k3 - OPTHALMOPHRMACOLOGY

8/17/2019 k3 - OPTHALMOPHRMACOLOGY

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M.Djamaludin dr,SpFK,M.Kes

Lab.Farmakologi

FK-UNJANI

!"#ALM!#A$MA%L&'


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In(rodu)(ionSome of the the many diseases of the eye

are listed below.

Despite claims to the contrary, there is noclear clinical evidence that drug treatment,or viitamin supplementation, prevent orcure cataracts, or genetic retinal dystrophy


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although possible useful responses areseen in age-related macular degenerationwhere diet supplementation with vitaminsC and E as well as β carotene has been

claimed to reduce the risk of progression ofthe disease although the evidence islimited


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Drug therapy of glaucoma, inamation ofthe eye age-related macular degenaration,ocular disorders, tear deciency andinamation of the eye are varyingly

e!ective and all are discused.


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Disease D S"

#-$ %laucoma υ --

C-$ %laucoma υ υ -

&namation ' $llergic υ -

-S(uint ) oculom.disorder υ -

-

*ear deciency υ -

-


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D SN

De(a)*ed re(ina --

%a(ara)(s --

$e(inal pigmen(a(ion - -

Amblopia - -

$e(inopa(*+ - -


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"!I%AL ANS"#"I%S"*e e)a)+ o "A usuall+ de(emined

b+ abili(+ (o suppress )orneal

sensi(i/+ %onen(ra(ion o ea)* drug is ob(ainedbe+ond 0*i)* no ur(*er in)reas ina)(i/i(+ o))urs

$.$"ES*+ES&$


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Ma1imum e2e)(i/e)on)en(ra(ion

"*e )on)en(ra(ion a( 0*i)* (*isma1imum e)a)+ o))urs

In)reasing (*e )on)en(ra(io o (*eanes(*e(i) be+ond (*e M% ser/es nouseul purpose bu( in)reases (*e risko lo)al and s+s(emi) (o1i)i(+


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M% o !ro)aine,"e(ra)aine,and%oa)aine are 3.45,65 and 7.35

In )lini)al pra)(i)e *o0e/er (*e %8p(imum 2e)(i/e %on)en(ra(ion9ma+ be less (*an M%


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For ins(an)e,3.45 (e(ra)aine is lessirri(a(ing (o (*e e+e (*an (*e M% 65and (*us is be((er sui(ed or )lini)aluse

%on(ribu(ion o (0o or more lo)alanes(*e(i)s dose no( produ)e andaddi(i/e e2e)(,bu( i( dose in)rease(*e risk o side e2e)(s so is

)on(raindi)a(ed


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":I%I"' &t is uncommon for topically applied

anesthetics,benoinate and tetracaine,tocause mild local stingging or burning afterinstallation

&n some patients,especially who over years old a di!use des(uamation of cornealepithelium may be occurs / 0unctatekeratitis


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"+pi)al manies(a(ion os+s(emi) in(o1i)a(ion

%NS

Ecitement,restlesness,headache,delirium,convul sion

%;S//1apid and irregular pulse2tachyarritmia3

)ular /Dilated pupils

&I"//"ausea,vomitus,and abdominal painNo(e/ $cute systemic 24 drps of a 56

solution3


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#+persensi(i/i(+)ular $llergi episode occur mainly with use of

the ester group of anesthetics,that is thecommonly for topical

7idocaine,mepivacaine,and bupivacaine isless fre(uently than the ester other group

Systemic anaphylactic reaction topical

anesthetics are etremely rare


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!s+)omo(or $ea)(ion0sycomotor reaction such as vasovagal

syncope may usually occur from anietyrelated to the o8ce visit

1espiration and cardivascular status shouldbe monitored to eliminate drug inducedanaphylacis as a possible cause of hecollapse


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!re/en(ion o Ad/erse S+s(emi)$ea)(ionsAd/erse

$dverse reactions to locl anesthetic drugsusually occur depend on dose

↓

7imit the dosage of drugs to thosecomparable with e!ective anesthesiawithout substantial risk of systemic toicity


