Eyedrop instillation for reluctant children.

Pupillary responses to pilocarpine eyedrops applied by different techniques have been studied in healthy volunteer subjects. In particular a novel method was evaluated in which eyedrops were applied to the inner canthus with eyes tightly closed and the subject supine, followed immediately by opening of the eyes. The response to this technique indicates that drug penetration into the eye was 66% (confidence intervals 28 to 104%) of that obtained by conventional instillation, into the conjunctival sac, with or without 2 min pressure on the inner canthus. This method of instillation, which is free of aggravation, may be clinically useful for patients, especially children, unwilling or unable to tolerate conventional instillation.     

Preoperative and postoperative medications used for cataract surgery.

The current state of cataract surgery for the millennium may be stated as "minimally invasive techniques." This review presents recent articles on the perioperative use of antibiotics (primarily fluoroquinolones), nonsteroidal antiinflammatory drugs (Voltaren and ketorolac), and new corticosteroids (rimexolone and loteprednol etabonate). Preoperative topical application of ofloxacin or ciprofloxacin results in a satisfactory minimal inhibitory concentration for most pathogens. However, one cannot determine the actual effect of intraoperative antibiotics on acute postoperative endophthalmitis, because of its low overall incidence. Nonsteroidal antiinflammatory drugs, especially Voltaren, may offer equivalent antiinflammatory efficacy (for both postoperative inflammation and cystoid macular edema) without the typically corticosteroid-associated adverse events. Rimexolone and loteprednol etabonate, two new corticosteroids, may offer good antiinflammatory efficacy with greatly reduced risk for elevation of intraocular pressure.     

Primary drug treatment for glaucoma: beta-blockers versus other medications.

This set of Viewpoints articles examines the merits of beta-blockers versus other medications as the primary drug treatment for glaucoma. Ophthalmologists must balance issues such as efficacy, compliance, cost, and side effects when deciding on the appropriate medication to prescribe. Dr. Stamper stresses the advantages of tailoring the choice of medication to the needs of the individual patient. Drs. Wigginton and Higginbotham review the benefits of beta-blockers and present some of the disadvantages of the non-beta-blocker class of medications.     

Microbial contamination of medications used to treat glaucoma.

AIMS--A study was conducted to estimate the frequency of contamination of topical antiglaucoma medications used by asymptomatic patients. METHODS--The drops and the bottle tips of 194 in use topical medications and the conjunctiva from 109 treated glaucoma patients were cultured. RESULTS--Bacteria were recovered from 55 (28%) medications. The bottle tip was more frequently contaminated than the drops (p = 0.008). Gram positive organisms were cultured from 50 (91%) of 55 contaminated medications. Thirteen patients (12%) had the same microorganism recovered from the conjunctiva and from the contaminated medication. The frequency of contamination of medications increased with increasing duration of use. Bacterial contamination occurred in 19% of eyedrops less than 8 weeks old in contrast with 40% of bottles used for more than 8 weeks. CONCLUSION--Our data suggest that ocular medications to treat glaucoma frequently become contaminated with bacteria and that contamination is related to duration of use. We therefore recommend that opened topical antiglaucoma eyedrops should be replaced on a regular basis.     

Fluorophotometry by instillation. II. Effect of beta-blocker eyedrops in the normal subject

The effects of various drugs on the human aqueous humor flow were studied by the fluorophotometric method of Yablonski (topical fluorescein instillation). The effect of the beta-adrenergic blocker (Timolol) on aqueous humor flow and on intra-ocular pressure has been studied in ten normal eyes on the Fluorotron Master. We found that the acute decrease in intra-ocular pressure was equal to 1.39 +/- 0.44 microliter.min-1 for the Timolol treated eyes, and equal to 2.79 +/- 0.57 microliter.min-1 for the untreated eyes (Placebo). The difference between Timolol and Placebo was statistically significant (Student t-tested, and Wilcoxon W-tested). The fluorophotometric method is superior to the tonographic method by giving a more favorable condition to study the facility of outflow in steady physiological state. Our results are in good agreement with other authors and show Timolol to have little or no effect on the facility of outflow.     

Punctal occlusion and topical medications for glaucoma

We studied the effects of punctal occlusion on the intraocular pressures of patients treated with topical medications for glaucoma. Silicone punctal plugs were used to occlude the inferior punctum of one eye in each of 19 patients treated with identical antiglaucoma eyedrops in both eyes. The intraocular pressures before and after punctal occlusion were compared. The eyes with the punctal plugs showed a statistically significant (P less than .0001) decrease in pressure of 1.32 mm Hg after punctal occlusion when compared to that of the fellow control unplugged eyes. The intraocular pressures in the plugged eyes decreased an average of 1.82 mm Hg after punctal occlusion when compared to before punctal occlusion (P = .001). The intraocular pressure in the unplugged control eyes did not change significantly after punctal occlusion of the fellow treated eye.     

