Povidone iodine: useful for more

than preoperative antisepsis

Primary
Care
Optometry
Andrew S. Gurwood, OD, FAAO; Marc D. Myers, OD, FAAO

News,

February

2004

While povidone iodine has long been used by surgeons as a preoperative antiseptic,
researchers have been looking at the agent for treating viral conjunctivitis as well as other
ocular diseases.
The microbicidal action spectrum of povidone iodine (PI) is broad, even after short exposure
times. Further, unlike local antibiotics and other antiseptic substances, no resistance seems
to develop. The high degree of bactericidal efficiency with respect to highly resistant grampositive pathogenic micro-organisms, such as methicillin-resistant Staphylococcus
aureus (MRSA) andEnterococcus strains, has made the agent particularly useful and
significant for hospital hygiene.
Povidone iodine has traditionally been used by surgeons as a preoperative antiseptic.
Cheaper than topical antibiotics, it is recognized as a staple solution for preparing the eye
for surgery.
About 2 years ago, a stir was created when an ophthalmologist published anecdotal
evidence that a brief povidone iodine eye wash in patients known to be suffering from viral
conjunctivitis successfully helped to resolve the malady far faster than observation and
supportive therapy alone. Since that time, investigators have been evaluating the agent to
officially validate its use in this regard as well as potentially expand its role in the
management of ocular disease. (Shovlin JP, Abel R. Steroids, povidone iodine
recommended
for
adenoviral
keratoconjunctivitis. Primary
Care
Optometry
News. 2001;6(6):22-23.)

Advantages over other agents

Povidone iodine has many potential advantages over some current popular medications,
including broader antibacterial spectrum, lack of identifiable bacterial resistances and
significantly lower price. It has made a significant contribution to pre- and postoperative
ocular surgical prophylaxis, ophthalmia neonatorum prophylaxis and treatment of bacterial
conjunctivitis. (Isenberg SJ, Apt L, Campeas D. Ocular applications of povidoneiodine. Dermatology.2002;204(suppl 1):92-95, and Editors. Ophthalmia neonatorum. Afr
Health. 1995;17(5):30.)

Mechanism of action

Povidone iodine is a broad spectrum microbicide Take-home pearls

that destroys microbial protein and DNA. It has
excellent in vitroantimicrobial activity and is
Anecdotal evidence has shown
indicated for preoperative preparation of the
periocular region (lids, brow, cheek) and irrigating povidone iodines efficacy against viral
the ocular surface. PI is supplied as Betadine (5% conjunctivitis.
sterile ophthalmic preparation solution, Alcon) and
In several studies, PI was effective
is packaged in a single-use, 1-fluid-ounce bottle.
for inactivating a range of viruses, from
mumps to herpes simplex to HIV.
Experimental evidence
Researchers have compared the antibacterial
One double-masked trial showed it
effect of povidone iodine and like agents with that to
be
effective
against
bacterial
of ofloxacin in a rabbit inoculated with bacterial conjunctivitis and Chlamydia but ineffective
keratitis. In those reports, the researchers against viral conjunctivitis.
concluded that Betadine 0.5% demonstrated a
statistically significant bactericidal effect compared
For treating viral conjunctivitis,
with cases of staphylococcal keratitis left practitioners recommend anesthetizing the
untreated (Melki SA, Safar A, Yaghouti F, et al. eye, instilling two drops of PI for 1 minute
Effect of topical povidone-iodine versus topical then lavaging the eye with sterile saline.
ofloxacin
on
experimental
staphylococcus Follow this with a course of topical steroids,
keratitis. Graefes
Arch
Clin
Exp artificial tears and cold compresses.
Ophthalmol.2000;238(5):459-462).
While ofloxacin had superior antibacterial effects under the conditions set forth by the study,
the povidone iodine solution demonstrated superb potential. Pending improvements in its
formulation for ocular maladies, it could be a formidable player in conditions such as
blepharitis and microbial-induced keratitis in countries where topical antibiotics are scarce.
Studies examining the uses of povidone iodine reach back into the 1990s. Kawana and coworkers determined that PI was an effective medicine for inactivating a range of viruses,
such as adenovirus, mumps, rotavirus, poliovirus (types 1 and 3), Coxsackie virus,
rhinovirus, herpes simplex, rubella, measles, influenza and HIV (Kawana R, Kitamura T,
Nakagomi O, et al. Inactivation of human viruses by povidone-iodine in comparison with
other antiseptics. Dermatology. 1997;195(suppl 2):29-35).
In their experiments, antiseptics such as PI solution, PI gargle and PI cream, along with
agents such as chlorhexidine gluconate, alkyldiamino ethylglycine HCl, benzalkonium
chloride and benzethonium chloride were compared. PI was found to be effective against all
the virus species tested. The PI drug products that were examined in these experiments
inactivated all the viruses within a short period of time. Rubella, measles, mumps viruses
and HIV were sensitive to all of the antiseptics. PI was determined to have the widest
viricidal spectrum, covering both enveloped and nonenveloped viruses.

