🔹
Antibiotics Specific antibiotic for almost each organisms
Sultonamides-
Chlamydial infections like
🔷 A) Antibiotics: There are numerous antibiotics available
with varying spectrum of activity against most bacteria.
-TRACHIOMIA
-INCLUSION CONJUNCTIVA
-TOXOPLAMIOSIS
These antibiotics can be divided in to following groups: Bacterial cell wall synthesis inhibitors-
1. Antibiotics mainly effective against graun positive -Penicillin
🔹
organisms:
🔹 Pencilllin
Erytheromycin
-Cephalosporins
I) First generation; Gram + cocci eg cephazoline
ii) Second generation ; Gram-ve and antistaphylococcal-cefuroxime
🔹
2. Antibiotics mainly effective against gran negative iii) Third generation; Gram -ve bacilli -ceftriaxones
🔹
organisms:
🔹 Polymyxin B
Streptomycin
Side effects:
-allergic reaction
-neutropenia
3.Broad spectrum antibiotics acting against both gramtve& gram-ve bacteria I- -thrombocytopenia
🔹
Ampicillin
🔹 Amoxycillin
🔹
🔹
🔹
Tetracyclin
Neomycin
Amino glycosides:
Mainly against gram negative bacilli
🔹
🔺
Gentamycine
Chloramphenicol
Indication:
Bacterial protein synthesis inhibitors
-Gentamycin- 0.3% eye drops
-Tobramycin- 0.3% eye drop
Bacterial conjunctivits, blepharitis, dacryocystitis, keratitis.....ect. -Neomycin 0.3-0.5% eye drops
🔹
-Amikacin -- 1% eye drops
🔹
Antibiotics
Used topically in prophylaxis (pre and postoperatively) and treatment of ocular
Tetracycline:
Inhibit protein synthesis
🔹
bacterial infections.
Used orally for the treatment of preseptal cellulitis e.g, amoxycillin with clavulanate,
active against both gramt and gram -ve, some
fungi, Chlamydia trachoma
🔹
cefaclor
Used intravenously for the treatment of orbital cellulitis e.g. gentamicin, 🔹 Fluoroginolones:
Antibacterials (antibiotics) 🔹
cephalosporin, vancomycin,
Can be injected intravitrally for the treatment of endophthalmitis
-Most frequently used topical broad spectrum antibiotics
-Ciprofloxacin -0.3% eye drops
-Ofloxacin - 0.3% eye drops
-Moxifloxacin - 0.5 % eye drops
🔹
-Levofloxacin eye drops
Chlornphenicol:
Broad spectrum ,bacteriostatic,
gram+/gram-ve, Chlamydia
0.5% Eye drops, ointment
🔹
Antibiotics
Trachoma can be treated by topical and systemic tetracycline or
🔹
erythromycin, or systemic azithromycin.
Bacterial keratitis (bacterial coneal ulcers) can be treated by topical fortified
🔹
cephalosporins, aminoglycosides, vancomycin, or fluoroquinolones.
Bacterial conjunctivitis is usually self limited but topical erythromycin,
aminoglycosides, fluoroquinolones, or chloramphenicol can be used
🔹
🔹 5-iodo2-deoxyuridine(IDU) drops & ointment
Acycloguanosine( Acyclovir ) ointment.
🔹
Indication:
Herpes simplex keratitis (denderetic ulcer), hepes
zoster ophthalmicus
Antimicrobial
🔹 Acyclovir
Most commonly used anti-viral
3% ointment 5 times-10-14 days
800mg oral 5 times 10-14 days
Antivirus drugs Intravenous for Herpes zoster retinitis
Others
Idoxuridine
Vidarabine
Cytarabine
Triflurothymidine
Gancyclovir
INDICATIONS
HZ keratitis
Viral uveitis
🔹
the available drugs mainly fungistatice
🔹 Arphotricin-E
🔹 Nystatin
🔺
Ketoconazol
Indication:
-Mycotic corneal ulcer
-Fungal Endophthalmitis
-Fungal retinitis
Antifungl drugs
🔹
Commonly used drugs are
Polyene's
-damage cell membrane of susceptible fungi
-e.g. amphotericin B, natamycin, nystatin
🔹
-side effect: nephrotoxicity
Imidazoles
-increase fungal cell membrane permeability
🔹
e.g. miconazole, ketoconazole,fluconazole
Flucytocine
-act by inhibiting DNA synthesis
🔵 Sympatholytic agents: (beta blocker)
Reduces IOP by decreasing aqueous production Beta-blockers should not be instilled at
bedtime as they may cause a profound drop in blood pressure while the individual is asleep,
🔵Carbonic anhyurase inhibitor CAIs 🔹
thus reducing optic disc perfusion and potentially causing visual field deterioration.
🔹 Timolol maleate 0.25%-0.5% drops, used twice daily ,is non selective beta blocker
🔹
🔹 Acetanolamide (Diamox)
Betaxolol as an example of Bl selective( cardio selective) can be used in asthmatic
patients
🔹
chemically related to sulfonamide antibiotics. They lower IOP by inhibiting aqueous
secretion. Side effects:
It inhibits the carbonic anhydrase enzyme decrease aqueous - Punctatate keratitis and allergy.
🔹
humour production.
It given orally as tablets 250mg, maximum effect reached in 2hours, and last more
-Reduced tear production.
-Bradycardia, nauses and vomiting
🔹
than 6hours or intravenous injection 500mg, reduced I.O.P in 5minuts
Uses : in short term
-Along with miotics in glaucoma
-Bronchospasm (not used in asthmatic patients)
-Mental depression
-Skin rash
-Pre and post operative in intraocular surgery
-In case of massive hyphema to avoid corneal blood staining
-Has benefit treatment of cystoid macular oedema 🔵
🔹 Sympathomimetic Agent as adrenaline and epinephrine
🔹 side effects: 🔹 Alpha-2 agonists
decreases aqueous synthesis via an effect on the ciliary epithelium, and increases
🔹
-Gasteroinstinal upset (abdominal cramps, severe nausea, vomiting and diarrhoea) uveoscleral outflow.
