The anti-infective equation: Finding the right drug mix to fight infectious organisms

Practitioner use of anti-infectives has undergone considerable change in the past few years, as they have waged an ongoing battle with infectious organisms. The continuing emergence of resistant bacteria has continued to confound prescribers. However, in other areas the struggle has tilted in favor of the eye care professional: powerful, new broad-spectrum agents and formulations have been developed and extensive research has helped all prescribers — from the primary care giver to the surgeon — hone and refine their treatment regimens.

Approaches to fighting ocular infections are as varied as individual practice styles. When considering a new treatment regimen, practitioners must consider numerous variables: infection incidence in their practices; prevalence of specific pathogens in their patient populations; and the relative toxicity, spectrum of effectiveness and tissue penetration of various drugs. With infections ranging in severity from bacterial conjunctivitis to endophthalmitis, practitioners must choose the most appropriate, effective medication from a plethora of drugs. Ocular infection medications now extend from familiar, well-understood agents like the antimicrobial bacitracin to the complex steroid/anti-infective combinations to the relatively new fluoroquinolones.

Without clear guidelines for choosing among the growing list of drugs, however, each practitioner is left to develop a treatment plan based on personal experience, recommendations of experts and the sometimes conflicting studies in the literature. In this article, Primary Care Optometry News presents expert clinical opinions from experienced practitioners on how to choose appropriate anti-infectives for the prevention and treatment of anterior segment infections.

Infections vary among practices

In the primary care practice, the types of infectious organisms and prevalence of infections that confront practitioners vary considerably across the country.

Bruce E. Onofrey, OD, RPh, who is responsible for primary eye care services at the Lovelace Montgomery Eye Clinic in Albuquerque, said the most common etiologies for the red eyes he sees are allergic and viral, followed by acute bacterial lid infections. Acute bacterial conjunctivitis is fairly rare. The most common bacterial infection is chronic infection of the lid. The most common bacteria he sees are Staphylococcus and Streptococcus in adults and Hemophilus in children.

Bobby Christensen, OD, private practitioner in Midwest City, Okla., said the infection he most commonly sees in practice is "blepharitis, chronic lid disease with staph infection." He also does not see much bacterial conjunctivitis, saying, "The most common conjunctivitis we see is viral."

New York City’s J. James Thimons, OD, who has a large, varied patient population including many contact lens patients, said he, too, sees a lot of lid disease, although he classified it as an abnormality of the physiology and metabolism of the eye, in most patients producing a chronic condition, rather than an acute infection. Otherwise, he said, conjunctival infections "constitute about 90% of the overall presenting group of individuals, with the remaining group being corneal involvement, either herpetic or bacterial."

Drugs for ocular surface disease

Primary care givers have a wide armamentarium to choose from when treating ocular surface disease. However, the main issue is determining if there is actually an infection and what the infectious agent is. Dr. Onofrey said proper diagnosis is crucial when treating infections. But when antibiotic use is indicated, he said, he has several drug preferences. He often uses a general broad-spectrum topical aminoglycoside, such as tobramycin or gentamicin. Gentamicin is inexpensive, he said, but it can be toxic to the cornea. Fluoroquinolones and aminoglycosides are useful against most of the infections practitioners will see, he added.

Dr. Onofrey often uses Polytrim (trimethoprim and polymyxin B, Allergan), particularly for pediatric indications. Polytrim is popular among eye care professionals. Paul C. Ajamian, OD, FAAO, of Omni Eye Services in Atlanta, said he, too, prefers Polytrim for infections, although he also often uses aminoglycosides and fluoroquinolones.

Dr. Christensen also gets a lot of use out of Polytrim: "It’s a nice, broad-spectrum, safe antibiotic. It’s readily available and works well against pediatric infections. In our practice, it’s the most common antibiotic drop we use."

Dr. Thimons said in non-contact lens patients who present with purulent infectious conjunctivitis, he prefers tobramycin. "In some instances I will use Polytrim, although I have found it to be more effective in children than in adults. It is good drug, but I don’t use it as much in patients with purulent disease."

