Pharmacology eye disorders

EYE DISORDERSEYE DISORDERS

Pharmacology PHM 212Pharmacology PHM 212DONE BY: AMEENAH KHANDONE BY: AMEENAH KHAN

09/0509/139109/0509/1391

AMBLYOPIAAMBLYOPIA

It is a condition that occurs in It is a condition that occurs in children when one eye has poorer children when one eye has poorer vision than the other.vision than the other.

It is commonly known as lazy eye.It is commonly known as lazy eye.

SYMPTOMSSYMPTOMSMild: not aware since vision in normal Mild: not aware since vision in normal

eye is stronger thus it is diagnose eye is stronger thus it is diagnose until later.until later.

Severe:Severe:most notably poor most notably poor depth perceptiondepth perception, , poor spatial poor spatial acuityacuity,, low sensitivity to low sensitivity to contrastcontrast "higher-level" deficits to vision such as "higher-level" deficits to vision such as

reduced sensitivity to reduced sensitivity to motionmotion..

CAUSES OF AMBLYOPIACAUSES OF AMBLYOPIA Nearsightedness or astigmatism in one eye. Nearsightedness or astigmatism in one eye.

When the child's brain is confronted with When the child's brain is confronted with both a blurry image and a clear image, it will both a blurry image and a clear image, it will begin to ignore the blurry image. If this begin to ignore the blurry image. If this continues, the vision in the defected eye will continues, the vision in the defected eye will start to deteriorate even further.start to deteriorate even further.

Strabismus or ocular misalignment prevents Strabismus or ocular misalignment prevents the eyes from focusing together on an the eyes from focusing together on an image. This causes double vision. In order to image. This causes double vision. In order to combat this, the child's brain generally combat this, the child's brain generally chooses to ignore the image from the chooses to ignore the image from the deviated eye, causing the vision in that eye deviated eye, causing the vision in that eye to eventually deteriorate to eventually deteriorate

DIAGNOSISDIAGNOSIS

Pediatricians or vision programs will check Pediatricians or vision programs will check three aspects of your child's eye health:three aspects of your child's eye health:

That your child's eyes let light all the way That your child's eyes let light all the way throughthrough

That both eyes see equally wellThat both eyes see equally well That the eyes are moving normally.That the eyes are moving normally. If there's a problem in any of those three If there's a problem in any of those three

areas, the pediatrician may recommend a areas, the pediatrician may recommend a visit to an eye specialist. visit to an eye specialist.

TREATMENTTREATMENT Common treatment for amblyopia is to Common treatment for amblyopia is to

force the brain to start using the "bad" force the brain to start using the "bad" eye by putting a patch over the "good" eye by putting a patch over the "good" eye.eye.

In cases of mild amblyopia, the doctor In cases of mild amblyopia, the doctor might recommend using an eye drop might recommend using an eye drop called atropine in the "good" eye called atropine in the "good" eye instead of a patch. Atropine makes it instead of a patch. Atropine makes it impossible for that eye to focus close-impossible for that eye to focus close-up, forcing the "bad" eye to do most of up, forcing the "bad" eye to do most of the work while the child is playing with the work while the child is playing with toys, eating, drawing or reading.toys, eating, drawing or reading.

If there is something blocking light If there is something blocking light from getting into the eye, the doctor from getting into the eye, the doctor might recommend surgery to remove might recommend surgery to remove the blockage. the blockage.

If strabismus is preventing the eyes If strabismus is preventing the eyes from moving together correctly, your from moving together correctly, your doctor might recommend surgery on doctor might recommend surgery on the muscles of the eye. the muscles of the eye.

And if the focus of one eye is very And if the focus of one eye is very different from the other, eyeglasses or different from the other, eyeglasses or contact lenses might be necessary.contact lenses might be necessary.

ATROPINEATROPINE

A topically applied muscarinic A topically applied muscarinic antagonist, which blocks the action of antagonist, which blocks the action of acetylcholine. This results in paralysis acetylcholine. This results in paralysis of the iris sphincter and resultant of the iris sphincter and resultant pupillary dilation. Paralysis of the pupillary dilation. Paralysis of the ciliary muscles also occurs, which ciliary muscles also occurs, which inhibits accommodation and relieves inhibits accommodation and relieves pain in iridocyclitis. The medication is pain in iridocyclitis. The medication is dispensed in a topical formulation, dispensed in a topical formulation, either an ointment or a solution.either an ointment or a solution.

Mechanism of Action Mechanism of Action

Muscarinic effects: Muscarinic effects: Atropine works Atropine works by competitively occupying by competitively occupying muscarinic receptor sites, thus muscarinic receptor sites, thus reducing the effects of excessive reducing the effects of excessive acetylcholine on these sites brought acetylcholine on these sites brought about by cholinesterase inhibition.about by cholinesterase inhibition.

DOSAGEDOSAGE

AdultAdult1 gtt in the fornix in affected eye 1-3 1 gtt in the fornix in affected eye 1-3

times qd, then taper as necessarytimes qd, then taper as necessaryPediatricPediatric

1 gtt in the fornix in affected eye qd1 gtt in the fornix in affected eye qd

DRUG INTERACTIONDRUG INTERACTION

Atropine is an alkaloid (a family of chemicals with Atropine is an alkaloid (a family of chemicals with pharmacologic activity and a common structure) pharmacologic activity and a common structure) that affects the nervous system. It is found in that affects the nervous system. It is found in deadly nightshade deadly nightshade (Atropa belladonna)(Atropa belladonna) and other and other plants. Some effects of atropine include blurred plants. Some effects of atropine include blurred vision, dilated pupils, constipation, dry mouth, and vision, dilated pupils, constipation, dry mouth, and dry eyes.dry eyes.

Coadministration with other anticholinergics have Coadministration with other anticholinergics have additive effects; pharmacologic effects of atenolol additive effects; pharmacologic effects of atenolol and digoxin may increase with atropine; and digoxin may increase with atropine; antipsychotic effects of phenothiazines may antipsychotic effects of phenothiazines may decrease with this medication; tricyclic decrease with this medication; tricyclic antidepressants with anticholinergic activity may antidepressants with anticholinergic activity may increase effects of atropine.increase effects of atropine.

Summary of Interactions with Vitamins, Summary of Interactions with Vitamins, Herbs, and FoodsHerbs, and Foods

Avoid: Tannin-containing herbs* such Avoid: Tannin-containing herbs* such as green tea, black tea, uva ursi, as green tea, black tea, uva ursi, black walnut, black walnut, red raspberryred raspberry, oak, and , oak, and witch hazelwitch hazel

Reduced drug Reduced drug absorption/bioavailabilityabsorption/bioavailability—Avoid —Avoid these these supplementssupplements when taking this when taking this medication since the supplement may medication since the supplement may decrease the absorption and/or decrease the absorption and/or activity of the medication in the body.activity of the medication in the body.

Summary of Interactions with Vitamins, Summary of Interactions with Vitamins, Herbs, and FoodsHerbs, and Foods

Depletion or interference; Depletion or interference; Side effect reduction/prevention;Side effect reduction/prevention;Supportive interaction;Supportive interaction;Adverse interaction- Adverse interaction- None knownNone known

Interactions with HerbsInteractions with Herbs

Tannin-containing herbsTannin-containing herbsTannins are a group of unrelated Tannins are a group of unrelated chemicals that give plants an chemicals that give plants an astringent taste. Herbs containing high astringent taste. Herbs containing high amounts of tanninsamounts of tannins which which may may interfere with the absorption of interfere with the absorption of atropine taken by mouth.atropine taken by mouth.

PREVENTIONPREVENTION

Early recognition and treatment of Early recognition and treatment of amblyopia in children can help to amblyopia in children can help to prevent permanent visual deficits. prevent permanent visual deficits.

All children should have a complete All children should have a complete eye examination at least once eye examination at least once between age three and five to avoid between age three and five to avoid the risk of allowing unsuspected the risk of allowing unsuspected amblyopia to go beyond the age amblyopia to go beyond the age where it can be treated successfully.where it can be treated successfully.

BLEPHARITISBLEPHARITIS

Medical term for inflammation of the Medical term for inflammation of the eyelids eyelids

It is not contagious.It is not contagious.And generally does not cause any And generally does not cause any

permanent damage to eyesight.permanent damage to eyesight.Another term for blepharitis is Another term for blepharitis is

granulated eyelids. granulated eyelids.

Cause of blepharitisCause of blepharitis A malfunction of the oil A malfunction of the oil

glands of the eye lids.glands of the eye lids. When these oil glands produce When these oil glands produce

too much, too little, or the too much, too little, or the wrong types of oils, the eyelid wrong types of oils, the eyelid margins can become inflamed, margins can become inflamed, irritated, and itchy. irritated, and itchy.

Blepharitis that are due to Blepharitis that are due to disorders of the lid margin disorders of the lid margin around the lashes include around the lashes include seborrheic blepharitis, which is seborrheic blepharitis, which is similar to similar to dandruffdandruff of the of the scalp, and infection of the lash scalp, and infection of the lash base by base by StaphylococcalStaphylococcal bacteria. bacteria.

Cause of blepharitisCause of blepharitis

AllergiesAllergiesA primary infection of the eyelids by A primary infection of the eyelids by

bacteria or infestation of the lashes bacteria or infestation of the lashes by tiny mites or by tiny mites or head licehead lice. .