-Frequency of micturation (diuretics) There is probably a neuroprotective effect. They cross the
-Tingling and numbness of extremities blood-brain barrier and should be used with great cution
-A granulocytosis in young children,, in whom severe central nervous system
-Steven Johmson's syndrome (CNS) depression and hypotension been reported, and are
-May precipitate corneal decompensation in patients with corneal endothelial contraindicated under the age of 2 years.
dysfunction.
-Serum electrolyte imbalances.
Topical carbonic-anhydrase inhibitors:
-Dorzolamide 1%
🔹
Agents:
Brinonidine
0.2% Alphagan-PB has a slightly less marked IOP-lowering effect than timolol. Allergic
-Brinzolamide 2%
🔹
conjunctivitis is relatively common.
Apraclonidine
1% (or 0.5%) not suitable for long-term use
because of a loss of therapeutic efiect over weeks to months and a high incidence of local
side effects.
🔵Hyper osmotic agents:
🔹 mannitos 🔵
🔹 Miotics:
-most commonly used, maximum effect achieved after one hour and last for 6hours, the
🔹
🔹
Direct acting (Cholinergic) as pilocarpine 1-4%, acetylcholine 1%,carbachol 1-2%
🔹
adult dose 1.5-2 grams/Kg body weight in 20% solution, in children it given in 10% Indirect acting (Anticholine esterase) as Eserine (physostigrnine) 0.5%, prostigrnine 3-5%
Drugs reducing the secretion of aqueous humor: solution, rate of administration is 50-60 drops per minute can be increase up to 100 In angle-closure glaucoma, miotic-induced contraction of the sphincter pupillae pulls the
-Cabonic arhydrase inhibitor as acetazolamide( Diamox),Dorzolamide, drops during the time of surgery,water is ‘drawn out trom the vitreous into the blood. peripheral iris away from the trabeculum, opening the angle. Miotics also reduce IOP by
Brinzolmide. -Used when a shortterm reduction in IOP is required that cannot be achieved by other contraction of the ciliary muscle, which increases the facility of aqueous outflow through
-Sympatholytic drugs (beta blocker) as Timolol means, such as in resistant acute angle-closure glaucoma or when the IOP is very high the trabecular meshwork.
Ocular Hypotensive Agents
-Sympathomimetic agent as adrenaline and epinephrine
-Hyper osmotic agents: 🔹
prior to intraocular surgery.
Side effects:
Headache
🔹 Uses:
-Treatment of glaucoma
-I.V. agents as Mannitol
🔹
Oral agents as Clycerol, Sorbitol Nausea and vomiting -Before some operations; as goniotomy, keratoplasty and glaucoma.
🔹
Drugs increasing the aqueous outflow: -After some operations; as ICCE+PI (intracapsular cataract extraction), cyclodyalsis &
Factors influencing local drug penetration into ocular tissue The effectivity of drugs depends on: concentration,
-parasympathomimetic agents (Miotics)
-prostaglandin analogs
Glycerol is an oral agent (1 g/kg body weight or 2 ml/kg
body weight of a 50% solution) with a sweet and sickly 🔹
goniotomy.
Side effect:
1.Headache
taste, and can be given with lemon (not orange) juice to
🔹
Mode of treatments of ocular disorders : 🔹
frequency, penetration
Drug concentration and solubility:
avoid nausea.
Peak action occurs within 1 hour.
2.Hasten cataract formation
3.Iris cyst
🔹 🔹
Pharmacological agents higher concentration -- better penetration e.g pilocarpine 1-4% but limited by reflex tearing Glycerol is metabolized to glucose, and careful monitoring with insulin cover may be 4.Follicular conjunctivitis
🔹 🔹
Cryotherapy Viscosity: required if administered to a (well- controlled only diabetic patient. 5.Decrease the field of vision
🔹Radiotherapy Isosoruide is a metabolically inert oral agent with a 6.Myopic shift
addition of methylcellulose and polyvinyl alcohol increases drug penetration by increasing contact time with
🔹Laser therapy minty taste; the dose is the same as for glycerol. 7. Confusion, bradycardia, bronchospasm, gastrointestinal symptoms and urinary frequency.
🔹Electrolysis
Physiotherapy
and diathermy
🔹
cornea and altering corneal epithelium
Lipid solubility: It may be safer for diabetic patients.
Pharmacological agents: 🔹
higher lipid solubility- more penetration
Surfactants: 🔵 Prostaglundin analogues:
The various routes of administration of drugs can be divided in to
🔹
two categories: 🔹
preservatives alter cell membrane in cornea and increase drug permeability e.g. benzylkonium and thiomersal
pH: 🔹
It reduced IOP by enhancing the uveoscleral outflow:
Latanoprost(Xalatan)
🔹
Systemic administration oral, intramuscular, intravenous,
subcutaneous
Local appreciation
🔹
the normal tear pH is 7.4 If drug pH is much different, this will cause reflex tearing
Drug tonicity:
when an alkaloid drug is put in relatively alkaloid medium, the proportion of the uncharged form will increase, thus
may cause fewer ocular adverse events than other PG agents and sois often used first
🔹
line
Trayoprost(Travatan) simiar to latanoprost,though it may lower IOP to a
🔹
more penetration
Molecular weight and size 🔹
slightlyxgreater extent, particularly in black patients
Bimatroprost (Lumigan)
have a greater OP lowering effect than the other PG agents in several studies, but may
🔹 Drops
-simplest and most convenient mainly for day time use 1mdrop=50
🔹
cause moe conjuncival hyperaemia. Preservative free bimatoprost is now available.