Many practitioners are enthusiastic about the broad-spectrum topical fluoroquinolones: ciprofloxacin (Ciloxan, Alcon), ofloxacin (Ocuflox, Allergan) and norfloxacin (Chibroxin, Merck). "They are quite effective against most of the common ocular pathogens we see today," Dr. Onofrey said. "They are overused in many cases, but they are a good group of drugs."

Mindful of overuse, Dr. Christensen reserves fluoroquinolones for more severe infections, particularly corneal infections. He uses ciprofloxacin or ofloxacin for infectious keratitis or for a significant mucopurulent conjunctivitis.

Infections in contact lens patients

--- This contact lens-related corneal ulcer has a ring infiltrate and liquefactive necrosis of the corneal stroma.

Contact lens patients can develop different types of infection compared to non-wearers. Contact lens specialist James D. Atwood, MD, in private practice in Sacramento, Calif., believes proper fitting and patient education are the most important infection control procedures. Dr. Atwood said he has not encountered a central corneal ulcer in about 10 years.

Cornea specialist Harold R. Katz, MD most frequently treats contact lens- and trauma-related corneal ulcers, which he said can be extremely serious if not treated properly. "In general, my regimen for treating them is to do a culture first," Dr. Katz said.

To treat them, he prefers ciprofloxacin. (For more on culturing, see "When do I culture?")

For contact lens patients, Dr. Thimons also uses a fluoroquinolone, either ofloxacin or ciprofloxacin, "because of the risk of a gram-negative infection."

Many practitioners consider blepharitis a chronic disease, rather than an acute infectious process. Dr. Thimons said "a few blepharitis patients will flare up and develop occasional blepharokeratoconjunctivitis, which is managed acutely."

Dr. Onofrey agreed, saying marginal lid infection is "actually chronic disease and is incurable. The problem is caused by S. epidermidis which is very resistant and is considered a normal variant of ocular flora unless it exists in numbers that make it pathological. They live intimately with the meibomian glands, and you can’t eradicate them."

With patients who have concurrent blepharitis along with presentations of other infections, Dr. Thimons said to make sure both elements are dealt with simultaneously. "You’ll find that the blepharitis will accelerate the level of symptomatology, and I think it prolongs the disease process," he said.

Treating lid disease

--- Despite resolution of the infiltrate after intensive treatment with topical 0.3% ciprofloxacin (Ciloxan, Alcon), residual corneal scarring results from this ulcer.

In treating lid disease, Dr. Christensen prefers Polysporin ointment (bacitracin zinc and polymyxin B sulfate, Glaxo Wellcome) twice a day for 2 weeks and then once a day for 2 weeks until resolved. For chronic conditions, he will use oral doxycycline. Dr. Ajamian also uses Polysporin ointment along the lids. "Obviously, we use oral agents only when topicals don’t work," he said.

Dr. Onofrey avoids ointments. For one, patients tend not to like ointments because they blur vision and may be messy, he said. "Also, they release medication more slowly, and there is a chance the drug may not be effective against all the pathogens, such as S. epidermidis" If he uses an ointment, he uses Polysporin.

To treat chronic lid disease, Dr. Onofrey uses an initial lid scrub regimen, followed by pulse antibiotic therapy. "Instead of using ointments on the lids, I use warm compresses, lid scrubs and one of the fluoroquinolones, either Ciloxan or Ocuflox, twice a day to the lid margin and let it air dry."

He continues this regimen for 2 weeks. If inflammation persists, he adds an oral tetracycline — if the patient can tolerate it — such as doxycycline, 50 to 100 mg a day, which has an anti-inflammatory effect.

