OPHTHALMOLOGY FINALS I

❑ OPTICS AND REFRACTION

❑ PREVENTIVE OPHTHALMOLOGY
❑ OPHTHALMIC THERAPEUTICS
❑ NEURO-OPHTHALMOLOGY
❑ OCULAR DISORDERS ASSOCIATED WITH SYSTEMIC
DISEASE
OPTICS and REFRACTION
Eliseo George A. Ave Jr. MD.
General Ophthalmology
 OPTICS
• Physical optics
• Physical properties of light
• Geometric optics
• Focusing of light onto the retina
• Physiologic optics
• Processes occurring in the retina producing
visual energy
• Neuro-ophthalmic optics
• Conduction of visual energy to the occipital
visual center
SNELL’S LAW

• When light travels from a medium of lower refractive

index (AIR) to a medium of higher refractive index
(GLASS), it bends towards the normal

• When light travels from a medium of higher refractive

index (GLASS) to a medium of lower refractive index
(AIR), it bends away from the normal
Snell’s Law

low index of refraction

refracting surface

normal
high index of refraction
Snell’s Law

low index of refraction

refracting surface

normal
high index of refraction
PRISMS

• Has a base and an apex

• Light passing through is deviated towards its base

Convex Lens

• AKA Convergent Lens

• 2 prisms put together at its base
• Concentrates light to a point
• (+) sphere
• Corrects HYPEROPIA
Concave Lens

• AKA Divergent Lens

• 2 prisms put together at its apex
• Scatters light
• (-) sphere
• Corrects MYOPIA
Cylindrical Lens

• Spherical lenses that are placed on top of the

other to form a cylinder
• Corrects ASTIGMATISM
90º

180º
REFRACTION
EMMETROPIA

• Emme – normal ; tropi – EOR

• Occurs when both shape of the cornea and axial
length of the eye focus light ray exactly on the
retina
• Focal point- on the retina
• 20/20 vision
AMMETROPIA

• Vision disorder characterized by inability of the

eyes to correctly focus images of objects on the
retina

• Infront of the retina – MYOPIA

• Behind the retina – HYPEROPIA
• ASTIGMATISM
• PRESBYOPIA
Error of Refraction Symptoms

• Headache (relieved by sleep)

• Blurred vision
• Head turn/tilt
• Squinting
• Tearing
• Droopy eyes
• Short work span
MYOPIA

• Nearsightedness
• Far objects tend to be blurry while near objects
are clear
• Focal point- infront the retina
• If objects are brought nearer, focal point also
moves nearer the retina.
Causes

• Cornea is too steep (Refractive Myopia)

• Cornea is too steep ➔higher refractive
power ➔lesser focal length ➔focal point
falls in front of the retina
• Excessive refraction of the eye
• Eyeball is too long (Axial Myopia)
• Eyeball too long ➔Focal point falls in front of
the retina
• Refractive power and focal length are normal
• Light focus is in front of the retina
Treatment

• Spectacle
• Concave lens (-)

• Contact Lens

• LASIK (Laser Assisted In- situ Keratomelieusis)

• Lens Extraction
HYPEROPIA

• Farsightedness
• Far objects may or may not be clear but near
objects are blurry
• Focal point- behind the retina
Causes

• Cornea is too flat (Refractive Hyperopia)

• Cornea is too flat ➔lesser refractive power
➔longer focal length ➔focal point falls
behind of the retina
• Insufficient refraction of the eye
• Eyeball is too long (Axial Myopia)
• Eyeball too short ➔Focal point falls behind of
the retina
• Refractive power and focal length are normal
• Light focus is behind of the retina
Treatment

• Spectacle
• Convex lens (+)

• Contact Lens

• LASIK (Laser Assisted In- situ Keratomelieusis)

• Lens Extraction
ASTIGMATISM
• Irregular curvature of the cornea
• Light rays do not come from a single point
focus
• Multiple focal points
• Light focuses on 2 focal points, neither of which
falls on the retina causing distortion or blurring
on all distances.