Tafluprost
is a newer prostaglandin derivative, and was the first avallable in presevative-tree form,
🔷
🔹Solution (drops): microlitre
Conjuctival sac capacity=7-13 micro liter so, even 1 drop is more
Its IOP-oweing efficacy maybe slightyless than that ofother PG agents, but it is well
tolerated and seems to cause less disruption of the ocular surface.
🔹Need frequent application
🔹 Has short contact time ▪️
than enough
🔹
🔹
measures to increase drop absorption: Side effect:
Don’t affect the vision -wait 5-10 minutes between drops Ocular:
-compress lacrimal sac -Conjunctival I
-keep lids closed for 5 minutes after instillation -hyperaemia (very common)
-Eyelash lengthening
🔷
🔹 Ointments:
-hyperpigmentation of eye ashes, iris (irreversibe)& periorbital
skin(common but reversible).
🔹
🔹
Has long contact time
Has less systemic absorption 🔹
Ointments
Increase the contact time of ocular medication to ocular surface,
-Anterior uveitis (rare).
-Cystoid macular edema (Preoperative use of PG agents may
🔹
🔹
Need less frequent application
May induce contact dermatitis
It decreases the mitotic activity of corneal
🔹
thus better effect
🔹 It has the disadvantage of blurring vision
The drug has to be highly lipid soluble with some water solubility to
🔹
increase the likelihood of cystoid macular oedema following cataract surgery).
Systemic:
Headache
🔹It causes blurred of vision as it form thin film
epithelium have maximum effect as ointment
Upper respiratory tract symptoms
🔹-Soft
Hydrophilic contact lens application:
drug 🔷
contact lens has the capability to absorb
and slowly release the chemicals in solution 🔵 Corticostervids; eg hydrocortisone, cortisone, prednisolone, dexamethanone,
🔹 Sustained-release devices
These are devices that deliver an adequate supply of -Used for sustained release of drugs& reduce betamethazone
application: 🔹
medication at a steady-state level
E.g.
the frequency of application e.g. miotics in
glaucoma
-The main effect of corticosteroids in ocular disease are:
-reduce the capillary penmeability
-decrease the tissue infiltration
Local application
🔹Drug insers in the conjunctival sac
– Ocusert delivering pilocarpine -decrease the cellular exudation
– Timoptic XE delivering timolol -inhibit the fibroblastic activity
– Ganciclovir sustained
(ocusert): -reducing the scaring following inflammation
-release intraocular device
– Collagen shields
-Give a unitorm concentration of drug for a period common ocular drugs -inhibit post inflammatory meovascularization
of time -retard regeneration of epithelium and endothelium
-Used in treatment of glaucoma e.g. pilocarpine It can be used locally in anterior segment disease (cornea, iris, sclera), or systemically
insert, tear substitutes in dryeye &locally in posterior segment disease (choroiditis, chorioretinitis, optic neuritis)
🔷Peri-ocular injections 🔹 Uses:
-Allergic condition; contact dermatitis of the lids, blepharitis and conjunctivitis.
- They reach behind iris lens -diaphragm better than topical -Infammatory lesion; non-pyogenic inflammation as stromal keratitis, iritis, choroiditis,
🔹
application papillitis, episcleritis, scleritis, retro bulbar neuritis, sympathetic ophthalmitis, after
🔹
- E.g. subconjunctival, subtenon, peribulbar, or retrobulbar Steroid corneal grafting.
- This route bypass the conjunctival and corneal epithelium Non-steroidal NSAIDS , inhibiting prostaglandin -Collagen disorders; sarcoidosis, temporal arteritis
which is good for drugs with low lipid solubility (e.g. penicillins) biosynthesis(diclofenac,ketrolac), indicated in episcleritis, scleritis ,cystoid -Traumaic condition; to prevent scarring especially in chemical burn, post operative.
🔹
- Also steroids and local anesthetics can be applied this way macular edema.
🔷 🔷 anti-inflammatory drugs
Anti-allergy:
-Decongestant (Naphazoline, Phenylephrine, Tetrahydrozoline)
🔹
🔹 Side effects:
🔹 Periocular
Subconjunctival - To achieve higher concentration in a short period of 🔹
🔹
Intra-cameral & Intna-vireal injection:
Used for severe infections
During surgery for anesthesia or pupi dilatation or
-Anti-histamine (Levacobastin, Emedastine)
-Mast cell stabilizer (Lodoxamide, Na-cromoglycate)
Locally:
-Delay the process of wound healing
-Activation of infection (herpertic , fungal and bacterial keratitis)
time Drugs which cannot penetrate cornea due to large size Penetrate via
-Non-steroidal anti-inflammatory
🔹
sclera
Subtenon -Ant. Subtenon– diseases anterior to the lens Post. Subtenon– 🔹
constriction
Intracameral acetylcholine (miocho) during cataract -Steroid
-Glaucoma
🔹
-Posterior sub capsular cataract (PSC)
🔹🔹Peribulbar
disease posterior to the lens For anesthesia, steroid
- For anesthesia, steroid, antibiotics 🔹
surgery
🔹 Intravitreal antibiotics in cases of endophthalnitis
Systemically:
-Derangement in carbohydrate metabolism( temporary increase in sugar)
Retrobulbar - Mainly for anesthesia, also can be for alcohol and steroids:
Optic neuritis Papillitis Posterior uveitis 🔹Intravitreal steroids in macular edema
Intravitreal Anti-VEGF for DR
-Moon face and other feature of Cushing's syndrome
-Edema, fluid retention and increase blood pressure
🔹 🔹
🔹 Contraindications
🔷 oral , IM or IV
Factors influencing systemic drugs penetration into ocular
Systemic:
Peptic ulcer
Systemic drugs
🔹
tissues:
lipid solubility of the drug: more penetration with high
Diabetes mellitus
Hypertension
🔹
lipid solubility
🔹 Protein binding more effect with low protein binding
Ocular inflammation: more penetration with ocular
🔹
Active or recently healed tuberculosis
Locally:
Herpes simplex keratitis
inflummation
Fungal infection
Glaucoma suspect (precaution)
Bacterial infection of cornea, conjunctiva
🔵 Diagnostic dyes: rose Benga, Flourescein, Alcian blue,
🔹
Methylene blue
Flourescein :
1-2%: it is mostuseful and commonly used vital stain.
