Ophthalmic Medications
in Understanding Pharmacology for Pharmacy TechniciansKEY TERMS AND DEFINITIONS
| Aqueous humor | the watery fluid produced in the ciliary body and leaving through mainly the trabecular meshwork drain, which provides nutrition to the front of the eye. |
| Cataract | a clouding of the lens occurring commonly in patients as they age. |
| Conjunctiva | the clear tissue around the white part (sclera) of the eye. |
| Conjunctivitis | an inflammation or infection of the conjunctiva. |
| Cornea | the clear covering over the front of the eye. |
| Cycloplegia | paralysis of the muscle that holds the lens in place and facilitates dilation of the pupil. Causes a loss of accommodation or ability to focus the lens and sensitivity to light. |
| Diplopia | double vision. |
| Glaucoma | an eye condition that can result from increased pressure in the eye, which can cause optic nerve damage and loss of vision. |
| Intraocular pressure (IOP) | a measurement of pressure in the eye, usually <21 mm Hg. Increases in IOP can lead to glaucoma or blindness. |
| Iris | the colored part of the eye. |
| Macula | the focal point on the retina that allows for clear, sharp vision especially when focusing on tasks straight ahead. |
| Miosis | constriction of the pupil, allowing less light into the eye. |
| Mydriasis | enlargement of the pupil, allowing more light into the eye. May be induced for some eye examination procedures. |
| Ocular hypertension | an increase in intraocular pressure, which may lead to glaucoma in some patients. |
| Pupil | the dark space in the middle of the iris that appears black. The pupil dilates and constricts to allow varying amounts of light into the eye. |
| Retina | the lining in the back of the eyeball that allows light messages to be transmitted to the optic nerve and then the brain. |
| Sclera | the white, outer part of the eyeball. |
LEARNING OBJECTIVES
After completing this chapter, you should be able to
Review the anatomy and physiology of the eye.
Describe glaucoma and the most commonly used treatment approaches.
Describe the causes and symptoms of conjunctivitis, and treatment options.
Identify common causes of blindness.
Identify medications used in the eye, including their dosage forms, therapeutic effects, most common side effects, and mechanisms of action.
The eye is the organ for sight. Many things can affect the eye, including diabetes, trauma, vision problems, and allergies. Some of these can be improved with treatments, including surgery and medications used in the eye. This chapter discusses these and how ophthalmic medications are used.
Anatomy of the Eye
The eye functions as our organ for sight. Light enters the eye, passing through the transparent cornea, enters the pupil, an open space in the center of the iris, and is refracted through the lens and onto the retina. The retina is attached to the inside back of the eyeball and transmits messages to the optic nerve. The optic nerve carries these light messages to the brain, where they are translated into pictures of what is being seen. These structures are illustrated in Figure 34-1.
Many problems can occur in this complicated organ and its communication process. Blurry vision is a common occurrence that can have many causes, including vision changes or some medications. One of these vision changes is myopia, or nearsightedness, where the light is focused through the lens to a place in front of the retina instead of on it. This means the person can see objects close up but those at a distance are blurry. The opposite of myopia is farsightedness, where patients can see things far away but items up close are blurry. This occurs when the lens focuses items beyond the back of the retina. Both of these conditions can be improved by corrective lenses and sometimes corrective surgery. Diplopia is double vision, which can occur for various reasons (some minor and some serious). Treatment will depend on the cause. Another common eye condition is presbyopia, where the eye gradually loses the ability to focus on close-up objects. Presbyopia usually occurs as people age, starting in the 40s, and gets worse until around age 60. A cataract is another relatively common eye condition, in which a clouding of the lens occurs as a person ages. As the lens clouds, there is usually a loss in vision. This development is commonly slow, occurring over many years, with a gradual decline in vision. Often, this can be corrected with surgery.
Glaucoma
CASE STUDY
Mrs. Griffen has recently been diagnosed with ocular hypertension in both eyes. She hasn’t noticed any vision changes yet, but both of her parents had glaucoma and her mother went blind in her 80s.
Aqueous humor, a watery fluid, is produced in the ciliary body and flows from the posterior chamber to the front of the eye or the anterior chamber through the pupil and out mainly through the drain (trabecular meshwork). Aqueous humor provides nutrition to the front of the eye. Intraocular pressure (IOP) reflects the amount of aqueous humor present in the front part of the eye. When the aqueous humor cannot flow out of the eye quickly enough, pressure can start to build and IOP can increase. Normal IOP is less than 21 mm Hg. Anything above that may be considered ocular hypertension.
CASE?
Does Mrs. Griffen have glaucoma?
Glaucoma is the second leading cause of blindness worldwide.1 It is caused by optic nerve damage, commonly due to elevated IOP, but can occur even when IOP is in the normal range. Patients can have elevated IOP without having glaucoma. There are two main types of glaucoma: open angle and closed angle. Closed-angle glaucoma refers to a physical limitation in the iris where outflow of aqueous humor is mechanically blocked in some way. This occurs in about 10% of glaucoma cases. More commonly, patients have open-angle glaucoma.2 Open angle means that there is an increase in IOP even though the angle of the iris and cornea appear to be unblocked. There are variations within each of these types.