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Indi)a(ions4.#perative9.1emove corpus alienum


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$ou(e o Adminis(ra(ion4.&n:ected9.*opical


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%on(raindi)a(ions+ypersensitivity7iver disease

Concommitans medications

Dry Eye0erporatory ocular &n:ury

Self $dministration of *opical $nesrherics *asting


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Me)*anism o !ain andAnalgesia

0rimary eye care practitioners oftenencounter patients who eperiencingsubstantial pain from an underlying oculardisease

;or eample patients with corneal orcon:unctival foreign bodies,abrasions oftraumatic hyperaemias usully complain ofpain as their primary complain


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%o)aineCocaine ehibits both anesthetic and

adrenergic activity

*he usual concentration for ocular topical46 to 56 but the 46 solution is often

used of diagnosis of +orner


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Cocaine is used as a nasal spray or indacrocystorhinostomy

Cocainogenic due to its adrenergic e!ectsi.e blocks reuptake of norephinephrine


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%o)aine )on(raindi)a(ed(oSystemc hypertension1etinal detachment surgery

1outine opthalmoscopy

%onioscopy$ngle-close glaucoma 2mydriatic e!ec3


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"e(ra)ineEster 0$=$&ntensity,D#$ comparable with

propaeracaine and benoinate

46 sol. Successfully to provide anesthesiaduring phacoemulsication cataractsurgery and intraocular lens implantation


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6 disodium ureon

&ndication/0rimary used for implantation

tonometrySide E!ects/

Stingging,burning,increase or decrease

corneal thikness and allergic reaction


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!ropara)aineConcentration solution,both with or without

sodium of .96 - .6 uoescein

A,in(ensi(+ and DA of anesthesiaare similar with tetracaine and

beionnoinate&t produce little or no irritation on

instillation and therefore readly acceptedby more patient

$llergic reaction/ Characteri?edcon:unctival hypeemia andedema,edematous eyelids,and

lacrimation.Corneal thickness instally can


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6.!ros(aglandineAnalogues7atanaprost *ravoprost

=imatroprost

!ros(aglandin %ombina(ion%ompounds

0rostaglandin and A-blocker


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7.


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=.Adrenergi) Agonis(.$drenalin"oradrenalin


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%*olinergi) agonis(Carbacchol


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!ros(aglandin AnaloguesLa(anapros( 8:ala(an90rostaglandin were originally discovered in

the eye as mediators of the ocularinamatory response and most of the

preliminary research focused on theirpotential role in uveitis and otherinamatory disease

7atanaprost demonstrates su8cienthypotensive activity with minimal sidee!ect


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7atanaprost is analogue of prodrugprostaglandin 0%E9α-isoprophyl ester.Bheninstalled topically into human eye it will beconverted by corneal esterase into

lanataprost acid,which eerts its biologicalactivity at the the ;0 receptor on the cilliarymuscle 2;0 is receptor for 0%;9α3.

Corneal esterase

↓

0%E9α-isoprophyl ester→

7anataprost


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7atanaprost appears to eert its ocularhypotensive e!ect eclusively byincreasing uveoscleral ow.

&n long term clinical trial,latanaprost has

been shown to be at least as e!ective astimolol in reducing

7atanaprost should be dosed only oncedaily in the evening or bed time


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*he additive ocular hypotensive e!ect7anataprost and timolol are greater than

when brimonidine,dorsolamide,orpilocarpine is used with timolol.

*he e!ect achived with miotis andpilocarpine seems to be most e!ective thebed time dosed is administered an hourafter latanaprost

7atanaprost available in concentration.6 preserved with .9 ben?alkoniumchloride 2=$C3


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Side 2e)(s

&ris color darking&ncreased eyelid pigmentation

+ypertrichosis

Con:unctival hyperemia$llergy

C@E 2Crystaloid macular edema3

$nterior uveitis

0unctate corneal erosionCorneal pseudodendrites


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%on(raindi)a(ions

1elative contraindicated to patient wih ahistory of uveitis or prior incisional ocularsurgery

0revious episodes of herpes simple virus

keratitisShould be used cautously after cataract

surgery in patients who have risk favouringthe development of C@E 2crystaloidmacular edema3.