Symptoms and Signs Symptoms and Signs Itchy eyelids ,Itchy eyelids , dryness of the eyesdryness of the eyes,, burning, gritty, sandy sensation in the burning, gritty, sandy sensation in the

eyeseyes foreign-body sensation (the feeling foreign-body sensation (the feeling

that something "may be in the eye")that something "may be in the eye") crusting of the eyelids,crusting of the eyelids, irritation,irritation, decreased comfort while wearing decreased comfort while wearing

contact lenses, andcontact lenses, and sensitivity to light.sensitivity to light.

DIAGNOSISDIAGNOSIS

Usually diagnosed by a physician Usually diagnosed by a physician The physical examination should The physical examination should

place special emphasis on evaluation place special emphasis on evaluation of the eyelids, lid margins, base of of the eyelids, lid margins, base of the lashes, oil gland openings, tear the lashes, oil gland openings, tear quantity and quality, and front quantity and quality, and front surface of the eyeball using a slit surface of the eyeball using a slit lamp, which allows a magnified view lamp, which allows a magnified view with sufficient illumination. with sufficient illumination.

TREATMENTTREATMENT

Good eyelid hygiene and a regular cleaning Good eyelid hygiene and a regular cleaning routine can control blepharitis. This includes routine can control blepharitis. This includes frequent scalp and face washing, using frequent scalp and face washing, using warm compresses to soak the eyelids, and warm compresses to soak the eyelids, and doing eyelid scrubs. doing eyelid scrubs.

Limiting or stopping the use of eye makeup Limiting or stopping the use of eye makeup when treating blepharitis is often when treating blepharitis is often recommended, as its use will make lid recommended, as its use will make lid hygiene more difficult. hygiene more difficult.

If you wear contact lenses, you may have to If you wear contact lenses, you may have to temporarily discontinue wearing them temporarily discontinue wearing them during treatment. during treatment.

TREATMENTTREATMENT In cases where a bacterial infection is the In cases where a bacterial infection is the

cause, various antibiotic drops or ointment cause, various antibiotic drops or ointment and other medications may be prescribed and other medications may be prescribed along with eyelid hygiene. along with eyelid hygiene.

Depending on the degree of inflammation Depending on the degree of inflammation of the lid margin, a combination of topical of the lid margin, a combination of topical antibiotic and steroid drops or ointments antibiotic and steroid drops or ointments can be prescribed by your physician. can be prescribed by your physician.

If the blepharitis is due to allergy, efforts If the blepharitis is due to allergy, efforts should be made to identify and reduce the should be made to identify and reduce the exposure to the offending agent. exposure to the offending agent. Prescription and Prescription and over-the-counterover-the-counter drop or drop or oral antihistamines may be used oral antihistamines may be used

CORTISPORIN® CreamCORTISPORIN® Cream(neomycin and polymyxin B sulfates and (neomycin and polymyxin B sulfates and

hydrocortisone acetate) Cream, USPhydrocortisone acetate) Cream, USP

topicaltopical antibacterialantibacterial cream. cream. Neomycin sulfate is the Neomycin sulfate is the

sulfate salt of neomycin B sulfate salt of neomycin B and C, which are produced and C, which are produced by the growth of by the growth of Streptomyces fradiaeStreptomyces fradiae Waksman (Fam. Waksman (Fam. Streptomycetaceae).. The Streptomycetaceae).. The structural formulae are:structural formulae are:

Polymyxin B sulfate is the Polymyxin B sulfate is the sulfate salt of polymyxin B1 sulfate salt of polymyxin B1 and B2, which are produced and B2, which are produced by the growth of by the growth of Bacillus Bacillus polymyxa polymyxa (Prazmowski) (Prazmowski) Migula (Fam. Bacillaceae). Migula (Fam. Bacillaceae). The structural formulae areThe structural formulae are::

Hydrocortisone Hydrocortisone acetate is the acetate acetate is the acetate ester of ester of hydrocortisone, an hydrocortisone, an anti-inflammatory anti-inflammatory hormonehormone. Its structural . Its structural formula is:formula is:

The base is a smooth The base is a smooth vanishing cream with vanishing cream with a pH of approximately a pH of approximately 5.05.0

DOSAGE AND DOSAGE AND ADMINISTRATIONADMINISTRATION

A small quantity of the cream should A small quantity of the cream should be applied 2 to 4 times daily, as be applied 2 to 4 times daily, as required. required.

The cream should, if conditions The cream should, if conditions permit, be gently rubbed into the permit, be gently rubbed into the affected areas. affected areas.

SIDE EFFECTSSIDE EFFECTS

Neomycin occasionally causes skin Neomycin occasionally causes skin sensitization. sensitization.

Ototoxicity and nephrotoxicity have Ototoxicity and nephrotoxicity have also been reported.also been reported.

Local adverse reactions have been Local adverse reactions have been reported with topical corticosteroids, reported with topical corticosteroids, especially under occlusive dressings: especially under occlusive dressings: burning, burning, itchingitching, irritation, dryness, , irritation, dryness, folliculitis, hypertrichosis.folliculitis, hypertrichosis.

Pred GPred G(gentamicin sulfate and prednisolone (gentamicin sulfate and prednisolone

acetate) Suspensionacetate) Suspension PRED-G® sterile ophthalmic suspension is a topical anti-PRED-G® sterile ophthalmic suspension is a topical anti-

inflammatory/anti-infective combination product for ophthalmic use.inflammatory/anti-infective combination product for ophthalmic use.

Gentamicin sulfate is the sulfate salt of gentamicin C1, gentamicin Gentamicin sulfate is the sulfate salt of gentamicin C1, gentamicin C2, and gentamicin C1A which are produced by the growth of C2, and gentamicin C1A which are produced by the growth of Micromonospora purpureaMicromonospora purpurea..

INDICATIONSINDICATIONS PRED-G® suspension is indicated for steroid-responsive PRED-G® suspension is indicated for steroid-responsive

inflammatory ocular conditions for which a inflammatory ocular conditions for which a corticosteroidcorticosteroid is is indicated and where superficial bacterial ocular infection or a indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists. risk of bacterial ocular infection exists.

Ocular steroids are indicated in inflammatory conditions of the Ocular steroids are indicated in inflammatory conditions of the palpebral and palpebral and bulbar conjunctivabulbar conjunctiva , , corneacornea, and anterior segment , and anterior segment of the globe where the inherent risk of of the globe where the inherent risk of steroidsteroid use in certain use in certain infective conjunctivitides is accepted to obtain a diminution in infective conjunctivitides is accepted to obtain a diminution in edemaedema and and inflammationinflammation. They are also indicated in chronic . They are also indicated in chronic anterior anterior uveitisuveitis and corneal injury from chemical, and corneal injury from chemical, radiationradiation, or , or thermal burns or penetration of foreign bodies.thermal burns or penetration of foreign bodies.

The use of a combination drug with an The use of a combination drug with an anti-infectiveanti-infective component component is indicated where the risk of superficial ocular infection is high is indicated where the risk of superficial ocular infection is high or where there is an expectation that potentially dangerous or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye.numbers of bacteria will be present in the eye.

The particular anti-infective drug in this product is active The particular anti-infective drug in this product is active against the following common bacterial eye pathogens:against the following common bacterial eye pathogens: Staphylococcus aureus, Staphylococcus aureus, Streptococcus pyogenesStreptococcus pyogenes , , Streptococcus pneumoniaeStreptococcus pneumoniae , Enterobacter aerogenes, , Enterobacter aerogenes, Escherichia coliEscherichia coli , Haemophilus influenzae, Klebsiella , Haemophilus influenzae, Klebsiella pneumoniae, Neisseria gonorrhoeae, pneumoniae, Neisseria gonorrhoeae, Pseudomonas aeruginosaPseudomonas aeruginosa , , and and Serratia marcescensSerratia marcescens..


Instill one drop into the conjunctival Instill one drop into the conjunctival sac two to four times daily. During sac two to four times daily. During the initial 24 to 48 hours, the dosing the initial 24 to 48 hours, the dosing frequency may be increased, if frequency may be increased, if necessary, up to 1 drop every hour. necessary, up to 1 drop every hour. Care should be taken not to Care should be taken not to discontinue therapy prematurely.discontinue therapy prematurely.

Not more than 20 milliliters should Not more than 20 milliliters should be prescribed initiallybe prescribed initially

Stinging/burning of Stinging/burning of the eyes for 1 to 2 the eyes for 1 to 2 minutes may occur minutes may occur when this when this medication is medication is applied. applied.

This includes:This includes: Keeping your hands Keeping your hands

and face clean.and face clean. Avoiding rubbing Avoiding rubbing

your eyes with dirty your eyes with dirty fingers, a soiled fingers, a soiled handkerchief, etc.handkerchief, etc.

Removing all eye Removing all eye makeup before makeup before bedtime.bedtime.

SIDE SIDE EFFECTSEFFECTS

PREVENTION

CATARACTCATARACT

It is a clouding of the lens in the eye It is a clouding of the lens in the eye that affects vision. that affects vision.

It is related to aging. It is related to aging. A cataract can occur in either or both A cataract can occur in either or both

eyes. It cannot spread from one eye eyes. It cannot spread from one eye to the other.to the other.

CAUSES OF CATARACTCAUSES OF CATARACT

As we age, proteins of the lens clump As we age, proteins of the lens clump together and start clouding a small together and start clouding a small area of the lens. area of the lens.