CASE?
If Mrs. Griffen’s initial IOP was 28 mm Hg, what would her IOP goal be?
Most patients with glaucoma start to have certain types of visual field defects that are indications for diagnostic testing (IOP measurements and optic disc examination), although glaucoma can be present with or without increased IOP. The goal of glaucoma treatments is to lower IOP by 20% or more if the disease is more progressed. Often ocular hypertension occurs but may not lead to glaucoma or vision changes; however, the goal in these patients is still to decrease IOP. Treatments include medications, laser surgery, and incisional surgery.
Glaucoma Treatment
Drug treatment is similar for most types of open-angle glaucoma. Several classes of medications are used to treat glaucoma. These include beta-blockers, alpha agonists, carbonic anhydrase inhibitors, prostaglandin analogues, and sympathomimetics, as well as a newer type, rho kinase inhibitors. The classes work in different ways, and can be used in a variety of combinations.
Beta-blockers, already discussed in Chapter 4 (“The Autonomic Nervous System”) and Chapter 15 (“Hypertension”) work by reducing the production of aqueous humor, therefore reducing IOP because there is less fluid being produced. Beta-blockers can be used chronically (long term). Drugs in this class for ophthalmic use include betaxolol, levobunolol, timolol, carteolol, and metipranolol (see Medication Table 34-1; Medication Tables are located at the end of the chapter). Prostaglandin analogues include bimatoprost, latanoprost, travoprost, and tafluprost. These help to decrease IOP by increasing outflow. Bimatoprost is also approved as the first 10 mcg intracameral (anterior chamber) biodegradable sustained-release implant indicated to reduce IOP in patients with open-angle glaucoma or ocular hypertension.
CASE?
Mrs. Griffen has prescriptions for timolol and pilocarpine eye drops. Is it likely that these will solve her problem and be discontinued next month?
PRACTICE POINT
Latanoprost is stored in the refrigerator until the bottle is opened. Once opened, it can be stored at room temperature for up to 6 weeks.
ALERT!
Prostaglandin analogues used for glaucoma should not be used more than once a day as more frequent use may reduce their IOP-lowering effect.
Cholinergic eye drops include pilocarpine and carbachol. These stimulate cholinergic receptors in the eye and are now considered third or fourth line therapy as described in Chapter 4, cause miosis (decrease in pupil size) and/or open the trabecular meshwork. While this helps to increase outflow of the aqueous humor, cholinergics are now considered third or fourth line therapy. Carbonic anhydrase inhibitors work in the eye by decreasing the production of aqueous humor. Topical preparations for ophthalmic application in this class include brinzolamide and dorzolamide. Oral carbonic anhydrase inhibitors, acetazolamide and methazolamide, can also be used for the treatment of glaucoma but usually have a much higher risk of side effects, including gastrointestinal (GI) effects and blood pressure changes. Sympathomimetics include brimonidine and apraclonidine. They both work at alpha-adrenergic receptors (described in Chapter 4) and decrease the production of aqueous humor, therefore decreasing IOP. Brimonidine also works to increase aqueous humor outflow.
Rho kinase inhibitors are the newest medications indicated for the treatment of glaucoma, and appear to reduce IOP by increasing the outflow of aqueous humor. Netarsudil is currently the only ophthalmic preparation of this type available in the United States.
ALERT!
Administration of prostaglandin analogues should be separated from other eye drop application by at least 5 minutes.
The most common side effects of eye drops used for glaucoma are burning or stinging. Some, like timolol, can be absorbed into the body and affect blood pressure, but this can be minimized by giving only one drop at a time and gently closing the eyes for 3–5 minutes (eyelid closure technique) to minimize systemic absorption.
Beta-blockers, carbonic anhydrase inhibitors, prostaglandin analogues, sympathomimetics, cholinergic drops, and rho kinase inhibitors are typically used in various combinations for the treatment of glaucoma. In closed-angle glaucoma, beta-blockers are used with cholinergic agents like pilocarpine. Patients may receive a laser procedure to lower the IOP. Some eye drops are available in combinations, such as Cosopt, which is dorzolamide and timolol together. Others, such as pilocarpine, are not available in the United States in combination with anything else but can be used with other products as long as there is separation between drop administrations.
CASE?
Mrs. Griffen returns to the pharmacy with a prescription for latanoprost. Does this mean that she should stop using the timolol?
Glaucoma treatment typically begins as a single medication in one eye to assess efficacy and tolerance. Beta-blockers, such as timolol or prostaglandins are usually started first, but brimonidine or topical carbonic anhydrase inhibitors can be used initially in patients who have contraindications to one of the first-line medications. After a few weeks, reassessment is needed to determine the response and tolerance to the initial drug. If there is not enough response, a second drug may be added and assessed after a few more weeks. If a drug cannot be tolerated, changes can be made in the regimen. This is continued until the desired response is seen, or drug therapy is maximized and surgery is the only option left.