Double-masked trial
In a double-masked, controlled, prospective clinical trial involving 459 children (mean age
6.6 years with a range of 7 months to 21 years) diagnosed with acute bacterial, viral and
chlamydial conjunctivitis and from Manila, Philippines, infected eyes were cultured for
bacteria and underwent immunofluorescent testing for Chlamydia trachomatis. Viral
conjunctivitis was diagnosed if bacterial cultures were negative and if the diagnostic criteria
set forth in the study were met. Subjects were alternated to receive povidone iodine 1.25%
or neomycin-polymyxin-B-gramicidin ophthalmic solution, one drop four times daily in the
affected eye.
Povidone iodine 1.25% ophthalmic solution was as effective as neomycin-polymyxin Bgramicidin for treating bacterial conjunctivitis and was somewhat more effective
against Chlamydia, but was ineffective against viral conjunctivitis (Isenberg SJ, Apt L,
Valenton M, et al. A controlled trial of povidone-iodine to treat infectious conjunctivitis in
children.Am J Ophthalmol. 2002;134(5):681-688).

Practical evidence
In the Review of Optometry 2002 Clinical Guide to Ophthalmic Drugs, Melton and Thomas
present an off-label use of Betadine 5% solution to treat viral conjunctivitis (Melton R,
Thomas RK. 2002 Clinical Guide to Ophthalmic Drugs.Supplement to Review of
Optometry. 2002;139(6):40s).
After anesthetizing the eye with proparacaine solution, two drops of Betadine are instilled
onto the infected ocular surface for 1 minute. A sterile saline rinse is then used to
completely lavage the Betadine from the eye. Melton and Thomas report that the Betadine
rinse treatment followed by a course of topical steroid drops (two to four times daily),
artificial tears and cold compresses over a 1- to 3-week period can result in the expeditious
resolution of the signs and symptoms of viral conjunctivitis.

Efficacy against other viruses

Evidence has also recently indicated the antiviral activity of PI against herpes simplex and
adeno- and enteroviruses, as well as reaffirmed its high degree of efficiency
against Chlamydia. Hence, alongside the classical fields of application, such as the
disinfection of the skin and hands, mucosa antisepsis and wound treatment, explorations for
additional useful indications for the substance seem to be well founded and should be
encouraged. Additionally, povidone iodine ophthalmic solution should be strongly
considered in the treatment of a variety of external, anterior segment diseases in developing
countries where topical antibiotics are often unavailable or costly.

For Your Information:

Marc D. Myers, OD, FAAO, is a 1999 graduate of the Pennsylvania College of

Optometry. Since completing a primary care residency at the Eye Institute of the
Pennsylvania College of Optometry, he has been employed as a staff optometrist in the
southern New Jersey area in an ocular disease and refractive surgery practice. He can be
reached at (856) 691-8188. Dr. Myers has no direct financial interest in the products
mentioned in this article, nor is he a paid consultant for the companies mentioned.

Andrew S. Gurwood, OD, FAAO, is an associate professor of clinical sciences and

an attending optometric physician at The Eye Institute of the Pennsylvania College of
Optometry. He is also a member of the clinical staff in the Department of Ophthalmology at
Albert Einstein Medical Center in Philadelphia. Dr. Gurwood can be reached at the
Pennsylvania College of Optometry, 1200 West Godfrey Ave., Philadelphia, PA 19141; (215)
276-6134; fax: (215) 276-1329; e-mail: Agurwood@pco.edu. Dr. Gurwood has no direct financial
interest in the products mentioned in this article, nor is he a paid consultant for the
companies mentioned.

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