EDE
`27EDITION
`
`ll
`
`:10we
`
`lge of all the essential I
`HCIS.
`
`nnation gives you the I
`ial data you need.
`
`)ur widespread net-
`
`ther, organize and
`
`1 a timely manner.
`
`ire it is published.
`
`xed for quick,
`
`ly for fast reference.
`
`Place
`Stamp
`Here
`
`
`
`i999
`
`
`
`PHYSICIANS’
`DESK
`P FEEENCE
`
`
`
`Editorial Consultants and Contributors
`clement A. Weisbecker, RPh, Director of Pharmacy, Wills Eye Hospital, Philadelphia, PA
`F.T. Fraunfelder, MD, Director, National Registry of Drug-induced Ocular Side Effects, Oregon Health Sciences University,
`Portland, OR
`Michael Naidoff, MD, Cornea Service, Wills Eye Hospital, Philadelphia, PA
`Douglas Rhee, MD, Wills Eye Hospital, Philadelphia, PA
`Richard Tippermann, MD, Wills Eye Hospital, Philadelphia, PA
`
`Vice President of Directory Services: Stephen B. Greenberg
`
`Director of Product Management: David P. Reiss
`Senior Product Manager: Mark A. Friedman
`Associate Product Manager: Bill Shaughnessy
`National Sales Manager: Dikran N. Barsamian
`National Account Manager, Customized Projects:
`Anthony Sorce
`Senior Account Manager: Don Bruccoleri
`Account Managers: Marion Gray, RPh, Lawrence C. Keary,
`Jeffrey F. Pfohl, Christopher N. Schmidt,
`Stephen M. Silverberg, Suzanne E. Yarrow, RN
`National Sales Manager, Trade Group: Bill Gaffney
`Director of Direct Marketing: Michael Bennett
`Direct Marketing Manager: Lorraine M. Loening
`Promotion Manager: Donna R. Lynn
`Director, Professional Support Services:
`Mukesh Mehta, RPh
`Senior Drug Information Specialist:
`Thomas Fleming, RPh
`
`Drug Information Specialist: Maria Deutsch, MS, RPh, CDE
`Editor, Special Projects: David W. Sifton
`Vice President of Production: David A. Pitler
`Director of Print Purchasing: Marjorie A. Duffy
`Director of Operations: Carrie Williams
`Manager of Production: Kimberly H. Vivas
`Senior Production Coordinators: Amy B. Brooks,
`Dawn B. McCall
`Production Coordinator: Mary Ellen R. Breun
`Index/Format Manager: Jeffrey D. Schaefer
`Senior Format Editor: Gregory J. Westley
`Index Editors: Johanna M. Mazur, Robert N. Woerner
`Art Associate: Joan K. Akerlind
`Senior Digital Imaging Coordinator: Shawn W. Cahill
`Digital Imaging Coordinator: Frank J. McElroy,
`lll
`Electronic Publishing Designer: Robert K. Grossman
`Fulfillment Managers: Stephanie DeNardi, Kenneth Siebert
`Inc. at Montvale, NJ 076451742. All rights reserved. None of the
`¥ Copyright © 1998 and published by Medical Economics Company,
`in a retrieval system, resold, redistributed, or transmitted in any form or by any
`content of this publication may be reproduced, stored
`means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the publisher. PHYSlClANS‘
`DESK REFERENCE“, PDR”, PDR For Nonprescription Drugs“, PDR For Ophthalmology”, Pocket PDR”, and The PDR“ Family Guide to Prescription
`D”J€$‘° are registered trademarks used herein under license. PDR Companion Guide“, PDR” for Herbal Medicines“, PDR” Medical Dictionary“,
`ED” NUi'Se's Handbook“, PDR” Nurse's Dictionary“, PDR” Atlas of Anatomy“, The PDR” Family Guide Encyclopedia of Medical Care“, PDR”
`lectronlc Library“, and PDR” Drug Interactions, Side Effects, Indications, Contraindications System“ are trademarks used herein under license.
`Vice President, New Media: L. Suzanne BeDe||;
`Offlcers of Medical Economics Company: President and Chief Executive Officer: Curtis E. Allen;
`Bilash: Vice President and Chief Information Officer: Steven M. Bressler; Senior Vice
`Vice President, Corporate Human Resources: Pamela M.
`President, finance, and Chief Financial Officer: Thomas W. Ehardt; Vice President, Directory Services: Stephen B. Greenberg; Vice President,
`:Thomas J. Kelly; Executive Vice
`
`Operations: John R. Ware
`‘SEN: 1-56363-290-X
`
`l
`
`
`
`MYLAN - EXHIBIT 1013
`
`MYLAN - EXHIBIT 1013
`
`

`
`
`
`Section 1: lndices
`
`Page I
`
`i
`1. Manufacturers’ lndex .......................................................................................................... ..
