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` PER”
`
`
`40IDIYION
`E61?
`
`
`
`
`PD®
`for Opltthahtric i_le(iici1£s:
`
`Editorial Donsultants and contriit-Jutors
`
`Douglas J. Rhee, MD, Assistant Professor of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School,
`Boston, MA
`Christopher J. Rapuano, MD, Director and Attending Surgeon, Cornea Service. Wills izye Hospital; Professor of Ophthalmology,
`Jefferson Medical College of Thomas Jefferson University, Philadelphia. PA
`George N. Papallodis, MD, instructor, Massachusetts Eye and i:ar Infirmary, Harvard Medical School, Boston. MA
`F.W. Fraunfeider, MD, Director, Cornea/Refractive Surgery and National Registry of Drug-induced Ocular Side Effects; and Professor
`
`of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland. OR
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`tor Ophtralmic Med.ci‘nes: FDR’ for Nnnprescript-on Drugs. Dietary Sunpicments. and Herbs; FDR‘ Plvairrlecopoela; and Poi?‘ Electronic ubrary are trademarks
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`ISBN: 978-1-563637964
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`SENJU—M|TSUB|SH| 2021
`
`

`
`FOREWORD TO THE 40th EDITION
`
`
`
`PDR Network is pleased to provide eyecare profes-
`sionals with this updated guide to ophthalmic medi-
`cations. PDR° for Ophthalmic Medicines includes FDA-
`approved guidelines for leading eyecare products, as
`well as information on newly released medications. In
`addition, the opening sections feature useful tables
`summarizing the major pharmaceutical alternatives
`currently available in ophthalmology, as well as a
`brief guide to suture materials and information on
`vision standards and low vision. There are also lens
`comparison and conversion tables, and a directory of
`softcontact lens manufacturers. Four detailed indi-
`ces help you locate products by manufacturer, prod-
`uct name, product category, and active ingredient;
`and a full-color product identification section features
`photos of leading ophthalmic medications.
`
`The special reference sections near the beginning
`of PDR for Ophthalmic Medicines have been prepared
`with the assistance of Douglas J. Rhee, MD, and
`George N. Papaliodls, MD, of the Massachusetts
`Eye and Ear Infirmary, Harvard Medical School
`in
`Boston; and Christopher J. Rapuano, MD. of Wills
`Eye Hospital, Jefferson Medical College of Thomas
`Jefferson University in Philadelphia. Our thanks also
`go to F.W. Fraunfelder, MD. of Oregon Health &
`Science University in Portland, who edited the section
`on ocular toxicology. The opinions expressed in these
`sections are those of the authors and are not neces-
`sarily endorsed by the publisher.
`
`About This Book
`
`PDR for Ophthalmic Medicines is published by PDR
`Network, LLC in cooperation with participating manu-
`facturers. PDR° contains FDA-approved labeling for
`drugs as well as prescription lnfonnation provided
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`
`Biomed
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`

`
`SECTION 2
`
`PHARMACEUTICALS
`IN OPHTHALMOLOGY
`
`
`Douglas J. Rhee, MD,‘ Christopher J. Rapuano, MD,’ and George N. Papaliodis, MD,‘
`with a section on ocular toxicology by F.W. Fraunfelder, MD’
`‘
`
`We are pleased to present this updated overview
`of pharmaceutical options in ophthalmology.
`in all.
`this section offers 30 reference tables presenting
`therapeutic alternatives in all major categories of
`ophthalmic treatment, as well as a survey of recently
`identified adverse drug reactions encountered in
`ophthalmology. The material is divided into 14 parts
`as follows:
`
`!~°9°.“9’."':"S-"E"
`
`1. Mydriatics and Cycloplegics
`Antimicrobial Therapy
`Ocular Anti-inflammatory Agents
`Anesthetic Agents
`Agents for Treatment of Glaucoma
`Medications for Dry Eye
`Ocular Decongestants
`Ophthalmic irrigating Solutions
`Hyperosmolar Agents
`10. Diagnostic Agents
`11. Viscoelastlc Materials Used in Ophthalmology
`12. Anti-Angiogenesis Treatments
`13. Off-Label Drug Applications in Ophthalmology
`14. Ocular Toxicology
`
`There are a number of excellent references related to
`pharmacology and treatment regimens in ophthalmol-
`ogy. Listed below are some of the ones we regard as
`particularly useful.