Sometimes for acute lid disease, such as preseptal cellulitis, an oral medication is indicated. Dr. Onofrey said he will use a penicillin that is effective against penicillinase-producing organisms, including fortified amoxicillins such as Augmentin (amoxicillin/clavulanate potassium, SmithKline Beecham). "I’ll use some of the cephalosporins such as Keflex (cephalexin, Dista) and some of the second-generation cephalosporins for gram-negative infections," he said. "For chlamydial infections, the drug of choice today is one of the new macrolides, which is azithromycin (Zithromax, Pfizer) or clarithromycin (Biaxin, Abbott). In penicillin-sensitive patients, these new macrolides produce fewer GI side effects and have greater efficacy."

An alternative for chlamydia is a 2- to 4-week course of oral doxycycline, which has worked in several patients in whom azithromycin has not, said David R. Hardten, MD.

When is a steroid appropriate?

A nagging philosophical question for practitioners who treat chronic infections or disease is when to introduce a steroid. Dr. Onofrey prefers not to use a steroid on the eye. "For marginal blepharitis, my preference is to use an oral tetracycline instead of a steroid, because it makes better sense mechanistically," he said. "Steroids are a short-term fix for a long-term problem and have no place in marginal blepharitis."

Studies show that tetracycline used for a few months can provide a benefit for a few years if the patient maintains the conservative hygiene regimen as well, he said.

However, Dr. Onofrey said, "Steroids can have a place in infectious disease if inflammation is also present. If inflammatory pseudomembranes or infiltrates are present I will use a steroid product, but only after the infection is controlled with an appropriate antibiotic."

Dr. Christensen also gauges steroid use by the degree of inflammation. "For an eye that is mattering some and is a little red and the lids stick together when the person wakes up, antibiotics and lid scrubs and rinses to clean the eye will be adequate," he said. "If you’ve got an infection process where there’s a high likelihood of scarring or an eye that has a lot of autoimmune response going on, then a steroid is appropriate."

Dr. Christensen’s rule of thumb is to know the diagnosis and "never be in a big hurry. If at first you don’t know, wait 24 to 48 hours before you begin steroids. Then you often have a better idea of what you have, and that also gives you time to culture."

Dr. Thimons said he rarely prescribes steroids for conjunctivitis, as most patients do well with topical antibiotic treatment. For peripheral infiltrates that are "suspect," he begins patients on an hourly, intensive antibiotic regimen with a fluoroquinolone. If the patient has responded well by the next day, he may add a mild steroid to help improve the condition quicker. "If there’s any question as to how well the patient is healing or whether, in fact, the lesion is improving, then I’ll delay the use of a steroid until I see epithelial improvement," he said.

For true ulcers, Dr. Thimons does not use steroids. "Steroid use with an ulcer is complex in the primary care arena for many reasons, including medicolegal issues," he said.

Dr. Thimons will obtain a corneal consult on a patient with a severe ulcer when steroids must be used concurrently with an antibiotic. "Steroids are a two-edged sword" Dr. Thimons said. "They can improve vision and reduce scarring, or they can increase the ability of the organism to grow rapidly and increase perforation."

Refractive surgery protocols

In refractive surgery, the refinement of postoperative drug regimens is gaining prominence as an important factor in surgical outcome. James P. McCulley, MD, in university practice and professor and chairman at the University of Texas-Southwestern in Dallas, uses antibiotics before and after refractive surgery. However, preoperatively, he tempers their use because of resistance concerns.

"With preop use it is immediately before surgery," Dr. McCulley said. Postoperatively, he uses topical antibiotics, but said, "If we think we are prophylaxing against endophthalmitis we are kidding ourselves because we are not getting therapeutic levels into the aqueous with our topical application."

When treating postoperative infection, Dr. McCulley does not wait for laboratory culture and sensitivity test results before initiating antibiotic therapy. He selects the "shotgun" or "best guess" approach, then adjusts the therapy after test results are received.

Richard A. Eiferman, MD, a refractive surgeon in Louisville, Ky., administers antibiotics pre- and postoperatively, although he does it more for medicolegal reasons.