`2. Product Name index .......................................................................................................... ..lii
`
`3. Product Category Index ...................................................................................................... ..Vl
`
`4. Active ingredients lndex ..................................................................................................... ..|X
`
`Section 2: Pharmaceuticals in Ophthalmology
`
`Page 1
`
`1. Mydriatics and Cycioplegics .......................................... ... ................................................... ..2
`2. Antimicrobial Therapy ......................................................................................................... ..2
`
`3. Ocular Anti—inflammatory Agents .......................................................................................... ..7
`4. Anesthetic Agents .............................................................................................................. ..9
`5. Agents for Treatment of Glaucoma .................................................................................... ..1O
`6. Medications for Dry Eye .................................................................................................... ..13
`
`7. Ocular Decongestants ...................................................................................................... ..14
`8. Ophthalmic irrigating Solutions .......................................................................................... ..15
`9. Hyperosmolar Agents ............................................................................... ..'. ..................... ..15
`10. Diagnostic Agents .......................................................................................................... ..16
`
`11. Viscoeiastic Materials Used in Ophthalmology .................................................................. ..17
`12. Off—Labei Drug Applications in Ophthalmology .................................................................. ..17
`13. Ocular Toxicology ............................................................................................................ ..19
`
`Section 3: Suture Materials
`
`Section 4: Ophthalmic Lenses
`
`Page 23
`
`Page 25
`
`1. Soft Contact Lenses ......................................................................................................... ..25
`
`2. Aphakic Lenses ................................................................................................................ ..5O
`
`3. Comparison and Conversion Tables ................................................................................... ..52
`
`Section 5: Vision Standards and Low Vision
`
`Page 56
`
`1. Vision Standards .............................................................................................................. ..56
`2. Low-Vision Aids ................................................................................................................ ..58
`
`Section 6: Evaluation of Permanent Visual Impairment
`
`59
`
`1. Criteria and Methods ....................................................................................................... ..59
`2. Visual System impairment Values ..................................................................................... ..68
`3- Combined Values Chart ........................................................... .. ...... .._._._. ............................ ..71
`
`iing family of PE
`00232-7379 or f.-
`
`netics (FD&C) Act,
`2 labeled, promote
`)r only those uses f:i
`ess have been estal
`ations 201.100(d)(:
`in products requirje
`)esk Reference F.
`;, dosages,
`route
`on of administratic;
`s, contraindicationr
`at be in the "san
`oved labeling for ti
`same language a
`se of the approvr,
`Furthermore,
`infi
`s emphasized by ti
`5, boldface, or italli
`in Physicians’ Del
`
`FD&C Act does nc
`rhysician may use:
`s been approved "i"
`re it for uses or.
`
`lations that are qr
`A also observes the
`des drug use that
`g. For products tit
`3, the publisher hz
`bing such produc.
`have access to;
`id informed decisic
`er-the—counter dietzi
`ed that this inform
`he Food and Dn
`; are not intendedl
`lisease.
`'
`
`Jmpiiation, organir
`tion. Each produ.
`a manufacturer,
`8:‘
`Jfacturer's media
`medical consuitan
`
`in Physiciarf
`terial
`a publisher does fl
`ducts described,>r
`connection with
`herein.
`Physician‘
`es not assume. at
`r obtain and inclul
`rvided to it by ii
`i that by making iii
`advocating the 1:9.
`or
`is the publislil.
`lue to typographic!‘
`iy product may ll,
`
`‘EFT"1""-."|F'
`
`

`
`
`
`
`
`Section 7: Product
`
`
`
`Guide
`
`Page 101
`
`....................
`...............................................
`................................
`Index ...........
`2. Full-Color Product Photographs ........................................................................................ ..103
`
`§,E.Cl|QLL1
`INDICE
`
`Section 8: Pharmaceutical and Equipment Product Information
`
`Page 201
`
`
`
`I_isted alphabetically by manufacturer
`
`4
`
`1-
`
`This section offers f
`mation you need:
`
`Section 9: lntraocular Product Information
`
`Key to Controlled Substances Categories
`
`Key to FDA Use—in-Pregnancy Ratings
`
`Page 315
`
`Page 319
`
`Page 320
`
`Amsler’s Grid
`
`Inside Front Cover
`
`
`
`%uP-.PIIfl.dTfV‘_''-
`
`1. Manufacturers’
`participating manu1
`two page numbers
`graphs in‘the Proc
`0nd to product
`i
`addresses and tele
`headquarters and re
`
`2. Product Namel
`uct information aip
`mond symbol to the
`tograph
`of
`the
`Identification Guid:
`page number refer:
`
`PART I/MANUF
`
`AKORN, INC. .... . .
`2500 Milibrook Driv
`Buffalo Grove, IL 6C
`Direct Inquiries to:
`Customer Service
`(800) 5357155
`
`ALGON LABORATOR
`and its Affiiiates
`Corporate Headqua
`6201 South Freewe
`Fort Worth, TX 761
`Direct Inquiries to:
`Ophthalmic/Vision(
`(Pharmaceuticals/L
`Surgical: (800) 862
`(Instrumentation/S
`Systems: (800) 281
`(Medical Managemi
`Systems)
`
`ALLERGAN . . . . . . .
