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They “have been used as ‘first-line treatments’ for neuropathic pain.” • Gabapentin (Neurontin) and pregabalin (Lyrica) are first-line therapies for neuropathic pain, but can also cause dizziness and somnolence. • For local pain (such as zoster-related, post-herpetic, dermatologic neuralgia), “lidocaine patches at a dose of 1.8% to 5%” are approved for such. Other than occasional skin irritation, these “patches” are applied over the sites of pain for up to twelve consecutive hours per day. • “Pharmacologic and interventional treatments for chronic pain often provide no reduction, or only a small reduction in pain, and are often judged by the patient to be inadequate.” “Education and training of healthcare professionals to ensure cost-effective and safe, evidence-based treatments are therefore considered essential for pain management.” Finnerup NB. Nonnarcotic Methods of Pain Management. N Engl J Med. 2019; Jun 20;380(25):2440-8. 28 REVIEW OF OPTOMETRY JUNE 15, 2020 • The only time we use acetazolamide is in the management of some cases of acute angle-closure. We would give the patient two 250mg tablets right away (because we proactively keep these on-hand in our offices). However, timolol and brimonidine drops are the mainstays of managing acute pressure rises. • The oral antivirals are a godsend for patients enduring shingles, and they represent the drug class of choice in treating herpes simplex epithelial keratitis, as well. Because of the antivirals’ unique mechanism of action, they are extremely safe. Viral thymidine kinase dynamically activates these otherwise inactive drugs, thus they are only therapeutically active in virally infected tissues, sparing any non-infected tissues. The only Achilles’ heel is that these medicines are metabolized in the kidneys, so that patients with renal disease will have to have reduced dosing. The PCP, nephrologist, internist or pharmacist can guide dosing based on the patient’s creatinine clearance levels, which should be able to be obtained from one of these providers by means of a quick telephone call. These antiviral medicines were developed primarily to treat shingles; however, their use in herpes simplex epithelial keratitis has become commonplace over the last couple of decades, and they are indeed the treatment-of-choice for such herpetic presentations.
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