The majority of refractive surgeons interviewed for this article preferred fluoroquinolones to treat infections. "The fluoroquinolones are more potent against more organisms," Dr. Katz said. "They have a broader spectrum of activity and they penetrate the cornea better than tobramycin or gentamicin."

Laser in situ keratomileusis (LASIK) surgeon Eric D. Donnenfeld, MD, from Garden Center, N.Y., performed a study comparing the deep stromal penetration of the aminoglycoside tobramycin with ciprofloxacin and ofloxacin. Tobramycin showed insignificant levels of penetration, whereas ciprofloxacin and ofloxacin penetrated well superficially, and ofloxacin penetrated twice as deep into stroma. "Ofloxacin penetrates better into the cornea due to its higher intrinsic solubility, and we feel that this is the antibiotic of choice for LASIK," he said.

Dr. Katz has studied the potency of ciprofloxacin, ofloxacin and norfloxacin and concluded that ciprofloxacin is preferred because of the drug’s broader spectrum of activity and greater potency against Pseudomonas which can cause serious infections. Although ofloxacin is more soluble and may penetrate into the anterior chamber of the eye slightly more than ciprofloxacin, Dr. Katz said when considering drug potency and tissue penetration in combination, ciprofloxacin is more effective (see "MIC is only part of overall effectiveness" ).

"When you are using antibiotics prophylactically, you really don’t care about penetration of the antibiotic into the eye because you want to eradicate the bacteria on the surface of the eye — on the conjunctiva and also on the lid margins," Dr. Katz said.

For Dr. McCulley, ciprofloxacin is the drug of choice because of its efficacy. "Ciprofloxacin is not as highly soluble as other fluoroquinolones," he said, "but it is a good broad-spectrum antibiotic that has very good minimal inhibitory concentrations and fairly good penetration."

Prophylaxis in cataract surgery

For many cataract surgeons and their comanagement partners, anti-infective prophylaxis in cataract surgery — especially the use of anti-infectives in irrigation fluid — has long been seen as the sensible thing to do. Others practice prophylaxis to avoid medicolegal problems. However, some practitioners reject the notion of routine prophylaxis due to insufficient evidence as well as the fear that it will hasten drug resistance in virulent microorganisms. Some believe treatment should be administered only after an infection is confirmed.

In the interest of preventing infection, Spencer P. Thornton, MD, FACS, begins antibiotics 1 day preoperatively. Dr. Thornton prefers ofloxacin because of its broad-spectrum activity. He has never used antibiotics in the irrigating fluid.

Dale Pilkinton, MD, in private practice in Nashville, however, recently switched to antibiotics in the irrigating fluid because "it sounds like a logical thing to do."

In comanaging cataract patients at Omni Eye Services, Dr. Ajamian said he uses either ciprofloxacin or ofloxacin pre- and postoperatively. He has not seen a serious infection in years, which he attributes to the skill of surgeons, but said, "We have an empirical feeling that putting them on an antibiotic preop and keeping them on it postop adds another layer of safety."

Stephen S. Lane, MD, who specializes in cornea/external disease as well as cataract surgery, said for corneal transplant patients he administers an antifungal preoperatively only if a culture-proven fungal infection exists: "I will use topical Viroptic (trifluridine, Glaxo Wellcome) preop in a corneal transplant patient if he or she has a history of herpes — along with oral acyclovir prior to transplant surgery — and continue them postoperatively."

Peter S. Hersh, MD, a cornea/external disease subspecialist, has used antivirals both pre- and postoperatively for patients with herpetic keratitis, citing studies that indicate such treatment "decreases the propensity for recurrence of herpetic keratitis after keratoplasty."

Management of bacterial endophthalmitis is no longer as controversial as in the past since last year’s release of the results of the National Eye Institute-sponsored Endophthalmitis Vitrectomy Study (EVS). The study concluded that routine, immediate vitrectomy is substantially beneficial only for those patients who have light perception only-vision at presentation.