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"ra/opros( 8"ra/a(an9. *ravoprost is a 0%;9α analog used for

treatment of patients with open-angleglaucoma or ocular hypertension.&ts

mechanism of action is similar withlatanaprost.

*he drugs is formulated as a(uous solutionin a concentration of .56 prserved with.4 ben?akonium chloride 2=$C3


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6solution incitratephophate bu!er preservedwith =$C 2.63


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=imatroprost dosed once dayly providerlower mean than doses timolol usedtwice daily

Side E!ect.

Similar to latanaprost andtravoprost,bimatoprsot reported to causechanges to pigmented tissues

Contraindications/

Similar with lanataprost


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!ros(aglandin %ombina(ion%ompound

!ros(aglandin and >-blo)ker *hese product include a combin ation of

latanaprost or travanost with timolol.

Studies have demonstrated comparableeecacy and in the case of travoprostimololcombination ,a favourable reductionproduct and the separate compoundsadministered concommitantly


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7.>-Adrenergi An(agonis(

"imololMA?


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%lini)al Uses. 4.0rimary open-angle glaucoma

9.#cular hypotension

>.Secondary glaucoma 5.0rophylactic in after laseriridotomy,posterior capsulotomy,andcataract surgery.

*imolol is supplied as .9 and .6solution

%iven once or twice installation


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Side 2e)(s?%;S/

=radycardia,arrythmias,hypotension,1eynaud


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&I"/ "ausea,diarrheaDerma(ologi)/ $lopecia and nail

hyperpigmentation

Me(raboli) e2e)( / +ypoglymia

)ular/

$llergic

=lepharitis

Dry eye Corneal anesthetic

@acular edema


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veitis Cataract progression

%on(raindi)a(ions? =ronchial asthma

=radycardia

Severe heart blok

#vert cardiac failure

+ypersensitivity


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Le/obunolol Similar with timolol is a non-selective A-

blocker

%lini)al Uses?

in ocular hypotension

#pen-angle glaucoma

0rophylactic after cataract surgery $nterior segment laser procedure

%on(raindi)a(ions? =ronchialasthma,C#0D


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Me(ipranolol

sed worlwide both orally in the treatmentof systemic hypertension and topically forthe treatment of elevated .

%lini)al Uses?

Chronis treatment of and open-angleglaucoma


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%ar(eolol

Carteolol is as a noncardioselective A-blocker similar to timolol,levobutolol,andmetipranolol

&n general carteolo, 4 an ocular

hypotensive e!ect similar so that of timololmaleat of 6 solution

%liji)al Uses?

Carteolol is used for chronic treatment ofelevated in patients with ocularhypertension and open-angle glaucoma.


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=.Adrenergi) Agonis(

Apra)lonidine $ relative selective 9-adrenoceptor

agonist,derived as a derivate of clonidine

%lini)al Uses?

0revention of post surgery

&nitial treatment of acute-angleglaucomas


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0revention of postcycloplegic apikes in

Side 2e)(s?

$fter topically installation can occurs/=lanching,eyelids retaction and mydriasis

%on(raindi)a(ions?

0atient sensitive to clonidine and taking@$#&


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%on(raindi)a(ions? 0atients receiving @$#&

&t is not contraindicated in cardiopulmunalydisease but must used with caution &

patients with severe cardiovascular disease

Side 2e)(s?

Sleepness

7erthargy ;atigue

Foun children , 9 kg


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@.%arboni) An*+drase In*ibi(ors

M A?


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*he presence of C$ in cilliary processes canbe also be demosntrated in both humanand animal

*he earliest reported ocular hypotensive

properties of aceta?olamide,a C$&demonstrated a decrease in inducedfrom inhibition of $+ production.

%lini)al Uses?

