Brimonidine
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Corneal complication due to excipient sodium chlorite: 2 case reports In a case report, 2 patients (one man aged 65 years and a woman aged 75 years) were described, who developed corneal opacity, blepharitis, Meibomian gland dysfunction, corneal sterile infiltration, conjunctival hyperemia or follicular conjunctivitis while receiving anti-glaucoma treatment with brimonidine containing sodium chlorite as an excipient. Case-1: The 65-year-old man was diagnosed with normal tension glaucoma in 2016. Subsequently, he started receiving treatment with 1% brimonidine [brimonidine tartarate] eye drops along with ripasudil [ripasudil hydrochloride hydrate] and brinzolamide. In January 2018 (while still on treatment with ocular hypertensive agents), he presented to a hospital in Japan with corneal opacity and prominent blood vessels in his left eye. Examinations showed best-corrected visual acuity of 20/20 in both eyes and intraocular pressure of 15mm Hg in both eyes. Slit lamp examination showed blepharitis with Meibomian gland dysfunction, conjunctival hyperemia and follicular conjunctivitis in both eyes. Additionally, corneal sterile infiltration along with neovascularisation in the temporal cornea of the left eye was noted. Consequently, all the three ocular hypertensive agents were stopped. He received treatment with fluorometholone in his left eye. After 2 weeks, the follicular conjunctivitis and corneal sterile infiltration in his left eye improved. Therefore, ripasudil and brinzolamide were reinitiated. No further recurrence of conjunctivitis or corneal sterile infiltration were noted in the left eye; however, corneal opacity in the deep layer of corneal stroma persisted. The ocular complications were attributed to the brimonidine therapy with a possible relation to its excipient 0.005% sodium chlorite used in it as a preservative. Case-2: The 75-year-old woman, who was diagnosed with primary angle closure glaucoma, underwent combined phacoemulsification with intraocular lens implantation and shunt surgery with intraoperative mitomycin [mitomycin-C] in the left eye in 2014. In December 2015, she started receiving brimonidine eye drops two times a day, along with dorzolamide and bimatoprost for bleb failure in the left eye. She developed a white spot (corneal opacity) on the temporal lower part of the left cornea and presented in December 2017. Slit lamp examination showed conjunctival hyperemia, follicular conjunctivitis, corneal sterile infiltration and neovascularisation in the temporal-lower side. Consequently, brimonidine was discontinued, and her treatment was started with fluorometholone eye drops. Subsequently, blepharitis and corneal neovascularisation improved, but subsequent slit lamp examination showed persistent corneal opacity. The ocular complications were attributed to the brimonidine therapy with a possible relation to its excipient 0.005% sodium chlorite used in it as a preservative. Manabe Y, et al. Corneal sterile infiltration induced by topical use of ocular hypotensive agent. European Journal