`2525 Dupont Drive
`P.0. Box 19534
`Irvine, CA 92623-9
`For Medical lnfom
`Outside CA: (800)
`CA: (714) 246450
`Sales and Ordering
`Outside CA: (800)
`CA: (714) 246-45C
`
`BAUSCH & LOMB .
`PHARMACEUTII
`8500 Hidden River
`Tampa. FL 33637
`
`
`
`

`
`PHARMACEUTICALS / 13
`
`6. MEDICATIONS FOR DRY EYE
`
`Dry eye refers to a deficiency in either the aqueous or
`mucin components of the precorneal tear film. The
`most commonly encountered aqueous—deficient dry
`eye in the United States is keratoconjunctivitis sicca,
`while mucin—deficient dry eyes may be seen in cases
`of hypovitaminosis A, Stevens-Johnson syndrome,
`ocular pemphigoid, extensive trachoma, and chemi-
`cal burns.
`
`Dry eye is treated with artificial tear preparations
`(see Table 20) and ophthalmic lubricants (see Table 21).
`The lubricants form an occlusive film over the ocular
`surface
`and
`protect
`the
`eye
`from drying.
`Administered as a nighttime medication,
`they are
`useful both for dry eye and in cases of recurrent
`corneal erosion.
`
`SET/DURATION
`ACTION
`
`nin/5-6 h
`
`45 min/5-6 h
`
`EFT URATION
`or Ac ION
`2 h/4-6 h
`
`TABLE 20
`
`ARTIFICIAL TEAR PREPARATIONS
`
`MAJOR COMPONENT(S)
`
`CONCENTRATION (°/a)
`
`95°/u
`0.25%
`
`"
`
`3%
`
`Carboxymethyl cellulose
`
`Glycerin
`Hydroxyethyl cellulose,
`polyvinyl alcohol
`Flydroxypropylrcellulose
`
`HydroT<ypropy| methylcellulose
`
`S|ZE(S)(mL)
`5
`
`single use bott|e_
`5,10,15
`
`SlZE(S)(mL)
`_i
`
`_
`
`Hydroxypropyl methylcellulose,_
`dextran 70
`
`Methylcellulose
`
`Polycarbophil, PEG-400, dextran 70
`
`Polysorbaie 80
`
`Polyvinyl alcohol
`
`Polyvinyl alcohol,
`PEG-400, dextrose
`
`Polyvinyl alcohol,
`povidone
`
`*EDTA = ethylenediarninetetraacetlc acid.
`
`TRADE NAME
`
`Refresh Plus
`Celluvisc
`Theratears
`
`Dry Eye Therapy
`TearGard
`
`Lacrisert Tbiode—
`gradable insert)
`lsopto Plain
`lsopto Tears
`Tearisol
`
`lsopto Alkaline
`Bion Tears
`Ocucoat
`Ocucoat PF
`Tears Naturale ll
`Tears Naturale Free
`Tears Renewed
`Murocel
`
`T Aouasite
`Aquaslte multi-dose
`Viva Drops
`AKWA Tears
`Dry Eyes
`Liquifilm Tears
`HypoTears
`HypoTears PF
`Puralube Tears__
`Murine Tears
`Refresh
`Tears Plus
`
`PRESHERTATIVE/EDTA*
`None
`None
`None
`None
`
`Sorbic acid, EDTA
`
`_None
`
`Benzalkonium chloride
`Benzalkonium chloride
`Benzalkonium chloride, EDTA
`Benzalkonium chloride
`None
`Benzalkonium chloride, EDTA
`None
`Polyquad
`None
`Benzalkonium chloride, EDTA
`Methyl-, propy_lparabens
`EDTA
`EDTA, Sorbic acid
`
`Benzalkonium chloride, EDTA
`Chlorobutanol
`Chlorobutanol
`
`Benzalkonium chloride, EDTA
`EDTA
`Benzalkonium chloride, EDTA
`
`Benzalkonium ch|ori_de,_l§D_TA
`None
`Chlorobutanol
`
`

`
`
`
`14 / PDR FOR OPHTHALMOLOGY
`
`__,._._
`
`,..______ I
`
`///__;4
`
`'
`'
`
`
`
`,
`
`8- OP“-[HA
`. Tame 23
`Efnzgairophthalmic
`products. There 3|’
`ti0Fl5 aVa"able for
`
`TABLE 23
`OP“-[HA|_M|c II
`
`TRAD_E NAME
`AK’RmSe
`
`_°°_”L‘J"_F'£flE_V£
`Dacriose
`
`Eye-Slreém
`
`
`
`Lavoptlk Eye Wash
`
`frigate
`
`7
`
`9'
`
`Hyperosmolar (hy
`
`They act through
`
`24
`Wi—
`HypERos|v|0l
`{J
` _
`A. Therapeutic prepa
`S°d'“"‘ °h‘°"de
`
`_j__é
`B‘ g‘|ag2:’i:t'° prepa
`._yj._
`
`TABLE 21_
`OPHTHALMIC LUBRICANTS“
`TRADE NAME __
`_
`AKWA Tears Ointment _
`Dry Eyes b
`buolube
`_
`Eluratears Naturale
`l_:lypoTears_
`Lacri—Lube S.O.P., Lubritears
`I
`Euralube
`Refresh P.M., Dry Eyes Lubricant
`
`7
`
`7
`
`_
`
`_
`
`'
`‘
`_ COMPQSITIDN OF STERILE 0lNTl!lEl_l_T
`_lll_/hite petrolatum, liquid lanolin, and mineral oh
`White petrolatum, liquid lanolin, and mineral oil
`/ White petrolatum andfineral oil
`White petrolatum, liquid lanolin, and mineral oil
`White petrolatum andiilfimineral oil
`42.5% mineral oil, 55% white petrolatum,
`lanolin alcohol, and chlorobutanol
`White petrolatum, hquirmolin, and mineral oil
`—__
`41.5% mineral oil, 55% white petrolatum, petrolatum, and lanolin alcohol
`_
`
`_
`
`_
`
`—
`_
`
`_
`_§ _
`_
`
`7. OGULAR DECONGESTANTS
`
`These topically applied adrenergic medications are commonly used to whiten the eye. Three types are avail-
`able. Those containing naphazoline and tetrahydrozoline are more stable than those with phenylephrine. Usual
`dosage is 1 or 2 drops no more than 4 times a day (see Table 22).
