Ophthalmology

Ocular Therapeutics
SECTION IV

Atul K Shankar
31
 Miotics
Mechanism of action:

- In primary open angle glaucoma

o Miotics reduce the intraocular pressure by enhancing the aqueous outflow facility
o This is achieved by changes in the trabecular meshwork produced by pull exerted by
contraction of the longitudinal fibres of ciliary muscle
- In primary angle-closure glaucoma
o Reduce the IOP by their miotic effect by opening the angle
o The mechanical contraction of the pupil moves the iris away from the trabecular
meshwork

Side effects

- Systemic side effects

o Bradycardia
o Increased sweating
o Diarrhoea
o Excessive salivation
o Anxiety
- Local side effects
o Reduced visual acuity
o Impairment of night vision
o Generalized contraction of visual fields
o Spasm of accommodation
 Causes myopia and frontal headache, retinal detachment, lenticular
opacities, iris cyst formation, mild iritis, lacrimation and follicular
conjunctivitis

Preparations:

- Pilocarpine
- Carbachol
- Echothiophate iodide
- Demecarium bromide
- Physostigmine bromide

Pilocarpine
- Directly acting sympathomimetic drug
- It was the most commonly used and the most extensively studied miotic
- Indications
o Primary open angle glaucoma
o Acute angle-closure glaucoma
o Chronic synechial angle-closure glaucoma
- Contraindications
o Inflammatory glaucoma
o Malignant glaucoma
o Known allergies
- Preparations – eyedrops, ocuserts, pilocarpine gel
 Anti-Glaucoma Drugs
The anti-glaucoma drugs are:

- Prostaglandin Analogs
o Latanoprost
o Bimatoprost
o Travoprost
o Unoprostone isopropyl
o Tafluprost
- Adrenergic Agonists
o Epinephrine
o Norepinephrine
o Clonidine hydrochloride
o Pargyline
o Isoproterenol
- Beta-adrenergic Blockers
o Timolol
o Betaxolol
o Levobunolol
o Carteolol
o Metipranolol
- Carbonic Anhydrase Inhibitors
o Methazolamide
o Dichlorphenamide
o Ethoxzolamide
o Brinzolamide
o Acetazolamide
- Parasympathomimetic Drugs
o Pilocarpine
o Carbachol
o Echothiophate iodide
o Demecarium bromide
o Physostigmine
- Hyperosmotic Drugs
o Glycerol
o Mannitol
o Urea
o Isosorbide
- Calcium channel blockers
o Verapamil

Classification by Mechanism:

- Drugs that increase trabecular outflow

o Miotics, Epinephrine, Bimatoprost
- Drugs that increase uveoscleral outflow
o Prostaglandins, epinephrine, dipivefrine, brimonidine, apraclonidine
- Drugs that decrease aqueous production
o Carbonic anhydrase inhibitors, Alpha receptor stimulators, Beta blockers
 Anti-Viral Drugs
- More often used locally in the eye
- The currently available agents are virostatic
- They are active against DNA viruses; especially Herpes Simplex Virus,
- The antiviral drugs are classified as:

For Herpes Simplex Virus:

- Idoxuridine
- Vidarabine
- Trifluridine
- Acyclovir
- Famciclovir

For Herpes Zoster Virus:

- Acyclovir
- Famciclovir
- Valaciclovir
- Vidarabine
- Sorivudine

For CMV Retinitis:

- Ganciclovir
- Foscarnet
- Zidovudine

Timolol Maleate
- Non-selective beta-1 and beta-2 blocker
- It is available as 0.25% and 0.5% eye drops
- The drug is very effective however it is a short-term escape and long term drift
- Short term escape implies a marked initial fall in IOP
- Long term drift implies a slow rise in IOP in patients who were well controlled with many
months of therapy
- Mechanism of action
o Lower IOP by blocking the beta 2 receptors in the ciliary processes
o Results in decreased aqueous production
- Contraindications
o Bronchial asthma, emphysema, COPD, heart blocks, congestive heart disease,
cardiomyopathy
- Side effects
o Ocular Side effects
 Burning, conjunctival hyperaemia, superficial punctate keratopathy
corneal anaesthesia
o Systemic Side Effects
 Cardiovascular effects – bradycardia, arrhythmias, heart failure, syncope
 Respiratory reactions – bronchospasm, airway obstruction,
 Central Nervous system – depression, anxiety, confusion, drowsiness,
disorientation, hallucination, emotional lability, dysarthria
 Lasers in Ophthalmology
MECHANISMS OF LASER EFFECTS AND THEIR THERAPEUTIC APPLICATIONS

Photochemical Effect:

- Produced following exposure of ocular tissues to the visible or near UV light

- Occurs due to cessation of oxygen free radicals, which are cytotoxic
- This toxicitiy is increased after administration of exogenous photosensitising agents, which
accumulate in the target tissue and produces free radicals when excited by lasers
- Therapeutic applications
o Photodynamic therapy
o Corneal collagen linking with riboflavin

Photothermal Effect:

- Absorbed light is converted into heat, thus raising the temperature of the target tissue and
producing either photocoagulation or vaporization effect
- Photocoagulation – effective intreating ocular diseases by production of a scar, occlusion of
vessels, tissue atrophy and tissue contraction
- Therapeutic applications
o Eyelid lesions
o Corneal conditions
o Laser for glaucoma
o Lesions of iris, retina and choroid

Photomechanical Effect:
- based on mechanism ionise the electrons of the target tissue producing a physical state
called plasma
- this plasma extends with momentary pressures as high as 10 kilobars
- the lasers used are:
o Nd:YAG Laser and its therapeutic uses:
 Capsulotomy
 Membranectomy
 Vitreolysis
 Phacolysis
o Femtosecond laser and its uses:
 Creation of corneal flap for LASIK
 Creation of tunnel for intracorneal rings
 Arcuate incisions to correct corneal astigmatism
 Keratoplasty incisions
 Small incision lenticule extraction
 Femtosecond laser assisted cataract surgery

Photoablation:
- Lasers based on this mechanism such as 193 nm argon fluoride laser produces a UV light
- It breaks molecular bonds of biologic material, converting them into molecules that diffuse
- Therapeutic Applications
o Photorefractive keratectomy (PRK), Laser assisted in situ keratomileusis (LASIK),
Phototherapeutic keratectomy (PTK)
 Cryotherapy in Ophthalmology
Cryopexy means to produce tissue injury by application of intense cold which is achieved by
cryoprobe from a cryo unit.

Principle:

- Working of cryoprobes is based on the Joule Thompson Principle of Cooling

Cryo Unit uses freon, nitrous oxide or carbon dioxide gas as a cooling agent

Cryoprobes are available in different sizes such as 1mm for intravitreal use, 2.5mm for retina and
4mm for cyclocryoplexy

Temperature produced is dependent upon

- the size of the cryoprobe tip

- duration of freezing process
- the gas used

Modes of Action:

- cryopexy produces the required therapeutic effect by different modes which include tissue
necrosis, production of adhesions between tissues, vascular occlusions and adherence of
the cryoprobe to the iceball in the tissue

Uses:

- Lids
o Cryolysis for trichiasis
o Cryotherapy for warts and Molluscum contagiosum
o Cryotherapy for basal cell carcinoma and haemangioma
- Conjunctiva
o Hypertrophied papillae of vernal catarrh and ocular surface squamous neoplasia
- Cornea
o Herpes simplex keratitis
- Lens
o Cryoextraction of lens
- Ciliary body
o Cyclocryopexy for absolute glaucoma and neovascular glaucoma
- Retina
o Cryopexy can be used for sealing retinal holes in retinal detachment
o Prophylactic cryopexy to prevent retinal detachment in certain predisposed case
o Anterior retinal cryopexy in retinal ischaemic disease
o Cryotreatment of retinoblastoma and angioma