• Main Goal: to bring multiple focal points to a

single focus onto the retina
Treatment

• Cylindrical Lenses
• Spectacles
• Contact Lens

• LASIK (Laser Assisted In- situ Keratomelieusis)

• Lens Extraction
• Use of TORIC IOL
PRESBYOPIA

• Presbi – aging ; opia – vision

• Progressively diminished ability to focus on near
objects with aging
• Most common during the 4th decade of life and
above
• Causes:
• Decreased lens elasticity
• Changes in lens curvature
• Decreased strength of the ciliary muscles
Treatment

• Reading Glasses
• Convex lenses

• LASIK (Laser Assisted In- situ Keratomelieusis)

• Lens Extraction
• Use of Accommodative IOL
 PREVENTIVE
OPHTHALMOLOGY
Eliseo George A. Ave Jr. MD.
General Ophthalmology
 In ophthalmology, the major avenues for
preventive medicine are ocular injuries and
infections, genetic and systemic diseases with
ocular involvement and ocular diseases in which
early treatable stages are often unrecognized or
ignored
Occupational Injuries

• Grinding and drilling

• Tools with sharp ends

• Welding arcs

• Industrial chemicals
Prevention

• Use of safety guards or goggles

• Proper education and training

• Early recognition and urgent expert

ophthalmologic assessment
Non Occupational Injuries

• Car windshield injuries

• Firework injuries

• Sport injuries

• Ultraviolet irradiation
Prevention

• Wearing of seat belts

• Proper education and regulation of fireworks

• Availability of safe guards and toughened

plastic protective glasses

• UV filters
Prevention of Acquired Ocular Infection

• Preventive measures are based on:

• Maintenance of the integrity of normal
barriers to infection
• Avoidance of inoculation with pathogenic
organisms

• Major barrier to exogenous ocular infection:

• Epithelium of the cornea
• Conjunctiva
Prevention of Acquired Ocular Infection

• Damaged by:
• Trauma
• Surgery
• Contact lens wear
• Patients level of consciousness
• Exposure to heavy load of pathogenic
organisms
Prevention of Iatrogenic Ocular Infection

• Outbreaks of epidemic keratoconjunctivitis

• Adenovirus is transmitted via the
ophthalmologist’s hands, the tonometer or
contaminated droppers

✓ Wiping the tonometer tip with 70%

isopropyl alcohol swabs
Prevention of Ocular Damage due to Congenital
Infections and Genetic Diseases

• Vaccination

• Genetic counseling
OPHTHALMIC THERAPEUTICS
Jenalyn M. Tagao-Matila, MD, DPBO, MHA
Commonly Used Eye Medications

•Ophthalmic Anesthetics
•Used for:
•initial assessment of minor eye trauma
•removal of superficial foreign body
•measurement of intraocular pressure using applanation
tonometry
•eye sx
•NOT for long term management of ocular pain
•toxic to corneal epithelium
•abolish corneal reflex
Anesthetic drops

•for initial assessment of minor trauma and for removal of

conjunctival and corneal foreign bodies.
•lidocaine hydrochloride
•oxybuprocaine hydrochloride
•proxymetacaine hydrochloride
•tetracaine hydrochloride (amethocaine hydrochloride)
•Contra-indications
•known hypersensitivity reaction, neonates.
•Caution
• hypertensive patients
Anaesthetic drops

• Administration
• come in single-dose preparations
• warn the patient of brief stinging on application:
• Proxymetacaine stings a little less (useful in highly anxious patients and
children)
• Tetracaine produces a more profound anesthesia
• Ocular side-effects
• transient stinging
• epithelial and stromal keratitis if overused
• inhibit corneal epithelial cell healing and interfere with repair
of corneal epithelial wounds.
• Tetracaine -repeated administration of LA drops should be avoided and they
should not be given to patients to take home for pain relief.
• Systemic side-effects
• none noted with these topical drops
Injected Anesthetics

• Used for minor operations, oculoplastic surgery, anterior segment

and cataract surgery
• lidocaine hydrochloride(MC)
• Bupivacaine
• cocaine.
• Contra-indications and cautions - see individual drug
monographs. Other contra-indications for LA use in
intraocular surgery include patient refusal and concurrent
medical conditions preventing correct positioning of the
patient. Such patients require general anesthesia.
 Injected Anesthetics
• Administration
• local subcutaneous injection to skin
• subconjunctival injection
• sub-Tenon injection
• peribulbar and retrobulbar injections
• Ocular side-effects
• none from the drug if correctly administered.
• Peribulbar and retrobulbar injections are trickier and can result
in retrobulbar haemorrhage, globe puncture, optic nerve
damage, muscle palsy and seventh cranial nerve complications
• Systemic side-effects
• rare but can occur if a very large dose is injected or if a normal
dose is inadvertently injected intravenously. These include:
• vasovagal reactions, Confusion, respiratory depression,
convulsions, hypotension and bradycardia.
Choice Of Anesthetic In Ocular Surgery

