Ophthalmology: Drugs

OPHTHALMOLOGY: DRUGS

Here's a file containing the compilation of the drugs that are mostly used in ophtho and of course, asked during the ward tests and prof table vivas. Everything is pretty haphazardly stated in the other files, so I hope this will prove helpful to all of you, as much as it did for me when I created it.

Note: You don't have to memorize all the side effects of the drugs but just have some basic knowledge about the main ones so you're able to answer whenever you're asked, especially if there's a specific side effect that you need to remember. Same old pharmacology tricks.
The important parts are: the mechanism of action of the drug, the clinical uses, and the contraindications, and you're good to go! Lastly, for the cycloplegics, half-life is something you definitely want to remember.

Reminder: Review this diagram before jumping ahead!

Class	Drug	MOA	S/Es	Uses
non-selective B-blocker	Levobunolol	Blockage of B1,B2 receptors. Blockage of B2 (rich in ciliary body epithelium) reduces AQ production, lowering IOP	Ocular:  burning, stinging, blepharo-conjunctivitis, Keratitis (rare, dec. corneal sensitivity after prolonged use) Systemic: Orthostatic Hypotension, Dec. in HR and BP, breathing problems in asthmatics and COPD patients, itching	Ocular HTN Chronic OAG No effect in ACG
non-selective B-blocker	Timolol	Blockage of B1,B2 receptors. Blockage of B2 (rich in ciliary body epithelium) reduces AQ production, lowering IOP	Ocular: Eye irritation, burning sensation, eye redness, superficial punctate keratopathy, corneal numbness Systemic: bronchospasm, arrhythmia etc.	Anti glaucoma, Ocular HTN
CA inhibitor (topical)	Dorzolamide	Decreased production of AQ by blocking CA action	Ocular stinging, burning, itching, punctate keratitis, and bitter taste, allergy, renal stones	Glaucoma (as a combo with Timolol maleate)
Combination of the above two				Used when Timolol is not sufficient alone
Fluoroquinolone	Moxifloxacin	Bactericidal, interferes with DNA synthesis by inhibiting DNA topoisomerase 2, and 4	Tendonitis, tendon rupture, phototoxicity, rashes, dizziness, headache, GI distress, prolong QT interval	corneal ulcers, eye infections
Aminoglycoside	Gentamicin, tobramycin	Inhibit bacterial protein synthesis, bactericidal	Nephrotoxicity, ototoxicity, skin rxns, NM blockade leading to muscle weakness, nausea	Bacterial ulcers, eye infections
	Polymyxin, Neomycin, Bacitracin		Hypersensitivity, rash, edema of the lids, chemosis	Antibacterial eye ointment - treatment for superficial infections of external eye and its adnexa e.g. superficial punctate keratitis, blepharitis, conjunctivitis. S.auerus, H. flu, S.pneumo, E. coli
	Tobcydex- Tobramycin Dexamethasone		Tobramycin: Ototoxicity, nephrotoxicity, rash Dexamethasone: blurred vision, dec. vision or other changes, eye pain or redness, sensitivity of eye to light	Chalazion, pre-op, infectious conditions
Cholinomimetic	Pilocarpine	Acts at muscarinic receptors (M3) to cause MIOSIS and pull and contraction of cililary muscle, opening of TM and drainage of AQ	Irritation of the eye, increased tearing, headache, and blurry vision.Other side effects include allergic reactions and retinal detachment, accommodative spasm	All types of glaucoma as an adjunct to surgery except congenital. in ACG, reduce IOP first and then use it.
Anti-muscarinic	Cyclopentolate (DOA: 24h)	Blocks Muscarinic receptors and causes dilation of pupil and is a cycloplegic	increase in pressure inside the eye, which is of particular concern when there is a predisposition toward or a presence of glaucoma. Burning sensations, photophobia, blurred vision, irritation, conjunctivitis, keratitis, and other issues.	All types of dilated eye exams, but tropicamide is preferred Mydriasis, cycloplegia for diagnostic eye exams
Anti-muscarinic	Tropicamide (DOA- 4-8h)	Blocks Muscarinic receptors and causes dilation of pupil and is a cycloplegic	Blurring of vision, redness, may ppt an attack of Acute glaucoma, allergies	Shorter DOA Dilated eye exams. For cycloplegic refraction. Pre op and pre exam ophthalmic dilation
