Acute and Chronic Conjunctivitis Due
`Acute and Chronic Conjunctivitis Due
`to Over-the-counter Ophthalmic Decongestants
`to Over-the-counter Ophthalmic Decongestants
`Charles N. S. Soparkar, MD, PhD; Kirk R. Wilhelmus, MD; Douglas D. Koch, MD;
`Charles N. S. Soparkar, MD, PhD; Kirk R. Wilhelmus, MD; Douglas D. Koch, MD;
`Gary W. Wallace, MD; Dan B. Jones, MD
`Gary W. Wallace , MD; Dan B. Jones, MD
`
`Objective: To describe patterns of conjunctivitis caused
`Obiectlve: To describe patterns of conjunctivitis caused
`by ophthalmic decongestants.
`by ophthalmic decongestants.
`Design: Case series.
`Design: Case series.
`Setting: Outpatient eye clinic.
`Setting: Outpatient eye clinic.
`Patients: We selected patients with conjunctival in-
`Patients: We selected patients with conjunctival in(cid:173)
`flammation who were using nonprescription deconges-
`flammation who were using nonprescription deconges(cid:173)
`tant eyedrops, who had no other cause for conjunctivi-
`tant eyedrops, who had no other cause for conjunctivi(cid:173)
`tis, and whose conditions improved after discontinuing
`tis, and whose conditions improved after discontinuing
`the incriminated preparations.
`the incriminated preparations.
`Main Outcome Measures: Clinical characteristics of
`Main Outcome Measures: Clinical characteristics of
`conjunctival inflammation and time to resolution of symp-
`conjunctiva] inflammation and time to resolution of symp(cid:173)
`toms and signs after discontinuing the use of eyedrops.
`toms and signs after discontinuing the use of eyedrops.
`Results: Seventy patients (137 eyes) were identified. Prepa-
`Results: Seventy patients (137 eyes) were identified. Prepa-
`
`rations containing the vasoconstrictors naphazoline, tet-
`rations containing the vasoconstrictors naphazoline, tet(cid:173)
`rahydrozoline, or phenylephrine were associated with 3
`rahydrozoline , or phenylephrine were associated with 3
`clinical patterns of conjunctivitis: conjunctival hyper-
`clinical patterns of conjunctivitis: conjunctival hyper(cid:173)
`emia (50 cases), follicular conjunctivitis (17 cases), and
`emia (50 cases), follicular conjunctivitis (17 cases), and
`eczematoid blepharoconjunctivitis (3 cases). Deconges-
`eczematoid blepharoconjunctivitis (3 cases). Deconges(cid:173)
`tants were used daily for a median of 3 years (range, 8 hours
`tants were used daily for a median of 3 years (range, 8 hours
`to 20 years) prior to presentation. The median time to reso-
`to 20 years) prior to presentation. The median time to reso(cid:173)
`lution of symptoms and signs was 4 weeks (range, 1-24
`lution of symptoms and signs was 4 weeks (range, 1-24
`weeks), and patients remained asymptomatic for a me-
`weeks), and patients remained asymptomatic for a me(cid:173)
`dian follow-up of 6 months (range, 0-12 years).
`dian follow-up of 6 months (range, 0-12 years) .
`Conclusion: Nonprescription decongestant eyedrops can
`Conclusion: Nonprescription decongestant eyedrops can
`produce acute and chronic forms of conjunctivitis by phar-
`produce acute and chronic forms of conjunctivitis by phar(cid:173)
`macological, toxic, and allergic mechanisms. Once rec-
`macological, toxic , and allergic mechanisms. Once rec(cid:173)
`ognized, conjunctival inflammation often takes several
`ognized, conjunctival inflammation often takes several
`weeks to resolve.
`weeks to resolve.
`Arch Ophthalmol. 1997;115:34-38
`Arch Ophthalmol. 1997;115:34-38
`
`Over-the-counter oph¬
`0 VER-THE- COUNTER oph(cid:173)
`
`thalmic decongestants
`thalmic decongestants
`are commonly used to
`are commonly used to
`control ocular redness
`control ocular redness
`and discomfort.1 " The
`and discomfort.1 11 The
`principal active ingredient in these eye-
`principal active ingredient in these eye-
`drops is an a-adrenergic, vasoconstric-
`drops is an a-adrenergic, vasoconstric(cid:173)
`tive amine such as naphazoline, tetrahy-
`tive amine such as naphazoline, tetrahy(cid:173)
`drozoline, or phenylephrine; some
`drozo line, or phenylephrine ; some
`preparations also contain an antihista-
`preparations also contain an antihista(cid:173)
`mine for type 1 histamine-receptor
`mine for type 1 histamine-receptor
`blockade.