• depends on the procedure

• Local anesthetics (LA) > General anesthetic (GA)
• GA is generally considered most appropriate for
children and younger cataract patients
• GA is also normally offered in trauma cases and to
patients who will have trouble keeping still (tremor or
confusion or distress)
Injected Local Anesthetic
• routinely used for oculoplastic procedures
• Usually the LA is infiltrated directly into the skin around the
operation site
• For globe surgery (eg, cataract operation), LA may be
administered through the lower lid and under the globe
(peribulbar/retrobulbar anaesthesia)
• Highly effective anaesthesia and extraocular muscle block can
be achieved but this method may be associated with serious
complications
• Alternatively, in globe surgery, the sub-Tenon's technique involves
making a very small incision in the anaesthetised conjunctiva, the
passage of a pre-curved blunted needle into the space between
it and the globe (the sub-Tenon's space) and infiltration of the
anaesthetic
• Sub-Tenon's technique revealed itself to be superior to the
peribulbar technique, particularly when higher doses of were
added
Risks of injected local Anesthetic

• Generally, safe techniques

• Localized self-limiting hemorrhage is reasonably common but
serious.
• Sight-limiting complications are very rare, occurring in 0.06%
of injected LAs
• They are 2.5 times more common in peribulbar/retrobulbar LA
than with the sub-Tenon's technique and include retrobulbar
hemorrhage, intravenous injection and globe perforation
• Whilst there are no absolutely safe techniques, the sub-Tenon's
block appears still to be the safest option to date
 Drops
• locally applied anesthetic
• easy to apply and are associated with minimal discomfort
and side-effects
• Problem
• they do not block muscular action
• It has been suggested that postoperative discomfort is
greater following topical anesthesia but this point remains
contentious
Agents Added To Local Anaesthetics
• Fluorescein - the dye is combined with either lidocaine or
proxymetacaine eyedrops to enable visualization of corneal
epithelial defects and used for tonometry
• Adrenaline - effectively diminishes local blood flow, so
decreasing systemic absorption and prolonging local effect.
Very low concentrations are used (in the order of 1:80,000 to
1:200,000). This is reserved for use in injected LAs and is not
added to eye drops
• Hyaluronidase - this enzyme is added to increase tissue
permeability to injected fluid, usually at a concentration of 15
units/mL
Medications for
Glaucoma
 TOPICAL PROSTAGLANDIN ANALOGS

MOA: increase the outflow of aqueous via the uveoscleral

pathway

Specific Drugs
● Latanoprost
● Bimatoprost
● Travoprost
● Tafluprost
● Unoprostone
 TOPICAL SYMPATHOLYTICS

MOA: Suppress aqueous production

CI: Asthma, COPD
* betaxolol- selective
Specific Medications
● Timolol maleate
● Levobunolol HCl
● Metipranol HCl
● Carteolol HCl
● Betaxolol HCl
 TOPICAL SYMPATHOMIMETICS

MOA: Variable effects on production and drainage of

aqueous

Specific Drugs
A. Alpha adrenergic Agonist
● Apraclonidine HCl - anterior segment laser procedures
● Brimonidine Tartrate
B. Non selective adrenergic Agonist
● Dipivefrin HCl
 TOPICAL CARBONIC ANHYDRASE INHIBITORS

MOA: Inhibition of Carbonic anhydrase in the

secretory epithelium of the ciliary body

Specific Drugs
● Dorzolamide HCl
● Brinzolamide
 TOPICAL DIRECT-ACTING CHOLINERGIC AGONIST

MOA: Increasing the outflow of aqueous through the

trabecular meshwork

Specific Drugs
● Pilocarpine HCl - avoided in uveitis
● Carbachol - requires a vehicle for penetration
 TOPICAL INDIRECT-ACTING
ANTICHOLINESTERASE AGENTS
A. Physostigmine Salicylate and Sulfate (Eserine)

Mechanism of action: Inhibits acetylcholinesterase

Dosage: 1 drop 3 or 4 times a day or 1/4 inch strip of

ointment once or twice daily

Limitation: Allergic reactions

B. Echothiophate Iodide (Phospholine Iodide)
Mechanism of Action:
Cholinesterase inhibitor; enhances activity of endogenous
acetylcholine

Ocular Side effects:

> Cataract Formation
> Spasm of Accommodation
> Iris cyst Formation

Adverse effects: Systemic toxicity in the form of

cholinergic stimulation
> Salivation
> Nausea
> Vomiting
> Diarrhea
C. Demacarium Bromide

Mechanism of Action:
Cholinesterase inhibitor; enhances activity of endogenous
acetylcholine