It may be that the protein in the lens It may be that the protein in the lens just changes from the wear and tear just changes from the wear and tear it takes over the years.it takes over the years.

Smoking Smoking Diabetes. Diabetes.

TYPES OF CATARACTSTYPES OF CATARACTS Secondary cataract.Secondary cataract. Cataracts can form after Cataracts can form after

surgery for other eye problems, such as surgery for other eye problems, such as glaucomaglaucoma. Cataracts also can develop in people . Cataracts also can develop in people who have other health problems, such as who have other health problems, such as diabetesdiabetes. Cataracts are sometimes linked to . Cataracts are sometimes linked to steroid use.steroid use.

Traumatic cataract.Traumatic cataract. Cataracts can develop Cataracts can develop after an eye injury, sometimes years later.after an eye injury, sometimes years later.

Congenital cataract.Congenital cataract. Some babies are born with Some babies are born with cataracts or develop them in childhood, often in cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses they do not affect vision. If they do, the lenses may need to be removed.may need to be removed.

Radiation cataract.Radiation cataract. Cataracts can develop after Cataracts can develop after exposure to some types of radiation.exposure to some types of radiation.

SYMPTOMSSYMPTOMS

Cloudy or blurry vision.Cloudy or blurry vision. Colors seem faded.Colors seem faded. Glare. Headlights, lamps, or sunlight may Glare. Headlights, lamps, or sunlight may

appear too bright. A halo may appear appear too bright. A halo may appear around lights.around lights.

Poor night vision.Poor night vision. Double vision or multiple images in one Double vision or multiple images in one

eye. (This symptom may clear as the eye. (This symptom may clear as the cataract gets larger.)cataract gets larger.)

Frequent prescription changes in your Frequent prescription changes in your eyeglasses or contact lenses.eyeglasses or contact lenses.

DIAGNOSISDIAGNOSIS Visual acuity test.Visual acuity test. This eye chart test This eye chart test

measures how well you see at various measures how well you see at various distances.distances.

Dilated eye exam.Dilated eye exam. Drops are placed in Drops are placed in your eyes to widen, or dilate, the pupils. your eyes to widen, or dilate, the pupils. Your eye care professional uses a special Your eye care professional uses a special magnifying lens to examine your retina and magnifying lens to examine your retina and optic nerve for signs of damage and other optic nerve for signs of damage and other eye problems. After the exam, your close-up eye problems. After the exam, your close-up vision may remain blurred for several hours.vision may remain blurred for several hours.

Tonometry.Tonometry. An instrument measures the An instrument measures the pressure inside the eye. Numbing drops may pressure inside the eye. Numbing drops may be applied to your eye for this test.be applied to your eye for this test.

TREATMENTTREATMENT

The symptoms of early cataracts The symptoms of early cataracts may be improved with new may be improved with new eyeglasses, brighter lighting, anti-eyeglasses, brighter lighting, anti-glare sunglasses, or magnifying glare sunglasses, or magnifying lenses.lenses.

SurgerySurgery

Phenylephrine HCl (Neo-Phenylephrine HCl (Neo-Synephrine)Synephrine)

NEO-SYNEPHRINE hydrochloride, NEO-SYNEPHRINE hydrochloride, brand of phenylephrine hydrochloride brand of phenylephrine hydrochloride ophthalmic solution, is a sterile ophthalmic solution, is a sterile solution used as a vasoconstrictor and solution used as a vasoconstrictor and mydriatic for use in ophthalmology. mydriatic for use in ophthalmology.

Hydrochloride is a synthetic Hydrochloride is a synthetic sympathomimetic compound sympathomimetic compound structurally similar to structurally similar to epinephrineepinephrine and and ephedrine. ephedrine.

Phenylephrine Phenylephrine hydrochloride has the hydrochloride has the following structural following structural formula:formula:

INDICATIONSINDICATIONS

NEO-SYNEPHRINE hydrochloride is NEO-SYNEPHRINE hydrochloride is recommended for use as a recommended for use as a decongestantdecongestant and vasoconstrictor and vasoconstrictor and for and for pupilpupil dilatationdilatation in in uveitisuveitis ( (posteriorposterior synechiae), wide angle synechiae), wide angle glaucomaglaucoma, prior to , prior to surgerysurgery, , refractionrefraction, ophthalmoscopic examination, and , ophthalmoscopic examination, and diagnostic procedures.diagnostic procedures.


AdultsAdultsInstill 1 drop of 2.5% solution in each Instill 1 drop of 2.5% solution in each

eye. Dilation lasts from 1 to 3 h.eye. Dilation lasts from 1 to 3 h.

DRUG INTERACTIONSDRUG INTERACTIONS As with all other adrenergic drugs, when NEO-As with all other adrenergic drugs, when NEO-

SYNEPHRINE 10 percent SYNEPHRINE 10 percent ophthalmicophthalmic solutions or 2.5 solutions or 2.5 percent ophthalmic solution is administered percent ophthalmic solution is administered simultaneously with, or up to 21 days after, simultaneously with, or up to 21 days after, administration of monoamine oxidase (MAO) inhibitors, administration of monoamine oxidase (MAO) inhibitors, careful supervision and adjustment of dosages are careful supervision and adjustment of dosages are required since exaggerated adrenergic effects may required since exaggerated adrenergic effects may occur. occur.

The The pressorpressor response of adrenergic agents may also be response of adrenergic agents may also be potentiated by tricyclic antidepressants, propranolol, potentiated by tricyclic antidepressants, propranolol, reserpine, guanethidine, methyldopa, and atropine-like reserpine, guanethidine, methyldopa, and atropine-like drugs. drugs.

It has been reported that the concomitant use of NEO-It has been reported that the concomitant use of NEO-SYNEPHRINE 10 percent ophthalmic solutions and SYNEPHRINE 10 percent ophthalmic solutions and systemicsystemic beta blockers has caused beta blockers has caused acuteacute hypertensionhypertension and, in one case, the and, in one case, the rupturerupture of a of a congenitalcongenital cerebral aneurysmcerebral aneurysm. NEO-SYNEPHRINE may potentiate . NEO-SYNEPHRINE may potentiate the the cardiovascularcardiovascular depressant effects of potent depressant effects of potent inhalation inhalation anestheticanesthetic agents. agents.

PreventionPrevention

regular eye exams,regular eye exams,quit smoking, and quit smoking, and eating foods rich in antioxidantseating foods rich in antioxidants

CORNEAL DISEASECORNEAL DISEASE

If your cornea becomes damaged If your cornea becomes damaged through disease, infection, or injury, through disease, infection, or injury, the resulting the resulting scarsscars can interfere with can interfere with vision by blocking or distorting light vision by blocking or distorting light as it enters the eye. as it enters the eye.

SYMPTOMSSYMPTOMS

Pain Pain Blurred vision Blurred vision Tearing Tearing Redness Redness Extreme sensitivity to light Extreme sensitivity to light Corneal scarringCorneal scarring

CONDITIONS THAT CAN DAMAGE CONDITIONS THAT CAN DAMAGE THE CORNEATHE CORNEA

KeratitisKeratitisOcular Herpes (Herpes of the Ocular Herpes (Herpes of the

EyeEye))Herpes Zoster (Shingles)Herpes Zoster (Shingles)Corneal Dystrophies:Corneal Dystrophies:

KeratoconusKeratoconusFuchs' DystrophyFuchs' DystrophyLattice DystrophyLattice DystrophyMap-Dot-Fingerprint DystrophyMap-Dot-Fingerprint Dystrophy

DIAGNOSISDIAGNOSIS

Corneal disease can only be Corneal disease can only be diagnosed after a thorough diagnosed after a thorough examination by an ophthalmologist examination by an ophthalmologist

PREVENTIONPREVENTION Infectious corneal disease caused from bacteria and Infectious corneal disease caused from bacteria and

viruses can be prevented by protecting the eye from viruses can be prevented by protecting the eye from injury and limiting physical contact with people who injury and limiting physical contact with people who have contagious forms of conjunctivitis. have contagious forms of conjunctivitis.

Avoid sharing eye makeup, contact solution, lens Avoid sharing eye makeup, contact solution, lens cases, and eye drops with people who are infected cases, and eye drops with people who are infected and wash your hands thoroughly with soap and and wash your hands thoroughly with soap and warm water for at least 15 seconds after contact warm water for at least 15 seconds after contact with an infected person. with an infected person.

Although corneal disease resulting from hereditary Although corneal disease resulting from hereditary factors, like dystrophies, cannot be prevented, vision factors, like dystrophies, cannot be prevented, vision can be preserved by early detection and treatment.can be preserved by early detection and treatment.

Symptoms may disappear with treatment, but a Symptoms may disappear with treatment, but a corneal transplant may be required. corneal transplant may be required.

KERATITISKERATITIS

This is an inflammation of the cornea This is an inflammation of the cornea that sometimes occurs with infection that sometimes occurs with infection after bacteria or fungi enter the after bacteria or fungi enter the cornea. These microorganisms can cornea. These microorganisms can enter the eye after deep injury, enter the eye after deep injury, causing infection, inflammation, and causing infection, inflammation, and ulceration of the cornea. ulceration of the cornea.

TYPICAL KERATITIS RED EYE KERATITIS

Ocular Herpes (Herpes of the Ocular Herpes (Herpes of the Eye)Eye)

This is a viral infection of the eye This is a viral infection of the eye that may reoccur.that may reoccur.