`blockade.
`Adverse systemic reactions to topical
`Adverse systemic reactions to topical
`vasoconstrictors are uncommon but in¬
`vasoconstrictors are uncommon but in(cid:173)
`clude nervousness,12 headache,13"16 dizzi¬
`clude nervousness, 12 headache, 13·16 dizzi(cid:173)
`ness,14 nausea,14 hypotension,1 ' '8 hyperten¬
`ness, 14 nausea, 14 hypotension, 17·18 hyperten(cid:173)
`sion,131416·19'20 and cardiac dysrhythmia.14
`sion, 13·14· 16·19·20 and cardiac dysrhythmia. 14
`The most frequent local side effect of oph¬
`The most frequent local side effect of oph(cid:173)
`thalmic vasoconstrictors is ocular sting¬
`thalmic vasoconstrictors is ocular sting(cid:173)
`ing.7'21,22 However, mydriasis,5'7-23"25 blurred
`ing.7·21 ·22 However, mydriasis,s.1.23·25 blurred
`vision,7'3 epithelial erosion,21·26 punctal ste¬
`vision, 7·15 epithelial erosion, 21 .26 punctal ste(cid:173)
`nosis,27·28 corneal epithelial pigment depo¬
`nosis, 27.28 corneal epithelial pigment depo(cid:173)
`sition,29 iris pigment release,22·23 iritis,30 in¬
`sition,29 iris pigment release, 22·23 iritis,30 in(cid:173)
`traocular pressure change (ie, increase or
`traocular pressure change (ie, increase or
`decrease),'13·23·24·31·32 and acute angle
`decrease) ,7·13·23 •24 ·31·32 and acute angle
`closure15·24·25 have also been described. Ad-
`closure15.24·25 have also been described. Ad-
`
`ditionally, antihistamines may produce al¬
`ditionally, antihistamines may produce al(cid:173)
`lergies and local irritations.33,34
`lergies and local irritations. 33·34
`Our experience indicates that decon-
`Our experience indicates that decon(cid:173)
`gestant eyedrops containing vasoconstric¬
`gestant eyedrops containing vasoconstric(cid:173)
`tors, with or without antihistamines, are
`tors, with or without antihistamines, are
`causes of acute and chronic conjunctival
`causes of acute and chronic conjunctival
`inflammation.
`inflammation.
`
`RESULTS
`RESl LTS
`Seventy patients with ophthalmic decon-
`Seventy patients with ophthalmic decon(cid:173)
`gestant-related conjunctivitis were iden¬
`gestant-related conjunctivitis were iden(cid:173)
`tified (50 from the external disease clinic
`tified (50 from the external disease clinic
`and 20 from the general clinics) (Table 1 ).
`and 20 from the general clinics) (Tallle 1 ).
`The mean age at presentation was
`The mean age at presentation was
`42.5± 15.9 years (range, 18-82 years). The
`42.5± 15.9 years (range, 18-82 years). The
`frequency of daily eyedrop application
`frequency of daily eyedrop application
`ranged from 1 to 12 times (mean, 3.7±2.2
`ranged from 1 to 12 times (mean, 3.7±2.2
`times per day). The duration of medica¬
`times per day) . The duration of medica(cid:173)
`tion use prior to presentation averaged
`tion use prior to presentation averaged
`
`See Patients and Methods
`on next page
`
`From the Cullen Eye Institute,
`From the Cullen Eye Institute,
`Department of Ophthalmology,
`Depanment of Ophthalmology,
`Baylor College of Medicine,
`Bay lor College of Medi cine,
`Houston, Tex. The authors
`Hou ston , Tex. The authors
`have no commercial or
`have no commercial or
`proprietary interest
`in the
`proprietary interest in the
`products discussed in this
`products di scussed in this
`article.
`article.