`
`TABLE 22
`OCULAR DEGONGESTANTS
`
`'
`nnuc
`Naphazoline hydrochloride
`
`Oxymetazoline hydrochloride
`_
`Phenylephrine hydrochloride
`
`_
`
`_
`
`Tetrahydrozoline hydrochloride
`
`TRADE NAME
`AK—Con*
`A|balon*
`
`Clear Eyes
`Naphcon
`Vasoclear
`Vasocon Regular*
`Visine L.R.
`mocuclear
`AK—Nefrin
`Eye Cool
`Prefrin Liquifilm
`
`Relief
`Collyrium Fresh
`Murine Plus
`Visine
`
`_ _A[lD_lTl0NAL COMPONENTS
`Benzalkonium chloride, edetate disodium
`Benzalkonium chloride, edetate disodium
`
`“
`
`Benzalkonium chloride, edetate disodium
`Benzalkonium chloride, edetate disodium
`Benzalkonium chloride, edetate disodium
`Phenylmercuric acetate
`Benzalkonium chloride, edetate disodium
`Benzalkonium chloride, edetate disodium _
`Benzalkonium chloride, edetate disodium
`Thimerosal, edetate disodium
`Benzalkonium chloride, edetate disodium
`
`—
`Benzalkonium chloride, edetate disodium
`Benzalkonium chloride, edetate disodium
`Benzalkonium chloride, edetate disodium
`
`DECONGESTANT/ASTHINGENT ClJlVIBlNATl0NS "
`
`_
`
`O
`
`Naphazoline hydrochloride
`mpluswzinc sulfate
`V
`Phenylephrine hydrochloride
`i,
`plus zincs_u|fate
`if
`Tetrahydr‘ozolinejm: zinc sulfate
`*Prescription medication.
`
`Clear Eyes ACR
`(allergy/cold relief)
`
`_
`
`Benzalkonium chloride, edetate disodium
`
`_ _ Zincfrin
`Visine Allergy Relief
`
`Benzalkonium chloride
`Benzalkonium chloride, edetate disodium
`
`
`
`

`
`3,.0PHTHALMIC IRRIGATING SOLUTIONS
`
`Listed in Table 23 are sterile isotonic solutions for
`general ophthalmic use. They are all over—the— counter
`oducts. There are also intraocular irrigating solu-
`tions available for use during surgical procedures.
`
`They include prescription medications such as
`Bausch & Lomb’s Balanced Salt Solution, Alcon's
`B83 and BSS Plus, and |olab's locare Balanced
`Salt Solution.
`
`PHARMACEUTICALS / 15
`
`I _
`
`ADDITIENAL COMPONENTS
`—__ —_
`.
`.
`Benzalkonium chloride
`
`_
`
`_
`
`_
`Benzalkonium chloride
`Benzalkonium chloride.
`edetate disodium
`
`Benzalkonium chloride
`
`Benzalkonium chloride,
`edetate disodium _ _ _
`Benzalkonium chloride
`
`/_,,_,
`TABLE 23
`
`OPHTHALMIC IRRIGATING SOLUTIONS
`_
` " " — '
`COMPONENTS _
`. T T
`————-’'’f’—— T
`.
`.
`AK_Rm5e
`Sodium, potassium, calcium, and
`magnesium chlorides,
`sodium acetate, and sodium citrate
`Antipyrine, boric acid, and borax
`Sodium and potassium
`chlorides, and sodium phosphate
`
`collyrium Fresh Eyes
`Dacriose
`
`
`Sodium, potassium, magnesium
`and calcium chlorides, sodium
`
`acetate, and sodium citrate
`Boric acid, potassium chloride, and
`sodium carbonate
`Sodium chloride, sodium biphosphate,
`and sodium phosphate
`
`);ye.stream
`
`_
`
`
`
`mgate
`
`Lavoptik Eye Wash
`
`9. HYPEROSMOLAR AGENTS
`
`Hyperosmolar (hypertonic) agents are used to reduce corneal edema therapeutically or for diagnostic purposes.