Herpes Zoster (Shingles)Herpes Zoster (Shingles)

ShinglesShingles is a recurrence is a recurrence of the of the chickenpoxchickenpox virus in virus in people who have already people who have already had the disease. After had the disease. After having chickenpox, this having chickenpox, this virus usually remains virus usually remains inactive within the nerves inactive within the nerves of the body. It can later of the body. It can later travel down these nerves, travel down these nerves, infecting specific parts of infecting specific parts of the body, like the eye.the body, like the eye.

KeratoconusKeratoconus

A type of corneal dystrophyA type of corneal dystrophy It a progressive disease where the It a progressive disease where the

cornea thins and changes shape cornea thins and changes shape

Map-Dot-Fingerprint Map-Dot-Fingerprint DystrophyDystrophy

It is the abnormal It is the abnormal appearance of the appearance of the basement membrane of the basement membrane of the epithelium of the cornea. epithelium of the cornea. As this membrane that As this membrane that separates the epithelium separates the epithelium and stroma grows and stroma grows irregularly (thicker in some irregularly (thicker in some places, thinner in others), places, thinner in others), findings in the cornea findings in the cornea appear, resembling maps, appear, resembling maps, dots and small fingerprints. dots and small fingerprints.

Fuchs' DystrophyFuchs' Dystrophy

It is the gradual deterioration of It is the gradual deterioration of endothelial cells for no apparent endothelial cells for no apparent reason. As these cells thin over time, reason. As these cells thin over time, the cornea is less capable of the cornea is less capable of removing water form the stroma, removing water form the stroma, causing it to swell and distort vision. causing it to swell and distort vision.

Lattice DystrophyLattice Dystrophy Lattice dystrophy is a Lattice dystrophy is a

condition condition characterized by an characterized by an accumulation of accumulation of abnormal protein abnormal protein fibers, throughout fibers, throughout the middle and the middle and anterior stroma. anterior stroma.

HYPEROPIAHYPEROPIA

Also known as farsightednessAlso known as farsightedness It is a problem where one cannot see It is a problem where one cannot see

up-close objectsup-close objects

It is a refractive It is a refractive errorerror

Glasses, Glasses, contact lenses, or contact lenses, or refractive surgery refractive surgery

SYMPTOMSSYMPTOMSHeadaches Headaches Eye strain Eye strain Difficulty concentrating or focusing on Difficulty concentrating or focusing on nearby objects nearby objects Fatigue or headache after performing a close Fatigue or headache after performing a close tasktask DIAGNOSISDIAGNOSIS

Eye examEye exam

CAUSECAUSE TREATMENT

IRITISIRITIS

Iritis is an inflammatory condition of Iritis is an inflammatory condition of the colored portion (the iris which the colored portion (the iris which surrounds the pupil) of the eye. surrounds the pupil) of the eye.

CAUSECAUSE

An infection of the eye or An infection of the eye or inflammation from trauma may inflammation from trauma may cause iritis. cause iritis.

Iritis may also be a complication of Iritis may also be a complication of many diseases such as many diseases such as juvenile rheumatoid arthritisjuvenile rheumatoid arthritis, , ankylosingankylosing spondylitisspondylitis, , tuberculosistuberculosis, , sarcoidosissarcoidosis, and collagen vascular , and collagen vascular diseases such as diseases such as lupuslupus. .

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

Iritis appears as a red, painful eye Iritis appears as a red, painful eye which may be accompanied by which may be accompanied by blurred vision and sensitivity to light. blurred vision and sensitivity to light.

In addition, the pupil of the affected In addition, the pupil of the affected eye may be smaller than that of the eye may be smaller than that of the healthy eye. healthy eye.

DIAGNOSISDIAGNOSIS

ophthalmologist ophthalmologist After measuring the vision, the eye is After measuring the vision, the eye is

inspected with a slit lamp inspected with a slit lamp (biomicroscope) where microscopic (biomicroscope) where microscopic cells are seen in the front part of the cells are seen in the front part of the eye. eye.

TREATMENTTREATMENT

Usually treat the underlying cause Usually treat the underlying cause e.g infectione.g infection

Anti-inflammatory cortisone (steroid) Anti-inflammatory cortisone (steroid) eye drops, often accompanied by eye drops, often accompanied by drops to enlarge (the pupil). drops to enlarge (the pupil).

Cyclopentolate 0.5-2% Cyclopentolate 0.5-2% (Cyclogyl)(Cyclogyl)

It is a Cycloplegics agent that causes It is a Cycloplegics agent that causes nerve impulses to the pupillary nerve impulses to the pupillary sphincter and ciliary muscles, easing sphincter and ciliary muscles, easing pain and photophobia.pain and photophobia.

DOSAGEDOSAGE

AdultAdult1 gtt tid1 gtt tid

PediatricPediatricAdminister as in adultsAdminister as in adults

Prednisolone acetate 1% Prednisolone acetate 1% (AK-Pred, Pred Forte)(AK-Pred, Pred Forte)

Topical anti-Topical anti-inflammatory inflammatory agent for agent for ophthalmic use. ophthalmic use.

It is a Topical It is a Topical steroids that steroids that decrease decrease inflammation. inflammation.

Structure:Structure:


PRED FORTE® is indicated for the PRED FORTE® is indicated for the treatment of steroid-responsive treatment of steroid-responsive inflammationinflammation of the palpebral and of the palpebral and bulbar conjunctivabulbar conjunctiva, , corneacornea, and , and anterioranterior segment of the globe. segment of the globe.


Shake well before using. Shake well before using. Instill one to two drops into the Instill one to two drops into the

conjunctivalconjunctival sac two to four times sac two to four times daily. During the initial 24 to 48 daily. During the initial 24 to 48 hours, the dosing frequency may be hours, the dosing frequency may be increased if necessary. increased if necessary.

SIDE EFFECTSSIDE EFFECTS Adverse reactions include, in Adverse reactions include, in

decreasing order of frequency:decreasing order of frequency: elevation of elevation of intraocularintraocular pressure ( pressure (IOPIOP) )

with possible development of with possible development of glaucomaglaucoma and infrequent and infrequent optic nerveoptic nerve damage, damage,

posteriorposterior subcapsular subcapsular cataractcataract formation, delayed wound healing. formation, delayed wound healing.

visual disturbance (blurry vision);visual disturbance (blurry vision);foreign body foreign body sensationsensation; ; allergic reactions.allergic reactions.

CONJUNCTIVITISCONJUNCTIVITIS

Pink eye, or conjunctivitis is redness Pink eye, or conjunctivitis is redness and inflammation of the membranes and inflammation of the membranes (conjunctiva) covering the whites of (conjunctiva) covering the whites of the eyes and the membranes on the the eyes and the membranes on the inner part of the eyelids. inner part of the eyelids.

CAUSESCAUSESINFECTIOUSINFECTIOUS

Viral pink eyeViral pink eyeBacterial pink eyeBacterial pink eyeChlamydia pink eyeChlamydia pink eye

NON-INFECTIOUSNON-INFECTIOUSAllergic pink eyeAllergic pink eye Chemical pink eyeChemical pink eye

Underlying diseasesUnderlying diseasesSubconjuctival hemorrhageSubconjuctival hemorrhage

TREATMENTTREATMENT

Moist warm compresserMoist warm compresserEyedropsEyedrops

PREVENTIONPREVENTION Infectious pink eye is contagious soInfectious pink eye is contagious so

avoid touching the eye area and avoid touching the eye area and wash your hands frequently, particularly wash your hands frequently, particularly

after applying medications to the eye after applying medications to the eye area. area.

Never share towels or handkerchiefs, and Never share towels or handkerchiefs, and throw away tissues after each use. throw away tissues after each use. Disinfecting surfaces like countertops, Disinfecting surfaces like countertops,

sinks, and doorknobs sinks, and doorknobs

AzaSite (azithromycin AzaSite (azithromycin ophthalmic solution)ophthalmic solution)

It is a It is a 1% sterile 1% sterile aqueous topical aqueous topical ophthalmic solution of ophthalmic solution of azithromycin azithromycin formulated in formulated in DuraSite® DuraSite® (polycarbophil, (polycarbophil, edetate disodium, edetate disodium, sodium chloride). sodium chloride).

AzaSite is an off-white, AzaSite is an off-white, viscous liquid viscous liquid



AzaSite is indicated for the treatment AzaSite is indicated for the treatment of bacterial conjunctivitis caused by of bacterial conjunctivitis caused by susceptible isolates of the following susceptible isolates of the following microorganisms: microorganisms:

CDC coryneform group G*CDC coryneform group G*Haemophilus influenzae Haemophilus influenzae Staphylococcus aureus Staphylococcus aureus Streptococcus mitis group Streptococcus mitis group Streptococcus pneumoniaeStreptococcus pneumoniae


The recommended dosage regimen The recommended dosage regimen for the treatment of bacterial for the treatment of bacterial conjunctivitis is: Instill 1 drop in the conjunctivitis is: Instill 1 drop in the affected eye(s) twice daily, eight to affected eye(s) twice daily, eight to twelve hours apart for the first two twelve hours apart for the first two days and then instill 1 drop in the days and then instill 1 drop in the affected eye(s) once daily for the affected eye(s) once daily for the next five days.next five days.