`
`GENERAL REFERENCES
`
`American Medical Association. Drug Evaluations Annual.
`Milwaukee, WI: AMA Department of Drugs, Division of
`Toxicology.
`Ehiers JP, Shah CP. Fenton GL. Hosking EN, Shelsta HN. The
`Wills Eye Manual, Fifth Edition, for PDA (Palm OS, Windows
`CE, and Pocket PC). Philadelphia, PA: Wolters Kluwer,
`Lipplncott Williams & Wilkins: 2008.
`Fraunfelder FT, Fraunfelder FW. Drug-Induced Ocular Side
`Effects, ed 5. Woburn. MA: Butterworth-Heinemann; 2001.
`Fraunfelder H, Roy FH. Current Ocular Therapy. ed 5.
`Philadelphia, PA: WB Saunders; 1999.
`Rhee DJ, Colby KA. Rapuano CJ, Sobrin L. Ocular Drug Guide,
`ed 2. New York, NY: Springer; 2010.
`Tasman W, laeger EA. Duane’s Clinical Ophthalmology on
`CD-ROM, 2004 Edition. Philadelphia, PA: Lippincott Williams
`& Wilkins; 2004.
`
`Vaughan D, AsburyT, Riordan-Eva P. Generalophthalmology,
`ed 15. Norwalk. CT: Appleton & Lange: 1999.
`
`1. Massachusetts Eye and Ear lnflrmary; Boston, MA.
`2. Wills Eye Institute; Philadelphia. PA.
`3. Casey Eye Institute: Portland, OR.
`
`

`
`
`8 / FDR“ FOR OPHTHALMIC MEDICINES
`3. OCIJLAR ANTI-INFLAMMATORY AGENTS
`
`
`
`
`
`
`NONSTENOIDAL ANTI-INFLATAMATOIIY DRUGS
`
`Bromienac Ophthalmic Solution
`Bromday
`0.09%
`Dicloienac Sodium
`Voltaren
`0.1%
`Ophthalmic Solution
`Available generically
`0.1%
`Flurbiproten Sodium
`Ocuien
`0.03%
`
`Ophthalmic Solution
`Available generically
`0.03%
`Ketorolac Tromethamine
`Acular L8
`0.4%
`Ophthalmic Solution
`Acular
`0.5%
`Acular PF
`0.5%
`Acuvail
`0.45%
`Available generically
`0.5%
`
`
`
`
`
`
`
`used synchronously with antibiotics and/or with other
`A wide variety of medications is available for the treat-
`appropriate antimicrobial, antifungal, or antiviral medi-
`ment of ocular inflammatory disorders, and the list
`cations, these agents may help prevent more serious
`expands annually. At one time, it was felt that corti-
`ocular damage. They are listed in Table 9.
`costeroids were contraindicated in infectious disease
`
`states. However,
`it is now appreciated that. when
`
`TABLE 9
`
`TOPICAL ANTI-INFLAIVIMATORY AGENTS
`
`NAME AND DOSAGE FORM
`Cyclosporine Ophthalmic Emulsion
`
`Dexamethasone Sodium Phosphate
`Ophthalmic Solution or Ointment
`
`Dexamethasone Sodium Phosphate
`Ophthalmic Suspension
`
`Diiluprednate Ophthalmic Emulsion
`
`Fluorometholone Ophthalmic Ointment
`
`Fluoromelholone
`Ophthalmic Suspension
`
`Fluorometholone Acetate Ophthalmic Suspension
`
`TRADE NAME
`Restasis
`
`Ocu-Dex. Maxldex Ointment
`
`CONCENTRATION
`0.05%
`
`0.1%. 0.5%
`
`Maxidex
`
`Ourezol
`
`FML S.0.P.