Adverse effects:
Systemic toxicity in the form of cholinergic stimulation
> Salivation
> Nausea
> Vomiting
> Diarrhea
TOPICAL COMBINATION PREPARATIONS
A. Azarga - Brinzalomide 1% and Timolol 0.5%
B. Combigan - Brimonidine 0.2% and Timolol 0.5%
C. Cosopt - Dorzolamide 2% and Timolol 0.5%
D. Duotrav - Travoprost 0.004% and Timolol 0.5%
E. Ganfort - Bimatoprost 0.03% and Timolol 0.5%
F. Xalacom - Latanoprost 0.005% and Timolol 0.5%
SYSTEMIC CARBONIC ANHYDRASE
INHIBITORS
A. Acetazolamide (Diamox)
B. Methazolamide (Neptazane)
C. Dichlorphenamide (Daranide)
•Reduce aqueous humor production by 40-60%
•Uses:
•Ocular pressure cannot be controlled with topical therapy
•Acute situations including Acute Angle Closure
•Maximum effect:
• 2 hours after oral administration lasting 4-6 hours
• 20 minutes after IV administration
• Adverse Effects:
• Potassium Depletion, Acidosis, Gastric Distress, Diarrhea,
Epidermal necrolysis, Shortness of breath, Fatigue, Tingling
of extremities
SYSTEMIC OSMOTIC AGENTS
Generally used in the management of acute
(angle-closure) glaucoma and occasionally
preoperatively
A. GLYCERINE (Osmoglyn)

• given orally usually as 50% solution with

water, orange juice, or flavored normal saline
solution over ice (1-1.5g/kg)
• maximal hypotensive effect occurs in 1 hour
and lasts 4-5 hours
• Toxicity: Nausea, headache and vomiting
B. Isosorbide (Ismotic)

• 45% solution, 1.5 g/kg given Orally

• each 220 mL of Isosorbide contain 4.6 meq of
sodium
• It does not produce calories nor elevated blood
sugar
• maximal hypotensive effect occurs in 1 hour and
lasts 4-5 hours
C. Mannitol (Osmitrol)

• 5-25% solution for injection

• 1.5-2 g/kg IV, usually in 20% concentration
• maximal effect occurs in about 1 hour and lasts 5-6
hours
• Cardiovascular and pulmonary edema are more
common problems
D. Urea (Ureaphil)

• 30% solution of lyophilized urea in invert sugar

• dosage: 1-1.5g/kg IV
• maximal effect occurs in about 1 hour and lasts 5-6
hours
• toxicity: Accidental extravasation at in the injection
site may cause local reactions ranging from mild
irritation to tissue necrosis
 TOPICAL
CORTICOSTEROIDS
Indications
• Inflammatory conditions of the anterior segment of the
globe:
• allergic conjunctivitis
• Uveitis
• Episcleritis, Scleritis
• Phlyctenulosis
• Superficial punctate keratitis
• Interstitial keratitis
• Vernal conjunctivitis
• Postoperative inflammation
ADMINISTRATION AND DOSAGE
• Initial therapy for a severely inflamed eye
consists of instilling drops every 1 to 2 hours
while awake
• Favorable response – gradually reduce dosage
and discontinue
ADVERSE EFFECTS
• Exacerbation / development of microbial
keratitis
• Reactivation of Herpes simplex keratitis
• Ocular hypertension
• Increased risk of open-angle glaucoma
• Cataract formation (Posterior subcapsular)
 List of available Topical Corticosteroids for
Opnthalmologic use
• Hydrocortisone ointment – 0.5%, 0.12%, 0.125%, 1%
• Prednisolone acetate suspension – 0.125% and 1%
• Prednisolone sodium phosphate solution - 0.125% and 1%
• Dexamethasone sodium phosphate suspension – 0.1%;
ointment 0.05%
• Medrysone suspension
• Fluorometholone suspension – 0.1% and 0.25%; ointment -0.1%
• Rimexolone suspension 1%
• Loteprednol etabonate suspension 0.5%
 TOPICAL COMBINATION
CORTICOSTEROID & ANTI-INFECTIVE
AGENTS
• Treat conditions in which both agents may be required:
- Marginal keratitis due to a combined staphylococcal
infection and allergic reaction
- Blepharoconjunctivitis
- Phlyctenular keratoconjunctivitis
• Used postoperatively
 TOPICAL COMBINATION
CORTICOSTEROID & ANTI-INFECTIVE
AGENTS
• Should not be used to treat conjunctivitis or blepharitis
due to unknown causes
• Not used as substitutes solely for anti-infective agents
but only when a clear indication for corticosteroids
exists as well
• These mixtures may cause all of the same complications
that occur with topical steroid preparations alone
 ORAL AND TOPICAL
NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
(NSAIDS)
NSAIDS
• Topical ophthalmic preparations provide ocular
bioavailability with little toxicity
• Act primarily by blocking prostaglandin synthesis
through inhibition of cyclooxygenase, the enzyme
catalyzing conversion of arachidonic acid to
prostaglandin
• Used in combination with topical corticosteroids to
manage ocular inflammation
• Used to prevent and treat cystoid macular edema
following cataract surgery
Indications and Dosage
• First line treatment for non-necrotizing scleritis
- Indomethacin 75 mg daily
- Flurbiprofen 150 mg daily
- Ibuprofen 600 mg daily