Macular Degeneration
The macula is located in the central part of the retina and helps to give sharp, clear vision when looking straight ahead and performing tasks such as reading or driving. Macular degeneration is a condition in which the macula is slowly destroyed and is often seen in older adults (age-related macular degeneration, AMD). It is classified as either wet or dry. Wet AMD is usually more serious than dry AMD. Wet AMD occurs when new blood vessels behind the retina start to grow under the macula. These new vessels tend to leak fluid and blood, raising the macula from its normal place and quickly damaging it. Dry AMD occurs as some of the cells in the macula start to break down, causing blurred vision in the central vision. Dry AMD can develop slowly over time, whereas wet AMD can occur quickly and damage vision significantly in a short period of time. The first symptom of wet AMD is typically that straight lines appear wavy. The first symptom of dry AMD is typically blurred vision. Treatment for wet AMD most often includes medications injected into the eye to stop blood vessel growth, and laser treatment.
Macular Degeneration Agents
Two types of drugs can be used in macular degeneration. The first type is a vascular endothelial growth factor (VEGF) inhibitor. Anti-VEGF agents have often stabilized and improved vision in patients with wet AMD. Ranibizumab, (Lucentis), aflibercept (Eylea), brolucizumab (BeoVu), and faricimab (Vabysmo) are the anti-VEGF inhibitors currently approved for treatment of wet AMD, and bevicizumab (Avastin) is often used off label. These agents are injected into the eye every 4–6 weeks and slow new blood vessel growth and vision loss. Another type of medication for AMD (not often used) is a choroidal vessel occluder, specifically verteporfin (Visudyne). This medication is given via intravenous (IV) infusion in the doctor’s office and a laser may activate the drug in the eye and slow new blood vessel growth. See Medication Table 34-2 for details about these medications.
CASE STUDY
Ms. Arth is a preschool teacher and several of her students have recently had pink eye. She woke up this morning with a matted, crusty left eye. Her conjunctiva looks very bloodshot and her eye feels itchy and dry.
ALERT!
LOOK-ALIKE/SOUND-ALIKE—Over-the-counter eye drops are available in a variety of formulations for different uses, many with similar names. For example, there are currently a dozen different products marketed under the name Visine, including Visine Original for “redness relief” (tetrahydrozoline, a decongestant), Visine for Contacts (wetting/lubrication solution), and Visine Allergy (includes an antihistamine). The label always lists the intended uses and active ingredients of a formulation.
Conjunctivitis
Conjunctivitis is an inflammation of the conjunctiva or tissue around the eye. This can be caused by irritants like dirt or debris, allergens, bacteria, or viruses. The eye will try to rid itself of anything bothersome by washing it away with tears. Patients with a history of allergic conjunctivitis should avoid allergens when possible; however, ophthalmic antihistamines, mast cell stabilizers, and decongestants can help eye allergy symptoms like itchy or watery eyes. Bacterial conjunctivitis is often treated with antibiotic preparations.
Allergic Conjunctivitis
Antihistamines/Decongestants
Histamine is released from cells when an allergen attaches to the cell and causes vasodilation leading to erythema (redness), stimulation of sensory nerves leading to itching, and increased secretions. Ophthalmic antihistamines work by blocking histamine in the eye and help with symptoms such as itchy or watering eyes. They typically do not cause drowsiness like oral or nasal antihistamines. Many are available over the counter (OTC), but some antihistamine eye drops like azelastine require a prescription. The antihistamine eye drops, along with other treatments for conjunctivitis, are listed in Medication Table 34-3.
ALERT!
Ophthalmic decongestants should not be used for more than 3 days, to reduce the risk of irritation to the eye.
Mast cell stabilizers help to prevent the release of histamine and other inflammatory mediators from the cells. Administered as eye drops, they often have antihistamine action as well. Bepotastine (Bepreve) requires a prescription, but ketotifen, olopatadine, and alcaftadine are available OTC.
ALERT!
Bacterial and viral conjunctivitis can be very contagious. Handwashing and avoiding contact of the hands with the face are important in stopping its spread.
Ophthalmic decongestants work like nasal and oral decongestants in that they cause vasoconstriction. Several decongestants are available OTC and ophthalmic decongestants are the classic ingredients in the well-known Visine Allergy (naphazoline/pheniramine) eye drops.
Infective Conjunctivitis
Bacterial conjunctivitis is an infection, commonly referred to as pink eye, due to the bloodshot appearance of the infected eye. Viral infections can also cause conjunctivitis.
Anti-infective Agents
Antibacterial, antifungal, and antiviral agents are all available in an ophthalmic form to treat eye infections. Antibacterial agents are available from several drug classes, similar to oral and injectable agents: macrolides, quinolones, aminoglycosides, sulfonamides, and others. Some of these, such as ciprofloxacin and bacitracin, are available in both an ointment form and ophthalmic drops. Many of the antiviral and antifungal ophthalmic agents work in similar ways to systemic agents but are only available for use in the eye. The most common side effects with anti-infective drops are burning or stinging in the eye after administration. More information on available anti-infective eye drops is available in Medication Table 34-3.
