This PPT is beneficial for undergraduate Medical students

1. Dr. Atul Kumar Anand
Senior Resident
AIIMS Patna

2. 4 Routes of drug administration
Topical
Periocular injection
Intraocular injection
Systemic administration

3. Topical instillation into conjunctival sac in
the form of
(a) Eyedrops:- simplest, most
convenient & most commonly used,
(specially in daytime) drugs available for
immediate action but quickly diluted by
tears

4. (b)Eye ointment : increases
bioavailability of drug by increasing tissue
contact time & by preventing dilution,
however drug not available for
immediadte action & ointment blur the
vision( better for bedtime)
Gel preparations cause less blurring but
costly
Benzalkonium chloride(BKC) used as
preservative, also acts as wetting agent so
increases drug absorption

5. (a)Subconjunctival injection: – to
achieve higher concentration of drug &
drug which cannot penetrate cornea due to
large size can easily pass through sclera
(b)Subtenon injection:- mainly for
steroid, Anterior subtenon for severe or
resistant anterior uveitis, posterior
subtenon for intermediate & posterior
uveitis

6. (c)Retrobulbar injection: - used to
deliver drug for optic neuritis, papillitis & for
retrobulbar anaesthesia
(d)Peribulbar injection:- for
anaesthesia

7. To deliver drug in maximum concentration
at target tissue
(a)Intracameral injection:- into
anterior chamber
(b)Intravitreal injection:- into vitreous
cavity

8. Oral
I/V
I/M

10. Two group
Penicillin & Cephalosporin
MOA – act by interfering with synthesis of
bacterial cellwall
Bactericidal

11. Bactericidal
Excreted mainly via kidney
S/E – hypersensitivity/allergic reaction,
urticaria anaphylactic shock
In deep seated inflammation of orbit or lids
given parenterally
Example:- benzyl penicillin, procaine
penicillin, methicillin cloxacillin,
carbenicillin, ampicillin, amoxycillin

12. Bactrericidal
Structure & MOA similar to penicillin
S/E low, usually allergic reaction of
penicillin type
Eg. cephazolin, cephalexin, cefotaxim,
ceftazidime{intraviterially also}


13. Bactericidal
Not absorbed orally
Maily against gram negative
Ototoxic and nephrotoxic
Eg.streptomycin,
gentamicin[topically 0.3 %]-retinotoxic
tobramicin-more potent [1% topical]
amicakin-intravitreal along with
vancomycin in endoph, less retinotoxic


14. Broad spctrum, bacteriostatic
Active against both gram positive &
negative, ricketissia, clamydia (trachoma)
C/I:- child, pregnancy, lactation

15. Broad spctrum, bacteriostatic
Active against both gram positive &
negative, ricketissia, clamydia
Topical 0.5%

16. Narrow spectrum, bacteriostatic
Active against gram positive, chlamydia,
toxoplasma
Eg:- erythromycin, azithromycin
S/E:- diarrohea

17. Eg:-Vancomycin – bactericidal, very
effective against nearly all gram +ve &
MRSA, staph aureus, staph epidim.
Given intravitereal
DOC endophthalmitis together with
amikacin and ceftazidime

18. Potent, bacteriocidal broad spectrum
against gram+ve & -ve
Eg.ciprofloxacin, norfloxacin, ofloxacin,
sparfloxacin, gatifloxacin -- all 0.3%
Moxifloxacin-0.5%

20. Amphotericin B : fungistatic or cidal
depending on concentration
Effective in superficial infection
Effective against both yeast & filamentous
fungi
Topically 0.1 -0.25% drop or 2.5% ointment
Can be given inrtavitreal or intravenous
S/E:- kidney, bone marrow & CNS toxicity

21. Broad spectrum (candida, fusarium,
aspergillus)
Topical 5% suspension, hrly
Adheres well to surface of ulcer making
contact time of drug with eye greater

22. Fungistatic
No oral only topical
Narrow spectrum, poor penertation

23. Less toxic
Miconazole:- against yeast & filamentous
fungi, fungicidal
Topical 1% drop, 2% ointment
Ketoconazoles :- against candida, less for
aspergillus
Orally 200-800mg, 7days to months in
fungal endoph.& for severe corneal
infection
S/E:- liver toxicity