It mark the areas of denuded epithelium, available as drops, disposable
🔹
strips &injection.
Uses:
-Applination tonometry.
-Diagnosis of corneal ulcer & abrasion.
-Siedle test for wound leakage.
-Primary & secondary John test for diagnosis oflacrimal system
obstruction.
-BUT (breakuptime test) for diagnosis of dryeye.
-In fitting of hard contact lenses
-During corneal surgery, to stain the trephine mark
-For diagnosis of retinal vascular disease as diabetic retinopathy before
laser application.
🔵 Antimetabolites;
It inhibit the natural healing response
-Mitomycin C
🔹
-5-Fluorouracil
Uses: (to reduce scanring)
-Glaucoma surgery
-Recurrent pteryglum
by fatema okoff -DCR
-Conjunctival tumors after excision
🔵 Diathermy:
Heat generated in the tissue of the eye by passing of high
🔹
frequency current through a conductor
Uses:
Surgical diathermy:
-Trichiasis
-Retinal detachment surgery
-Intraocular neoplasm
-Glaucome(cyclo-diathermy)
Therpeutic Procedures:
🔵 Cryotherupy (co2,Freon,Nitrous oxide)
Tissue coagulation by application of intense cold
Uses:
Glaucoma: cyclocryotherapy
Lids: xanthelasma, haemangioma, lipoma
Conea: herpes simplex keratitis
Cataract surgery
Retina: RD surgery
🔵 Radiotherapy
🔹
(X, Beta& Gammarays)
Used in minimum dosage to avoid destruction to
normal tissues
Uses:
-Non neoplastic lesion: Mooren"s ulcer, corneal vascularization after
keratoplasty, recurrent pterygium
-Neoplastic lesion: Haemangioma, retinoblastoma
1🔷 Photocoagulatior:
Argon, Diode, hema lasers depend on absorption ofthe laser light by tissue pigments
which converted into
heat-->coagulation-->scar formation ,occlusion of bl.vessels, tissue atrophy and tissue
contraction ;used in Retinal disorders: diabetic
retinopathy (DR), Central serous chorioretinopathy, small
retinoblastoma, angiomatosis.in Inis: reconstruction of the pupil
Laser therapy
🔷
,Others: trabeculoplasty (glaucoma) 2.
2 Photodisruption;
Yag laser ,ionize the electrons of the target tissue producing a physical state called
plasma exerting cutting /incising effect upon the tissue: Capsulotomy,
Iridotomy, Membranotomy, DCR.
3 🔷Photoablation;
Excimer laser, photorefractive surgery, produce UV light of very short wavelenght which
breaks bonds of biological materials converting them into
small molecules that diffuse away .
Used in PRK (photorefracive keratectomy), Lasik (laser assisted insitu keratomileusis), PLK
(phototherapeutic keratectomy)
🔹
🔹 Dilate the pupil, ciliary muscle paralysis
CLASSIFICATION
-Shot acting-Tropicamide, phenylepherine( sympathetic) (4-6 hrs)
-Intermediate- homatropine (24 hrs)cyclopentolate
parasympatholytic(5- 18hrs)
-Long acting- atropine parasympatholytic (2 weeks)
🔷 The mydriatics act by two mechanisms and are accordingly
🔹
divided in to two groups:
Parasympatholytic drugs:
These drugs also cause cycloplegia as it affect the ciliary
muscle such as Atropine sulphate 1-2% drops & ointment, Homatropine,
🔹
Tropicamide
Sympathomimetic drugs: These drugs act by stimulating the dilator
pupillae muscle .The commonly used drugs as adrenalin, Cocain Hcl 2-5%
drops, Phenylepherine 5-10%
Indications:
-For examination of the media and fundli corneal ulcer, relef pain
-uveitis for relieving pain and prevents and breaks synaechia
-cycloplegic refracion
Mydriuties and cycloplegics -For doing flourescein angiography
-For giving photocoagulation therapy
-For temporary improvement of vision in patient with central cataract
-Preuperative before cataract surgery
-Postoperative in intraocular surgery
🔷 Cycloplegie drugs:
The commonly used cyclopegics are:
-Atropine
-Scopolamine(hyoscine)
-homatropine
-Cyclopentolate
-Tropicamide
🔷tropine sulphate: 1% drop and ointment
🔹 Uses:
-Treatment of iridocyelitis
-To (diate pupil post operatively after intraocular surgery
-For retinoscopy in children below the age of 15years
-For partia occlusion in the treatment of umblyopia exanopsia
-For relieving the accommodation spasm as in accommodational squint
🔹 side effects: Atropine sensitivity" i irritation" manifested as follicular
conjunctivitis, allergic dermatitis of the lid margins
-Atropine poisoning "toxicity" as result of systemic absorption, common in
children manifested as redness of the face, fever, dry mouth& skin,
tachycardia and excitement.