CASE?
Ms. Arth has asked where she can find Visine eye drops on the shelf. What do you think might be the cause of Ms. Arth’s eye problem? Should the technician just ring up her Visine or might the pharmacist be consulted for other ideas?
PRACTICE POINT
Eye infections must be diagnosed and treated by a physician. Ophthalmic anti-infectives are available only by prescription.
PRACTICE POINT
An ointment is often prescribed when the medication should be in contact with the eye longer than can be achieved with a drop. Ointments can make vision blurry and should be used after any eye drops.
ALERT!
Contact lenses should not be worn while an eye infection is present and should not be used again until the infection has cleared up, usually 7–10 days after treatment started.
Anti-inflammatory Agents
Nonsteroidal anti-inflammatory agents (NSAIDs) and corticosteroids, discussed in previous chapters, are available as eye drops. NSAIDs can be used to decrease inflammation in the eye and sometimes to aid in the treatment of allergic symptoms. They are also used after eye surgery, like cataract surgery, to help decrease the inflammation in the eye. Corticosteroids can be used for similar reasons: conjunctivitis, inflammation after surgery, and sometimes allergy symptoms. Other anti-inflammatory agents used in the eye are cyclosporine and lifitegrast, which are prescribed for chronic dry eye. They work by helping to increase tear production. Agents for ophthalmic inflammation are detailed in Medication Table 34-4.
PRACTICE POINT
Dexamethasone and prednisolone are corticosteroids found in combination with an antibiotic like tobramycin or sulfacetamide, in products such as Tobradex or Blephamide.
CASE?
If Ms. Arth sees a physician, what do you think might be prescribed? Why?
Blepharospasm and Blindness
Blepharospasm is a twitch of the eyelid. In some cases, this can be ongoing. Onabotulinum toxin A (Botox) is an intramuscular injection that helps paralyze the muscle so that it doesn’t keep twitching.
Blindness is a condition that can be gradual or immediate and may have many causes. Blindness may also be temporary or permanent. Whether onset is gradual or immediate and temporary or permanent depends on the cause. The leading disease causes of blindness in the United States are glaucoma, diabetic retinopathy, macular degeneration, and cataracts.3 Accidents may also cause blindness, from incidents such as sports injuries or chemical burns. Other causes of blindness (rare in the United States) may be onchocerciasis (river blindness), trachoma, leprosy, and vitamin A deficiency. Many of these, especially cataracts, glaucoma, and macular degeneration, can be treated with surgery and/or medications.
Miscellaneous Ophthalmic Conditions and Treatments
For mild or occasional dry eyes there are eye drops that act like natural tears, usually called artificial tears. They contain compounds such as carboxymethylcellulose or hydroxypropyl cellulose that work as lubricating agents. These can usually be used as often as needed. These and other ophthalmic agents are detailed in Medication Table 34-5.
For diagnostic procedures where the back of the eye is to be examined, mydriasis and/or cycloplegia may be needed. Mydriatics work by dilating the pupil. Cycloplegics cause pupillary dilation and temporarily paralyze the ciliary muscle, which helps the lens to change shape as we focus on objects. Atropine, cyclopentolate, and homatropine are all cycloplegic agents that are used for these purposes. These may cause burning or stinging, as well as temporary vision changes like sensitivity to light and blurry vision or difficulty focusing.
ALERT!
Eye drops are sometimes used in the ear to help treat certain infections, but ear drops should never be used in the eye. For example, Ciloxan (ciprofloxacin 0.3%) ophthalmic solution can be used in the eye or ear, but Cetraxal (ciprofloxacin 0.2%) otic solution should only be used in the ear and never in the eye. Eye drops are specifically buffered and formulated for ophthalmic use because eye tissue is much more sensitive than ear tissue. Using ear drops in the eye causes immediate burning and stinging, redness, and sometimes swelling.
Dosage Forms and Administration of Ophthalmic Agents
Ophthalmic preparations are most commonly available in a solution or suspension formula. Some ophthalmic medications are available as sterile ointments, which allow the medication to have longer contact with the eye because of thicker viscosity of the preparation. Gel-forming solutions, such as Timoptic-XE, have a component that allows a gel to form on contact with the precorneal tear film. This formulation allows the medication to be in contact with the eye longer before it is washed away by normal tear production.
PRACTICE POINT
Contact lenses should be removed before installing drops into the eye. They should be left out for at least 15 minutes after the dose is applied, and perhaps longer depending on the medication.
ALERT!
All dosage forms applied to the eye must be sterile. If they are compounded in the pharmacy, aseptic technique, sterile ingredients, and sterile dispensing containers are required.
Although ophthalmic products usually have brief instructions for use included, it cannot be assumed that all patients know how to administer them properly. Some physicians and their staff demonstrate application techniques to patients and caregivers, but this is not always the case. Patients purchasing eye drops in the pharmacy, whether OTC or prescription, should always be asked whether they know how to use them, and consultation with the pharmacist may be required to ensure proper administration. When a suspension or gel-forming eye drop and a solution eye drop are used at the same time, the solution eye drop should be instilled first. After 5 minutes, the suspension or gel-forming eye drop can be administered. The suspension or gel-forming eye drop should be used last because it is formulated to stay in the eye for a longer period of time.