• S/E: gastric irritation and hemorrhage

 Indications and Dosage
• Flurbiprofen (Ocufen) 0.03%
• Suprofen (Profenal) 1% - inhibition of miosis during cataract surgery
• Ketorolac (Acular) 0.5% - seasonal allergic conjuctivitis
• Diclofenac (Voltaren) 0.1 - treatment of postoperative
• Ketorolac (Acular) 0 5% inflammation after cataract surgery
- relief of pain & photophobia
(laser corneal refractive surgery)
• Nepafenac suspension (Nevanac) 0.1%
• Bromfenac solution (Xibrom) 0.09%
• Indomethacin sispension (Indocid) 1%
 Other Drugs used in the
Treatment of the Allergic
Other Drugs used in the Treatment of
the Allergic
• Cromolyn Sodium(Crolom)
• Ketotifen Fumarate (Zaditor)
• Lodoxamide Tromethamine (Alomide)
• Nedocromil Sodium (Alocril)
• Olapadin Hydrochloride (Patanol)
• Levocabastine Hydrochloride (Livostin)
• Emedastin Difumarate (Emadine)
• Ketorolac Tromethamine (Acular)
• Vasoconstrictors and decongestants
Cromolyn Sodium (Crolom)
• Preparation: Solution, 4%
• Dosage; 1 Drop four to six times a day.
• Comment: Cromolyn acts by thee inhibiting the
release of antihistamine and slow-reacting substance
of anaphylaxis (SRS-A) from mast cells.
• It is not useful in the treatment for acute symptoms.
Ketotifen Fumarate (Zaditor)
• Preparation: Solution , 0.025%
• Dosage: twice daily
• Comment: ketotifen has antihistamine and mast cell-
stabilizing activity.
Lodoxamide Tromethamine (Alomide)
• Preparation: Solution, 0. 1%
• Dosage: 1 drop 4 times a day
• Comment: it is mast cell stabilizer that inhibits type 1
intermediate hypersensitivity reactions.
•It is indicated in the treatment of allergic
reactions of the external ocular tissues,
including vernal conjunctivitis and vernal
keratitis.
•As with cromolyn, a therapeutic response does
not usually occur until after a few days of
treatment.
Nedocromil Sodium (Alocril)
• Preparation: Solution, 2%.
• Dosage: Twice daily.
• Comment: rapid onset of an antihistamine and true
mast cell–stabilizing activity.
Olapadine Hydrochloride (Patanol)
• Preparation: Solution, 0.1%.
• Dosage: Twice a day at intervals of 6–8 hours.
• Comment: Olapatadine has both antihistamine and
mast cell–stabilizing actions.
Levocabastine Hydrochloride (Livostin)
• Preparation: Suspension, 0.05%.
• Dosage: 1 drop four times a day.
• Comment: a selective, potent histamine H1-receptor
antagonist.
• reduces acute symptoms of allergic conjunctivitis.
• Relief of symptoms that occurs within minutes after
application and lasts up to 2 hours.
Emedastine Difumarate (Emadine)
• Preparation: Solution, 0.05%.
Ketorolac Tromethamine (Acular)
• Preparation: Solution, 0.5%.
• Dosage: 1 drop four times daily.
• Comment: This is the only cyclooxygenase inhibitor
approved for allergy by the FDA
Vasoconstrictors and decongestants
• Active ingredients: ephedrine 0.123%
• Naphazoline 0.012%-0.1%
• Phenylephrine 0.12%
• Tetrahydrozoline 0.05%-0.15%
• Indication: relieve redness, relieve minor surface
irritation
 ANTI-INFECTIVE
OPTHALMIC DRUGS
 USUAL ADULT DOSE OF SELECTED ANTIMICROBIALS
IN ENDOPHTHALMITIS
INTRAVITREAL DOSE Subconjunctival Dose Oral or IV dose
(0.1 mL) 3,4 (0.5 mL) 3
1. AMIKACIN (AMIKIN) 0.4 mg 25 mg 6mg/kg IV every 12
hours
2. AMPHOTERICIN B 0.005 – 0.01 mg 1-2 mg Varies (determined on
(Fungizone) case-by-case basis)
3. CEFAMANDOL 1-2 mg 75 mg 1 g IV every 6-7 hours
(Mandol)
4. CEFAZOLIN ( Ancef, 2.25 mg 100 mg 1-1.5 g IV every 6-8
Ketzol) hours
5. CEFTAZIDIME 2 mg 100 mg 2 g IV every 12 hours
(Fortraz, others)
6. CEFTRIAXONE 1 mg 1-2 g IV once or twice
(Rocephin) a day
7. CIPROFLOXACIN 750 mg orally twice a
day
 INTRAVITREAL Subconjunctival Oral or IV dose
DOSE Dose
(0.1 mL) 3,4 (0.5 mL) 3
8. CLINDAMYCIN 0.5 – 1 mg 30 mg 600 – 900 mg IV
(Cleocin) every 8 hours
9. GENTAMYCIN 0.1-0.2 mg 20 mg 1 mg/kg IV every 8
(Garamycin, hours
Jenamycin)
10. Methicillin 2 mg 100 mg 1-2 mg g IV every 6
(Staphcillin) hours
11. Miconazole 0.025 mg 5 mg 200-600 mg IV every
(Monistat) 8 hours
12. Tobramycin 0.5 mg 20 mg 1 mg/kg IV every 8
(Nebcin) hours
13. Vancomycin 1 mg 25 mg 1 g IV every 12 hours
(Vancocin, others)
1. TOPICAL ANTIBIOTIC SOLUTIONS
AND OINTMENTS
• BACITRACIN