`
`ARCH OPHTHALMOVVOL 11 5, J AN 1997
`34
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`

`

`PATIENTS AND METHODS
`PATIENTS AND METHODS
`
`Adverse reactions to ophthalmic decongestants were
`Adverse reactions to ophthalmic decongestants were
`sought in medical records coded with a primary di¬
`sought in medical records coded with a primary di(cid:173)
`agnosis of conjunctivitis. These records were gener¬
`agnosis of conjunctivitis. These records were gener(cid:173)
`ated from patients examined during the past 12 years
`ated from patients examined during the past 12 years
`by 2 external disease specialists (K.R.W. and D.BJ.)
`by 2 external disease specialists (K.R.W. and D.B.j.)
`at the Cullen Eye Institute, Houston, Tex, and from
`at the Cullen Eye Institute, Houston, Tex, and from
`patients examined during the past 4 and 6 months
`patients examined during the past 4 and 6 months
`at general ophthalmology clinics at Ben Taub Gen¬
`at general ophthalmology clinics at Ben Taub Gen(cid:173)
`eral Hospital, Houston, and the Veterans Affairs Medi¬
`eral Hospital, Houston, and the Veterans Affairs Medi(cid:173)
`cal Center, Houston, respectively. Cases were ex¬
`cal Center, Houston, respectively. Cases were ex(cid:173)
`cluded if other ocular surface disease was present,
`cluded if other ocular surface disease was present,
`nondecongestant eyedrop use occurred within 2
`nondecongestant eyedrop use occurred within 2
`weeks of presentation, or follow-up failed to dem¬
`weeks of presentation, or follow-up failed to dem(cid:173)
`onstrate improvement of the conjunctival inflamma¬
`onstrate improvement of the conjunctiva! inflamma(cid:173)
`tion after discontinuing decongestant use. In some
`tion after discontinuing decongestant use. In some
`cases, conjunctival scrapings were obtained for cy¬
`cases , conjunctiva! scrapings were obtained for cy(cid:173)
`tologie examination and chlamydial infection test¬
`tologic examination and chlamydia! infection test(cid:173)
`ing (eg, Giemsa-stain examination, organism cul¬
`ing (eg, Giemsa-stain examination, organism cul(cid:173)
`ture, or fluorescent antibody detection of the
`ture, or fluorescent antibody detection of the
`chlamydial antigen).
`chlamydia! antigen).
`After resolution of decongestant-induced con¬
`After resolution of decongestant-induced con(cid:173)
`junctivitis by discontinuing use of their eyedrops, 4
`junctivitis by discontinuing use of their eyedrops, 4
`patients agreed to be rechallenged for 2 weeks with
`patients agreed to be rechallenged for 2 weeks with
`new preparations of the presumed offending medi¬
`new preparations of the presumed offending medi(cid:173)
`cations at the same frequency as used prior to pre¬
`cations at the same frequency as used prior to pre(cid:173)
`sentation.
`sentation.
`Nonparametric analyses included the Spear¬
`Nonparametric analyses included the Spear(cid:173)
`man rank correlation, the Wilcoxon rank sum test,
`man rank correlation, the Wilcoxon rank sum test,
`and the Fisher 2-tailed exact test. Values are ex¬
`and the Fisher 2-tailed exact test. Values are ex(cid:173)
`pressed as the mean(± 1 SD).
`pressed as the mean(±l SD).
`
`3.5±4.5 years (range, 8 hours to 20 years). The ocular
`3.5±4.5 years (range, 8 hours to 20 years). The ocular
`symptoms on presentation included eyelid swelling,
`symptoms on presentation included eyelid swelling,
`epiphora, ocular awareness, irritation, itching, burning,
`epiphora, ocular awareness, irritation, itching, burning,
`pain, foreign-body sensation, or redness. Twelve brands
`pain, foreign-body sensation, or redness. Twelve brands
`of ophthalmic decongestants were implicated (Table 2).
`of ophthalmic decongestants were implicated (Table 2).
