Inadvertent Instillation of Nonophthalmic Antiseptic Drops Due to Packaging Similarity

Previously we have reported on the misuse of nonophthalmic and ophthalmic drops due to packaging similarity.¹ Other reports document the inadvertent instillation of nonophthalmic drops into the eye because of bottle size or packaging similarity, including Hemoccult developer,² cyanoacrylate,³ and sodium hydroxide.⁴

An 87-year-old woman underwent penetrating keratoplasty, anterior vitrectomy, and lens exchange for pseudophakic corneal edema. Six months postoperatively her medications included prednisolone acetate (Pred Forte, Allergan Inc, Irvine, Calif), four times a day, and 5% sodium chloride drops (Muro 128, Bausch & Lomb Pharaceutical Inc, Tampa, Fla), four times a day. A nurse's aide assisting with eye drops mistakenly placed an antiseptic solution, (<1% benzalkonium chloride, Mycocide NS, Woodward Laboratories Inc, Los Alamitos, Calif) into the postoperative eye resulting in immediate eye pain, redness, and tearing. This antiseptic is typically used as a topical treatment for nailbed fungus. The eye was flushed repeatedly with tap water, and the patient was seen 2 hours later in the eye clinic with a visual acuity of 20/100 OD. Diffuse injection and mucoid drainage were seen. Slitlamp examination revealed a large bulbar conjunctival epithelial staining defect extending into the inferior fornix and on to the upper eyelid margin. The corneal transplant showed diffuse punctate keratopathy with staining defects at the graft host junction inferiorly. The patient was started on a combination of neomycin sulfate, polymixin B sulfate, and gramicidin (Neosporin Ophthalmic Solution, Glaxo Wellcome Inc, Research Triangle Park, NC) drops, four times a day, and told to increase the topical steroid to every 2 hours while awake. She was seen 4 days later with a visual acuity of 20/100 OD, a healed ocular surface, and mild corneal graft edema.

Previous reports have documented the inadvertent use of nonophthalmic drops because of similarities in bottle shape, size, labeling, or cap. This case (Figure 1) shows a similarity in bottle label and color (both labels are blue and white). Suggestions^1-5 for uniform bottle sizing, cap shape, or cap color for all nonophthalmic preparations have not resulted in voluntary changes in packaging by manufacturers. We emphasize that many patients taking eye medicines are partially sighted, and it is the responsibility of manufacturers and health professionals alike to take the necessary steps to avoid preventable misuse of eye drops. We now make it a point to instruct patients that eye drops should always be stored separately from all other nonophthalmic topical preparations.

This investigation was supported in part by an unrestricted departmental grant from Research to Prevent Blindness Inc, New York, NY.

Corresponding author: Thomas L. Steinemann, MD, Jones Eye Institute–University of Arkansas Medical School, 4301 W Markham, Slot 523, Little Rock, AR 72205.