$ll type of glaucomas


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#ral aceta?olamide is often preserved forshort term reduction only

$dditional decrease in when added tomiotics, A-blocker and prostaglandin is

occurs.$cute angle-glaucoma is often

administered soon after the diagnosis ismade


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S+s(emi) 2e)(s

"umbless *ingling of the ngers,toes and perioral

region are most common events

@alaise

;atigue

Beight loss

Depression

$noreia7ibido decreasing

Diarhea


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)ular 2e)(s

Drug induced transient myopia@yopia probably results cilliary body

edema that produces a forwarddisplacement of the lens-iris diaphragma

*he myaopia subside on reduction ordiscontinuation of aceta?olamide therapy


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%on(raindi)a(ions

4.7iver diseases9.Severe C#0D

>.Certain secondary edema

5.1enal disease including renal stone

.0regnancy

G.+istory hypersensitivity to sulphonamide


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!*arma)okine(i) o %AI

D$U& DS ADA

$cet? tab G-9 mgH(id .-4 h 5-G h

$cet? cap mg bid .-4 h -4I h

$cet? in: ng 4 min 5h

@t?l 9-4 mgbHtid 4 h 4-45 h

Dichp 9- mgbHtH(id min G-

49 h


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Me(*aBolamide

Structurally similar with aceta?olamideDecrease ioni?ation and thereby improve

intraocular penetration

Bell absorbed after oral adiministtration


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%lini)al Uses

@ethami?ole like other C$&s may be adddedto treat patients with primary open-angleglaucoma and secondary glaucoma whentopical ocular hypotensive agents alone

provide inade(uate pressure control&t is the rst C$& usedfor systemic

glaucoma therapy


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Side 2e)(s

Compared with acetami?ole it producesless acidosisi and less e!ect on urinarylevel and less causes paresthesia but oftencause more drowsiness.

Skin eruption can also occur


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%on(raindi)a(ions

$re the same as those associated with theuse of aceta?olamide

@erhami?ole is more safty in patient withhistory of kidney stones or renal

impairment


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"!I%AL %AI

DorBolamide 8"rusop(9 *he rst commercially available C$& show

signicant ocular hypotensive activity inhuman

Indi)a(ions/ ,#$%S/ 7ocal irritation

2Stingging,burning,blurring3

%on(raindi)a(ions/ $llergic,renalimpairment 2CrCl,> mlHmin3.


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%lini)al ad/en(age o %AI

C$&s reduced nocturnal a(eous ow by96


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Carbachol

In)rease drainage o aeous *u,or


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MI"I%

%*olinergi) agonisDire)( a)(ing ? $cethylcholine

@etacholine

0ilocarpine

Carbachol Indire)( a)(ing? 8%*olies(erase in*ibi(ors9.

0hysostigmine

"eostigmine

Edrophonium Demecarium


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Irre/ersible ? Echothipate

Diisoprophylourophosphate


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!ilo)arpine

&ts activity at muscarinic receptor sited onthe iris sphincter cilliary muscle,pilocarpinecauses pupillary constriction and varyingdegrees of accomodative spasm depending

on patient


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)ular 2e)(s $ccomodative spasm

S+s(emi) 2e)(s?

Beakness

"ausea,vomitus,diarrhea

Salivation

7acrimatiom +eadache

=rowache 2$ggressive3


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0ulmonary edema Systemic hypertension

=radycardia

%enerali?ed muscle eweakness

&ncreased tone and motility of git

2$bdiominal pain,diarrhea3

1espiratory paralysis


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%on(raindi)a(ions

Cataract 2"uclear sclerotic,posteriorsubcapsular cataract3

"o pre/en( re(inal de(a)*men(

1etinal detachment

0atient with myopia

0eripheral retinal dieas

$phakia or pseudoaphakia


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0ilocarpine should be avoided in patientswith asthma or a history of asthma

%arba)*ol and )*o(ip*a(e

Due to their side e!ects these drugs arerarely used for treatment of glaucoma


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M'D$I"I%

$tropine$drenaline

"or-adrenaline


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@ydritic indications

"$A"MN" F


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A


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*he goal of ocular surface disease 2#SD3therapy are/

