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Ocular Drug Delivery: topical
Absorption: prompt, depending on formulation
Special: convenient, economical, relatively safe
Limitations/cautions: compliance, corneal/conjunctival toxicity, nasal mucosal toxicity, systemic side effects from nasolacrimal absorption
Ocular Drug Delivery: injections (subconjunctival, retrobulbar, sub-Tenon)
Absorption: prompt or sustained, depending on formulation
Special: anterior segment infxns, posterior uveitis, cystoid macularedema
Limitations/precautions: local toxicity, tissue injury, globe perforation, optic nerve trauma, ocular muscle trauma, etc
Ocular drug delivery: injections (intraocular)
Absorption: prompt
Special: anterior segment surgery, infections
Limitations/precautions: corneal toxicity, intraocular toxicity, relatively short duration of action
Ocular drug delivery: intravitreal injection or device
Absorption: circumvented, immediate local effect, potential sustained effect
Special: endophtalmitis, retinitis, age-related macular degenration
Limitations/precautions: retinal toxicity
What does the rate and extent of absorption of ocular drugs depend on?
cul-de-sac and preconeal tear film
nasolacrimal drainage
drug binding to tear/tissue proteins
diffusion across cornea and conjunctiva
Macrolides
Azithromycin, Erythromycin (most common)
MOA: inhibits synthesis at 50S ribosome
Uses: bacterial conjuctivitis
Adverse: eye irritation, hypersensitivity
Trimethoprim/Polymyxin B solution
MOA: Tri= inhibits folic acid synthesis; Poly= binds to phospholipids → alters membrane’s permeability
Uses: bacterial conjunctivitis
Adverse: ocular irritation
Sulfacetamide (ointment/solution)
MOA: inhibits folic acid synthesis via antagonism of PABA
Uses: bacterial conjunctivitis
Adverse: ocular, irritation, allergic reactions (avoid in pts w/ sulfa allergy)
Bacitracin ointment
MOA: inhibits bacterial cell wall synthesis
Uses: bacterial conjunctivitis
Adverse: ocular irritation
Fluoroquinolones
Cipro, Ofloxacin, levofloxacin, moxi, gatifloxacin
MOA: inhibits DNA-gyrase & topoisomerase 4 → breaks DNA
Uses: conjunctivitis, corneal ulcers, cover pseduomonas, preferred for contact lens wearers
Adverse: ocular irritation, white precipitate, unpleasant taste after instillation
Aminoglycosides
gentamicin, tobramycin
MOA: inhibits 30S ribosome sythesis
Uses: conjunctivitis
Adverse: ocular irritation, corneal ulceration, reactive keratoconjunctivitis
Trifluridine (Viroptic)
MOA: interferes w/ viral replication by inhibiting thymidylate
Uses: keratoconjunctivitis due to HSV
Adverse: ocular irritation, punctate keratopathy
Ganciclovir (Zirgan)
MOA: interferes w viral DNA synthesis by binding deoxyguanosine triphosphate to DNA polymerase
Uses: herpetic keratitis, CMV retinitis
Adverse: ocular irritation, punctate keratitis
Cytovene: IV, oral; Vitrasert: intravitreal implant
Natamycin
MOA: inc cell membrane permeability in fungi by binding to sterol
Uses: conjunctivitis: keratitis -Aspergillus, candida, cephalosporium, fusarium, penicillium
Adverse: ocular irritation
H1 receptor antagonist
MOA: inverse agonists - causes histamine receptor inactivation
dec capillary dilation, itch, swelling; act w/in minutes; preferred over MCS
Azelastine, Alcaftadine, Bepotastine, Emedastine, Epinastine, Ketotifen, Olopatadine
Adverse: ocular irritation, HA, inc ocular dryness
Mast Cell Stabilizers
MOA: inhibit mast cell degranulation, limit release of histamine tryptase, prostaglandin D2, inhibit leukocyte activity, dampen mediator release from pro-inflammatory cells
cromyln, lodoxamide, nedocromil
Adverse: ocular irritation, unpleasant taste, HA
Vasoconstrictor/Antihistamine
MOA: activates postjunctional a-adrenergic receptors on blood vessels → dec conjuctival edema
tetrahydrozoline, naphazoline, pheniramine, naphazoline
good for short term use; prolong → hyperemia post d/c
Imidazoline Derivatives
systemically will target a-2 receptors
locally will act on a-1 receptors
NSAIDS
MOA: block action of COX, inhibits conversion of arachidonic acid to prostaglandins and thromboxanes (pro-inflammatory agents)
Bromfenac, diclofenac, flurbiprofen, ketoralac, nepafenac
Uses: postoperative inflammation/pain & allergic conjunctivitis
Adverse: lacrimation, keratitis, IOP inc, ocular irritation
Glucocorticoids