`They act through osmotic attraction of water through the semipermeable corneal epithelium.
`
`TABLE 24
`
`HYPEROSMOLAR AGENTS
`
`GENERIC tiAiiiiE
`A. Therapeutic preparations
`Sodium chloride
`'
`
`__TlTADE NAME
`
`'
`
`'
`
`GONCIENTRATION (_°/.)
`
`Adsorbonac Ophthalmic
`AK—NaCl
`Muro-128
`
`2% or 5% (solution)
`5% (solution and ointment)
`2% or 5% (solution),
`5% (ointment)
`
`_ _
`
`B. Diagnostic preparation
`Glycerin
`
`Ophthalgan
`
`ilcohol, and chlorobutanol
`
`m, and lanolin alcohol
`
`3. Three types are avail-
`rith phenylephrlne. Usual
`
`IHJNENTS
`iloride, edetate disodium
`iloride. edetate disodium
`iloride, edetate disodium
`iloride, edetate disodium
`iloride, edetate disodium
`acetate
`
`iloride, edetate disodium
`iloride, edetate disodium
`
`iloride, edetate disodium
`ate disodium
`iloride, edetate disodium
`
`iloride, edetate disodium!
`iloride, edetate disodium
`iloride, edetate disodium
`
`Eriie, edetate disodium
`
`iloride
`
`iloride, edetate_disod_ium
`
`
`
`

`
`
`
`16 / PDR FOR OPHTHALMOLOGY
`
`10. DIAGNOSTIC AGENTS
`
`Some of the more common diagnostic agents and
`tests used in ophthalmologic practice are listed
`below.
`
`A. Examination of the conjunctiva, Cornea,
`and Lacrimal Apparatus
`Fluorescein, applied primarily as a 2% alkaline solu-
`tion, and with impregnated paper strips, is used to
`examine the integrity of
`the conjunctival and
`corneal epithelia. Defects in the corneal epithelium
`will appear bright green in ordinary light and bright
`yellow when a cobalt blue filter is used in the light
`path. Similar
`lesions of the conjunctiva appear
`bright orange-yellow in ordinary illumination.
`Fluorescein has also come into wide use in the fit-
`ting of rigid contact lenses,
`though it cannot be
`used for soft lenses, which absorb the dye. Proper
`fit is determined by examining the pattern of fluo-
`resceln beneath the contact lens.
`
`in addition, fluoresceln is used in performing appla-
`nation tonometry and one test of lacrimal appara-
`tus patency (Jones test) uses 1 drop of 1% fluo-
`rescein instilled into the conjunctival sac. if the dye
`appears in the nose, drainage is normal}
`
`Rose bengal, as a 1% solution, is particularly use-
`ful
`for demonstrating abnormal conjunctival or
`corneal epithelium. Devitalized cells stain bright
`red, while normal cells show no change. The abnor-
`mal epithelial cells present in dry eye disorders are
`effectively revealed by this stain.
`The Schirmer test is a valuable method of assess-
`ing tear production.
`It employs prepared strips of
`filter paper 5 by 30 mm in size. The strips are
`inserted into the topically anesthetized conjunctival
`sac at the junction of the middle and outer third of
`the lower lid, with approximately 25 mm of paper
`exposed. After 5 minutes, the strip is removed and
`the amount of moistening measured. The normal
`range is 10 to 25 mm.
`If inadequate production of
`tears is found on the initial test, a Schirmer ll test
`can be performed by repeating the procedure while
`stimulating the nasal mucosa? A number of varia-
`tions of the Schirmer test can be found in text-
`books and journals.
`
`B. Examination of Acquired Ptosis or
`Extraocular Muscle Palsy
`To confirm myasthenia gravis as the cause of pto-
`sis or muscle palsy, an intravenous injection of
`2 mg of edrophon/um chloride is administered, fol-
`lowed 45 seconds later by an additional 8 mg if
`there is no response to the first dose. (in case of
`a severe reaction to the edrophonium, immediate-
`ly give atropine sulfate, 0.6 mg intravenously.)
`
`0. Examination of the Retina and choroid
`Sodium fluoresceln solution, in concentrations of 5%,
`10%, and 25%, is injected intravenously to study the
`
`retinal and choroidal circulation. It has been used pri-
`marily in examination of lesions at the posterior pole
`of the eye, but anterior segment fluoresceln angiog-
`raphy (wherein the vessels of the iris, sclera, and con-
`junctiva are studied) is also a useful clinical tool.