24. Fluconazole:- fungistatic, against candida,
cryptococcus
Oral 100 -200 mg
Topical 0.2%
Low S/E
Itraconazole:- similar to ketoconazole
Oral 100-400 mg
Topical 1%

26. Aim of treatment is lowering the IOP
Achieved by decreasing the aqueous
production or by increasing outflow of
aqueous through trabecular meshwork or
uveoscleral pathway

27. Parasympathomimetic drug(cholinergic
drugs) - miotics
Sympathomimetic drug(adrenergic
agonists)
Beta adrenergic blockers
Prostaglandins analogues
Carbonic anhydrase inhibitors(CAI)
Hyperosmotic agents

28. MOA: - in PACG constriction of pupil pulls
peripheral iris away from angle structures,
opening a functionally closed angle.
Example Pilocarpine(1%, 2%, 4%)
Carbachol
S/E:- Local:- spasm of accommodation,
iris cyst formation, frontal headache,
myopia, impairment of night vision &
generalised contraction of visual field due
to miosis

29. C/I:- inflammatory glaucoma, malignant
glaucoma & known allergy

30. Non-selective alpha & beta
agonists
Epinephrine 1%(adrenaline) twice daily
Decreases IOP by increasing rate of
aqueous outflow
S/E:- Local:- stinging, hyperaemia, CME in
aphakic eyes
C/I:- in patient with narrow anterior
chamber as it causes mydriasis

31. Dipivefrine 0.1% :- a prodrug, converted to
epinephrine once inside eye, 17 times
more corneal penetration but less S/E
than epinephrine

32. Alpha-agonist:-
Clonidine:- 0.06 to 0.125% drop 6-8 hrly
Decreases IOP by decreasing aqueous
production & to lesser extent by
increasing trabecular uveoscleral outflow
Available in europe
Apraclonidine :-1% potent ocular
hypotensive
Used prophylactically for prevention of IOP
rise following LASER trabeculoplasty, YAG
laser iridotomy & posterior capsulptony

33.  S/E: conjunctival blanching, follicular
conjunctivitis, dry mouth, drowsiness
 Brimonidine 0.2% drops twice or thrice
selective alpha 2 agonist, lowers IOP by
decreasing aqueous production & enhancing
uveoscleral outflow
 S/E:- similar to apraclonidine
 Neuroprotective

34. Lowers IOP by decreasing aqueous
production
Commonly used AGM, useful in all types of
glaucoma(congenital, primary, 2ndary)
Non-selective beta-1& beta-2 blockers:-
timolol, levobunolol, carteolol, metipranolol
have greater IOP lowering effect than beta 2
selective (cardioselective) Betaxolol but it is
safe in asthma & COPD

35. S/E:- dry eye, burning, hyperaemia,
bronchospasm, bradycardia depression
C/I:- COPD, asthma, heart block, CHF
Timolol Maleate 0.5% BD, tachyphylaxis
Betaxolol 0.5% BD, less effective, less
pulmonary side effect, increase perfusion
of optic nerve head

36. Lowers IOP by increasing uveoscleral
outflow,( lower IOP 25-30% equivalent to
Timolol)
Given Once daily(OD at HS)
Latanoprost (0.005%)
Travoprost (0.004%)
Bimatoprost (0.03%)
S/E: hyperemia, FB sensation,
pigmentation of iris

37. Decrease aqueous production by blocking
carbonic anhydrase enzyme
Acetazolamide potent, systemic AGM,
used for controlling very high IOP in any
glaucoma, tablet 250 mg 6 hrly, or 500mg I/V
S/E: paraesthesia of hand & feet, loss of
appetite, altered taste, potassium depletion,
diarrhoea, renal calculi SJ
syndome(sulfonamide related side effect)

38. Dorzolamide 2% BD or TDS, 1st topical
CAI
S/E: allergic reaction, burning
Brinzolamide 1% BD, topical CAI

39. Increase osmolality of serum causing water
to leave vitreous cavity, so lowering IOP,
reducing vitreous volume & deepening AC
An ideal hyperosmotic agent should be
rapidly absorbed & distributed & have a high
molecular weight so that it does not enter the
eye
Rapidally lowering IOP, used in emergenecy(
glaucoma with very high IOP)