Ocular hypotensive medications for the treatment of glaucoma

The past 10 years have seen dramatic changes in the pharmacologic treatment of glaucoma. The treatment of glaucoma has changed from surgical to primarily medical. These treatments have improved the effectiveness and safety of lowering the intraocular pressure to prevent progressive vision loss and blindness, but no cure for glaucoma or reversal of blindness is available yet. Research is progressing and can hopefully achieve these final goals sometime in the future.     

Antiretroviral therapy for HIV infection: a review of current medications and therapies.

BACKGROUND: Management of HIV infection has been revolutionized in the past 3 years by the introduction of drugs significantly more potent than those previously available. Simultaneously revelations about dynamics of HIV infection and viral replication have altered concepts about HIV disease, as well as the need for therapeutic interventions. METHODS: A literature search was conducted of journals listed in the Index Medicus, as well as abstracts from annual meetings of the American Society for Microbiology, the Infectious Disease Society of America (Conference on Retroviruses and Opportunistic Infections), and the International Conferences on AIDS. RESULTS: Antiretroviral drugs of four differing pharmacologic classes are able to achieve profound suppression of viral replication when combined in varying regimens. Costs of medications remain high, many toxicities are associated with drug therapy, and regimens are both complex and daunting. In spite of many difficulties associated with highly active anti-retroviral therapy (HAART), many patients are able to achieve improved quality of life and longer survival. CONCLUSIONS: Optometrists, as members of the health care team, play a role in diagnosis and management of HIV patients, in providing encouragement and empathy to patients--particularly emphasizing the need for adherence to complex therapy regimens, as well as the importance of regular followup.     

Ocular toxicity of systemic medications: a case series.

BACKGROUND: There are many visually threatening conditions that may result from long-term use of systemic medications. Many of these adverse side effects can be greatly reduced or prevented with close monitoring of patients. In view of current knowledge, updated clinical guidelines for appropriate monitoring of ocular toxicity from systemic medications need to be developed for the eye care practitioner. CASE REVIEW: There have been many reports of ocular toxicity from isoniazid, thioridazine, steroids, and amiodarone therapy. Clinical cases illustrating possible adverse ocular side effects are presented, which include INH-induced optic neuropathy, phenothiazine-induced retinopathy, steroid-induced glaucoma, and vortex epitheliopathy secondary to amiodarone. CONCLUSION: Optometrists should be aware of the potential for ocular side effects from systemic medications. Eye care guidelines for monitoring ocular side effects from thioridazine, INH, steroids, and amiodarone use are suggested.     

Pharmacoeconomics of new medications for common chronic ophthalmic diseases

There is increasing pressure for medical care reimbursement to be linked to outcomes. New medications approved for glaucoma, age-related macular degeneration (AMD), and dry eye disease may offer improved outcomes, but they have higher acquisition costs. This article reviews published pharmacoeconomic studies assessing the incremental change in outcomes achieved vs. the increased medication costs incurred. The different types of pharmacoeconomic evaluations are described. Identified pharmacoeconimic evaluations range from simple cost-consequence statements to more complex cost-utility analyses conducted across many healthcare systems. Notably missing in all analyses are the effects of improved treatment on patient productivity. Although the diversity and small number of studies limit conclusions, there is some evidence that the newer glaucoma medications, as a group, produce economic offsets such as reduced glaucoma surgeries and fewer physician visits. Photodynamic therapy for AMD may be cost-effective when used early in patients with better visual acuity allowing cost-offsets over longer periods of time to be considered. The single pharmacoeconomic analysis of topical cyclosporine for dry eye disease was only hypothesis-generating. Comprehensive studies that investigate clinical, economic, and humanistic outcomes for the patient and society are needed to adequately assess the comparative value of current and future ophthalmic medications.     

Effect of instillation of aldose reductase inhibitor FR74366 on diabetic cataract.

The authors investigate the effect of aldose reductase inhibitor FR74366 on diabetic cataract. Streptozocin (STZ)-induced diabetic rats were treated with eye drops of FR74366 (0.03%, 0.1%, and 0.3%) for 16 weeks. Lenses were examined using a slit lamp, and the score of lens opacity was determined on a scale of from 0 (normal lens) to 4 (matured nuclear cataract). Diabetic placebo control rats developed lens opacity linearly, beginning at 3 weeks and reaching a maximum at 8 weeks after STZ injection. Instillation of FR74366 to diabetic rats delayed the cataract formation and inhibited lens sorbitol accumulation in a dose-dependent manner. At 16 weeks after STZ injection, the score of lens opacity was more than 3 (diffuse central opacities) in diabetic placebo control rats, whereas it was less than 2 (peripheral vesicles and cortical opacities) and the lenses remained clear in animals treated with 0.3% of FR74366. Measurement of tissue drug concentrations indicated that FR74366 penetrated into the lens, where its levels were increased in a dose- and time-dependent manner. These three parameters (score of lens opacity and sorbitol and FR74366 levels) were well correlated with each other. Instillation of FR74366 also reduced the sorbitol levels in the retina. However, the sorbitol levels in the sciatic nerve and renal cortex were not changed by instillation of FR74366. Instillation or oral administration of FR74366 has not shown serious side effects in animal toxicity studies. These results suggested that instillation of FR74366 may be a useful therapeutic agent against diabetic cataract and retinopathy.     