`Three clinical patterns of conjunctivitis were iden¬
`. Three clinical patterns of conjunctivitis were iden(cid:173)
`tified: (1) conjunctival hyperemia (Figure I), which is
`tified: (1) conjunctiva! hyperemia (Figure 1 ), which is
`defined as diffuse hyperemia and chemosis of the con¬
`defined as diffuse hyperemia and chemosis of the con(cid:173)
`junctiva extending beyond the interpalpebral fissure, epi¬
`junctiva extending beyond the interpalpebral fissure , epi(cid:173)
`scleral vascular dilation, and papillae of the upper and
`scleral vascular dilation, and papillae of the upper and
`lower pretarsal conjunctiva; (2) follicular conjunctivitis
`lower pretarsal conjunctiva; (2) follicular conjunctivitis
`(Figure 2), which is defined as bulbar or palpebrai fol¬
`(Figure 2), which is defined as bulbar or palpebral fol(cid:173)
`licles with ocular symptoms, regardless of the degree of
`licles with ocular symptoms, regardless of the degree of
`conjunctival inflammation; and (3) blepharoconjunctivi-
`conjunctiva! inflammation; and (3) blepharoconjunctivi(cid:173)
`tis (Figure 3), which is defined as subcutaneous edema
`tis (Figure 3) , which is defined as subcutaneous edema
`and hyperemia of the eyelids, diffuse chemosis, and bul¬
`and hyperemia of the eyelids, diffuse chemosis, and bul(cid:173)
`bar and pretarsal conjunctival hyperemia.
`bar and pretarsal conjunctiva! hyperemia.
`Eighteen patients (including all patients with fol¬
`Eighteen patients (including all patients with fol(cid:173)
`licular conjunctivitis) were tested for chlamydial infec¬
`licular conjunctivitis) were tested for chlamydia! infec(cid:173)
`tion; the results of all tests were negative. Ten patients
`tion; the results of all tests were negative. Ten patients
`(4 with conjunctival hyperemia and 6 with follicular con¬
`( 4 with conjunctiva! hyperemia and 6 with follicular con(cid:173)
`junctivitis) underwent conjunctival scrapings, all of which
`junctivitis) underwent conjunctiva! scrapings, all of which
`demonstrated many lymphocytes, occasional polymor-
`demonstrated many lymphocytes, occasional polymor(cid:173)
`phonuclear leukocytes, and few or no eosinophils.
`phonuclear leukocytes, and few or no eosinophils.
`Conjunctival hyperemia was present in 50 cases
`Conjunctiva! hyperemia was present in 50 cases
`(71%); follicular conjunctivitis, 17 cases (24%); and
`(71%); follicular conjunctivitis, 17 cases (24%); and
`blepharoconjunctivitis, 3 cases (4%). Ophthalmic de-
`blepharoconjunctivitis , 3 cases ( 4%). Ophthalmic de-
`
`congestants, individually and as a group, were most likely
`congestants, individually and as a group, were most likely
`to cause conjunctival hyperemia (P<.001, data not
`to cause conjunctiva! hyperemia (P<.001, data not
`shown). Naphcon-A (naphazoline hydrochloride, Al¬
`shown). Naphcon-A (naphazoline hydrochloride, Al(cid:173)
`con Laboratories, Fort Worth, Tex), an exception, was
`con Laboratories, Fort Worth, Tex), an exception, was
`associated with follicular conjunctivitis (P=.01, data not
`associated with follicular conjunctivitis (P= .01, data not
`shown).
`shown).
`All patients with conjunctival hyperemia or follicu¬
`All patients with conjunctiva! hyperemia or follicu(cid:173)
`lar conjunctivitis were first treated by discontinuing the
`lar conjunctivitis were first treated by discontinuing the
`topical medication. After initial improvement of their con¬
`topical medication. After initial improvement of their con(cid:173)
`ditions, 24 (36%) of these 67 patients were then pre¬
`ditions , 24 (36%) of these 67 patients were then pre(cid:173)
`scribed a corticosteroid drop at an initial frequency of 4
`scribed a corticosteroid drop at an initial frequency of 4
`times daily; this frequency was tapered during a 1- to 10-
`times daily; this frequency was tapered during a 1- to 10-
`week period. The corticosteroids used included 0.1% fluo¬
`week period. The corticosteroids used included 0.1 % fluo(cid:173)
`rometholone, 0.1% fluorometholone acetate, 0.125% or
`rometholone, 0.1 % fluorometholone acetate, 0.125% or
`1% prednisolone phosphate, and 1% prednisolone ac¬
`1 % prednisolone phosphate, and 1 % prednisolone ac(cid:173)
`etate. Patients with conjunctival hyperemia showed no
`etate. Patients with conjunctiva! hyperemia showed no
`difference in time to recovery whether they were treated
`difference in time to recovery whether they were treated
`with corticosteroids or not (Wilcoxon rank sum test,
`with corticosteroids or not (Wilcoxon rank sum test,
`z=—0.49, P=.63, Table 1). In contrast, patients with fol¬
`z= - 0.49, P=.63, Table 1). In contrast, patients with fol(cid:173)
`licular conjunctivitis showed faster improvement of their
`licular conjunctivitis showed faster improvement of their
`conditions with corticosteroid use (mean recovery time,
`conditions with corticosteroid use (mean recovery time,
`3.3±1.0 weeks vs 10.3±7.2 weeks; Wilcoxon rank sum
`3.3± 1.0 weeks vs 10.3±7.2 weeks; Wilcoxon rank sum
`test, 2=2.58, P=.01). All patients with eczematoid blepha-
`test, z=2.58, P= .01). All patients with eczematoid blepha(cid:173)
`roconjunctivitis were treated with topical corticoste¬
`roconjunctivitis were treated with topical corticoste(cid:173)
`roids.