ALERT!
Dropper bottles containing ophthalmic suspension preparations must be rolled between the hands prior to administration in order to resuspend active ingredients that may settle with time. Rolling rather than vigorous shaking will prevent the formation of bubbles, which could interfere with proper administration.
SUMMARY
As the eye can have a variety of problems, it can also have a variety of treatments, including medications. Many treatment options exist for glaucoma, including beta-blockers and prostaglandin analogues. Eye allergy symptoms can be improved with antihistamines and mast cell stabilizers. Anti-infective ophthalmic options are many and include drugs that are also used in oral forms. Anti-inflammatory eye drops and corticosteroids help to decrease inflammation in the eye, especially after surgery. Other agents help to lubricate the dry eye or cause mydriasis to aid examinations. Care should be taken to protect the eyes from trauma and permanent vision loss.
ACKNOWLEDGMENT
The authors wish to acknowledge and thank Celtina K. Reinert, PharmD, author of this chapter in the first edition of this book.
REFERENCES
- 2.↑
Fiscella RG, Lesar TS, Owaidhah OA, Edward DP. Glaucoma. In: DiPiro JT, Yee GC, Posey L, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 11th edition. New York, NY: McGraw-Hill; 2020.
- 3.↑
National Institutes of Health, National Library of Medicine. Medline Plus: Blindness and Vision Loss. http://www.nlm.nih.gov/medlineplus/ency/article/003040.htm. Accessed July 6, 2021.
- 4.↑
Lexi-Drugs. Lexicomp® [database]. Hudson, OH: Wolters Kluwer. http://online.lexi.com. Accessed July 6, 2021.
- 5.
National Institutes of Health, National Eye Institute. http://www.nei.nih.gov. Accessed April 7, 2022.
REVIEW QUESTIONS
What are the leading causes of blindness in the United States? Which are preventable and how?
List two classes of medication used as eye drops for the treatment of glaucoma.
Name two types of conjunctivitis. List a medication used in the treatment of each type and its mechanism of action.
How should patients who are using eye drops deal with contact lenses?
Discuss the dosage forms in which ophthalmic medications are available and the considerations for administration of each.
MEDICATION TABLES
Glaucoma Agents 4,a,b
CLASS Generic Name (pronunciation) |
Brand Name |
Dose |
||
|---|---|---|---|---|
Beta-Blockers |
||||
Betaxolol (be TAX oh lol) |
Betoptic-S |
0.25% suspension: 1 drop in affected eye twice daily 0.5% solution: 1–2 drops in affected eye twice daily |
||
Carteolol (KAR tee oh lole) |
(Generics) |
1% solution: 1 drop in affected eye twice daily |
||
Levobunolol (lee voe BYOO noe lole) |
(Generics) |
0.25%: 1–2 drops in affected eye twice daily 0.5%: 1–2 drops in affected eye daily |
||
Timolol (TYE moe lole) |
Timoptic, Betimol |
0.25%: 1 drop in affected eye twice daily, increase to 0.5% if needed to increase response, decrease to 1 drop daily if controlled Gel-forming solution 0.25%, 0.5%: 1 drop in affected eye daily |
||
Glaucoma/Prostaglandin Analogues |
||||
Bimatoprost (bi MA toe prost) |
Lumigan |
0.03% and 0.01%: 1 drop in affected eye every evening |
||
Latanoprost (la TA noe prost) |
Xalatan Xelpros |
0.005% solution: 1 drop in affected eye every evening 0.005% emulsion: 1 drop in affected eye every evening |
||
Latanoprostene Bunod (la tan oh PROS teen BU nod)4 |
Vyzulta |
0.024% solution: 1 drop in affected eye(s) once daily in the evening |
||
Tafluprost (TA floo prost)4 |
Zioptan |
0.0015% solution (preservative free): 1 drop in affected eye(s) once daily in the evening |
||
Travoprost (TRA voe prost) |
Travatan Z |
0.004% solution: 1 dose in affected eye every evening |
||
Sympathomimetics |
||||
Apraclonidine (a pra KLON i deen) |
(Generics) |
0.5% solution: 1–2 drops in affected eye 3 times daily, separated from other drops by at least 5 min; not commonly used for chronic therapy |
||
Brimonidine (bri MOE ni deen) |
Alphagan P |
0.1%, 0.15%, 0.2% solution: 1 drop in affected eye 3 times daily, approximately 8 hr apart; may often be administered off label twice daily |
||
Carbonic Anhydrase Inhibitors |
||||
Brinzolamide (brin ZOE la mide) |
Azopt |
