Sparfloxacin corneal deposits
Dear Editor,
Fluoroquinolones are broad spectrum, bactericidal
agents with activity against both gram-positive and
gram-negative corneal pathogens. Topical
fluoroquinolones are widely used in the treatment of
bacterial corneal ulcers. They are safe, but a white
crystalline deposit, that in most cases spontaneously
dissolves, has been reported with topical ciprofloxacin
0.3% and norfloxacin 0.3% and very recently with
ofloxacin 0.3%.1-3 Sparfloxacin, a newer quinolone, is
now available as 0.3% eye drops for the treatment of
serious corneal and conjunctival infections. It has better
penetration and a high therapeutic index. I noticed
sparfloxacin corneal deposits after prolonged topical use
in four patients. Two patients were treated for graft
infiltrate and two for corneal ulcer. A representative case
is described briefly.
Case
A 65-year-old patient presented with acute
dacryocystitis in her right eye. She had previously
undergone corneal grafts for bullous keratopathy in
both eyes. The grafts in both eyes were clear at
presentation and she was on prednisolone acetate 1 %
eye drops once daily in both eyes. She was prescribed
sparfloxacin eye drops 0.3% five times a day in the right
eye along with oral amoxycillin 500 mg and ibuprofen
400 mg + paracetamol 325 mg combination, both thrice
daily for 5 days. The patient did not return for follow
up and continued using the drops. On her next visit two
months later, multiple refractile crystalline deposits
were seen in the corneal graft. The deposits were seen
throughout the stroma and also along the suture tracks
(Figure). The eye was quiet, there was no inflammation
and the patient was asymptomatic. She was advised to
discontinue topical sparfloxacin and continue the
topical prednisolone only. She was also advised a
dacryocystorhinostomy in the right eye. At her next visit
two months later the graft was clear with complete
resolution of the deposits.
Comments
Analysis of ciprofloxacin, norfloxacin and ofloxacin eye
drops related drug deposits have confirmed the
presence of quinolones. The specific factors contributing
to the formation of the fluoroquinolone precipitate are
unknown, but pH solubility profiles are of importance.
Sparfloxacin is deposited as a refractile crystalline
deposit in all layers of the corneal stroma. Deposits can
develop in the absence of an epithelial defect, ulceration
or inflammation. Unlike surface deposits noted with
other quinolones, sparfloxacin is deposited throughout
the corneal stroma. The deposits do not cause any
inflammation and patients are asymptomatic. This was
not suspected initially. However the absence of any
other known cause of crystalline corneal deposits
suggested a possibility of drug deposition. The deposits
also resolved on discontinuation of sparfloxacin drops.
The deposits can be analysed biochemically only if a
corneal graft or biopsy is done in a patient who has
these deposits. Clinicians should be aware that refractile
deposits can occur after prolonged topical use of
sparfloxacin; these deposits resolve slowly after
cessation of therapy.
Nikhil S Gokhale, MD
Correspondence to Dr. Nikhil S. Gokhale, Gokhale Eye
Hospital and Eyebank, Anant building, Gokhale road (S),
Dadar West, Mumbai 400 028. E-mail: <gokhlay@vsnl.com>
References
1. Castillo A, Benitez Del Castillo JM, Toledano N, Diaz-Valle
D, Sayagues O, Garcia-Sanchez J. Deposits of topical
norfloxacin in the treatment of bacterial keratitis. Cornea
1997;16:420-23.
2. Eiferman RA, Snyder JP, Nordquist RE. Ciprofloxacin
microprecipitates and macroprecipitates in the human
corneal epithelium. J Cataract Refract Surg 2001;27:1701-2.
3. Claerhout I, Kestelyn Ph, Meire F, Remon JP, Decaestecker
T, Van Bocxlaer J. Corneal deposits after the topical use of
ofloxacin in two children with vernal keratoconjunctivitis.
Br J Ophthalmol 2003;87:646.