`roids.
`The time to resolution of signs and symptoms for
`The time to resolution of signs and symptoms for
`all cases of conjunctivitis averaged 6.8±6.7 weeks (me¬
`all cases of conjunctivitis averaged 6.8±6. 7 weeks (me(cid:173)
`dian, 4 weeks; range, 1-24 weeks). A positive correla¬
`dian, 4 weeks; range, 1-24 weeks). A positive correla(cid:173)
`tion was found between the duration ofdecongestant eye-
`tion was found between the duration of decongestant eye(cid:173)
`drop use prior to presentation and the time required for
`drop use prior to presentation and the time required for
`recovery (Spearman rank correlation, r=0.346, P=.01).
`recovery (Spearman rank correlation, r=0.346 , P= .01).
`No association was found between individual deconges¬
`No association was found between individual deconges(cid:173)
`tant preparations or the frequency of daily eyedrop use
`tant preparations or the frequency of daily eyedrop use
`and the time to recovery (P=.62).
`and the time to recovery (P= .62).
`Four patients in whom conjunctival hyperemia was
`Four patients in whom conjunctiva! hyperemia was
`diagnosed were rechallenged with new preparations of
`diagnosed were rechallenged with new preparations of
`their vasoconstrictors. Three patients applied their de¬
`their vasoconstrictors. Three patients applied their de(cid:173)
`congestants (Visine [tetrahydrozoline hydrochloride],
`congestants (Visine [ tetrahydrozoline hydrochloride],
`Pfizer Ine, New York, NY; Clear Eyes [naphazoline hy¬
`Pfizer Inc , New York, NY; Clear Eyes [naphazoline hy(cid:173)
`drochloride], Ross Laboratories, Columbus, Ohio; and
`drochloride], Ross Laboratories, Columbus, Ohio; and
`Murine Plus [tetrahydrozoline hydrochloride], Ross Labo¬
`Murine Plus [ tetrahydrozoline hydrochloride], Ross Labo(cid:173)
`ratories) in 1 or both eyes for 2 weeks and had a relapse
`ratories) in 1 or both eyes for 2 weeks and had a relapse
`of their signs and symptoms in the treated eye(s). The
`of their signs and symptoms in the treated eye(s). The
`fourth patient was unavailable for follow-up.
`fourth patient was unavailable for follow-up.
`
`-------i!Qi§ii• -f-------
`
`COMMENT
`Nonprescription ophthalmic decongestants can cause
`Nonprescription ophthalmic decongestants can cause
`acute and chronic conjunctivitis. Three clinical pat¬
`acute and chronic conjunctivitis . Three clinical pat(cid:173)
`terns are described that likely represent distinct patho-
`terns are described that likely represent distinct patho(cid:173)
`physiological mechanisms.
`physiological mechanisms.