-Photophobia& blurred vision due to pupil dilatation
Antibiotics Specific antibiotic for almost each organisms
Sultonamides-
Chlamydial infections like
🔷 A) Antibiotics: There are numerous antibiotics available
with varying spectrum of activity against most bacteria.
-TRACHIOMIA
-INCLUSION CONJUNCTIVA
-TOXOPLAMIOSIS
These antibiotics can be divided in to following groups: Bacterial cell wall synthesis inhibitors-
1. Antibiotics mainly effective against graun positive -Penicillin
🔹
organisms:
🔹 Pencilllin
Erytheromycin
-Cephalosporins
I) First generation; Gram + cocci eg cephazoline
ii) Second generation ; Gram-ve and antistaphylococcal-cefuroxime
🔹
2. Antibiotics mainly effective against gran negative iii) Third generation; Gram -ve bacilli -ceftriaxones
🔹
organisms:
🔹 Polymyxin B
Streptomycin
Side effects:
-allergic reaction
-neutropenia
3.Broad spectrum antibiotics acting against both gramtve& gram-ve bacteria I- -thrombocytopenia
🔹
Ampicillin
🔹 Amoxycillin
🔹
🔹
🔹
Tetracyclin
Neomycin
Amino glycosides:
Mainly against gram negative bacilli
🔹
🔺
Gentamycine
Chloramphenicol
Indication:
Bacterial protein synthesis inhibitors
-Gentamycin- 0.3% eye drops
-Tobramycin- 0.3% eye drop
Bacterial conjunctivits, blepharitis, dacryocystitis, keratitis.....ect. -Neomycin 0.3-0.5% eye drops
🔹
-Amikacin -- 1% eye drops
🔹
Antibiotics
Used topically in prophylaxis (pre and postoperatively) and treatment of ocular
Tetracycline:
Inhibit protein synthesis
🔹
bacterial infections.
Used orally for the treatment of preseptal cellulitis e.g, amoxycillin with clavulanate,
active against both gramt and gram -ve, some
fungi, Chlamydia trachoma
🔹
cefaclor
Used intravenously for the treatment of orbital cellulitis e.g. gentamicin, 🔹 Fluoroginolones:
Antibacterials (antibiotics) 🔹
cephalosporin, vancomycin,
Can be injected intravitrally for the treatment of endophthalmitis
-Most frequently used topical broad spectrum antibiotics
-Ciprofloxacin -0.3% eye drops
-Ofloxacin - 0.3% eye drops
-Moxifloxacin - 0.5 % eye drops
🔹
-Levofloxacin eye drops
Chlornphenicol:
Broad spectrum ,bacteriostatic,
gram+/gram-ve, Chlamydia
0.5% Eye drops, ointment
🔹
Antibiotics
Trachoma can be treated by topical and systemic tetracycline or
🔹
erythromycin, or systemic azithromycin.
Bacterial keratitis (bacterial coneal ulcers) can be treated by topical fortified
🔹
cephalosporins, aminoglycosides, vancomycin, or fluoroquinolones.
Bacterial conjunctivitis is usually self limited but topical erythromycin,
aminoglycosides, fluoroquinolones, or chloramphenicol can be used
🔹
🔹 5-iodo2-deoxyuridine(IDU) drops & ointment
Acycloguanosine( Acyclovir ) ointment.
🔹
Indication:
Herpes simplex keratitis (denderetic ulcer), hepes
zoster ophthalmicus
Antimicrobial
🔹 Acyclovir
Most commonly used anti-viral
3% ointment 5 times-10-14 days
800mg oral 5 times 10-14 days
Antivirus drugs Intravenous for Herpes zoster retinitis
Others
Idoxuridine
Vidarabine
Cytarabine
Triflurothymidine
Gancyclovir
INDICATIONS
HZ keratitis
Viral uveitis
🔹
the available drugs mainly fungistatice
🔹 Arphotricin-E
🔹 Nystatin
🔺
Ketoconazol
Indication:
-Mycotic corneal ulcer
-Fungal Endophthalmitis
-Fungal retinitis
Antifungl drugs
🔹
Commonly used drugs are
Polyene's
-damage cell membrane of susceptible fungi
-e.g. amphotericin B, natamycin, nystatin
🔹
-side effect: nephrotoxicity
Imidazoles
-increase fungal cell membrane permeability
🔹
e.g. miconazole, ketoconazole,fluconazole
Flucytocine
-act by inhibiting DNA synthesis
🔵 Sympatholytic agents: (beta blocker)
Reduces IOP by decreasing aqueous production Beta-blockers should not be instilled at
bedtime as they may cause a profound drop in blood pressure while the individual is asleep,
🔵Carbonic anhyurase inhibitor CAIs 🔹
thus reducing optic disc perfusion and potentially causing visual field deterioration.
🔹 Timolol maleate 0.25%-0.5% drops, used twice daily ,is non selective beta blocker
🔹
🔹 Acetanolamide (Diamox)
Betaxolol as an example of Bl selective( cardio selective) can be used in asthmatic
patients
🔹
chemically related to sulfonamide antibiotics. They lower IOP by inhibiting aqueous
secretion. Side effects:
It inhibits the carbonic anhydrase enzyme decrease aqueous - Punctatate keratitis and allergy.
🔹
humour production.
It given orally as tablets 250mg, maximum effect reached in 2hours, and last more
-Reduced tear production.
-Bradycardia, nauses and vomiting
🔹
than 6hours or intravenous injection 500mg, reduced I.O.P in 5minuts
Uses : in short term
-Along with miotics in glaucoma
-Bronchospasm (not used in asthmatic patients)
-Mental depression
-Skin rash
-Pre and post operative in intraocular surgery
-In case of massive hyphema to avoid corneal blood staining
-Has benefit treatment of cystoid macular oedema 🔵
🔹 Sympathomimetic Agent as adrenaline and epinephrine
🔹 side effects: 🔹 Alpha-2 agonists
decreases aqueous synthesis via an effect on the ciliary epithelium, and increases
🔹
-Gasteroinstinal upset (abdominal cramps, severe nausea, vomiting and diarrhoea) uveoscleral outflow.