`
`Fluor-Op
`FML
`FML Foite
`Available generically
`Flarex
`
`0.1%
`
`0.05%
`
`0.1 %
`
`0.1%
`0.1%
`0.25%
`0.1%
`0.1%
`
`~
`
`0.5%
`Lotemax
`Loteprednoi Etabonate Ophthalmic Ointment
`Loteprednol Etabonate Ophthalmic Suspension
`Alrex
`0.2%
`
`Lotemax
`0.5%
`
`_ i
`
`_
`
`O:'t:"nf‘Q’:—i'r13rv2r\r~.u:r\:n-'~,n—r---v~—-v-~
`
`Madrysone Opmhalmic Suspension
`Prednisolone Acetate
`Ophthalmic Suspension
`
`Prednisoione Sodium Phosphate
`Ophthalmic Solution
`Rimexolone Ophthalmic Suspension
`
`._
`HMS
`Econopred Plus
`Omnipred
`Pred Forte
`Pred Mild
`
`Available generically
`AK-Pred
`Available generically
`Vexol
`
`_ M
`
`_ _
`
`1%
`
`ti
`
`1%
`1%
`0.12%
`
`__
`
`1%
`1%
`0.125%. 1%
`1%
`
`~
`
`i
`
`__ ‘A
`
`.
`
`Nepaienac Ophthalmic
`_INTflAOt_:l_iLAiI STEROIOL
`
`Fluocinolone acetonide
`Ozurdex
`
`Triamcinolone
`
`_Nev_an_ac
`
`Retisert
`Dexamethasone
`
`Triesence
`Trivaris
`
`0.1%
`
`0.59 mg
`0.7 mg
`
`40 mg/mL
`80 mg/mL
`
`_
`
`

`
`
`
`-—-\uUJT"‘
`
`Steroids may be administered by four different routes
`in the treatment of ocular inflammation. Table 10 lists
`the preferred route in various conditions.
`
`Topical corticosteroids can elevate intraocular pressure
`and.
`in susceptible individuals. can induce glaucoma.
`Some corticosteroids, such as fluorometholone acetate.
`medrysone. and Ioteprednol cause less elevation of
`intraocular pressure than others but are lower potency.
`Corticosteroids. particularly intravitreal and topically
`administered forms, may also cause cataract formation.
`However.
`long-term systemic use can also accelerate
`cataract formation.
`
`in addition to topical, subtenons. and singular intravitreal
`dosing of triamcinolone acetonide 4 mg per 0.05 mL
`(Trivaris; Allergan) or 40 mg/mL (Triesence; Aicon).
`sustained-release dosing of fluocinolone acetonide
`0.59 mg (Retisert) is also available. Additionally, a
`sustained-release intravitreal implant, dexamethasone
`0.7 mg (ozurdex; Allergan). was approved by the FDA.
`Ozurdex is approved for
`the treatment of macular
`edema following branch retinal vein occlusion or central
`retinal vein occlusion-. and also for the treatment of
`posterior, noninfectious uveitis.
`There are also five nonsteroidal anti-inflammatory drugs
`(NSAIDs) available. They are: bromfenac (Bromday).
`diclofenac (Voitaren);
`flurbiprofen (Ocufen): ketorolac
`(Acular.
`and Acuvail) and nepafenac (Nevanac).
`Flurbiprofen is
`indicated solely for
`inhibition of
`intraoperative miosis. Diclofenac has an official indication
`for the postoperative prophylaxis and treatment of
`ocular
`inflammation. Ketorolac is Indicated for
`the
`treatment of postoperative inflammation and for relief
`of ocular itching due to seasonal allergic conjunctivitis.
