthalmic Medications Guide

Dosing tables, prescribing frameworks, and clinical decision guides by drug class

How to Navigate This Section by Clinical Scenario

Red eye: decide what you are treating first

A red, painful, or photophobic eye requires an early decision about whether infection is plausible or whether the picture is primarily sterile inflammation. Many conditions overlap in appearance, but the treatment priorities differ. The Antibiotics page covers topical drops and ointments for conjunctivitis, keratitis, and adnexal infections with pediatric and Rx considerations. The Antivirals page provides a framework for HSV keratitis (epithelial, stromal, and endothelial disease), herpes zoster ophthalmicus, HEDS-based prophylaxis guidance, and the neurotrophic vs active infection distinction. When inflammation control is the primary goal, the Steroids page compares potency, formulation (acetate vs phosphate vs emulsion), taper strategy, and IOP monitoring. When both infection and inflammation are present, the Antibiotic and Steroid Combinations guide reviews when combination therapy fits and what to monitor.

Chronic disease: glaucoma, dry eye, and allergy

Long-term outcomes depend on stable regimens that match the patient's systemic history, ocular surface status, and adherence realities.

  • Glaucoma and ocular hypertension: The Glaucoma guide covers stepwise IOP-lowering therapy from prostaglandin analogs through ROCK inhibitors and fixed combinations, plus preservative and ocular surface considerations, SLT as an alternative to drops, angle-closure differences, and when to refer for MIGS or surgery.
  • Dry eye disease: The Dry Eye page covers mechanism-based prescribing with cyclosporine (Restasis, Cequa, Vevye), lifitegrast (Xiidra), varenicline nasal spray (Tyrvaya), and perfluorohexyloctane (Miebo) for MGD, plus steroid induction, punctal plugs, autologous serum, and Sjögren workup triggers.
  • Ocular allergy: The Allergy page covers dual-action antihistamine and mast cell stabilizers, OTC vs Rx options, and age and pregnancy guidance for allergic conjunctivitis.

Perioperative care: steroids, NSAIDs, and pain management

Cataract surgery, PRK, and other ocular procedures require coordinated anti-inflammatory and analgesic regimens. The Steroids page compares potency tiers and taper strategies for post-operative inflammation. The NSAIDs page covers perioperative CME prophylaxis with bromfenac, nepafenac, and ketorolac, including pre-operative timing, high-risk CME patients, and corneal safety considerations. The Pain Management page addresses cycloplegic selection for ciliary spasm, bandage contact lenses, oral analgesics, red-flag differentials, and neuropathic ocular pain. These three pages work together as a perioperative toolkit.

Diagnostics, procedures, and systemic therapy

The Cycloplegics page covers agent selection for cycloplegic refraction, uveitis management, and therapeutic dilation with pediatric safety considerations. When systemic therapy is needed, the Oral Medications section summarizes commonly used systemic antibiotics (including sub-antimicrobial doxycycline for MGD), oral antivirals for HSV and HZO, oral CAIs for acute IOP control, and analgesic options with contraindication screening. The Other Medications page covers specialty agents including hypertonic saline (Muro 128) for corneal edema, oxymetazoline (Upneeq) for acquired ptosis, pilocarpine for angle-closure and presbyopia (Vuity), low-dose atropine for myopia control, and cenegermin (Oxervate) for neurotrophic keratitis.

How to use ODReference medication tables

Each category page groups drugs by class and route, with tables that highlight typical adult dosing ranges, formulation strengths, and high-impact cautions such as systemic contraindications, pediatric restrictions, and intraocular pressure considerations. This is a chairside reference and does not replace full prescribing information, package inserts, local guidelines, or pharmacist review. Confirm dosing and safety for the individual patient, especially in pregnancy, breastfeeding, renal or hepatic disease, significant cardiopulmonary history, and when interacting medications are present.

Pharmacology and Prescribing FAQs

When is a topical steroid preferred over an NSAID, and vice versa?

Topical steroids provide broad anti-inflammatory control and are chosen for anterior uveitis, immune or stromal keratitis, and significant post-operative inflammation. Key risks include IOP elevation, delayed epithelial healing, and cataract formation. Topical NSAIDs are most commonly used for peri-operative CME prophylaxis, pain control, and maintaining pupil dilation. They do not raise IOP, but prolonged use can cause surface toxicity or delayed epithelial healing. In post-cataract regimens, the two classes are routinely used together because they act on different arms of the inflammatory cascade. See the Steroids and NSAIDs pages for selection details.

What systemic factors matter most when prescribing eye drops?

Systemic absorption of topical medications can be clinically relevant. Beta blockers (timolol) require caution in asthma, COPD, bradycardia, and heart failure. Alpha-2 agonists (brimonidine) are avoided in young children due to CNS depression risk. Carbonic anhydrase inhibitors require attention to renal function and sulfonamide allergy. Oral antivirals need renal dose adjustment. Tetracyclines are contraindicated in pregnancy and young children. Review systemic history, current medications, and teach punctal occlusion when appropriate to reduce systemic exposure.

How should topical medications be managed in contact lens wearers?

Most preserved ophthalmic medications should not be instilled over soft contact lenses, as preservatives and active drugs can bind to the lens matrix and increase toxicity exposure. Remove lenses before instillation and wait at least 15 minutes before reinsertion unless the product is explicitly labeled for in-lens use. For frequent dosing or prolonged courses, consider preservative-free formulations, daily disposable lenses, or temporarily discontinuing lens wear until the acute issue is controlled.

Why is preservative exposure a concern in long-term drop therapy?

Benzalkonium chloride (BAK), the most common ophthalmic preservative, is directly toxic to the corneal and conjunctival epithelium with chronic use. Long-term multi-drop regimens — especially in glaucoma and dry eye — can cause punctate epithelial erosions, conjunctival inflammation, tear film instability, and meibomian gland changes. BAK-related conjunctival scarring can also reduce surgical success if filtering surgery is later needed. Strategies include preservative-free formulations, combination drops to reduce total bottle count, and laser alternatives such as SLT for glaucoma. See the Glaucoma and Dry Eye pages for specific options.

When should a patient with a red eye NOT be started on a steroid?

Do not start a steroid on an undifferentiated red eye without ruling out infectious causes. HSV epithelial keratitis can enlarge from a small dendrite to a geographic ulcer under steroid therapy. Fungal keratitis and atypical microbial ulcers can also worsen. Steroids are appropriate once infection is reasonably excluded or when concurrent antimicrobial coverage is in place under close follow-up. The Antivirals page covers the HSV steroid decision in detail.