-Frequency of micturation (diuretics) There is probably a neuroprotective effect. They cross the
-Tingling and numbness of extremities blood-brain barrier and should be used with great cution
-A granulocytosis in young children,, in whom severe central nervous system
-Steven Johmson's syndrome (CNS) depression and hypotension been reported, and are
-May precipitate corneal decompensation in patients with corneal endothelial contraindicated under the age of 2 years.
dysfunction.
-Serum electrolyte imbalances.
Topical carbonic-anhydrase inhibitors:
-Dorzolamide 1%
🔹
Agents:
Brinonidine
0.2% Alphagan-PB has a slightly less marked IOP-lowering effect than timolol. Allergic
-Brinzolamide 2%
🔹
conjunctivitis is relatively common.
Apraclonidine
1% (or 0.5%) not suitable for long-term use
because of a loss of therapeutic efiect over weeks to months and a high incidence of local
side effects.
🔵Hyper osmotic agents:
🔹 mannitos 🔵
🔹 Miotics:
-most commonly used, maximum effect achieved after one hour and last for 6hours, the
🔹
🔹
Direct acting (Cholinergic) as pilocarpine 1-4%, acetylcholine 1%,carbachol 1-2%
🔹
adult dose 1.5-2 grams/Kg body weight in 20% solution, in children it given in 10% Indirect acting (Anticholine esterase) as Eserine (physostigrnine) 0.5%, prostigrnine 3-5%
Drugs reducing the secretion of aqueous humor: solution, rate of administration is 50-60 drops per minute can be increase up to 100 In angle-closure glaucoma, miotic-induced contraction of the sphincter pupillae pulls the
-Cabonic arhydrase inhibitor as acetazolamide( Diamox),Dorzolamide, drops during the time of surgery,water is ‘drawn out trom the vitreous into the blood. peripheral iris away from the trabeculum, opening the angle. Miotics also reduce IOP by
Brinzolmide. -Used when a shortterm reduction in IOP is required that cannot be achieved by other contraction of the ciliary muscle, which increases the facility of aqueous outflow through
-Sympatholytic drugs (beta blocker) as Timolol means, such as in resistant acute angle-closure glaucoma or when the IOP is very high the trabecular meshwork.
Ocular Hypotensive Agents
-Sympathomimetic agent as adrenaline and epinephrine
-Hyper osmotic agents: 🔹
prior to intraocular surgery.
Side effects:
Headache
🔹 Uses:
-Treatment of glaucoma
-I.V. agents as Mannitol
🔹
Oral agents as Clycerol, Sorbitol Nausea and vomiting -Before some operations; as goniotomy, keratoplasty and glaucoma.
🔹
Drugs increasing the aqueous outflow: -After some operations; as ICCE+PI (intracapsular cataract extraction), cyclodyalsis &
Factors influencing local drug penetration into ocular tissue The effectivity of drugs depends on: concentration,
-parasympathomimetic agents (Miotics)
-prostaglandin analogs
Glycerol is an oral agent (1 g/kg body weight or 2 ml/kg
body weight of a 50% solution) with a sweet and sickly 🔹
goniotomy.
Side effect:
1.Headache
taste, and can be given with lemon (not orange) juice to
🔹
Mode of treatments of ocular disorders : 🔹
frequency, penetration
Drug concentration and solubility:
avoid nausea.
Peak action occurs within 1 hour.
2.Hasten cataract formation
3.Iris cyst
🔹 🔹
Pharmacological agents higher concentration -- better penetration e.g pilocarpine 1-4% but limited by reflex tearing Glycerol is metabolized to glucose, and careful monitoring with insulin cover may be 4.Follicular conjunctivitis
🔹 🔹
Cryotherapy Viscosity: required if administered to a (well- controlled only diabetic patient. 5.Decrease the field of vision
🔹Radiotherapy Isosoruide is a metabolically inert oral agent with a 6.Myopic shift
addition of methylcellulose and polyvinyl alcohol increases drug penetration by increasing contact time with
🔹Laser therapy minty taste; the dose is the same as for glycerol. 7. Confusion, bradycardia, bronchospasm, gastrointestinal symptoms and urinary frequency.
🔹Electrolysis
Physiotherapy
and diathermy
🔹
cornea and altering corneal epithelium
Lipid solubility: It may be safer for diabetic patients.
Pharmacological agents: 🔹
higher lipid solubility- more penetration
Surfactants: 🔵 Prostaglundin analogues:
The various routes of administration of drugs can be divided in to
🔹
two categories: 🔹
preservatives alter cell membrane in cornea and increase drug permeability e.g. benzylkonium and thiomersal
pH: 🔹
It reduced IOP by enhancing the uveoscleral outflow:
Latanoprost(Xalatan)
🔹
Systemic administration oral, intramuscular, intravenous,
subcutaneous
Local appreciation
🔹
the normal tear pH is 7.4 If drug pH is much different, this will cause reflex tearing
Drug tonicity:
when an alkaloid drug is put in relatively alkaloid medium, the proportion of the uncharged form will increase, thus
may cause fewer ocular adverse events than other PG agents and sois often used first
🔹
line
Trayoprost(Travatan) simiar to latanoprost,though it may lower IOP to a
🔹
more penetration
Molecular weight and size 🔹
slightlyxgreater extent, particularly in black patients
Bimatroprost (Lumigan)
have a greater OP lowering effect than the other PG agents in several studies, but may
🔹 Drops
-simplest and most convenient mainly for day time use 1mdrop=50
🔹
cause moe conjuncival hyperaemia. Preservative free bimatoprost is now available.