• Most GRAM-POSITIVE organisms are sensitive to

bacitracin

• Preparation: Ointment, 500 U/g . Commercially

available in combinations with polymyxin B.

• ADVERSE EFFECT: Nephrotoxicity

B. ERYTHROMYCIN

• Effective agent particularly in STAPHYLOCOCCAL

CONJUNCTIVITIS.
• May be used instead of silver nitrate in prophylaxis
of ophthalmia neonatorum.

• Preparation: Erythromycin ointment, 0.5%

C. NEOMYCIN

• Effective against gram negative and gram positive organisms

• It is best known in ophthalmologic practice as NEOSPORIN in
which it is combined with polymixin and bacitracin
• Contact skin sensitivity develops if drug is used for more than
1 week.

• Preparation:
• Solution, 2.5 and 5 mg/ml
• Ointment, 3.5-5 mg/g

• Dosage: Apply ointment or drops 3 ot 4 times daily. Solutions

containing 50-100mg/ml have been used for corneal ulcers
D. POLYMYXIN B

• Effective against gram negative organisms

• Preparation:
• Ointment, 10, 000U/g
• Suspension, 10,000 U/g
2. TOPICAL PREPARATION OF
SYSTEMIC ANTIBIOTICS
TETRACYCLINES

• PREPARATION: Suspension, 10mg/ml; ointment 10mg/g

• COMMENTS:
• Tetracycline, oxytetracycline and chlortetracycline have
limited used in ophthalmology because their
effectiveness is so often impaired by the development of
resistant strains
• Solutions of these compounds are unstable with the
exception of ACHROMYCIN in sesame oil (widely used
for prophylaxis of ophthalmia neonatorum)
B. GENTAMICIN (GARAMYCIN, GENOPTIC,
GENTACIDIN, GENTAK)

• Widely accepted for used in serious ocular

infections, especially corneal ulcers caused by gram
negative organisms.
• Also effective against many gram positive
staphylococci but is not effective against strep.

• Preparation: Solution, 3 mg/ml, Ointment, 3 mg/g

C. TOBRAMYCIN
• Similar antimicrobial activity to gentamycin but more
effective against strep
• Best reserved for treatment of PSEUDOMONAS KERATITIS –
for which it is more effective.
• Preparation:
• Solutions, 3mg/ml
• Ointment, 3 mg/ml

D. CHLORAMPHENICOL (Chloromycetin, Chloroptic)

• Effective against wide variety of gram negative and gram
positive organisms.
• It rarely causes local sensitization
• AE: aplastic anemia in long term users
• Preparation:
• Solution 5 and 10 mg/ml, Ointment, 10 mg/ml
E. CIPROFLOXACIN

• Preparation: Solution, 3mg/ml

• Dosage:
• For treatment of conjunctivitis – 1 drop every 2-4
hours
• Corneal ulcers – 1 drop every 15-30 mins for the
first day, 1 drop every hour the 2nd day, 1 drop
every 4 hours thereafter.
F. GATIFLOXACIN (Zymar)
• 4th generation fluoroquinolone
• More effective against a broader spectrum of
gram-positive bacteria and atypical mycobacteria
than earlier fluoroquinolones.