4.*o relieve symptoms of oSD

9.*o prevent serious complications of #SD

"*e )a(agories o dr+ e+e


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g + +(rea(men(

4.*ear supplementation9.*ear conservation

>.*ear stimulation

= op(ion (rea(men( or dr+


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p +e+e

*ear supplement 2articial tears3→/7acrisert27actic acid3

*ear conservation ointment/→0unctatocclusion

*ear stimulation/ Secretogogues,antiinamatories

or imunomodulators


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"ear supplemen(a(ion

!ol+mer-based ar(i)ial (ear mostcommon tear supplement product used dryeye treatment/

)ular lubri)an( are used (o (rea(?

4.Corneal abration 9.K keratitis

>.+erpes simple keratitis

5.+erpes ?oster keratitis


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"*e ideal ar(i)ial (ear

.!rodu)ed (*e me(aboli) op(i) andp*+si)al )*ara)(eris(i) o na(ure (ear

+ave a long residence time

Contain therapeutical additive to treat

primary and secondary damage to eyeSupplemen( o na(ural (ear 0i(* a

subs(an)ed (*a( prolongs residen)e(ime,impro/e (ear lm break up

8"


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ormula(ion

Bater based0olymer to enhance/

Kiscosioty

7ubricant

1etention time to promote tear lmability

(*er /is)osi(+ in)reasing


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(*er /is)osi(+ in)reasingagen(s

%elatin

%lycerin

0olyethyleneglycol

0oloamer 5J

0olysorbate I


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"aCl LCl

=oric acid

#elp (o main(ain (oni)i(+ and p#simlar (o normal (ear

$#" "A$S 8$o*(o Lab9

"e(ra*+doBoline #%l

Mg-L-aspar(a(e,K-L-aspar(a(e 86?69

!ol+sa)*arides and /in+l


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!ol+sa)*arides and /in+lderi/a(es

No( produ)e )ons(an(l+ 4.*he sustitutes should have properties to

enhance retention in the tear lm

9.$ddition of polymer to articial tear

improve/

1etention

&ncrease corneal surface wetability

Decrease blink friction @inimi?e surface tension.


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Na(ural (ear )on(ain

&l+)opro(ein Sura)(an( ma)romole

↓

De)rease sura)e (ennsion

(*ers subs(i(u(es


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)ellulose

+ydroy ethylene cellulose+ydroyprophyl cellulose

@ethyl cellulose

Carboymethyl cellulose

"*ese )ellulose *a/e been? 4.sed in articial formulation

9.Dissolve in water to produce colories solution

of varying visvcocity

>.+aving proper optical clarity reective similarto

cornea


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;i)oelas(i) agen(s

"a hyaluronat"a chondroiti sulfateM@ucopolysach in

etracell

Such as/Kitreous,cornea,and a(eous humor

sed for/&ntraocular surgery

Severe dry eye disorders

Concentration / .4 N .6

Subje)(i/e and obje)(i/eimpro/emen( 8i()*ing9


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Sodium hyaluronate

+ydrophylic +igh molecular weight

0olysacharide polyrmer

Sub:ective and ob:ective symptoms in dry

eye patients


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%*ondroi(in sula(e

+yaluronic acid .46Chondroitin sulfate 46

@iture/ ChS 2.>I63 and +$ 2.>63

2e)(i/e in pa(ien(s 0i(*?

&tching

=urning

;oregn body sensation


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!ol+/in+l al)o*ol

!"IF$S# 8Konime19.Enhance contact time of ophthalmic

medication

$s wetting agent for contact lens

Concentration 4 N 56

+as good retention time due to adsorptiveproperties

Can be easily sterili?edIndi)a(ion? Lubri)an( ,pre/en(

irri(aion on dr+ e+e


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;is)o)i(+ en*an)e agen(s

#thers vinyl derivates/ O.0K0/ "on ionic surfactant

*o increase viscicity

Concentration/ >- 6

9.+0$- guar 2+ydroyprophyl-guar3

+igh mollecular weight

$ gallable lubricant,to mimic the mucin

layer of tears


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!reser/a(i/es

$dded to ophthalmic sol.