Tafluprost
is a newer prostaglandin derivative, and was the first avallable in presevative-tree form,
🔷
🔹Solution (drops): microlitre
Conjuctival sac capacity=7-13 micro liter so, even 1 drop is more
Its IOP-oweing efficacy maybe slightyless than that ofother PG agents, but it is well
tolerated and seems to cause less disruption of the ocular surface.
🔹Need frequent application
🔹 Has short contact time ▪️
than enough
🔹
🔹
measures to increase drop absorption: Side effect:
Don’t affect the vision -wait 5-10 minutes between drops Ocular:
-compress lacrimal sac -Conjunctival I
-keep lids closed for 5 minutes after instillation -hyperaemia (very common)
-Eyelash lengthening
🔷
🔹 Ointments:
-hyperpigmentation of eye ashes, iris (irreversibe)& periorbital
skin(common but reversible).
🔹
🔹
Has long contact time
Has less systemic absorption 🔹
Ointments
Increase the contact time of ocular medication to ocular surface,
-Anterior uveitis (rare).
-Cystoid macular edema (Preoperative use of PG agents may
🔹
🔹
Need less frequent application
May induce contact dermatitis
It decreases the mitotic activity of corneal
🔹
thus better effect
🔹 It has the disadvantage of blurring vision
The drug has to be highly lipid soluble with some water solubility to
🔹
increase the likelihood of cystoid macular oedema following cataract surgery).
Systemic:
Headache
🔹It causes blurred of vision as it form thin film
epithelium have maximum effect as ointment
Upper respiratory tract symptoms
🔹-Soft
Hydrophilic contact lens application:
drug 🔷
contact lens has the capability to absorb
and slowly release the chemicals in solution 🔵 Corticostervids; eg hydrocortisone, cortisone, prednisolone, dexamethanone,
🔹 Sustained-release devices
These are devices that deliver an adequate supply of -Used for sustained release of drugs& reduce betamethazone
application: 🔹
medication at a steady-state level
E.g.
the frequency of application e.g. miotics in
glaucoma
-The main effect of corticosteroids in ocular disease are:
-reduce the capillary penmeability
-decrease the tissue infiltration
Local application
🔹Drug insers in the conjunctival sac
– Ocusert delivering pilocarpine -decrease the cellular exudation
– Timoptic XE delivering timolol -inhibit the fibroblastic activity
– Ganciclovir sustained
(ocusert): -reducing the scaring following inflammation
-release intraocular device
– Collagen shields
-Give a unitorm concentration of drug for a period common ocular drugs -inhibit post inflammatory meovascularization
of time -retard regeneration of epithelium and endothelium
-Used in treatment of glaucoma e.g. pilocarpine It can be used locally in anterior segment disease (cornea, iris, sclera), or systemically
insert, tear substitutes in dryeye &locally in posterior segment disease (choroiditis, chorioretinitis, optic neuritis)
🔷Peri-ocular injections 🔹 Uses:
-Allergic condition; contact dermatitis of the lids, blepharitis and conjunctivitis.
- They reach behind iris lens -diaphragm better than topical -Infammatory lesion; non-pyogenic inflammation as stromal keratitis, iritis, choroiditis,
🔹
application papillitis, episcleritis, scleritis, retro bulbar neuritis, sympathetic ophthalmitis, after
🔹
- E.g. subconjunctival, subtenon, peribulbar, or retrobulbar Steroid corneal grafting.
- This route bypass the conjunctival and corneal epithelium Non-steroidal NSAIDS , inhibiting prostaglandin -Collagen disorders; sarcoidosis, temporal arteritis
which is good for drugs with low lipid solubility (e.g. penicillins) biosynthesis(diclofenac,ketrolac), indicated in episcleritis, scleritis ,cystoid -Traumaic condition; to prevent scarring especially in chemical burn, post operative.
🔹
- Also steroids and local anesthetics can be applied this way macular edema.
🔷 🔷 anti-inflammatory drugs
Anti-allergy:
-Decongestant (Naphazoline, Phenylephrine, Tetrahydrozoline)
🔹
🔹 Side effects:
🔹 Periocular
Subconjunctival - To achieve higher concentration in a short period of 🔹
🔹
Intra-cameral & Intna-vireal injection:
Used for severe infections
During surgery for anesthesia or pupi dilatation or
-Anti-histamine (Levacobastin, Emedastine)
-Mast cell stabilizer (Lodoxamide, Na-cromoglycate)
Locally:
-Delay the process of wound healing
-Activation of infection (herpertic , fungal and bacterial keratitis)
time Drugs which cannot penetrate cornea due to large size Penetrate via
-Non-steroidal anti-inflammatory
🔹
sclera
Subtenon -Ant. Subtenon– diseases anterior to the lens Post. Subtenon– 🔹
constriction
Intracameral acetylcholine (miocho) during cataract -Steroid
-Glaucoma
🔹
-Posterior sub capsular cataract (PSC)
🔹🔹Peribulbar
disease posterior to the lens For anesthesia, steroid
- For anesthesia, steroid, antibiotics 🔹
surgery
🔹 Intravitreal antibiotics in cases of endophthalnitis
Systemically:
-Derangement in carbohydrate metabolism( temporary increase in sugar)
Retrobulbar - Mainly for anesthesia, also can be for alcohol and steroids:
Optic neuritis Papillitis Posterior uveitis 🔹Intravitreal steroids in macular edema
Intravitreal Anti-VEGF for DR
-Moon face and other feature of Cushing's syndrome
-Edema, fluid retention and increase blood pressure
🔹 🔹
🔹 Contraindications
🔷 oral , IM or IV
Factors influencing systemic drugs penetration into ocular
Systemic:
Peptic ulcer
Systemic drugs
🔹
tissues:
lipid solubility of the drug: more penetration with high
Diabetes mellitus
Hypertension
🔹
lipid solubility
🔹 Protein binding more effect with low protein binding
Ocular inflammation: more penetration with ocular
🔹
Active or recently healed tuberculosis
Locally:
Herpes simplex keratitis
inflummation
Fungal infection
Glaucoma suspect (precaution)
Bacterial infection of cornea, conjunctiva
🔵 Diagnostic dyes: rose Benga, Flourescein, Alcian blue,
🔹
Methylene blue
Flourescein :
1-2%: it is mostuseful and commonly used vital stain.