40. Mannitol 20%(1-2gm/kg),
given I/V rapidlly in 20-30 minutes, does
not enter glucose metabolism, so safe in
diabetics, but given with caution in
hypertensive, pulmonary edema cardiac or
renal failure patient.
Urinary retention may occur in prostatic
hypertrophy patient

41. Glycerol 50%(1-1.5gm/kg) given orally
Induces nausea & vomiting, so taken
mixed with lemon juice
Metabolised to glucose in body, so less
suitable for diabetics
Urea: given I/V, lower efficacy & more
side effect, so not routinely used

43. For herpes simplex:- Idoxuridine, acyclovir
For herpes zoster:- acyclovir, famiciclovir
For CMV retinitis :- ganciclovir, foscarnet

44. Pyrimidine derivative:-
Virostatic
Against DNA virus
For dentritic ulcer 0.1% drop, 1-2 hrly
0.5% ointment,
no deep penetration(not useful in stromal
keratitis)
s/e follicular conjunctivitis, spk, punctal
stenosis

45. Virustatic, safe & effective in most forms of
H.simplex & zoster
3% ointement, 5 times daily in epithelial
and stromal keratitis
Oral 400 – 800 mg, 5 times day for 7-10
days

46. Derivative of acyclovir
Used in CMV retinitis, H.simplex 1 & 2
May be given intraviterally

48. Dilate pupil causing mydriasis & impair
accommodation leading to cycloplegia
Used in determining correct refraction of
eye specially in child & hypermetrops
Atropine 1% ointment, most potent,
longest acting, 7days or more, used in
child less than 5 yrs, systemic absorption
may cause facial flushing, so ointment
preferred , also used as penalisation
therapy in better eye in amblyopia

49. Homatropine 2% drop, less potent, effect
lasts for 4-5 days, used in treatment of
uveitis & refraction in children
Cyclopentolate 1% drop, less potent,
shorter duration of action, lasting upto 24
hrs, used for refraction
Tropicamide 0.5%, 1% drop shortest
acting, effective upto 3-4 hrs, used for
fundus examination & refraction
S/E : blurred vision & photophobia

50. Phenylephrine 5-10%(selective alpha 1
agonist) only mydriatics no cycloplegics
Used in combination with cyclopegics to
dilate pupil for fundus exam, retinal laser
prior to cataract surgery
S/E: stinging on application , rise in blood
pressure in predisposed individual

52.  Replaces aqueous component of tear
 Contain electrolytes, viscous, alkaline ph
 Eg. Hydroxypropylmethylcellulose (HPMC),
carboxymethylcellulose (CMC) ,
hydroxymethylcellulose, polyvinyl alcohol,
hyaluronic acid, chondroitin sulfate
 Preservatives are epitheliotoxic to cornea and
conjunctiva
 Benzalkonium chloride(BKC) is most
epitheliotoxic

53. Povidone and chlorobutanol are better
tolerated so better
Preservative free drops are best
alternative
Newer preservatives as sod.perborate and
purite disintegrate into harmless molecule
on contact with eye and exposure to light

55.  Viscous material that asist surgeon in different
intraocular surgery
 Properties of an ideal viscoelastic:-
 Chemically inert
 Non antigenic, non toxic, isoosmotic & sterile
 Free from particulate matter
 Optically clear
 Viscosity enough to provide sufficient space for
manipulation within eye
 Hydrophilic and dilutable properties to irrigate
material out of eye after surgery
 Protectibility to protect corneal endothelium

56. Types :
Cohesive & Dispersive
Cohesive mol. adhere to each other, useful
as spacers for manipulation & easy to
remove
Used for capsulorhexis & placement of IOL

57. Dispersive:
Coats ocular surfaces, remain in position
during irrigation
Used for protecting corneal endothelium
eg. Sod.hyaluronate 1% :- cohesive, best
but expensive
Methylcellulose :- most commonly used
Hypermellose 2%
Combination of 4% chondroitin sulphate &
3% sod.hyaluronate

58. Uses:-
During cataract surgery for
1.maintenantace of ant. Chamber
2.protection of corneal endothelium
3.coating the IOL
Other uses
Repair of globe in perforating injury
Glaucoma surgery
keratoplasty

59. S/E:-
Postop rise in iop if cosiderabl amount of
viscoelastic is left inside the ant.chamber