1% suspension: 1 drop in affected eye 3 times daily, separated from other drops by at least 10 min; often prescribed twice daily off label |
||
Dorzolamide (dor ZOLE a mide) |
Trusopt |
2% solution: 1 drop in affected eye 3 times daily; often prescribed twice daily off label |
||
Cholinergic |
||||
Pilocarpine (pye loe KAR peen) |
Isopto Carpine, generics Vuity |
1%, 2%, 4%, solution: 1–2 drops in affected eye up to 4 times daily Dose 1 time daily 1.25%, solution: 1 drop daily for presbyopia |
||
Treatment of Macular Degeneration 4,a,b
CLASS Generic Name (pronunciation) |
Brand Name |
Dose |
||
|---|---|---|---|---|
Intravitreal VEGF Inhibitors |
||||
Aflibercept (a FLIB er sept)4 |
Eylea |
2 mg (0.05 mL) once every 4 weeks (monthly) for the first 12 weeks (3 months), followed by 2 mg (0.05 mL) once every 8 weeks (every 2 months) |
||
Brolucizumab (BROE lue SIZ ue mab)4 |
Beovu |
6 mg (0.05 mL) once per month (approximately every 25–31 days) for 3 months, followed by 6 mg once every 8 to 12 weeks |
||
Faricimab (far IK I mab) |
Vabysmo |
6 mg (0.05 mL every 4 weeks) for 4 doses, followed by 6 mg once every 8 to 16 weeks |
||
Ranibizumab (ra ni BIZ oo mab)4 |
Lucentis |
0.5 mg once a month (approximately every 28 days); frequency may be reduced (eg, 4–5 injections over 9 months) after the first 3 injections or may be reduced after the first 4 injections to once every 3 months if monthly injections are not feasible |
||
Choroidal Vessel Occluder |
||||
Verteporfin (ver te PORE fin) |
Visudyne |
Two-step process; first the infusion of verteporfin, then the activation of verteporfin with a nonthermal diode laser; not used commonly for wet AMD |
||
All the agents listed in the table are prescription products. AMD = age-related macular degeneration; VEGF = vascular endothelial growth factor.
Except where otherwise referenced, Pronunciations have been adapted with permission from USP Dictionary of USAN and International Drug Names (USP Dictionary) © 2022.
Conjunctivitis 4,a
Class Generic Name (pronunciation) |
Brand Name |
Dose |
Regulatory Status |
|||
|---|---|---|---|---|---|---|
Ophthalmic Antihistamines and/or Mast Cell Stabilizers |
||||||
Azelastine (a ZEL as teen) |
(Generics)_ |
0.05%: 1 drop in affected eye twice daily |
Rx |
|||
Epinastine (ep i NAS tine) |
Various generics |
0.05%: 1 drop in affected eye twice daily |
Rx |
|||
Ketotifen (kee toe TYE fen) |
Zaditor, Alaway, various others |
0.025%: 1 drop in affected eye twice daily, separated by 8–12 hr |
OTC |
|||
Olopatadine (oh la pat TA deen) |
Pataday |
0.1%: 1 drop in affected eye twice daily, separated by 6–8 hr 0.2% and 0.7%: 1 drop in affected eye daily |
OTC |
|||
Ophthalmic Antihistamines/Decongestant Combo |
||||||
Pheniramine/naphazoline (fen NIR a meen) (Naf AZ oh leen) |
Naphcon-A, Visine products Opcon-A |
0.025%/0.3%: 1–2 drops in affected eye up to 4 times daily 0.027%/0.315%: 1 to 2 drops in affected eye(s) up to 4 times daily |
OTC |
|||
Ophthalmic Mast Cell Stabilizers |
||||||
Bepotastine (bep oh TAS teen) |
Bepreve |
1.5%: 1 drop in affected eye twice daily |
Rx |
|||
Cromolyn (KROE moe lin) |
Various generics |
4%: 1–2 drops in affected eye 4–6 times daily |
Rx/OTC |
|||
Lodoxamide (loe DOX a mide) |
Alomide |
0.1%: 1–2 drops in affected eye 4 times daily |
Rx |
|||
Nedocromil (ne doe KROE mil) |
Alocril |
2%: 1–2 drops in affected eye twice daily |
Rx |
|||
Ophthalmic Decongestant |
||||||
Tetrahydrozoline (tet ra hye DROZ a leen) |
Optigene 3, Visine Original |
0.05%: 1–2 drops in affected eye 2–4 times daily |
OTC |
|||
Anti-Infective Agents/Macrolides |
||||||
Azithromycin (az ith roe MYE sin) |
AzaSite |
1%: 1 drop in affected eye twice daily (separated by 8–12 hr) for 2 days, then 1 drop daily for 5 days |
Rx |
|||
Erythromycin (er ith roe MYE sin) |
(Generics) |
5 mg/g ointment: apply 0.5-inch ribbon to affected eye 2–6 times/day |
Rx |
|||
Representative Anti-Infective Agents: Quinolones |
||||||
Besifloxacin (be si FLOX a sin) |
Besivance |
0.6%: 1 drop in affected eye 3 times daily for 7 days |
Rx |
|||
Ciprofloxacin (sip roe FLOX a sin) |
Ciloxan |