• Preparation: Solution, 3 mg/ml

• Dosage:
• For conjunctivitis and corneal ulcers – same with
ciprofloxacin
G. MOXIFLOXACIN (VIGAMOX)
• 4th generation fluoroquinolone is more effective
against a broader spectrum of gram positive
bacteria and atypical mycobacteria than earlier
fluoroquinolones.

• Preparation: Solution, 5 mg/ml

• H. NORFLOXACIN (CHIBROXIN)
• Indicated for conjunctivitis and corneal ulcers

• Preparation: Solution, 3 mg/ml

• OFLOXACIN (OCUFLOX)

• Preparation: Solution 3 mg/ml

• Dosage: for conjunctivitis and corneal ulcers same as

ciprofloxacin
 3. COMBINATION ANTIBIOTIC AGENTS

GENERIC NAME TRADE NAME

Bacitracin and Polymixin B Ak-Poly-Bac, Polycin-B,
PolyTracin
Bacitracin (or gramicidin), Various
neomycin and polymyxin B
Oxytetracycline and Terramycin with polymyxin
Polymyxin B B, terak
Polymyxin B and Polytrim
trimethroprim
4. SULFONAMIDES
Used in the treatment of Bacterial Conjunctivitis

• ADVANTAGES:
• Activity against both gram positive and gram
negative organisms
• Relatively low cost
• Low allergenicity
• The fact that their use is not complicated by
secondary fungal infections
SULFACETAMIDE SODIUM (VARIOUS)
• Preparation: Ophthalmic solution, 10%, 15% and
30%; Ointment, 10%
• Dosage: Instill 1 drop frequently, depending on the
severity of the conjunctivitis

SULFISOXAZOLE (GANTRISIN)
• Preparation: Ophthalmic Solution, 4% ; Ointment.
4%
• Dosage: Instill 1 drop frequently, depending on the
severity of the conjunctivitis
TOPICAL ANTIFUNGAL
AGENTS
Natamycin
(Natacyn)

• Preparation:
• Suspension, 5%
• Dosage:
• Instill 1 drop every 1-2 hours
• Comment:
• Effective against filamentary and yeast forms.
INITIAL DRUG OF CHOICE for most MYCOTIC
CORNEAL ULCERS
NYSTATIN
(MYCOSTATIN)

• Preparation:
• Not available in ointment form.
• Dermatologic preparation (100,000 U/g)
• Comment:
• Dermatologic preparation is not irritating to ocular
tissues and can be used in the treatment of fungal
infection of the eye.
Amphotericin b
(Fungizone)

• Preparation:
1.5-8 mg/ml of distilled water in 5% dextrose
• Dosage:
Instill 1 drop every 1-2 hours
• Comment:
May cause extreme ocular discomfort following
application of this drug.
Miconazole
(Monistat)

• Preparation:
Intravenous, 1%
• Comment:
Not available in ophthalmic form
Fluconazole
(Diflucan)

• Preparation:
Parenteral, 0.2%
• Comment:
Not available in ophthalmic form
Antiviral agents
Idoxuridine
(Herplex)

• Preparation: Ophthalmic solution, 0.1% Ointment, 0.5%

• Dosage:
Day: 1 drop every hour
Night: 1 drop every 2 hours
*with improvement (fluorescein staining): frequency of
instillation gradually decreased
• Ophthalmic Solution: may be used during the day
• Ointment: 4x to 6x; may be used during bedtime
• Comment: Treatment of herpes keratitis. Epithelial infection
improves within few days. Therapy used be continued 3 to
4 days after apparent healing.
Vidarabine
(Vira-a)

• Preparation: Ophthalmic Ointment, 3%

• Dosage:
• Herpetic epithelial keratitis: 4 times daily for 7-10 days
Comment:
• Effective against Herpes simplex virus but not other RNA
or DNA viruses. Effective in some patients unresponsive
to idoxuridine. Interferes the viral DNA synthesis.
Principal metabolite is arabinosylhypoxanthine (Ara-Hx).
Effective against herpetic corneal epithelial disease.
Limited efficacy in stromal keratitis or uveitis. May cause
cellular toxicity(less than that of idoxuridine) and delay
corneal regeneration.
Trifluridine
(Viroptic)