`
`lntravascular fluoresceln is normally prevented from
`entering the retina by the intact
`retinal vascular
`endothelium (blood-retinal barrier) and the intact reti-
`nal pigment epithelium. Defects in either the retinal
`vessels or the pigment epithelium will allow leakage
`of fluorescein, which can then be studied by either
`direct observation or photography. For good results,
`appropriate filters are needed to excite the fluores-
`cein and exclude unwanted wavelengths. The peak
`frequencies for excitation lie between 485 and 500 nm
`and, for emission, between 520 and 530 nm.
`
`Fluorescein has proved to be a safe diagnostic agent,
`the most common side effects being nausea and
`vomiting. However, occasional allergic and vagal reac-
`tions do occur, so oxygen and emergency equipment
`should be readily available when angiography is per-
`formed. Patients should also be warned that the dye
`will temporarily stain their skin and urine; in the aver-
`age patient this lasts no more than a day.
`
`lndocyanine green (|C—Green) has been used in recent
`years, either alone or with fluorescein, to obtain bet-
`ter frames of choroid neovascularization.
`
`D. Examination of Abnormal Pupillary Responses
`Methacholine, as a 2.5% solution instilled into the
`conjunctival sac, will cause the tonic pupil (Adie’s
`pupil)
`to contract, but will
`leave a normal pupil
`unchanged. A similar pupillary response is seen fol-
`lowing instillation of 2.5% methacholine in patients
`with familial dysautonomia (Riley—Day syndrome).
`
`Table 25 shows the effects of several drugs on mio—
`sis due to interruption of the sympathetic system
`(Horner’s syndrome). The effect depends on the location
`of the lesion in the sympathetic chain.
`
`TABLE 25
`
`HORNER’S SYNDROME
`
`TOPICAL DROP
`(CENTRAL)
`
`'
`
`NEURDN Ill
`(POST-
`GANGLIONIC)
`
`NEURON ll‘ __ _ _
`(PRE-
`GANGLIONIC)
`
`NEURON l
`
`Cocaine 2%—10%
`
`—
`
`Epinephrine
`(‘id@%"“) ‘1°°°_
`Phenylephrine 1%
`
`“L
`+++
`
`—
`
`_ +_
`+
`
`i
`
`+/—
`
`_
`
`+/—
`
`
`
`
`
`_.._.__-—......._...:j....__._.Z.:_....—_.._..._
`
`Pilocarpine may be use
`dilated pupil is due to
`ruption of the pupil's p
`an atropine—like drug
`if
`react to pilocarpine.
`of the parasympatheti:
`aneurysm, Adie’s tor
`carpine will cause the
`
`11. VISCOEI
`
`Viscoelastic substam
`surgery to maintain the
`dissect tissues, act as
`ade, and prevent mecr
`cially the corneal end:
`teristics of the various
`result of the chain leng
`ecular interactions of
`viscoelastic substance
`the potential to produc
`in pressure if they are
`the anterior chamberf
`
`AMVISC (Chiron Vision
`of sodium hyaluronate
`viscosity is 40,000 0
`and molecular weigh‘
`shelf life is estimated
`
`AMVISC PLUS (Chiror
`composed of sodium
`saline. The viscosity
`shear rate), and mo
`1,500,000 daltons. T
`by increasing total c
`hyaluronate of lower l
`estimated at 1 year.
`
`DUOVISC (Alcon) — l
`syringes. One syringe
`taining Viscoat. Plea
`below for details of ex
`
`HEALON (Pharmacia —
`hyaluronate 1% in ph
`200,000 (@ 0/sec
`weight is approximate
`
`12. OFF-LAI
`
`B. Acetylcysteine
`This agent is used to
`alkali burns, cornea
`sicca. It is thought to
`action of collagenase
`healing. The drug is
`trade name Mucomj
`Though none of the
`are approved for use
`administered as frec
`and up to 4 times a
`
`

`
`
`
`PHARMACEUTICALS / 17
`
`
`
`REFERENCES
`
`1. Thompson HS, Mensher JH. Adrenergic mydrisis in
`Homer's syndrome: hydroxyampheta mine test for diagnosis
`of post-ganglionic defects.Am J Ophthalmol. 1971;72:472.
`2. Hecht SD. Evaluation of the lacrimal drainage system.
`Ophthalmology. 1978;853:1250.
`3. Thompson HS, Newsome DA, Lowenfeld I E. The fixed dilated
`pupil. Sudden iridoplegia or mydriatic drops; a simple
`diagnostic test. Arch Ophthalmol. 1971;86:12.
`
`Pilocarpine may be used to determine whether a fixed
`dilated pupil is due to an atropine-like drug or inter-
`ruption of the pupil's parasympathetic innervation} If
`an atropine-like drug is involved, the pupil will not
`react to pilocarpine.
`If dilation is due to interruption
`of the parasympathetic innervation (compression by
`aneurysm, Adie’s tonic pupil)
`instillation of pilo-
`carpine will cause the pupil to constrict.
`
`3 been used pri-
`a posterior pole
`rescein angiog-
`sclera, and con-
`iical tool.
`
`prevented from
`‘etinal vascular
`:J the intact reti-
`ither the retinal
`ll allow leakage
`zudied by either
`DI’ good results,
`site the fluores-
`gths. The peak
`185 and 500 nm
`530 nm.