The use of intravitreal antibiotics has been and continues to be the mainstay of therapy in treating post-cataract extraction endophthalmitis. The EVS further concluded, however, that the omission of systemic intravenous antibiotics can diminish toxic effects, costs and length of hospital stay, while not adversely af fecting outcome.

If the EVS guidelines were to be strictly applied, the savings nationwide could be enormous. Kirk H. Packo, MD, principal investigator of the Chicago center for the EVS, said the study’s guidelines could allow a nationwide cost savings of $4 million to $35 million a year in endophthalmitis treatment. He cautioned that intravenous antibiotics might still be necessary if the patient is diagnosed with endophthalmitis following trauma or foreign body or has more unusual forms of endophthalmitis.

Dr. Lane objects to indiscriminate use of medications but does practice prophylaxis in cataract surgery. "[Patients] will get a drop of Ciloxan the night before surgery, three times along with the dilating drops prior to surgery and one drop immediately after surgery," Dr. Lane said. "They don’t get any more antibiotics unless there is a problem."

Question of resistance

A troubling dilemma facing prescribers is how to balance infection prophylaxis and control against over use of anti-infectives, which can lead to toxicity problems and bacterial resistance. Many practitioners say indiscriminate antibiotic use is at least part of the resistance problem.

New York’s Dr. Thimons said resistance is not usually generated just by topical use of drugs. "It’s from the use of topicals that can be used concurrently as oral therapy by all of medicine," he said. "If you look at drugs that have high resistance profiles, a lot of them are used systemically as well. When drugs are used both topically and systemically on a broad level, then resistance develops reasonably quickly."

He pointed out that common drugs such as bacitracin and polymyxin B, which are not used systemically, have developed little resistance. Treating resistant strains may require more intensive therapy, additional medication or changing drugs in those cases where treatment is ineffective, Dr. Thimons said.

Dr. Christensen said he believes antibiotics are being used indiscriminately in primary care settings. "There’s probably a significant use of antibiotics, whether in the eye or orally, because patients feel that an antibiotic fixes everything," he said, "and doctors feel drawn into that sometimes, giving out antibiotics when they know they won’t do anything."

Many eye care practitioners feel those outside the eye care field are particularly guilty of overusing ocular antibiotics. "Many people, and particularly non-eye doctors, are probably giving every red eye an antibiotic," Dr. Onofrey said. "Most red eyes are caused by environmental factors, allergic reactions, viruses or overwear of lenses. Without a proper diagnosis of an infectious component that is treatable with antibiotics, they shouldn’t be used."

Dr. Ajamian agrees. "I’ve seen much more of a problem with indiscriminate use with general and family practitioners — people who, in my opinion, shouldn’t be treating eye disease," he said.

Strains of microorganisms that are highly resistant to many antibiotics are developing in general, according to cornea specialist Dr. Katz, in response to frequent use of these drugs in all of medicine. He believes resistance will continue to increase. "That is why we have to keep developing new antibiotics to stay ahead of bacteria," he said.

Overuse not only culprit

But drug resistance cannot be eliminated simply by avoiding the overuse of anti-infectives, according to Thomas B. Connor Jr., MD, in private practice at the Milwaukee County Medical Complex. He pointed out that resistance arises from random genetic defects and mutation: "Bacteria don’t ‘figure out’ how to become resistant. The genetic defects occur all the time, they get a chance to develop and some of those defects may coincidentally be beneficial to the bacteria and enable them to resist certain types of antibiotics," he said.

One particularly troublesome area of resistance is with an infectious corneal ulcer, Dr. Ajamian said. He avoids gentamicin, because he said a number of Pseudomonas strains have developed resistance against it. He will use a fluoroquinolone and/or Polytrim. "And, of course, we culture these people and make sure the ulcers are sensitive to the drug," he said.

Surgical prophylaxis has contributed to the problem as well, practitioners say. Dr. Hardten said, "I think many people are starting to use antibiotics routinely before as well as after surgery. But the big risk to that is the resistance that can occur. That is why we have to keep coming out with new antibiotics."