SIDE EFFECTSSIDE EFFECTS

Eye irritationEye irritationBurningBurningStinging Stinging

PresbyopiaPresbyopia Presbyopia is part of the Presbyopia is part of the

natural aging process of natural aging process of the eye, and can be the eye, and can be easily corrected. easily corrected.

Technically, presbyopia is Technically, presbyopia is the loss of the eye's the loss of the eye's ability to change its focus ability to change its focus to see objects that are to see objects that are near. near.

It is not a disease It is not a disease Presbyopia occurs when Presbyopia occurs when

the eye's lens loses the eye's lens loses flexibility. flexibility.

SYMPTOMSSYMPTOMS

Blurred vision at a normal reading Blurred vision at a normal reading distance distance

The need to hold reading material at The need to hold reading material at arm's length arm's length

Headaches from doing close work Headaches from doing close work

DIAGNOSISDIAGNOSIS•Eye examEye exam

TREATMENTTREATMENT

It cannot be curedIt cannot be curedHowever, use of:However, use of:

prescription glasses, prescription glasses, contact lens, contact lens, reading glasses, reading glasses, progressive addition lenses, or progressive addition lenses, or bifocals can help correct the effects of bifocals can help correct the effects of

presbyopia presbyopia

Strabismus Strabismus

Also known as crossed Also known as crossed eyes,or eyes,or Esotropia Esotropia is a is a condition in which the condition in which the eyes don't look towards eyes don't look towards an object together. One an object together. One of the eyes may look in of the eyes may look in or out, or turn up or or out, or turn up or down. The eye turning down. The eye turning can occur all of the time can occur all of the time or only sometimes, such or only sometimes, such as during stressful as during stressful situations or illness.situations or illness.

CAUSECAUSE

congenital strabismus- where congenital strabismus- where persons born with such a disorderpersons born with such a disorder

TREATMENTTREATMENT

Physical therapy of eye musclePhysical therapy of eye muscleVision therapyVision therapySurgerySurgery

ULTIVA®ULTIVA®(remifentanil hydrochloride) for (remifentanil hydrochloride) for

InjectionInjection It is a sterile, It is a sterile,

nonpyrogenic, nonpyrogenic, preservative-free, preservative-free, white to off-white white to off-white lyophilized powder lyophilized powder for for intravenousintravenous (IV) (IV) administration administration after reconstitution after reconstitution and dilution. and dilution.


ULTIVA is indicated for IV administration:ULTIVA is indicated for IV administration: As an As an analgesicanalgesic agent for use during the agent for use during the

induction and maintenance of general induction and maintenance of general anesthesiaanesthesia for for inpatientinpatient and and outpatientoutpatient procedures.procedures.

For continuation as an analgesic into the For continuation as an analgesic into the immediate immediate postoperativepostoperative period in adult period in adult patients under the direct supervision of an patients under the direct supervision of an anesthesia practitioner in a postoperative anesthesia practitioner in a postoperative anesthesia care unit or anesthesia care unit or intensive careintensive care setting.setting.

As an analgesic component of monitored As an analgesic component of monitored anesthesia care in adult patients.anesthesia care in adult patients.


ULTIVA is for IV use only. ULTIVA is for IV use only. Continuous infusions of ULTIVA Continuous infusions of ULTIVA should be administered only by should be administered only by an infusion device. The injection an infusion device. The injection site should be close to the site should be close to the venous cannula and all IV tubing venous cannula and all IV tubing should be cleared at the time of should be cleared at the time of discontinuation of infusiondiscontinuation of infusion..

CONTRAINDICATIONSCONTRAINDICATIONS

Due to the presence of Due to the presence of glycineglycine in the in the formulation, ULTIVA is formulation, ULTIVA is contraindicated for contraindicated for epiduralepidural or or intrathecal administration. ULTIVA is intrathecal administration. ULTIVA is also contraindicated in patients with also contraindicated in patients with known hypersensitivity to fentanyl known hypersensitivity to fentanyl analogs.analogs.

Chalazion Chalazion

A chalazion is a tiny A chalazion is a tiny lump of the upper or lump of the upper or lower eyelid caused by lower eyelid caused by inflammation of a inflammation of a gland of the lid. gland of the lid.

It may be soft and It may be soft and fluid-filled or firmer. fluid-filled or firmer.

A chalazion is also A chalazion is also referred to as a referred to as a meibomianmeibomian cyst cyst, , tarsal cysttarsal cyst, or , or conjunctival conjunctival granulomagranuloma..

CAUSESCAUSES

The narrow opening through which a The narrow opening through which a meibomianmeibomian gland gland secretes its secretes its material can become clogged from material can become clogged from narrowing of the opening or narrowing of the opening or hardening of the sebaceous liquid hardening of the sebaceous liquid near the opening. near the opening.

If this occurs, the gland will have a If this occurs, the gland will have a backup of the material it secretes backup of the material it secretes and it will swell. and it will swell.

SYMPTOMSSYMPTOMS

Thickening of the walls of the glandThickening of the walls of the glandLeakage of oil into the lid itself, Leakage of oil into the lid itself,

causing inflammation both within the causing inflammation both within the gland and the eyelid. gland and the eyelid.

TREATMENTTREATMENT

Warm compresses to the eyelid to Warm compresses to the eyelid to promote healing and circulation of promote healing and circulation of blood to the inflamed area. blood to the inflamed area.

An antibiotic drop or ointment to be An antibiotic drop or ointment to be used immediately after the used immediately after the compresses compresses

SurgerySurgery

Triamcinolone (Amcort)Triamcinolone (Amcort)

For inflammatory dermatosis For inflammatory dermatosis responsive to steroids; decreases responsive to steroids; decreases inflammation by suppressing inflammation by suppressing migration of polymorphonuclear migration of polymorphonuclear leukocytes and reversing capillary leukocytes and reversing capillary permeability permeability

DOSAGEDOSAGE

AdultAdult0.1-0.2 mL of 40 mg/mL 0.1-0.2 mL of 40 mg/mL

PediatricPediatricNot establishedNot established

Injected directly into chalazion's Injected directly into chalazion's center; second injection may be center; second injection may be necessary after a few weeks for larger necessary after a few weeks for larger chalaziachalazia

PREVENTIONPREVENTION

Proper care of eyes should be takenProper care of eyes should be taken It means he/she should perform It means he/she should perform

proper cleansing of the eyelid. proper cleansing of the eyelid. Cleansing the eyelash area with baby Cleansing the eyelash area with baby

shampoo will help reduce clogging of shampoo will help reduce clogging of the ducts. the ducts.

Blindness Blindness

Blindness is defined as the Blindness is defined as the state of being sightless. state of being sightless.

A blind individual is unable A blind individual is unable to see. to see.

In a strict sense the word In a strict sense the word blindnessblindness denotes the denotes the condition of total condition of total blackness of vision with blackness of vision with the inability of a person to the inability of a person to distinguish darkness from distinguish darkness from bright light in either bright light in either eyeeye

TYPES OF BLINDNESSTYPES OF BLINDNESS

Color blindnessColor blindness:- Is the inability to :- Is the inability to perceive differences between some of perceive differences between some of the colors that others can distinguish. the colors that others can distinguish.

Night blindness:-Is a difficulty in Night blindness:-Is a difficulty in seeing under situations of decreased seeing under situations of decreased illumination. illumination.

Snow blindness:-Is loss of vision after Snow blindness:-Is loss of vision after exposure of the eyes to large amounts exposure of the eyes to large amounts of ultraviolet light. of ultraviolet light.

CAUSESCAUSES

diabetesdiabetes, , macular degenerationmacular degeneration, , traumatic injuries. traumatic injuries. infections, infections, cataractscataracts, , glaucomaglaucoma, , inability to obtain any glasses.inability to obtain any glasses.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

discomfort in the eyes, discomfort in the eyes, awareness of the eyes,awareness of the eyes,foreign body sensation, and foreign body sensation, and pain in the eyespain in the eyes or discharge from or discharge from

the eyes may be present or absent, the eyes may be present or absent, depending on the underlying cause depending on the underlying cause of the blindness. of the blindness.

DIAGNOSISDIAGNOSIS

Blindness is diagnosed by visual Blindness is diagnosed by visual acuity testing in each eye acuity testing in each eye individually and by measuring the individually and by measuring the visual field or peripheral vision. visual field or peripheral vision.

TREATMENTTREATMENT The treatment of blindness depends on the The treatment of blindness depends on the

cause of blindness. cause of blindness. Many people who have poor vision as a Many people who have poor vision as a

result of a refractive error, merely result of a refractive error, merely prescribing and giving glasses will alleviate prescribing and giving glasses will alleviate the problem the problem

NutritionalNutritional causes of blindness can be causes of blindness can be addressed by dietary changes. addressed by dietary changes.

Cataract patients may undergo surgery to Cataract patients may undergo surgery to restore their sightsrestore their sights

Inflammatory and infectious causes of Inflammatory and infectious causes of blindness can be treated with medication in blindness can be treated with medication in the form of drops or pills. the form of drops or pills.

PREVENTIONPREVENTION Most traumatic causes of blindness can be prevented Most traumatic causes of blindness can be prevented

through instruction in eye protection. through instruction in eye protection. Nutritional causes of blindness are preventable Nutritional causes of blindness are preventable

through proper diet. through proper diet. Most cases of blindness from glaucoma are Most cases of blindness from glaucoma are

preventable through early detection and appropriate preventable through early detection and appropriate treatment. treatment.