`Conjunctival hyperemia, the most common form of
`Conjunctiva! hyperemia, the most common form of
`decongestant-associated conjunctivitis, is probably a phar¬
`decongestant-associated conjunctivitis, is probably a phar(cid:173)
`macologically induced rebound phenomenon following
`macologically induced rebound phenomenon following
`vasoconstrictor discontinuation. The mechanism may be
`vasoconstrictor discontinuation. The mechanism may be
`either vasoconstrictor-induced tissue ischemia35 with re¬
`either vasoconstrictor-induced tissue ischemia35 with re(cid:173)
`lease of a vasodilating substance or constrictor tachy¬
`lease of a vasodilating substance or constrictor tachy(cid:173)
`phylaxis.36 Nasal preparations containing a-adrenergic
`phylaxis.36 Nasal preparations containing a-adrenergic
`amines are well known to cause rebound vascular dila¬
`amines are well known to cause rebound vascular dila(cid:173)
`tion in the nasal mucosa,7·12·37"40 and such a reaction also
`tion in the nasal mucosa, 7·12·37-40 and such a reaction also
`occurs in the conjunctiva following epinephrine eye-
`occurs in the conjunctiva following epinephrine eye(cid:173)
`drop use.30·41 Although previous experience suggests that
`drop use. 30,41 Although previous experience suggests that
`
`ARCH OPHTHALMOUVOL 115, JAN 1997
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`

`.
`
`.
`
`,_ ...
`
`.
`
`.
`
`Table 1. Characteristics of Vasoconstrictor-Associated Conjunctivitis
`Table 1. Charat.t,ristitS: ~t v,soco~strietor-Associated .qonJ"nctMtis* •
`
`Time to Recovery, wk
` -1
`Frequency,
`With
`Without
`Drops/d
`Corticosteroids Corticosteroids
`ge. y
`9.8±8.6
`6.2±6.1
`41.2±16.3
`3.5±2.3
`(38,18-82)
`(5, 3-24)
`(4, 2-24)
`(3,1-12)
`10.3±7.2f
`3.3+1.Of
`4.5±1.9
`46.1 ±157
`(43, 22-79)
`(4, 2-9)
`(7, 3-20)
`(3.5,1-4)
`1.3±0.6
`3.7±1.5
`44.3±2.1
`(45, 42-46)
`(4, 2-5)
`(1.1-2)
`6.5 + 7.25
`7.1+6.5
`3.7±2.2
`42.5±15.9
`(4,1-12)
`(4,1-24)
`(4, 2-24)
`(41.5,18-82)
`1 SD. The median and the range are given in parentheses unless otherwise indicated. Ellipses indicate data not applicable.
`* Values are expressed as the mean
`·•· Values are expressed as the mean :!: 1 SD. The median and the range are given in parentheses unless otherwise indicated. Ellipses indicate data not applicable.
`tSignificantly different (P=.01).
`t Significantly different (P=.01 ).
`
`Form of Conjunctivitis
`Conjunctival hyperemia
`Follicular conjunctivitis
`Blepharoconjunctivitis
`
`All forms
`All forms
`
`Sex, No. of Cases (% of Total)
`
`M
`24
`(89)
`2
`(7)
`1
`(4)
`27
`
`26
`(60)
`15
`(35)
`2
`(5)
`43
`
`-
`
`Duration of Use, y
`3.2±3.6
`(3,10d-20y)
`5.0±6.7
`(2, 0.3-20)
`0.2+0.2
`(0.2, 8 h-0.3 y)
`3.5±4.5
`(3, 8 ri-20 y)
`
`Table 2. Ophthalmic Decongestants Causing Conjunctivitis
`
`Antazoline, 0.50
`
`Antihistamine, %
`
`Adrenergic Agonist, %
`Medication! (Manufacturer, Location)
`Albalon Liquifilm (Allergan Inc.
`Naphazoline, 0.050
`Calif)
`.··. . ...... ·· ., > .
`...•.••. ~apll~ > ... ·· ••....
`Albatiin UqJ/tilmJ
`Irvine
`Naphazoline, 0.050
`Albalon-A Liquifilm (Allergan Ine)
`. ·••· ... •.•.···•· ... • : .\· :·· .··•. i .· .·, .. NaP,haztJlfn~rQ-95Q ..•
`AlbalOrt·A Li(!Uffil ........ .
`Ohio)
`Naphazoline, 0.012
`Clear Eyes (Ross Laboratories, Columbus,
`. Naphiizo!I0!!, ·0·:01:2 • ·.
`Clear Eyes (RtJ~sLab .. ·· .. ··•. •·•· ··· ... colµ!llbUS;Qhio)
`Collyrium Fresh-Eye Drops (Wyeth-Ayerst
`"
`· · ·
`Collyrium fresh 0Ey~ Dn)p~ ('(v'yetll,;~yerst •·
`>
`Tetrahydrozoline, 0.050
`Laboratories, Philadelphia, Pa)
`.