Although resistance to antifungals or antivirals is not as common as resistance to antibiotics, Dr. Hardten uses these medicines postoperatively only when a virus or fungus is present. He administers anti-herpes simplex virus (HSV) drugs prophylactically before surgery in patients diagnosed with HSV. Dr. Hersh, the corneal surgeon, also believes practitioners tend to overuse antivirals and antifungals. The latter should not be used on a prophylactic or presumptive basis, he said.

Dr. Thornton stresses that he limits a drug’s use to the period of potential risk. "We treat actively, at the time of risk only, stopping postoperatively when the danger period is over," he said.

About a year ago, Dr. Lane abandoned the use of antibiotics in irrigation fluid because of his concerns about emerging drug resistance. "I probably wasn’t really treating anything," Dr. Lane said, "and, considering the potential risk of developing strains resistant to vancomycin, I didn’t want to abuse it."

He added that vancomycin is probably the best drug to use against gram-positive bacteria.

While he grants that antibiotic overuse can cause resistance, Mark P. Lesher, MD, said when patients have a compromised epithelium because of refractive surgery, "you want to cover that patient because they are at risk for infection until that epithelial defect heals."

Risk of infection can outweigh risk of resistance, Dr. Lesher said. "We have to take care of our patients first and foremost," he said. "If [antibiotics] are being used judiciously ... you should reduce the risk of resistant strains. But that is the nature of bacteria; they develop resistance."

Toxicity, allergic reactions

In addition to resistance, Dr. Hersh notes that epithelial toxicity is frequently seen in corneal practice and believes it is often associated with the overuse or inappropriate use of all anti-infectives. He gives the example of a patient with a keratitis of unknown cause that is actually herpetic. The patient is placed on topical antiviral agents for months and develops chronic epitheliopathy, an inflamed eye or, perhaps, an epithelial defect.

Practitioners must be "judicious" and "not lengthy" in the use of antivirals, he said. "I think there is a tendency for anti-infective overuse without isolation of what is actually causing the problem, particularly in the case of herpes or a fungus."

Dr. Hardten added that practitioners must not indiscriminately prescribe. "Occasionally I’ll see a patient who has been left on HSV treatment too long — typically Viroptic — resulting in corneal toxicity," he said. "Typically HSV infectious keratitis requires only 10 to 14 days of therapy to allow resolution of the keratitis."

Dr. Onofrey frequently sees toxicity and allergic reactions to antibiotics at his Albuquerque clinic. "Any drop has the potential to irritate the eye, and antibiotics are no different," he said. "They have toxicity. If you’re using the antibiotic in a situation where mechanistically they have no benefit, you’re simply adding to the problem."

He added that overusing an antibiotic after the infectious process is gone "can perpetuate the red eye." Neomycin, in particular, induces allergic reactions, so he tries to use more cornea-friendly drugs such as the fluoroquinolones.

Dr. Ajamian also has seen many neomycin reactions, and he, again, said non-eye care practitioners shoulder much of the blame for these problems.

The aminoglycosides have a reputation of being cornea toxic, Dr. Onofrey said, although he added that tobramycin is the least toxic of them. Dr. Christensen also warned against toxicity with aminoglycoside use of 7 days or longer. "You can end up with lots of staining and even some erosion of the cornea," he said.

After chronic aminoglycoside use, Dr. Thimons said, practitioners may see hyperemia, superficial punctate keratitis and some crusting related to toxicity. Discontinuing the use of the drug should address the problem, he said.

"The potential for medicamentosus is real in every patient you see," Dr. Thimons said, "and a lot of patients that we see on a referral basis are individuals who have been treated and have developed a response to the medication, which confuses the presentation considerably. The patient still has active disease and now concurrently has a medication response on top of that."

Dr. Thimons noted that he has seen some corneal precipitates after intense use of Ciloxan. "They look almost like corneal edema in a diffuse way, but they’re right below the epithelial layer, having a crystalline appearance under the slit lamp. It can look quite dramatic at first."