`
`iagnostic agent.
`ng nausea and
`2 and vagal reac-
`gency equipment
`giography is per-
`wed that the dye
`rine; in the aver-
`a day.
`
`:n used in recent
`n, to obtain bet-
`tion.
`
`ry Responses
`nstilled into the
`1ic pupil
`(Adie’s
`a normal pupil
`>nse is seen fol-
`oline in patients
`ysyndrome).
`
`'a| drugs on mic-
`lpathetic system
`ds on the location
`in.
`
`NH
`
`IONIC)
`
`NEURON
`+/-
`
`+/-
`
`11. VISCOELASTIC MATERIALS USED IN OPHTHALMALOGY
`
`Viscoelastic substances are used in ophthalmic
`surgery to maintain the anterior chamber, hydraulically
`dissect tissues, act as a vitreous substitute/tampon-
`ade, and prevent mechanical damage to tissue, espe-
`cially the corneal endothelium. The individual charac-
`teristics of the various viscoelastic materials are the
`result of the chain length and intra- and interchain mol-
`ecular interactions of the compounds comprising the
`viscoelastic substance. All viscoelastic materials have
`the potential to produce a large postoperative increase
`in pressure if they are not adequately removed from
`the anterior chamber following surgery.
`
`AMVISC (Chiron Vision — Bausch and Lomb) - Composed
`of sodium hyaluronate 1.2% in physiologic saline. The
`viscosity is 40,000 cst (@25 C, 1/sec shear rate),
`and molecular weight
`is 2 2,000,000 daltons.
`Its
`shelf life is estimated at 2 years.
`
`AMVISC PLUS (Chiron Vision — Bausch and Lomb) -
`composed of sodium hyaluronate 1.6% in physiologic
`saline. The viscosity is 55,000 cSt (@25 C, 1/sec
`shear rate), and molecular weight
`is approximately
`1,500,000 daltons. The greater viscosity is obtained
`by increasing total concentration and using sodium
`hyaluronate of lower molecular weight. lts shelf life is
`estimated at 1 year.
`
`DUOVISC (Alcon) — Package contains two separate
`syringes. One syringe containing Proviso; the other con-
`taining Viscoat. Please see individual descriptions
`below for details of each.
`
`HEALON (Pharmacia — UpJohn) — Composed of sodium
`hyaluronate 1% in physiologic saline. The viscosity is
`200,000 (@ 0/sec shear rate), and the molecular
`weight is approximately 4,000,000 daltons.
`
`HEALON GV (Pharmacia — UpJohn) — Composed of
`sodium hyaluronate 1.4% in physiologic saline. The vis-
`cosity is 2,000,000 (@ O/sec shear rate), and the mol-
`ecular weight is approximately 5,000,000 daltons.
`In
`the presence of high positive vitreous pressure,
`Healon GV has three times more resistance to pres-
`sure than does Healon.
`
`OCCUCOAT (Storz — Bausch and Lomb) — Composed of
`hydroxypropylmethylcellulose 2% in balance salt solu-
`tion (BSS). The viscosity is 4,000 cSt (@ 37 C mea-
`sured on Cannon-Fenske viscometer), and the molec-
`ular weight is approximately 80,000 daltons. Occucoat
`is termed a viscoadherent rather than a viscoelastic
`because of its coating ability, which is related to its
`contact angle and low surface tension.
`
`PROVISC (Alcon) — Composed of sodium hyaluronate
`1% in physiologic saline. The viscosity is 39,000 cps
`(@ 25 C, 2/sec shear rate) and the molecular weight
`is approximately 1,900,000 daltons. Clinical studies
`demonstrate that Proviso functions in a similar fashion
`to Healon.
`
`VISCOAT (Alcon) — Composed of a 1:3 mixture of chon-
`droitin sulfate 4% (CS) and sodium hyaluronate 3%
`(SH) in physiologic saline. The viscosity is 40,000 cps
`(@ 25 C, 2/sec shear rate), and the molecular weight
`is 22,500 daltons for CS and 500,000 daltons for SH.
`
`VITRAX (Allergan) — Composed of sodium hyaluronate
`3% in balanced salt solution (BS8). The viscosity is
`30,000 cps (@ 2/sec shear rate) and the molecular
`weight is 500,000 daltons. It is highly concentrated to
`produce a significantly viscous material.
`it does not
`require refrigeration and has a shelf life of 18 months.
`
`12. OFF-LABEL DRUG APPLICATIONS IN OPHTHALMOLOGY
`
`B. Acetylcysteine
`This agent is used to treat corneal conditions such as
`alkali burns, corneal melts, and keratoconjunctivitis
`slcca. it is thought to improve healing by inhibiting the
`action of collagenase, which may contribute to delay in
`healing. The drug is available generically or under the
`trade name Mucomyst
`in 10% and 20% solutions.
`Though none of the commercially available solutions
`ale approved for use in ophthalmology, they have been
`administered as frequently as hourly in acute cases,
`and up to 4 times a day in maintenance therapy.