• Preparation: Solution, 1%
• Dosage:
• 1 drop every 2 hours (maximum total, 9 drops daily)
• Comment:
• Interfere with viral DNA synthesis. More soluble than
either idoxuridine or vidarabine. Probably more
effective in stromal disease.
Acyclovir
(Zovirax)

• Preparation: 200, 400, and 800 mg

• Comment:
• Inhibitory action against herpes simplex types 1 and 2,
varicella-zoster virus, Epstein-Barr virus, and
cytomegalovirus. Phosphorylated initially by virus-
specific thymidine kinase to acyclovir monophosphate,
which inhibits viral DNA polymerase. Marked selectivity
for virus-infected cells. Low toxicity. No ophthalmic
preparation available. Topical form for treatment of
genital herpes. Oral form for selected herpes zoster
ocular infections.
Ganciclovir
(Vitrasert)

• Preparation: Intravitreal implant, 4.5 mg

• Dosage:
• Replacement every 5-8 months as required
• Comment:
• Treatment for cytomegalovirus retinitis without
adverse effects of
Diagnostic Dye Solution
Fluorescein Sodium

• Preparation:
• Solution, 2%, in single-use disposable units;
• Sterile paper strips;
• Intravenous, 10% (for fluorescein angiography)
• Dosage: 1 drop
• Comment:
• Use as a diagnostic agent for:
• Detection of corneal epithelial defects
• Applanation tonometry
• Application of contact lens
Rose Bengal

• Preparation: Solution, 1% Strips, 1.3 mg

• Dosage: 1 drop
• Comment:
• Used as diagnostic agent for:
• Keratoconjunctivitis sicca
• Stained mucous shreds and devitalized corneal
epithelium
Tear replacement and
lubrication agents
• Methylcellulose, polyvinyl alcohol, and gelatin:
• Used in the formulation of artificial tears, ophthalmic
lubricants, contact lens solutions, and gonioscopic lens
solution.
• Treatment:
• Keratoconjunctivitis sicca
• Comment:
• Methylcellulose: added to eye solutions (pilocarpine)
to increase viscosity and prolong corneal contact
time.
• Preservative-free preparations: for patients sensitive
to these agents/substances.
Vasoconstrictors and
Decongestants
Active ingredients of these agents:
• Ephedrine: 0.123%
• Naphazoline: 0.012-0.1%
• Phenylephrine: 0.12%
• Tetrahydrozoline: 0.05-0.15%
Also contains:
• Antihistamine
• Antazoline phosphate: 0.25-0.5%
• Pheniramine maleate: 0.3%
• Comment:
These agents constrict the superficial vessels of the
conjunctiva and relieve redness. Also relieve minor surface
irritation and itching of the conjunctiva (represent a
response noxious or irritating agents such as smog,
swimming pool chlorine, etc).
Corneal Dehydrating Agents
• Preparation:
Anhydrous glycerin solution (Ophthalgan); Hypertonic
sodium chloride 2% and 5% ointment and solution
(Absorbonac, Ak-NaCl, Hypersal, Muro-128)
• Dosage:
1 drop of solution or ¼-inch strip of ointment to clear
cornea. May be repeated every 3-4 hours
• Comment:
Reduces edema by creating an osmotic gradient in
which the tear film is made hypertonic to
OPHTHALMIC & SYSTEMIC
EFFECTS of OPHTHALMIC
MEDICATIONS
OCULAR EFFECTS OF SYSTEMIC
MEDICATIONS
OCULAR EFFECTS OF EYE
MEDICATIONS
SYSTEMIC EFFECTS OF
OPHTHALMIC DRUGS
PROPER WAY OF
ADMINISTRATION
• Tilt head backwards

• Grasp the lower eyelid below the lashes and

gently pull the lid away from the eye
• Patient should look up

• One drop of solution or a "match head" amount of

ointment should be placed in the inferior cul-de-sac
• gently lift the lower eyelid to make contact with the upper lid
• Eyelids should be kept closed for 3 minutes to prevent
blinking

• Apply firm pressure over the inner corner of the closed

eyelids for ≥2 minutes
• Excess medication in the medial canthus should be
blotted away before pressure is released or the
eyelids opened.

• The patient receiving multiple topical medications

should wait 10 minutes between doses
Flowchart for evaluation of Anisocoria
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