Anti-muscarinic	Atropine sulphate (DOA- 7-14 days) Hompatropine-up to 4-5 days	Blocks Muscarinic receptors and causes dilation of pupil and is a cycloplegic	Blurring of vision	Acute and chronic uveitis and corneal ulcers, sec glaucoma, to rule out accommodative squint, to do cycloplegic refraction to determine type of error. Contraindication: ACG
Corticosteroid	Prednisolone acetate	immunosuppressive	Steroid induced glaucoma, cataract systemic: fluid retention, osteoporosis, Cushing’s, mania, immunosuppression	to reduce post op inflammation, non infective keratitis, uveitis (to reduce swelling, redness, itching, allergic rxns)
Alpha 1 agonist	Phenylephrine HCL	stimulates dilator pupillae - causes mydriasis without cycloplegia	Frequent transient burning or stinging, headache or brow-ache , blurred vision, reactive hyperemia, transient keratitis, sensitivity to light, Rise in BP in predisposed individuals	decongestant, mydriatic (ophthalmoscopy, ocular surgery, posterior synechiae prevention, anterior uveitis, post- iridectomy.
Alpha 2 agonist	Brimonidine	Decreased production of AQ by decreasing cAMP production via stimulation of Gi. and increased uveoscleral outflow. (The increased uveoscleral outflow from prolonged use may be explained by increased prostaglandin release due to α adrenergic stimulation. This may lead to relaxed ciliary muscle and increased uveoscleral outflow)	itching, dry nose and eyes, drowsiness	Anti-glaucoma (OAG, Ocular HTN)
Lubricant	PolyAcrylic acid(VisolGel)	Tear substitute	allergies, discoloration of contact lenses	Dry eyes, tear fluid substitute
Artificial tears-	Polyethylene glycol, glycerin, polyvinyl alcohol	Tear substitute	allergies, discoloration of contact lenses	Dry eyes, tear fluid substitute
Fluoroquinolone	Ofloxacain	Bactericidal, interferes with DNA synthesis by inhibiting DNA topoisomerase 2, and 4	Allergy, puffiness of eyes, tearing, itching, irritation, lacrimation, dryness	Bacterial ulcer, conjunctivitis
Local Anesthetic	Proparacaine (ALCAINE)	Antagonist to voltage gated sodium channels	Allergy, irritation, redness, stinging, keratitis	To numb the eye- topical anesthesia of cornea and conjunctiva, for tonometry, gonioscopy etc
Mast cell stabiliser	Cromogil- Sodium Chromoglycate	Mast cell stabilizer	irritation, blurring of vision	eye allergy symptoms
	Lari Lube GEL	Petroleum mineral oil	Allergy, discoloration of contact lens, irritation	Dry eyes
Corticosteroid	Dexamethasone	immunosuppressive	Burning, itching blurred vision, cataracts glaucoma, corneal rupture, dry eyes, raised IOP. open angle glaucoma, visual defects	Reduces inflammation, not used in acute infections
Ophthalmic Hypertonic saline	Sodium chloride	Draws water out of swollen cornea	Burning sensation, irritation, blurring of vision, red eyes	For drawing water out of a swollen cornea-Corneal edema
Prostaglandin analogue	Travoprost	PG analogue; (of PGF2 alpha) increases outflow of aqueous from the eyes. acts as an agonist at the prostaglandin F receptor, increasing outflow of aqueous fluid from the eye and thus lowering intraocular pressure.	red eyes, blurry vision, eye pain, dry eyes, and change in color of the eyes, cataract	OAG, Ocular HTN
NSAID	Nepafenac	Blocks COX and PG production reducing pain and inflammation	Stinging, burning, eye redness, headache, vision changes	to relieve eye pain, irritation, and redness following cataract eye surgery.
Dye	Fluorescin Sodium			Stains abnormal cornea Conj. abrasions: Yellow/orange Corneal abrasions/ulcers: bright green Foreign bodies: surrounded by green ring Diagnostic purposes: Goldmann tonometer Fitting of a hard contact lens

Another useful note: Just have a general idea about the different half lives of the corticosteroids; It won't just help you in ophthalmology, but also in other aspects of medicine.

Comparative oral corticosteroid potencies

Name	Terminal half-life (hours)
Cortisol (hydrocortisone)	8
Cortisone	8
Fludrocortisone acetate	24
Triamcinolone	12–36
Prednisone	16–36
Prednisolone	16–36
Methylprednisolone	18–40
Dexamethasone	36–54
Betamethasone	36–54

That's all. I hope this was helpful. If anything's missing, (there might be, but these are the most commonly asked drugs i.e. 9/10 times) feel free to add more to your list. If there is any kind of error, I apologize. Happy studying.