*o kill or inhibit growth of microorganism

Nu(rien(s

"ecessary for corneal and con:ucntivalmeabolim

PPPP mucin synthrsis

Kit $ deciency e!ect a variety of epithelial-lined

organ,including eye


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(*er ingredien(s

le)(rol+( PP "aCl


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Mu)ol+(i) agen(s

Soften mucus and make it more uid$cetylcystein

$vailable as mucomyst in a 46 or 96solution of the sodium salt acetylcystein


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Ar(i)ial (ear inser(

7$C1&SE1*Batersoluble

Contain hydroyprophylcellulose

Indi)a(ions?

=lurred vision


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Au(ologos serum

$ source of tears replacement in serve dryeye

&mproved ocular surface staining

i


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in(men(

&ndicated for moderate to severe dry eye1etain longer than other ophthalmic

vechicles

0atient acceptance ointment preparation

highly variable

i l l i d i


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La)rimal o))lusi/e de/i)e

sed to preserved eisting tears$bsorble insert made with hydroyprophyl

cellulose,collagen and silicone

*opical anesthetics may be used to

minimi?e eyelids reaction.

"*G $D '


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"*G.$D '

$#" 8$o*(o Lab9;ISIN 8!Ber9

%on(ain? "e(ra*+droBoline


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AN"IINF%"I;S A&N"S

AL


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ANAL&SI%GAN"IINFLAMA"IN

;L"A$N !#"#AContain/ Diclofenac "a

&ndication/

0revent myosis during cataract lens

operation,prrevent inamation aftercataract surgery


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AL


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%NDM'%"IN 2Cendo3

Qalf contained/%*lorap*eni)ol 65

!ol+mi1in < sulp*a(e 4333 IUGg

&ndications/

*racoma

=lepharitis

Con:unctivitis

LeratitisDacryocystitis

%$"I%S"$IDS


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%$"I%S"$IDS

%NDM'%S +idrocortisone acetate .6

Chloramphenicol .96

Indi)a(ions? Con:unctivitis non-purulent

Dose? =dd g(( 6-7

%ND:I"$L d


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%ND:I"$L drops

Deamethasone .46 "eomycin sulphate >. mg

0olyniin = sulphate G &

Indi)a(ions?

=acterial Con:unctivitis,keratititis,

Leratocon:unctivitis,

=lepharocon:unctivitis

AN"I;I$AL


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AN"I;I$AL

;I$A: 2%lao Smith Lline3Contained /$yclovir

Indi)a(ions/ +erpes viral infection.

"!#A$MA%L&'


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"!#A$MA%L&'

AN"IINF%"I; AN"IS!"I%An(ibio(i)s e2e)(i/e (o &ramnega(i


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"LIN dropsContained/

0olymiin = sulfate 4. &

Chloramphenicol 6

=en?ocaine 46

"ipagin 46


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SF$AD: drops%on(ained

Frami)e(i sula(e 4 mg

&rami)idine 3,34 mg

De1ame(*asone 3,4 mg

Indi)a(ion? 1(ernal o(i(is

%on(raindi)a(ion? !erora(ion o(+mp*ani)

membrane


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"!AIN drops%on(ained

!ol+mi1in


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S$MUNL'"I%

A:SL%on(ained Do)usa(e Na

Desin(egra(ion %erumen prop

Using?Drop in(o in(ernal ear 7 da+Gnig*(beore

)leaning


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%on(raiindi)a(ion?0erforation of tymphanic

membrane or internal ear infection

!$:ID 8#779 Solu(ion 6-=5

Drug indu)ed o(o(o1i)


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Drug indu)ed o(o(o1i)

$minoglycocides$mikacin

%entamycin

Lanamycin

D-streptomycin→deafness

7-Streptomycin→e(uilibrium


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ND

"*ank +ou

k3 - OPTHALMOPHRMACOLOGY

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