Visual impairment and blindness caused by Visual impairment and blindness caused by infectious diseases have been greatly reduced infectious diseases have been greatly reduced through international public-health measures.through international public-health measures.

The majority of blindness from The majority of blindness from diabetic retinopathydiabetic retinopathy is is preventable through careful control of blood-sugar preventable through careful control of blood-sugar levels, levels, exerciseexercise, avoidance of , avoidance of obesityobesity and and smokingsmoking, , and emphasis on eating foods that do not increase and emphasis on eating foods that do not increase the sugar load (complex, rather than simple the sugar load (complex, rather than simple carbohydrates). carbohydrates).

TIMOPTIC® TIMOPTIC®

Ophthalmic Solution Ophthalmic Solution 0.25% AND 0.5% 0.25% AND 0.5% TIMOPTIC* (timolol TIMOPTIC* (timolol maleate ophthalmic maleate ophthalmic solution) is a non-solution) is a non-selective beta-selective beta-adrenergic receptor adrenergic receptor blocking agent.blocking agent.

Optically active drugOptically active drug It is a white, odorless, It is a white, odorless,

crystalline powder which crystalline powder which is soluble in water, is soluble in water, methanol, and alcohol.methanol, and alcohol.



TIMOPTIC TIMOPTIC OphthalmicOphthalmic Solution is Solution is indicated in the treatment of indicated in the treatment of elevated elevated intraocular intraocular pressure in pressure in patients with patients with ocularocular hypertensionhypertension or or open-angle glaucomaopen-angle glaucoma..


Starting dose is one drop of 0.25 Starting dose is one drop of 0.25 percent TIMOPTIC in the affected percent TIMOPTIC in the affected eye(s) twice a day. eye(s) twice a day.

If the clinical response is not If the clinical response is not adequate, the dosage may be adequate, the dosage may be changed to one drop of 0.5 percent changed to one drop of 0.5 percent solution in the affected eye(s) twice a solution in the affected eye(s) twice a day.day.

DRUG INTERACTIONSDRUG INTERACTIONS Although TIMOPTIC used alone has little or no effect on pupil Although TIMOPTIC used alone has little or no effect on pupil

size, size, mydriasismydriasis resulting from concomitant therapy with resulting from concomitant therapy with TIMOPTIC and TIMOPTIC and epinephrineepinephrine has been reported occasionally. has been reported occasionally.

Beta-adrenergic blocking agentsBeta-adrenergic blocking agents:: Patients who are Patients who are receiving a beta-adrenergic blocking agent orally and receiving a beta-adrenergic blocking agent orally and TIMOPTIC should be observed for potential additive effects TIMOPTIC should be observed for potential additive effects of beta-blockade, both systemic and on of beta-blockade, both systemic and on intraocular pressureintraocular pressure. The concomitant use of two topical beta-adrenergic . The concomitant use of two topical beta-adrenergic blocking agents is not recommended.blocking agents is not recommended.

Calcium antagonistsCalcium antagonists:: Caution should be used in the Caution should be used in the coadministration of beta-adrenergic blocking agents, such coadministration of beta-adrenergic blocking agents, such as TIMOPTIC, and oral or intravenous calcium antagonists as TIMOPTIC, and oral or intravenous calcium antagonists because of possible because of possible atrioventricularatrioventricular conduction conduction disturbances, left ventricular failure, and hypotension. In disturbances, left ventricular failure, and hypotension. In patients with impaired cardiac function, coadministration patients with impaired cardiac function, coadministration should be avoided.should be avoided.

Catecholamine-depleting drugsCatecholamine-depleting drugs:: Close observation of the Close observation of the patient is recommended when a patient is recommended when a beta blockerbeta blocker is administered to is administered to patients receiving catecholamine-depleting drugs such as patients receiving catecholamine-depleting drugs such as reserpine, because of possible additive effects and the production reserpine, because of possible additive effects and the production of hypotension and/or marked bradycardia, which may result in of hypotension and/or marked bradycardia, which may result in vertigo, syncope, or vertigo, syncope, or postural hypotensionpostural hypotension..

Digitalis and calcium antagonistsDigitalis and calcium antagonists:: The concomitant use of The concomitant use of beta-adrenergic blocking agents with digitalis and calcium beta-adrenergic blocking agents with digitalis and calcium antagonists may have additive effects in prolonging antagonists may have additive effects in prolonging atrioventricular conduction time.atrioventricular conduction time.

CYP2D6 inhibitorsCYP2D6 inhibitors: : Potentiated systemic beta-blockade (e.g., Potentiated systemic beta-blockade (e.g., decreased decreased heart rateheart rate, depression) has been reported during , depression) has been reported during combined treatment with CYP2D6 inhibitors (e.g. quinidine, combined treatment with CYP2D6 inhibitors (e.g. quinidine, SSRIs) and timolol.SSRIs) and timolol.

ClonidineClonidine:: Oral beta-adrenergic blocking agents may exacerbate Oral beta-adrenergic blocking agents may exacerbate the rebound hypertension which can follow the withdrawal of the rebound hypertension which can follow the withdrawal of clonidine. There have been no reports of exacerbation of rebound clonidine. There have been no reports of exacerbation of rebound hypertension with ophthalmic timolol maleate.hypertension with ophthalmic timolol maleate.

Xalatan®Xalatan®

Ophthalmic solution Ophthalmic solution 0.005% (50 µg/mL 0.005% (50 µg/mL Latanoprost is a Latanoprost is a prostaglandin F2α prostaglandin F2α analogue.analogue.

Structure:Structure: Latanoprost is a Latanoprost is a

colorless to slightly colorless to slightly yellow oil that is very yellow oil that is very soluble in acetonitrile soluble in acetonitrile and freely soluble in and freely soluble in acetone, ethanol, ethyl acetone, ethanol, ethyl acetate, isopropanol, acetate, isopropanol, methanol and octanol. methanol and octanol. It is practically It is practically insoluble in water.insoluble in water.


XALATAN Sterile Ophthalmic Solution XALATAN Sterile Ophthalmic Solution is indicated for the reduction of is indicated for the reduction of elevated elevated intraocular pressureintraocular pressure in in patients with patients with open-angle glaucomaopen-angle glaucoma or ocular hypertension.or ocular hypertension.


The recommended dosage is one The recommended dosage is one drop (1.5 ìg) in the affected eye(s) drop (1.5 ìg) in the affected eye(s) once daily in the evening. If one dose once daily in the evening. If one dose is missed, treatment should continue is missed, treatment should continue with the next dose as normal.with the next dose as normal.

DRUG INTERACTIONSDRUG INTERACTIONS

In vitroIn vitro studies have shown that studies have shown that precipitation occurs when eye drops precipitation occurs when eye drops containing thimerosal are mixed with containing thimerosal are mixed with XALATAN. If such drugs are used XALATAN. If such drugs are used they should be administered at least they should be administered at least five (5) minutes apart.five (5) minutes apart.

Glaucoma Glaucoma

Glaucoma is a disease of Glaucoma is a disease of the major nerve of the major nerve of vision, called the vision, called the optic nerveoptic nerve

Glaucoma is Glaucoma is characterized by a characterized by a particular pattern of particular pattern of progressive damage to progressive damage to the optic nerve that the optic nerve that generally begins with a generally begins with a subtle loss of side vision subtle loss of side vision (peripheral vision). (peripheral vision).

CAUSECAUSE

Elevated pressure in the eye is the Elevated pressure in the eye is the main factor leading to glaucomatous main factor leading to glaucomatous damage to the eye (optic) nerve. damage to the eye (optic) nerve.

TYPES OF GLAUCOMATYPES OF GLAUCOMA

open-angle open-angle glaucomasglaucomas:-are :-are conditions of long duration (chronic)conditions of long duration (chronic)

closed-angle (angle closure) closed-angle (angle closure) glaucomas:-which include conditions glaucomas:-which include conditions occurring suddenly (acute)occurring suddenly (acute)

DIAGNOSISDIAGNOSIS ophthalmologist ophthalmologist TESTS:-TESTS:-

TonometryTonometry determines the pressure in the eye by determines the pressure in the eye by measuring the tone or firmness of its surface. measuring the tone or firmness of its surface.

PachymetryPachymetry determines the thickness of the determines the thickness of the corneacornea

GonioscopyGonioscopy is done by numbing the eye with is done by numbing the eye with anesthetic drops and placing a special type of thick anesthetic drops and placing a special type of thick contact lens with mirrors inside on the eye. contact lens with mirrors inside on the eye.

OphthalmoscopyOphthalmoscopy is an examination in which the is an examination in which the doctor uses a handheld device to look directly doctor uses a handheld device to look directly through the pupil (the opening in the colored iris) through the pupil (the opening in the colored iris) into the eye. into the eye.

Visual Field testingVisual Field testing actually maps the visual fields to actually maps the visual fields to detect any early (or late) signs of glaucomatous detect any early (or late) signs of glaucomatous damage to the optic nerve. damage to the optic nerve.

TREATMENTTREATMENT

Although nerve damage and visual loss Although nerve damage and visual loss from glaucoma cannot usually be from glaucoma cannot usually be reversed, glaucoma is a disease that can reversed, glaucoma is a disease that can generally be controlled. generally be controlled.

That is, treatment can make the That is, treatment can make the intraocular pressure normal and, intraocular pressure normal and, therefore, prevent or retard further nerve therefore, prevent or retard further nerve damage and visual loss. damage and visual loss.