A cost analysis of the prostaglandin analogs.

BACKGROUND: The efficacy, ease of use, and favorable side effect profile has increased the popularity of the prostaglandin analogs for topical treatment of a variety of glaucoma types. We undertook a cost analysis study of all the prostaglandin analogs. METHODS: Mean number of drops per bottle, mean drop volume, total bottle volume, percent overfill per bottle, mean national bottle cost, daily cost of therapy, and yearly cost of therapy were calculated for all four of the prostaglandin analogs. RESULTS: Yearly cost of monocular therapy was $230.68 for latanoprost, $219.37 for travoprost, $211.34 for bimatoprost, and $178.85 for unoprostone. Unoprostone was by far the least expensive of the prostaglandin analogs tested. Bimatoprost, latanoprost, and travoprost were essentially the same price, varying in yearly cost to the patient by less than twenty dollars. Bimatoprost had the most expensive bottle price, unoprostone the least expensive. Bimatoprost also had the largest percentage of overfill from labeled volume. Unoprostone had the most monocular treatment days per bottle. CONCLUSION: Cost, in addition to efficacy and side affect profile, should be considered when determining which prostaglandin analog to prescribe to glaucoma patients.     

Sterility of glaucoma medications among chronic users in the community.

PURPOSE: To evaluate the sterility of topical glaucoma medications among chronic glaucoma medication users in the community. SETTING: Glaucoma service, Sanz Medical Center, Laniado Hospital, Netanya. Research mode: Cross-sectional laboratory and clinical study. PATIENTS AND METHODS: Chronic glaucoma patients were asked to submit their topical glaucoma preparations to the microbiology laboratory at Laniado hospital. Samples taken from the interior of the bottle and the tip were cultured using MacConkey agar, blood agar, and chocolate agar plates. RESULTS: Sixty-two bottles of topical glaucoma medications used by 27 patients were tested. Bacterial growth was detected in eight (12.9%) preparations, three of which revealed Pseudomonas aeruginosa, three Staphylococcus epidermidis, one Streptococcus viridans, and one Klebsiella. During the study, acute conjunctivitis was found in one patient, possibly due to the use of infected drops. In another case, two identical medications, which had been used simultaneously for more than 6 weeks by the same patient, were found to be infected. CONCLUSIONS: Glaucoma topical preparations are generally found safe in terms of sterility, though bacterial growth may be found in a small percentage. In most cases, the cause of the loss of sterility could not be determined. However, in two preparations, contamination was related to the noncompliance of the patient who continued using the same preparation longer than instructed. It is imperative to increase the awareness of glaucoma patients to the fact that improper use can lead to eye-drop contamination.     

Effects of topical instillation of traditional herbal medicines,herbal extracts,and their components on prostaglandin E2-induced aqueous flare elevation in pigmented rabbits

PURPOSE: To evaluate the effect of topical instillation of traditional herbal medicines, herbal extracts, and their components on the elevation of aqueous flare induced by prostaglandin E(2) (PGE(2)) in pigmented rabbits. METHODS: Transcorneal diffusion of 25 micro g/mL of PGE(2) was carried out through a glass cylinder placed on the cornea to induce aqueous flare elevation in pigmented rabbits. Traditional herbal medicines, herbal extracts, and their components were topically instilled before the PGE(2) application. Aqueous flare was measured with a laser flare-cell meter. RESULTS: Two instillations, 60 and 30 minutes before PGE(2), of Kakkon-to, Sairei-to, Orengedoku-to, Senkanmeimoku-to, Scutellariae radix extract, Coptidis rhizoma extract, Gardeniae fructus extract, Phellodendri cortex extract, baicalein, baicalin, wogonin, crocetin, berberine, or glycyrrhizine did not inhibit the elevation induced by PGE(2). Two instillations, 60 and 30 minutes before PGE(2), of a Ligusticum wallichii extract (100 mg/mL) inhibited the elevation by 20%. Two instillations (5 and 3 hours before PGE(2)) of baicalein (1 mg/mL) or baicalin (5 mg/mL) inhibited the elevation by 16% and 24%, respectively. Two instillations, 5 and 3 hours before PGE(2), of wogonin, crocetin, berberine, or glycyrrhizine did not inhibit the elevation. CONCLUSION: Two instillations of Ligusticum wallichii extract 60 and 30 minutes before the PGE(2), and two instillations of baicalein or baicalin, 5 and 3 hours before the PGE(2), inhibited the PGE(2)-induced aqueous flare elevation in pigmented rabbits.