Discontinuing therapy will normally solve the problem, which he believes is caused by the pH of the drug.

"When you have a corneal ulcer, because of the prolonged period of treatment, almost all patients will have some toxicity from the drug," Dr. Thimons said. "You need to balance that against the treatment of the infectious process. Every once in a while you need to switch antibiotics."

For Your Information:

• Thomas B. Connor Jr., MD can be contacted at The Eye Institute, 8700 West Wisconsin Ave., Milwaukee, WI 53226; (414) 257-5292; fax: (414) 456-6301.
• Spencer P. Thornton, MD can be reached at the Thornton Eye Center, 2010 Church St. #307, Nashville, TN 37203; (615) 329-7890; fax: (615) 329-7892.
• Drs. Connor and Thornton did not disclose whether or not they have a direct financial interest in the products mentioned in this article or if they are a paid consultant for any companies mentioned.
• The following practitioners have stated they have no financial interest in any products mentioned in this article, nor are they paid consultants for any companies mentioned:
• Paul C. Ajamian, OD, FAAO, an be reached at 5505 Peachtree Dunwoody Rd., 3rd Floor, Suite 300, Atlanta, GA 30312; (404) 257-0814; fax: (404) 256-5446.
• James D. Atwood, MD, in private practice, can be contacted at (916) 442-4693; fax: (916) 442-5701.
• Bobby Christensen, OD, can be contacted at Heritage Park Medical Center, 6912 E. Reno, Suite 101, Midwest City, OK 73110; (405) 732-2277; fax: (405) 737-4776.
• Eric D. Donnenfeld, MD, performs LASIK at the 20/20 Vision Center in Garden Center, N.Y., and can be reached at 2000 N. Village Ave., Rockville Centre, NY 11570; (516) 766-2519; fax: (516) 678-7377.
• Richard A. Eiferman, MD, practices at Suite 220, 6400 Dutchans Parkway, Louisville, KY 40205; (502) 895-4200; fax (502) 895-0819.
• David R. Hardten, MD, can be reached at Suite 106, 710 East 24th St., Minneapolis, MN 55404; (612) 336-5493; fax: (612) 336-5606.
• Peter S. Hersh, MD, an associate professor at UMDNJ-New Jersey Medical School, can be reached at (201) 883-0505; fax: (201) 692-9646; e-mail: phersh@compuserve.com.
• Harold R. Katz, MD, assistant professor at Johns Hopkins University, can be contacted at Sinai Hospital of Baltimore, 2411 West Belvedere Ave., Baltimore, MD 21215; (410) 601-5991; fax (410) 601-6284.
• Stephen S. Lane, MD, associate clinical professor at the University of Minnesota, can be reached at 232 North Main St., Stillwater, MN 55082; (612) 439-8500; fax: (612) 439-5102.
• Mark P. Lesher, MD, can be reached at Suite 203, 101 Hospital Loop NE, Albuquerque, NM 87109; (505) 883-6800; fax: (505) 886-2863.
• James P. McCulley, MD, a professor and chairman at the University of Texas-Southwestern, can be reached at the University of Texas-Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9057; fax: (214) 648-9061.
• Bruce E. Onofrey, OD, RPh, can be reached at 9101 Montgomery Blvd. NE, Albuquerque, NM 87111; (505) 275-4226; fax: (505) 275-4203.
• Kirk H. Packo, MD, engaged in private group practice at Ingalls Memorial Hospital and an associate professor at Rush-Presbyterian-St. Luke’s, can be reached at 1725 West Harrison, Chicago, IL 60612; (312) 942-2117; fax: (312) 942-4045.
• Dale Pilkinton, MD, practices at 307 Mid-State Medical Center, 2010 Church St., Nashville, TN 37203.
• J. James Thimons, OD, can be contacted at SUNY College of Optometry, 100 East 24th St., New York, NY 10010; (212) 780-5007; fax: (212) 780-4980.