Treatment may involve the use of eye Treatment may involve the use of eye drops, pills (rarely), laser, or surgery.drops, pills (rarely), laser, or surgery.

Medications (eye drops)Medications (eye drops)Beta-adrenergic antagonists act Beta-adrenergic antagonists act

against, or block, adrenalin-like against, or block, adrenalin-like substances. These drops work in the substances. These drops work in the treatment of glaucoma by reducing the treatment of glaucoma by reducing the production of the aqueous humor. production of the aqueous humor.

These medications include These medications include timololtimolol (Timoptic), levobunolol (Betagan), (Timoptic), levobunolol (Betagan), carteolol (Ocupress), and metipranolol carteolol (Ocupress), and metipranolol (Optipranolol).(Optipranolol).

BETAGAN®BETAGAN®(levobunolol hydrochloride) (levobunolol hydrochloride)

Ophthalmic Solution USP with C Cap® Ophthalmic Solution USP with C Cap® Compliance CapCompliance Cap

BETAGAN®BETAGAN® (levobunolol (levobunolol hydrochloride hydrochloride ophthalmic solution ophthalmic solution USP) sterile is a USP) sterile is a noncardioselective noncardioselective beta-adrenoceptor beta-adrenoceptor blocking agent for blocking agent for ophthalmic use.ophthalmic use.

Structure: Structure: Levobunolol HCl


BETAGAN® BETAGAN® ophthalmicophthalmic solution has solution has been shown to be effective in been shown to be effective in lowering lowering intraocular pressureintraocular pressure and and may be used in patients with chronic may be used in patients with chronic open-angle glaucoma or ocular open-angle glaucoma or ocular hypertension.hypertension.


The recommended starting dose is The recommended starting dose is one to two drops of BETAGAN® one to two drops of BETAGAN® ophthalmic solution 0.5% in the ophthalmic solution 0.5% in the affected eye(s) once a day. affected eye(s) once a day.

Typical dosing with BETAGAN® Typical dosing with BETAGAN® 0.25% is one to two drops twice 0.25% is one to two drops twice daily. daily.

In patients with more severe or In patients with more severe or uncontrolled uncontrolled glaucomaglaucoma, BETAGAN® , BETAGAN® 0.5% can be administered b.i.d.0.5% can be administered b.i.d.

DRUG INTERACTIONSDRUG INTERACTIONS Although BETAGAN® ophthalmic solution used alone Although BETAGAN® ophthalmic solution used alone

has little or no effect on pupil size, mydriasis has little or no effect on pupil size, mydriasis resulting from concomitant therapy with BETAGAN® resulting from concomitant therapy with BETAGAN® and and epinephrineepinephrine may occur. may occur.

Close observation of the patient is recommended Close observation of the patient is recommended when a beta-blocker is administered to patients when a beta-blocker is administered to patients receiving catecholamine-depleting drugs such as receiving catecholamine-depleting drugs such as reserpine, because of possible additive effects and reserpine, because of possible additive effects and the production of hypotension and/or marked the production of hypotension and/or marked bradycardia, which may produce vertigo, syncope, or bradycardia, which may produce vertigo, syncope, or postural hypotensionpostural hypotension..

Patients receiving beta-adrenergic blocking agents Patients receiving beta-adrenergic blocking agents along with either oral or intravenous calcium along with either oral or intravenous calcium antagonists should be monitored for possible antagonists should be monitored for possible atrioventricular conduction disturbances, left atrioventricular conduction disturbances, left ventricular failure and hypotension. In patients with ventricular failure and hypotension. In patients with impaired cardiac function, simultaneous use should impaired cardiac function, simultaneous use should be avoided altogether.be avoided altogether.

The concomitant use of beta-adrenergic The concomitant use of beta-adrenergic blocking agents with digitalis and calcium blocking agents with digitalis and calcium antagonists may have additive effects on antagonists may have additive effects on prolonging atrioventricular conduction prolonging atrioventricular conduction time.time.

Phenothiazine-related compounds and Phenothiazine-related compounds and beta-adrenergic blocking agents may have beta-adrenergic blocking agents may have additive hypotensive effects due to the additive hypotensive effects due to the inhibition of each other's metabolism.inhibition of each other's metabolism.

Risk of anaphylactic reaction: Risk of anaphylactic reaction: While While taking beta-blockers, patients with a taking beta-blockers, patients with a history of severe anaphylactic reactions to history of severe anaphylactic reactions to a variety of allergens may be more reactive a variety of allergens may be more reactive to repeated challenge, either accidental, to repeated challenge, either accidental, diagnostic, or therapeutic. Such patients diagnostic, or therapeutic. Such patients may be unresponsive to the usual doses of may be unresponsive to the usual doses of epinephrine used to treat epinephrine used to treat allergic reactionallergic reaction..

TREATMENT CONT`DTREATMENT CONT`D

Prostaglandin analogsProstaglandin analogs These drops work in glaucoma by These drops work in glaucoma by

increasing the outflow (drainage) of fluid increasing the outflow (drainage) of fluid from the eye.from the eye.

These medications include These medications include latanoprostlatanoprost (Xalatan), (Xalatan), travoprosttravoprost (Travatan), and (Travatan), and brimatoprost (Lumigan).brimatoprost (Lumigan).

Mannitol Mannitol (mannitol) Injection, Solution(mannitol) Injection, Solution

Mannitol I.V. Mannitol I.V. (Mannitol Injection, (Mannitol Injection, USP) is a sterile, USP) is a sterile, nonpyrogenic nonpyrogenic solution of solution of mannitol in water.mannitol in water.

Mannitol Injection, Mannitol Injection, USP is a USP is a parenteralparenteral obligatory osmotic obligatory osmotic diureticdiuretic


INDICATIONSINDICATIONSMannitol I.V. (Mannitol Injection, USP) is Mannitol I.V. (Mannitol Injection, USP) is

indicated for the following purposes in indicated for the following purposes in adults and pediatric patients.adults and pediatric patients.Therapeutic UseTherapeutic Use

Promotion of diuresis in the prevention or Promotion of diuresis in the prevention or treatment of the oliguric phase of treatment of the oliguric phase of acute renal failureacute renal failure before irreversible renal failure before irreversible renal failure becomes established. becomes established.

Reduction of intracranial pressure and brain mass. Reduction of intracranial pressure and brain mass. Reduction of high Reduction of high intraocular pressureintraocular pressure when the when the

pressure cannot be lowered by other means. pressure cannot be lowered by other means. Promotion of urinary excretion of toxic materials. Promotion of urinary excretion of toxic materials.

Diagnostic UseDiagnostic UseMeasurement of glomerular filtration rate.Measurement of glomerular filtration rate.

TREATMENT CONT`DTREATMENT CONT`DThere are several forms of laser There are several forms of laser

therapy for glaucoma. therapy for glaucoma. Laser iridotomyLaser iridotomy Laser trabeculoplastyLaser trabeculoplasty Laser cilioablationLaser cilioablation

Glaucoma surgeryGlaucoma surgeryTrabeculectomyTrabeculectomy Aqueus shunt devices (Glaucoma Aqueus shunt devices (Glaucoma

implants or tubes)implants or tubes) ViscocanalostomyViscocanalostomy


Mannitol I.V. (Mannitol Injection, USP) Mannitol I.V. (Mannitol Injection, USP) should be administered only by should be administered only by intravenous infusionintravenous infusion

The usual adult dosage ranges from 50 The usual adult dosage ranges from 50 to 200 g in a 24-hour period, but in to 200 g in a 24-hour period, but in most instances an adequate response most instances an adequate response will be achieved at a dosage of will be achieved at a dosage of approximately 100 g/24 hours. approximately 100 g/24 hours.

The rate of administration is usually The rate of administration is usually adjusted to maintain a adjusted to maintain a urineurine flow of at flow of at least 30 to 50 mL/hr. least 30 to 50 mL/hr.


Additives may be incompatible. Additives may be incompatible. When introducing additives to the flexible When introducing additives to the flexible

container, use container, use asepticaseptic technique, mix technique, mix thoroughly and do not store.thoroughly and do not store.

Do not place 25% Mannitol Injection, USP Do not place 25% Mannitol Injection, USP in polyvinylchloride bags; a white in polyvinylchloride bags; a white flocculent precipitate may form from flocculent precipitate may form from contact with PVC surfaces. contact with PVC surfaces. ParenteralParenteral drug drug products should be inspected visually for products should be inspected visually for particulate matter and discoloration; particulate matter and discoloration; whenever container and solution permit. whenever container and solution permit.

Myopia (or nearsightedness) Myopia (or nearsightedness)

People who have myopia or People who have myopia or nearsightedness have difficulty nearsightedness have difficulty seeing distant objects, but can see seeing distant objects, but can see objects that are near clearly. objects that are near clearly.

CAUSECAUSE

Refractive error -light rays bend Refractive error -light rays bend incorrectly into the eye to transmit incorrectly into the eye to transmit images to the brain images to the brain

SYMPTOMSSYMPTOMS

headaches, headaches, eyestrain, eyestrain, squinting or squinting or fatigue when driving, playing sports, fatigue when driving, playing sports,

or looking more than a few feet or looking more than a few feet away.away.