`It has also shown some success in alleviating the pain
`associated with keratotomy. although unapproved for
`this use. Both diclofenac and ketorolac have also been
`used successfully to prevent and treat cystoid macular
`TABLE 11
`
`PHARMACEUTICALS / 9
`
`TABLE 10
`
`IJSUAL ROUTE OF STEROID ADMINISTRATION
`IN OOULAR INFLAMMATION
`
` CONDITION ROUTE
`Anterior uveitis
`Topical and/or peribulbar
`Blepharitis
`Topical
`Conjunctivitis
`Topical
`Cranial arteritis
`Systemic
`Endophthalmitis
`Systemic-periocular. and/or Intravitreal
`Episcleritis
`Topical
`Keratitis
`Topical
`Optic neuritis
`Systemic or periocular
`Posterior uveitls
`Systemic and/or periocuiar.
`and/or intravitreal
`Topical. regional. and/or systemic
`Scleriiis
`
`Sympathetic ophlhalmia Systemic and periocular, and intravitreal
`edema. Bromfenac and nepafenac are both indicated
`for the treatment of postoperative inflammation and
`reduction of ocular pain in patients who have undergone
`cataract extraction. NSAlDs cause little.
`if any. rise in
`intraocular pressure. However, in rare instances. topical
`NSAlDs have been associated with corneal melts and
`perforations, especially in older patients with ocular
`surface disease such as dry eyes.
`
`Inhibitors,
`include mast-cell
`agents
`Other useful
`lowconcentration
`steroids,
`and
`antihistamines,
`decongestants to treat vernal conjunctivitis or allergic
`keratoconjunctivltis. Tetracycline, taken orally.
`in doses
`of 250 mg 4 times daily for 4 weeks, then 250 mg once
`daily. is useful in treating ocular rosacea. Alternatively,
`doxycycline or minocycline. taken orally, in doses of 100
`mg twice daily for 1 to 2 weeks. then 40-100 mg once
`daily or in divided doses may be used.
`
`in treatment of seasonal allergic con-
`Agents useful
`junctivitis are listed in Table 11.
`
`AGENTS FOR RELIEF OF SEASONAL ALLERGIC GONJUNCTIVITIS
`
`CLASS
`ast-ceilifiliiiiitor
`o
`.- n
`Fl,-iintagor'iisi7l7lasi-cell lniiliiitfir
`
`TYPICAL DAILY DOSE
`1
`2
`
`TRADE NAME
`am
`OitiiTaF‘
`Available generically
`Bepreve
`Croiom
`Available generically
`Emadine
`Elestat
`Available genericdly
`Acular. Acular LS, Acular PF
`Alaway (OTC). Zadltor (OTC)
`Available generically
`Aiomide
`Alrax
`Vasocon-A (OTC)
`Naphcon-A (OTC)
`Opcon-A (OTC)
`__
`Vislne-A (OTC)
`2-4
`Mast-call inlilb itor
`Alocril
`Nedocromli sodium
`2
`H,-Antagonist/Mast-cell inhibitor
`Patanol
`Olopatadine HCI 0.1%
`1
`H,-Antagonist/Mast-cell inhibitor
`Pataday
`Olopatadine HCI 0.2%
`
`
`
`Pemirolast potassium 4-ll Aiamast Mast-cell inhibitor
`
`GENERIC NAME
`ca
`no
`Afiiasfine FICI
`
`Bepota§tine iiesiiate
`cromolyn sodium
`
`Emedastine ditumarate
`Epinastlne HCI
`
`Ketorolac tromethamine
`Ketotifen tumarate
`
`Lodoxamide tromathamlne
`Loteprednol etabonate
`Napliazollne/antazoline
`lilapilazoline/pheri ramine
`
`H.-Iniaoofiiswlast-cell infiifiitor
`Mast-cell inhibitor
`
`H,-Antagonist
`H,- and H,-Antagonist/Mast-cell inhibitor
`
`NSAID
`H,-Antagonist/Mast-cell inhibitor
`
`Mast-cell inhibitor
`corticosteroid
`Antlhistarnine/decongestant
`Antihlstamine./decongestant
`
`2
`4-12
`
`4
`2
`
`4
`2
`
`4
`4
`4
`4-8