`
`B. Alteplase (tissue plasminogen activator)
`is
`This thrombolytic agent,
`trade-named Activase,
`used to treat
`fibrin formation in postvitrectomy
`patients. Though initial studies were based on
`intraocular injections of 25 pg, more recent work has
`shown the drug to be effective in doses of as little as
`3 to 6 pg. Because by-products of alteplase activity
`may mediate endothelial cell toxicity, the lower doses
`are preferred..This.agenthas also been used for sub
`macular hemhorrage, but this use is controversial.
`
`
`
`

`
`
`
`18 / PDR FOR OPHTHALMOLOGY
`
`13. OCULA
`
`The table on the fc
`the more recently r
`effects of drugs In 2
`effects of drugs con
`it is not a catalog of
`would be too length
`
`The volume of ocul:
`ture is overwhelmi
`soft data, since,
`ll
`patients on a Pam‘
`an adequate sampl
`tal environment, it
`andeffect relation:
`multitude of variab
`impossible. It was
`National Registry 0'
`was founded.
`
`bY_
`Established
`Administration, wit
`
`l l
`
`F. Edetate disodium
`This chelating agent plays a role in the treatment of band
`keratopathy. After removal of the corneal epithelium, it is
`used to remove calcium from Bowman's membrane.
`
`REFERENCES
`
`Nesburn A. Trauma topics: small corneal perforations. Audio Digest:
`Ophthalmol. 1983;12:21.
`in: Tasman W, Jaeger E, eds.
`Ralph R. Chemical burns of the eye.
`Duane's Clinical Ophthalmology. Philadelphia, Pa: JB Lippincott;
`1989 vol. 4, chap 28:14.
`Jaffe G, Abrams G, et al. Tissue plasminogen activator for post
`vitrectomy fibrin formation. Opthalmology. 1990;97:189.
`McDermott M, Edelhauser H, et al. Tissue plasminogen activator
`and corneal endothelium. Am J Ophthalmol. 1989;108.
`Williams D, Benett S, et al. Low—dose intraocular tissue plasminogen
`activator for treatment of postvitrectomy firbrin formations.
`Am J Optha/mol. 1990;109:606.
`Williams G, Lambrou F, et al. Treatment of postvitrectomy fibrin
`formation with intraocular tissue plasminogen activator.
`Arch Ophthalmol. 1988;106:1055.
`Ando H, Tadayoshi I, et al. inhibition of corneal epithelial
`wound healing. A comparative study of mitomycin C and
`5fluorouraci|. Ophthalmology. 1992;99:1809.
`Falck F, Skuta G, Klein T. Mitomycin versus 5-fluorouracil
`antimetabolite therapy for glaucoma filtration surgery.
`Semln in Ophthalmol. 1992;7:97.
`Who should receive antimetabolites after filtering surgery?
`Arch Ophthalmol. 1992;110:1069. Editorial.
`Welsh R, Palmer 8. Mitomycin in trabeculectomy: alter your
`technique. Ocular Surgery News. May 1, 1992267.
`Dunn J, Seamone S, Ostler H. Development of scleral ulceration and
`calcification after pterygium excision and mitomycin therapy.
`Am J Ophthalmol. 1991;112:343.
`Rubinfeld R, Pfister R, et al. Serious complications of topical
`mitomycin—C after pterygium surgery. Ophthalmology.
`1992;99:1647.
`Bonomi L. Medical treatment of glaucoma. Current Science.
`1992;1040:70.
`Lish A, Camras C, Podos 8. Effect of apraclonidine on intraocular
`pressure in glaucoma patients receiving maximally tolerated
`medications. Glaucoma. 1992;1:19.
`Holland E, Chan 0, et al. lmmunohistologic findings and results of
`_treatment with cyclosporine in ligneous conjunctivitis.
`Am J Ophthalmol. 1989;107:160.
`Bouchard C. Belin M, Letter to Editor concerning above article, with
`reply by author. Am J Ophthalmol. 1989;108:210.
`Secchi A, Tognan M, Leonardi A. Topical use of cyclosporine in the
`treatment of vernal conjunctivitis. Am J Ophthalmol.
`1990;110:641.
`BenEzra D, Matamoros N, Cohen E. Treatment of severe vernal
`keratoconjunctivitis with cyclosporine A eyedrops.
`Transplant Proc. 1988;20,No.2(suppl 2):644. ’
`Zierhut H, Thiel E, et al. Topical treatment of severe corneal ulcers
`with cyclosporine A. Graefe's Arch Clin Exp Opthalmol.
`1989;227:30.
`Hill J. The use of cyclosporin in high-risk keratoplasty.
`’Am J Ophthalmol. 1989;107:506.
`Belin M, Bouchard C, Frantz S, et al. Topical cyclosporine in high—risk
`corneal transplants. Ophthalmology 1989;96:1144.
`Quarterman MJ, et al. Signs, symptoms, and tear studies before
`and after treatment with doxycycline. Arch Dermatol. 1997;
`133289.
`
`Frucht-Perry J, et al.