It mark the areas of denuded epithelium, available as drops, disposable
🔹
strips &injection.
Uses:
-Applination tonometry.
-Diagnosis of corneal ulcer & abrasion.
-Siedle test for wound leakage.
-Primary & secondary John test for diagnosis oflacrimal system
obstruction.
-BUT (breakuptime test) for diagnosis of dryeye.
-In fitting of hard contact lenses
-During corneal surgery, to stain the trephine mark
-For diagnosis of retinal vascular disease as diabetic retinopathy before
laser application.
🔵 Antimetabolites;
It inhibit the natural healing response
-Mitomycin C
🔹
-5-Fluorouracil
Uses: (to reduce scanring)
-Glaucoma surgery
-Recurrent pteryglum
by fatema okoff -DCR
-Conjunctival tumors after excision
🔵 Diathermy:
Heat generated in the tissue of the eye by passing of high
🔹
frequency current through a conductor
Uses:
Surgical diathermy:
-Trichiasis
-Retinal detachment surgery
-Intraocular neoplasm
-Glaucome(cyclo-diathermy)
Therpeutic Procedures:
🔵 Cryotherupy (co2,Freon,Nitrous oxide)
Tissue coagulation by application of intense cold
Uses:
Glaucoma: cyclocryotherapy
Lids: xanthelasma, haemangioma, lipoma
Conea: herpes simplex keratitis
Cataract surgery
Retina: RD surgery
🔵 Radiotherapy
🔹
(X, Beta& Gammarays)
Used in minimum dosage to avoid destruction to
normal tissues
Uses:
-Non neoplastic lesion: Mooren"s ulcer, corneal vascularization after
keratoplasty, recurrent pterygium
-Neoplastic lesion: Haemangioma, retinoblastoma
1🔷 Photocoagulatior:
Argon, Diode, hema lasers depend on absorption ofthe laser light by tissue pigments
which converted into
heat-->coagulation-->scar formation ,occlusion of bl.vessels, tissue atrophy and tissue
contraction ;used in Retinal disorders: diabetic
retinopathy (DR), Central serous chorioretinopathy, small
retinoblastoma, angiomatosis.in Inis: reconstruction of the pupil
Laser therapy
🔷
,Others: trabeculoplasty (glaucoma) 2.
2 Photodisruption;
Yag laser ,ionize the electrons of the target tissue producing a physical state called
plasma exerting cutting /incising effect upon the tissue: Capsulotomy,
Iridotomy, Membranotomy, DCR.
3 🔷Photoablation;
Excimer laser, photorefractive surgery, produce UV light of very short wavelenght which
breaks bonds of biological materials converting them into
small molecules that diffuse away .
Used in PRK (photorefracive keratectomy), Lasik (laser assisted insitu keratomileusis), PLK
(phototherapeutic keratectomy)
🔹
🔹 Dilate the pupil, ciliary muscle paralysis
CLASSIFICATION
-Shot acting-Tropicamide, phenylepherine( sympathetic) (4-6 hrs)
-Intermediate- homatropine (24 hrs)cyclopentolate
parasympatholytic(5- 18hrs)
-Long acting- atropine parasympatholytic (2 weeks)
🔷 The mydriatics act by two mechanisms and are accordingly
🔹
divided in to two groups:
Parasympatholytic drugs:
These drugs also cause cycloplegia as it affect the ciliary
muscle such as Atropine sulphate 1-2% drops & ointment, Homatropine,
🔹
Tropicamide
Sympathomimetic drugs: These drugs act by stimulating the dilator
pupillae muscle .The commonly used drugs as adrenalin, Cocain Hcl 2-5%
drops, Phenylepherine 5-10%
Indications:
-For examination of the media and fundli corneal ulcer, relef pain
-uveitis for relieving pain and prevents and breaks synaechia
-cycloplegic refracion
Mydriuties and cycloplegics -For doing flourescein angiography
-For giving photocoagulation therapy
-For temporary improvement of vision in patient with central cataract
-Preuperative before cataract surgery
-Postoperative in intraocular surgery
🔷 Cycloplegie drugs:
The commonly used cyclopegics are:
-Atropine
-Scopolamine(hyoscine)
-homatropine
-Cyclopentolate
-Tropicamide
🔷tropine sulphate: 1% drop and ointment
🔹 Uses:
-Treatment of iridocyelitis
-To (diate pupil post operatively after intraocular surgery
-For retinoscopy in children below the age of 15years
-For partia occlusion in the treatment of umblyopia exanopsia
-For relieving the accommodation spasm as in accommodational squint
🔹 side effects: Atropine sensitivity" i irritation" manifested as follicular
conjunctivitis, allergic dermatitis of the lid margins
-Atropine poisoning "toxicity" as result of systemic absorption, common in
children manifested as redness of the face, fever, dry mouth& skin,
tachycardia and excitement.
-Photophobia& blurred vision due to pupil dilatation