`•
`La.. borato.rt~ ;Ph.\latlelp.hi.a, .. P.a).;
`tetfahyd,f6Z~Jinto,050
`. . :alqrie$)'... . . .
`Murine Plus (Ross Laboratories)
`Tetrahydrozoline, 0.050
`Murine P;Iu,s '.(Rq~s
`.o~o i
`.. . ·.. .. ;
`T!!
`. /tiWilifh/ tex} . < N .
`<
`Naphazoline, 0.012
`Naphcon (Alcon Laboratories, Fort Worth,
`Tex)
`. Nap-hcoq(~leont
`Naphazoline, 0.025
`Naphcon-A (Alcon Laboratories)
`Pheniramine, 0.30
`· · ·
`fiap1tq9n~1;(~1e>o
`NaphfOrt :\o.1rt · ·
`Naphcon Forte (Alcon Laboratories)
`Naphazoline, 0.100
`Prefrin Liquifilm (Allergan Ine)
`Phenylephrine, 0.120
`• · ... Pretrlq, Liquifil':I
`d~o ,: i Antazoline, 0.05 , .
`Vasocon-A (lolab Corporation, Claremont, Calif)
`Naphazoline, 0.050
`Antazoline, 0.05
`(!fa~ •,He
`·
`Tetrahydrozoline, 0.050
`Visine (Pfizer Ine, New York, NY)
`Tetrahydrozoline, 0.050
`Visine AC (Pfizer Ine)
`050
`*Ellipses indicate data not applicable.
`* Ellipses indicate data not applicable.
`t Trademark names.
`t Trademark names.
`
`Preservatives, %
`Benzalkonium Chloride
`0.004
`0.004
`0.010
`
`Edetic Acid
`0.013
`0.013
`0.100
`
`0.010
`0.010
`0.010
`0.010
`0.010
`0.005
`0.010
`0.010
`0.005
`
`0.100
`0.020
`0.050
`0.010
`0.050
`0.015
`
`0.100
`0.015
`
`vasoconstrictors never1·2·5·7·8424^ or rarely43·464'
`incite
`vasoconstrictors never 1·2 ·5 ·7·8 4 H 5 or rarely 4 ' ·40 ·4 7 incite
`conjunctival hyperemia, the 50 cases in this series
`conjunctiva! hyperemia , the 50 cases in this series
`clearly demonstrate that ophthalmic decongestants
`clearly demonstrate that ophthalmic decongestants
`containing phenylephrine, naphazoline, or tetrahydro¬
`containing phenylephrine, naphazoline, or tetrahydro(cid:173)
`zoline can cause rebound dilation of conjunctival
`zoline can cause rebound dilation of conjunctiva!
`blood vessels.
`blood vessels.
`Follicular conjunctivitis, which probably repre¬
`Follicular conjunctivitis, which probably repre(cid:173)
`sents a toxic effect,34 4S accounts for one fourth of the cases
`sents a toxic effect, 34·48 accounts for one fourth of the cases
`in this series. Follicles were most prominent in the lower
`in this series. Follicles were most prominent in the lower
`palpebrai conjunctiva and fornix but were also present
`palpebral conjunctiva and fornix but were also present
`on the bulbar and upper palpebrai conjunctiva. These 17
`on the bulbar and upper palpebral conjunctiva. These 17
`cases are the first reports of bulbar follicles resulting from
`cases are the first reports of bu I bar follicles resulting from
`the use of decongestants. The factor(s) responsible may
`the use of decongestants. The factor(s) responsible may
`be any of a number of agents in the decongestant prepa¬
`be any of a number of agents in the decongestant prepa(cid:173)
`rations: the vasoconstrictor,30·34 an antihistamine (if pre¬
`rations: the vasoconstrictor,30·34 an antihistamine (if pre(cid:173)
`sent),34 or 1 of the preservatives. 33'34'W54
`sent), Hor l of the preservatives_ 33 .3H 4· 54
`Eczematoid blepharoconjunctivitis was the least
`Eczematoid blepharoconjunctivitis was the least
`common reaction in this series. Although benzalko¬
`common reaction in this series. Although benzalko(cid:173)
`nium chloride,21·34 edetic acid,34·55 and phenyleph¬
`nium chloride, 21 ·34 edetic acid, 1 4 · 5 5 and phenyleph(cid:173)
`rine21·22 can cause contact hypersensitivity, to our knowl¬
`rine2122 can cause contact hypersensitivity, to our knowl(cid:173)
`edge, our cases are the first reports of allergic
`edge , our cases are the first reports of allergic
`blepharoconjunctivitis associated with preparations con¬
`blepharoconjunctivitis associated with preparations con(cid:173)
`taining naphazoline and tetrahydrozoline.