0.3% solution: 1–2 drops in affected eye q 2 hr while awake for 2 days then 1–2 drops q 4 hr while awake for 5 days; please note different directions for treating bacterial conjunctivitis and bacterial keratitis 0.3% ointment: apply 0.5-inch ribbon to affected eye 3 times daily for 2 days then twice daily for 5 days |
Rx |
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Gatifloxacin (gat i FLOX a sin) |
Zymaxid |
0.5%: 1 drop in affected eye q 2 hr while awake for 1 day (max 8 doses/day) then 1 drop in affected eye 2–4 times daily while awake on days 2–7 |
Rx |
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Levofloxacin (lee voe FLOX a sin) |
(Generics) |
0.5%: 1–2 drops in affected eye q 2 hr while awake (max 8 doses per day) for 2 days, then 1-2 drops q 4 hr while awake (max 4 doses/day) for 7 days total |
Rx |
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Moxifloxacin (moxs i FLOX a sin) |
Vigamox |
Moxeza (0.5%): Instill 1 drop into affected eye(s) 2 times daily for 7 days Vigamox (0.5%): Instill 1 drop into affected eye(s) 3 times daily for 7 days |
Rx |
|||
Ofloxacin (oh FLOX a sin) |
Ocuflox |
0.3%: 1–2 drops in affected eye q 2–4 hr while awake for 2 days, then 4 times daily for 5 days; please note different directions for treating bacterial conjunctivitis and corneal ulcer |
Rx |
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Aminoglycosides |
||||||
Gentamicin (jen ta MYE sin) |
Gentak |
0.3% solution: 1–2 drops in affected eye q 4 hr, max 2 drops every hr 0.3% ointment: apply 0.5-inch ribbon to affected eye 2–3 times daily, using q 3–4 hr |
Rx |
|||
Tobramycin (toe bra MYE sin) |
Tobrex |
0.3% solution: 1–2 drops in affected eye q 2–4 hr, max 2 drops every hr 0.3% ointment: apply 0.5-inch ribbon to affected eye 2–3 times daily, using q 3–4 hr |
Rx |
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Sulfonamide |
||||||
Sulfacetamide sodium (sul fa SEE ta mide) (SOE dee um) |
Bleph-10 |
10%: 1–2 drops in affected eye several times daily, up to q 2–3 hr for 7–10 days 10% ointment: Apply 0.5-inch ribbon into the conjunctival sac of affected eye(s) q 3–4 hr and at bedtime |
Rx |
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Miscellaneous |
||||||
Bacitracin, polymixin B (bass i TRAY sin) (pol i MIX in) |
AK-Poly Bac, Polycin |
500/10,000 units/g ointment: apply a thin strip to affected eye q 3–4 hr for 7–10 days |
Rx |
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Bacitracin, neomycin, polymixin B (bass i TRAY sin) (nee oh MYE sin) (pol i MIX in) |
Neo-Polycin |
400/3.5/10,000 units/g ointment: apply 0.5-inch ribbon to affected eye q 3–4 hr for 7–10 days |
Rx |
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Bacitracin, neomycin, polymyxin B, hydrocortisone (bass i TRAY sin) (nee oh MYE sin) (pol i MIX in) (hye droe KOR’ ti sone) |
Neo-Polycin HC |
400/3.5/10,000/10 units/g ointment: apply to inside of lower lid of affected eye(s) q 3 or 4 hr (depending on severity of condition) |
Rx |
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Trimethoprim, polymyxin B (trye METH oh prim) (pol i MIX in) |
Polytrim |
1 mg/10,000 units/mL: 1 drop in affected eye q 3 hr (max 6 doses/day) for 7–10 days |
Rx |
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Antifungal |
||||||
Natamycin (na ta MYE sin) |
Natacyn |
blepharitis/conjunctivitis: 1 drop in conjunctival sac 4 to 6 times daily keratitis: 1 drop in conjunctival sac every 1 to 2 hours x3–4 days, then 1 drop 6 to 8 times daily for total of 14–21 days |
Rx |
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Antiviral |
||||||
Ganciclovir (gan SYE kloe veer) |
Zirgan |
Gel, ophthalmic, 0.15%: Apply in affected eye 5 times daily (approximately every 3 hours while awake) until corneal ulcer heals, then apply 1 drop 3 times daily for 7 days |
Rx |
|||
Trifluridine (trye FLURE i deen) |
Viroptic |
1%: 1 drop in affected eye q 2 hr while awake (max 9 drops/day), until re-epithelialization of corneal ulcer occurs, then use 1 drop q 4 hr while awake for another 7 days; max 21 days of treatment |
Rx |
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Pronunciations have been adapted with permission from USP Dictionary of USAN and International Drug Names (USP Dictionary) © 2022.