MOA: suppress late phase allergic reaction: dec formative of pro-inflammatory mediators; inhibits fibrin/collagen deposition → no scar
Uses: severe ocular allergy, anterior uveitis, external eye inflammation, inflammation following ocular surgery, cataract formation, elevated IOP, ulcers, infections, delayed wound healing
Dexamethasone, prednisolone, difluprednate, fluorometholone*, Loteprednol*, Rimexolone*, Triamcinolone
*= have lower IOP risk
Therapy for Dry Eyes
tx the disease first
Physical: punctal plugs, surgical occlusion of lacrimal drainage
Tear subs: hypo-isotonic solutions, balanced salt solution, carboxymethylcellulose (Refresh), Hydroxyproply cellulose, polyvinvyl alcohol (artifical tears)
Immunomodulators
Cyclosporine (restasis)
MOA: inhibits production/release of interleukin II → less T cell activation
eye: dec inflammatory markers in lacrimal, inc tear production, improve vision and comfort
Uses: chronic dry eye associated w/ inflammation (keraconjuct sicca)
Adverse: ocular burning, FB sensation, blurred vision
Glaucoma & ocular HTN
inc aqueous outflow
prostaglandins (1st line agents)
a-adrenergic agonists
cholinergic agonists
dec aqueous production
a-adrenergic agonists
B blockers (2nd line agents)
carbonic anhydrase inhibitors
Prostaglandins
MOA: analogs of PGF2a, binds to prostaglandin receptors & lowers IOP by inc aqueous outflow
Uses: most commonly glaucoma
latanoprost, travoprost, bimatoprost, tafluprost
Adverse: conjunctival hyperemia, ocular irritation, changes in eyelash length and iris color
Beta Blocking Agents
MOA: blocks B receptors in ciliary body → less catecholamine activation → dec cAMP → less aqueous production
Uses: oc HTN or glaucoma
Beta 1 selective: Betaxol (primarily heart, better for asthma pts)
non-selective: carteolol, timolol, levobunolol (affect B 1 & 2)
more efficacious, but more side effects
Adverse: worsening HF, bradycardia, heart block, inc airway resistance
Alpha Adrenergic Agonists
MOA: alpha 2 agonist; presynaptically: dec catecholamine release to dec aqueous production and inc outflow; postsynaptically: alpha 2 activation dec aqueous production
Uses: oc HTN or glaucoma
apraclonidine, brimonidine
Adverse: ocular irration, hyperemia, pruritus, allergic conjunctivitis
contradicted in children <2 yrs
Carbonic Anhydrase Inhibitors
MOA: inhibits carbonic anhydrase in ciliary body epithelium → dec production of bicarb → dec fluid transport and IOP
Uses: oc HTN or glaucoma
dorzolamide, brinzolamide
Adverse: bitter taste, burning/stinging after administration, allergic conjunctivitis
Cholinergic Agonists
MOA: activates muscarinic receptors causing ciliary muscle contraction facilitating aqueous outflow
Uses: oc HTN or glaucoma
acteylcholine, carbachol, pilocarpine
Adverse: fixed/small pupils, myopia, visual disturbances, HA
poor compliance due to side effects and frequent admin, visual burning in young pts
Combination Products
Uses: oc HTN or glaucoma
brimonidine w/ timolol (Combigan), brinzolamide w brimonidine (simbrinza), dorzolamdie w/ timolol (cosopt)
Synergistic IOP lowering by targeting multiple routes
few drops to administer → inc compliance
Glaucoma tx
start w/ prostaglandin or B blocker
can start in one eye to determine efficacy/tolerability
w/o risk factor → monitor until changes occur
w/ risk factor → treat
goal: 20-30% reduction in IOP
Ocular Anesthetics
MOA: inhibit Na influx into the neuron preventing signal propagation
tetracaine, proparacaine
Uses: tonometry, FB removal, superficial corneal surgery
Adverse: hypersensitivity, burning sensation
will be numb for 10-20 minutes -no blink reflex
Cycloplegic Agents: antimuscarinics
Uses: diagnostically (fundoscopic), uveitis (prevent synechiae, relive ciliary spasm)
MOA: block muscarinic acetylcholine receptors, cause mydriasis
Atropine, Cyclopentolate, Tropicamide
Adverse: photosensitivity, blurred vision
Cycloplegic Agents: sympathomimetics
Uses: diagnostically (fundoscopic), uveitis (prevent synechiae, relive ciliary spasm)
MOA: adrenergic receptor agonist, cause mydriasis, more reactive to light
Phenylephrine
Adverse: photosensitivity, conjunctival hyperemia
Fluorescein
MOA: reveals epithelial defects of the cornea and conjunctiva
Uses: anterior segment staining, disclosing corneal injury
Adverse: hypersensitivity, burning sensation