`taining naphazoline and tetrahydrozoline.
`The incidence of adverse reactions to ophthalmic de¬
`The incidence of adverse reactions to ophthalmic de(cid:173)
`congestants is unknown. Even if the incidence is low, the
`congestants is unknown. Even if the incidence is low, the
`
`Figure 1. Conjunctival hyperemia. A 43-year-old woman who used 0.05%
`Figure 1. Conjunctiva/ hyperemia. A 43-year-old woman who used 0.05%
`tetrahydrozoline eyedrops. 3 times daily, for 12 years had bilateral, symmetric
`tetrahydrozoline eyedrops, 3 times daily, for 12 years had bilateral, symmetric
`hyperemia of the upper and lower tarsal conjunctiva; marked, diffuse
`hyperemia of the upper and lower tarsal conjunctiva; marked, diffuse
`hyperemia of the bulbar conjunctiva; and dilated superficial episcleral vessels.
`hyperemia of the bu/bar conjunctiva; and dilated superficial episcleral vessels.
`One week after discontinuing use of the decongestant. her conjunctival and
`One week after discontinuing use of the decongestant, her conjunctiva/ and
`episcleral hyperemia were diminished. A 1-week tapering course of 0.125%
`episc/eral hyperemia were diminished. A I-week tapering course of 0.125%
`prednisolone phosphate drops was used.
`In 3 weeks, she was asymptomatic
`prednisolone phosphate drops was used. In 3 weeks, she was asymptomatic
`and remained so during 7 months of follow-up.
`and remained so during 7 months of follow-up.
`
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`solve; the longer the duration ofeyedrop use prior to pre¬
`solve; the longer the duration of eyedrop use prior to pre(cid:173)
`sentation, the longer the time to recovery. In our series,
`sentation, the longer the time to recovery. In our series,
`topical corticosteroids did not alter the rate of recovery
`topical corticosteroids did not alter the rate of recovery
`for cases ofconjunctival hyperemia, but they did shorten
`for cases of conjunctiva] hyperemia, but they did shorten
`the recovery time for cases of follicular conjunctivitis and
`the recovery time for cases of follicular conjunctivitis and
`were routinely used in all cases of contact hypersensi¬
`were routinely used in all cases of contact hypersensi(cid:173)
`tivity.
`tivity.
`Accepted for publication May 29, 1996.
`Accepted for publication May 29, 1996.
`This study was supported in part by a grant from
`This study was supported in part by a grant from
`the Heed Ophthalmic Foundation, Cleveland, Ohio; an
`the Heed Ophthalmic Foundation , Cleveland, Ohio; an
`unrestricted grant from Research to Prevent Blindness
`unrestricted grant from Research to Prevent Blindness
`lnc, New York, NY; and by grant EY02520 from the
`Inc, New Yorh, NY; and by grant EY02520 from the
`National Eye Institute, Bethesda, Md. Dr Wilhelmus is
`National Eye Institute, Bethesda, Md. Dr Wilhelmus is
`a Research to Prevent Blindness senior scientific investi¬
`a Research to Prevent Blindness senior scientific investi(cid:173)
`gator.
`gator.
`We thank Emile J. Farge, PhD, and Myrna M. Khan,
`We thanh Emile]. Farge, PhD, and Myrna M. Khan,
`of Baylor College of Medicine, Houston, Tex, for their help
`of Baylor College of Medicine, Houston, Tex, for their help
`with statistical analysis.
`with statistical analysis.
`Corresponding author: Douglas D. Koch, MD, Cullen
`Corresponding author: Douglas D. Koch, MD, Cullen
`Eye Institute, 6501 Fannin St, NC 200, Houston, TX 77030.
`Eye lnslitule, 6501 Fannin St , NC 200, Houston, TX 77030.
`
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