Agents for Ophthalmic Inflammationa
CLASS Generic Name (pronunciation) |
Brand Name |
Dose |
Regulatory Status |
|||
|---|---|---|---|---|---|---|
Nonsteroidal Anti-Inflammatory Preparations |
||||||
Ketorolac (kee toe ROLE ak) |
Acular, Acular LS, Acuvail |
0.4%, 0.45%, 0.5%: 1 drop in affected eye 4 times daily |
Rx |
|||
Nepafenac (ne paf FEN ak) |
Nevanac |
0.1%: 1 drop in affected eye 3 times daily starting 24 hr before surgery and continuing for 2 wk after surgery 0.3% solution: 1 drop to the affected eye once daily, starting 24 hours prior to surgery; the day of surgery, and continuing for 2 wk after surgery |
Rx |
|||
Ophthalmic Corticosteroid |
||||||
Dexamethasone (dex a METH a sone) |
Maxidex, various, many in combination with other agents (AK-Neo Dex, Maxitrol, Ciprodex, Tobradex) |
0.1% solution: 1–2 drops in affected eye every hour while awake and q 2 hr during the night, gradually reduce dose to q 3–4 hr then 3–4 times daily |
Rx |
|||
Difluprednate (dye floo PRED nate) |
Durezol |
0.05%: 1 drop in affected eye 4 times daily starting 24 hr after surgery, continuing 4 times daily for 2 wk then twice daily for 1 wk then taper off |
Rx |
|||
Fluorometholone (flure oh METH oh lone) |
FML, Flarex |
0.1% ointment: apply 0.5-inch ribbon 1–3 times daily, may increase to q 4 hr in initial 24-48 hr 0.25%, 0.1% suspension: 1 drop in affected eye 2–4 times daily, may increase to q 4 hr in initial 24–48 hr |
Rx |
|||
Loteprednol (loe te PRED nol) |
Alrex, Lotemax |
(Examples) Alrex 0.2% suspension: 1 drop in affected eye 4 times daily; indicated for allergic conjunctivitis Lotemax 0.5% suspension: 1–2 drops in affected eye 4 times daily, may increase to 1 drop every hour if needed for 1 wk Lotemax 0.5% gel, 0.5% suspension: Instill 1–2 drops into the conjunctival sac of the affected eye(s) 4 times daily beginning 24 hr after surgery and continuing throughout the first 2 wk of the postoperative period |
Rx |
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Prednisolone (pred NISS oh lone) |
Pred Forte, Pred Mild |
0.12%, 1%: 1–2 drops in affected eye q 1 hr while awake and q 2 hr at night then decrease to 1 drop q 4–6 hr when response obtained |
Rx |
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Anti-Inflammatory, Miscellaneous |
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Cyclosporine (SYE kloe spor een)4 |
Restasis Cequa |
0.05%, 0.1% emulsion: 1 drop in each eye q 12 hr, separate from other drops by 15 min 0.09% solution: 1 drop in each eye q 12 hr, separate from other drops by 15 min |
Rx |
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Lifitegrast (lif i TEG rast)4 |
Xiidra |
5%: 1 drop in each eye q 12 hr, separate from other drops by 15 min |
Rx |
|||
Blepharospasm |
||||||
Onabotulinumtoxin A (o na BOTT you lye num tox in eh) |
Botox |
100 units: 1.25–2.5 units injected into muscles in upper and lower lid; max dose per site: 5 units, may repeat in 3 mo |
Rx |
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Except where otherwise referenced, Pronunciations have been adapted with permission from USP Dictionary of USAN and International Drug Names (USP Dictionary) © 2022.
Miscellaneous Ophthalmic Preparations 4
Indication |
Generic Name (pronunciation) |
Brand Name |
Dosage Form |
Dose |
Regulatory Status |
|---|---|---|---|---|---|
Ophthalmic Lubricants |
“Artificial tears” |
Various |
Ophthalmic solution or ointment |
Apply to or place 1–2 drops in affected eye 3–4 times daily as needed for eye dryness/irritation |
OTC |
Carboxymethylcellulose (kar box ee meth ill SEL yoo lose) |
Refresh, various |
Ophthalmic solution |
0.25%, 0.5%, 1%: 1–2 drops in affected eye 3–4 times daily |
OTC |
|
Hydroxypropyl cellulose (hye drox ee PROE pil SEL yoo lose) |
Lacrisert |
Translucent rod ophthalmic insert |
5 mg: insert in eye once daily |
Rx |
|
Hydroxypropyl methylcellulose (hye drox ee PROE pil meth ill SEL yoo lose) |
GenTeal, various |
Ophthalmic solution or gel |
0.2%, 0.3%, 0.4%, 0.5%, 2.5%: 1–2 drops in affected eye as needed |
Rx/OTC |
|
Cyloplegic Agents |
Atropine (A troe peen) |
Isopto Atropine |
Ophthalmic solution |
1%: 1 drop in the conjunctiva 40 min prior to intended maximal dilation time; may repeat up to twice daily as needed |
Rx |
Cyclopentolate (sye kloe PEN toe late) |
Cyclogyl |
Ophthalmic solution |
0.5%, 1%, 2%: 1–2 drops now and repeat in 5–10 min; higher concentrations may be needed in heavily pigmented irises |
Rx |
|
Homatropine (hoe MA troe peen) |
Homatropaire |
Ophthalmic solution |
5%: 1–2 drops before procedure, repeat q 5–10 min as needed |
Rx |
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