BLOG: The drops that should be in every eye clinic and ER
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Corneal ulcers are one of the fastest ways our patients with healthy eyes can quickly lose vision, but they’re also easy for any clinician with a slit lamp to identify.
Because the most common organisms, especially among contact lens wearers, are bacterial and often virulent pathogens, we cornea specialists almost always initially treat opaque, white infiltrates with topical antibiotics, and for larger or more central lesions, we usually obtain a scraping for culture and employ fortified drops. In an ideal world, a patient would receive their fortified antibiotic the moment the culture is completed. Now, a widely available and long-term stable compounded combination antibiotic is available, and I believe that every eye clinic and emergency room should stock this product.
Many studies have taught us that prompt and aggressive treatment of aggressive bacterial pathogens yields the fastest recovery and best acuity outcome. For years, many of us treating ulcers have ordered fortified antibiotics from a compounding pharmacy while sending a patient to the pharmacy to get initial treatment drugs, usually fluoroquinolones like besifloxacin 0.6%, which have historically been the best treatments we could get quickly. The problem, of course, is pharmacies usually stock a narrow range of antibiotics, and often the patients must accept whatever is on hand. In some cases, patients will wait for the pharmacist to order the out-of-stock drug that was prescribed, not informing the doctor and not recognizing the significant risk of a 2- to 3-day wait. And they may pay $300 or more for that temporary-use product at the pharmacy, only to pay again when their fortified antibiotic arrives.
A better solution for patients with vision-threatening ulcers is a product called Fortisite available from ImprimisRx, a Harrow company and a 503B compounding pharmacy that can sell this drug to doctors without a patient-specific prescription. Other 503B pharmacies may provide similar products, but I highlight this company because it has made it easy to keep this drug on hand.
Fortisite combines tobramycin 1.5% (equivalent to 15 mg/cc) with vancomycin 5% (equivalent to 50 mg/cc) in an aqueous solution. It requires refrigeration but can be stored in a clinic for 6 months. The cost is around $200 for a 7 mL bottle — about 140 drops, so enough for 7 days of round-the-clock hourly treatment, which means many patients only need one bottle before they could step down to a non-fortified drug.
This drop stings like it means business, but it’s a full-fledged fortified antibiotic that sits waiting for patients to show up. We keep two bottles in each of our three offices, and the company will replace at no cost any bottles that expire before use. We collect the cost from the patient when we give them a bottle. In general, our offices don’t sell drugs or other products to patients because the administrative headache of stocking them, tracking inventory, processing returns, etc, is not worth the limited revenue. We make an exception for this drug because its immediate availability will definitely save many ulcer patients from suffering unnecessarily.
Having a fortified antibiotic instantly available reduces much of the stress when a patient is referred at 4 p.m. on Friday with a corneal ulcer. Now if only we could get all our patients to actually take the drops we’ve given them.
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