DIAGNOSISDIAGNOSIS

Standard eye exams given by an eye Standard eye exams given by an eye doctor doctor

TREATMENTTREATMENT

Glasses, Glasses, contact lenses, or contact lenses, or refractive surgery can correct refractive surgery can correct

myopia myopia Photorefractive keratectomy.Photorefractive keratectomy.Laser-assisted in situ Laser-assisted in situ

keratomileusis.keratomileusis. Corneal rings.Corneal rings.

AstigmatismAstigmatism

Astigmatism is characterized by an Astigmatism is characterized by an irregular curvature of the cornea. irregular curvature of the cornea. This type of disorder is also known as This type of disorder is also known as a refractive error. a refractive error.

Causes Causes

Astigmatism can be hereditary and is Astigmatism can be hereditary and is often present at birth. It can also often present at birth. It can also result from pressure from the eyelids result from pressure from the eyelids on the cornea, incorrect posture or on the cornea, incorrect posture or an increased use of the eyes for an increased use of the eyes for close work.close work.

Symptoms of AstigmatismSymptoms of Astigmatism

People with undetected astigmatism People with undetected astigmatism often experience headaches, fatigue, often experience headaches, fatigue, eyestrain and blurred vision at all eyestrain and blurred vision at all distances. While these symptoms distances. While these symptoms may not necessarily be the result of may not necessarily be the result of astigmatism, you should schedule an astigmatism, you should schedule an eye exam if you are experiencing eye exam if you are experiencing one or more symptoms. one or more symptoms.

DiagnosisDiagnosis

A thorough eye exam. A thorough eye exam.

TreatmentTreatment

Corrective lenses (eyeglasses or Corrective lenses (eyeglasses or contact lenses).contact lenses).

Refractive surgery.Refractive surgery.

PreventionPrevention

Astigmatism cannot be prevented. It Astigmatism cannot be prevented. It appears to run in families and is appears to run in families and is present from birth.present from birth.

Optic neuritis Optic neuritis

Optic neuritis is inflammation of the Optic neuritis is inflammation of the optic nerve, the structure that optic nerve, the structure that connects the eye to the brain. connects the eye to the brain.

Optic neuritis typically affects young Optic neuritis typically affects young adults ranging from 18-45 years of adults ranging from 18-45 years of age, with a mean age of 30-35 years. age, with a mean age of 30-35 years.

There is a strong female There is a strong female predominance. predominance.

CAUSESCAUSES The precise cause of optic neuritis is unknown, but it is The precise cause of optic neuritis is unknown, but it is

thought to be a type of autoimmune disorder that may thought to be a type of autoimmune disorder that may be triggered by a viral infection. be triggered by a viral infection.

Some autoimmune conditions that may cause optic Some autoimmune conditions that may cause optic neuritis are:neuritis are: neuromyelitis optica neuromyelitis optica multiple sclerosis multiple sclerosis

Bacterial Infections, including Bacterial Infections, including Lyme diseaseLyme disease, , tuberculosistuberculosis, , cat scratch fevercat scratch fever, , toxoplasmosistoxoplasmosis and and syphilissyphilis, or , or

Viral infections such as HIV (Viral infections such as HIV (human immunodeficiency virushuman immunodeficiency virus), ), hepatitis Bhepatitis B, and , and herpes zosterherpes zoster can cause optic neuritis. can cause optic neuritis.

Bacterial Bacterial meningitismeningitis, , encephalitisencephalitis, and , and sinusitissinusitis (all (all especially in children) may cause optic neuritis or optic especially in children) may cause optic neuritis or optic nerve damage.nerve damage.

SYMPTOMSSYMPTOMS

Vision loss, frequently maximal Vision loss, frequently maximal within one or two days and varying within one or two days and varying from a small area of from a small area of blurringblurring to to complete complete blindnessblindness

Distorted vision, reduced color vision, Distorted vision, reduced color vision, loss of contrasts, and washed out or loss of contrasts, and washed out or less vivid vision than normal. less vivid vision than normal.

SIGNSSIGNS

Reduced visual accuracy (acuity), Reduced visual accuracy (acuity), a measurable change in peripheral a measurable change in peripheral

vision, vision, decreased perception of brightness decreased perception of brightness

in the affected eye, and a change in in the affected eye, and a change in color vision (often out of proportion color vision (often out of proportion to loss of visual acuity). to loss of visual acuity).

DIAGNOSISDIAGNOSIS

A complete medical examination, A complete medical examination, including chemical analysis of the including chemical analysis of the blood can help rule out related blood can help rule out related diseases. diseases.

Tests may include visual acuity Tests may include visual acuity testing, pupillary testing, visual field testing, pupillary testing, visual field testing, color vision testing, and testing, color vision testing, and visualization of the optic disc by visualization of the optic disc by direct and indirect ophthalmoscopy. direct and indirect ophthalmoscopy.

TREATMENTTREATMENT If a definite cause (such as infection or underlying other disease) is If a definite cause (such as infection or underlying other disease) is

determined, appropriate therapy for that cause can be instituted. determined, appropriate therapy for that cause can be instituted.

In optic neuritis of undetermined cause or related to multiple sclerosis, In optic neuritis of undetermined cause or related to multiple sclerosis, vision often returns to normal within two to 12 weeks with no treatment but vision often returns to normal within two to 12 weeks with no treatment but may also advance to a permanent state of partial or complete visual loss.may also advance to a permanent state of partial or complete visual loss.

Treatment with steroid medications (cortisone medications such as Treatment with steroid medications (cortisone medications such as

prednisoneprednisone [Deltasone, Orasone, Prednicen-M, Liquid Pred] and [Deltasone, Orasone, Prednicen-M, Liquid Pred] and methylprednisolonemethylprednisolone, [Solu-Medrol]) may speed up vision recovery. , [Solu-Medrol]) may speed up vision recovery. Although treatment with steroids have little effect on the final visual Although treatment with steroids have little effect on the final visual outcome in patients with optic neuritis, patients treated initially with outcome in patients with optic neuritis, patients treated initially with intravenous (IV) steroids have about one-half the risk of developing intravenous (IV) steroids have about one-half the risk of developing multiple sclerosis in two years as untreated patients do. This effect multiple sclerosis in two years as untreated patients do. This effect disappears by the third year of follow up. In addition, patients treated with disappears by the third year of follow up. In addition, patients treated with IV steroids have fewer repeated attacks of optic neuritis than untreated IV steroids have fewer repeated attacks of optic neuritis than untreated patients. patients.

Ophthalmologists treat patients with optic neuritis with either IV -- followed Ophthalmologists treat patients with optic neuritis with either IV -- followed by oral steroids -- or no treatment at all. For those who are treated, the by oral steroids -- or no treatment at all. For those who are treated, the regimen typically includes three days of IV steroids, followed by about 11 regimen typically includes three days of IV steroids, followed by about 11 days of oral steroids. days of oral steroids.

When optic neuritis is associated with MRI lesions suggestive of multiple When optic neuritis is associated with MRI lesions suggestive of multiple sclerosis (MS), immunomodulator or immunosuppressive therapy may be sclerosis (MS), immunomodulator or immunosuppressive therapy may be prescribed to reduce the incidence of future attacksprescribed to reduce the incidence of future attacks

METHYLPREDNISOLONE SODIUM METHYLPREDNISOLONE SODIUM SUCCINATE - INJECTION SUCCINATE - INJECTION

BRAND NAME(S): BRAND NAME(S): Solu-MedrolSolu-Medrol

This medication is used This medication is used to treat various to treat various conditions such as conditions such as severe allergic reactions, severe allergic reactions, arthritisarthritis, blood diseases, , blood diseases, breathing problems, breathing problems, certain cancers, eye certain cancers, eye diseases, intestinal diseases, intestinal disorders, and skin disorders, and skin disease disease

It is a corticosteroid It is a corticosteroid hormone (glucocorticoid) hormone (glucocorticoid)



This preparation may be This preparation may be administered by intravenous administered by intravenous injection, by intravenous infusion, or injection, by intravenous infusion, or by intramuscular injectionby intramuscular injection

In high dose In high dose corticosteroidcorticosteroid therapy therapy should be continued only until the should be continued only until the patient's condition has stabilized; patient's condition has stabilized; usually not beyond 48 to 72 hours.usually not beyond 48 to 72 hours.

DRUG INTERACTIONSDRUG INTERACTIONS Aminoglutethimide:Aminoglutethimide:

Aminoglutethimide may lead to a loss of Aminoglutethimide may lead to a loss of corticosteroidcorticosteroid - induced adrenal - induced adrenal suppression.suppression.

Amphotericin B injection and potassium - depleting agents:Amphotericin B injection and potassium - depleting agents: When corticosteroids are administered concomitantly with potassium - depleting When corticosteroids are administered concomitantly with potassium - depleting

agents (i.e., amphotericin - B, diuretics), patients should be observed closely for agents (i.e., amphotericin - B, diuretics), patients should be observed closely for development of development of hypokalemiahypokalemia. There have been cases reported in which concomitant . There have been cases reported in which concomitant use of amphotericin B and hydrocortisone was followed by cardiac enlargement and use of amphotericin B and hydrocortisone was followed by cardiac enlargement and congestive congestive heart heart failure.failure.

Antibiotics:Antibiotics: Macrolide antibiotics have been reported to cause a significant decrease in Macrolide antibiotics have been reported to cause a significant decrease in

corticosteroid clearance (see corticosteroid clearance (see DRUG INTERACTIONS, Hepatic Enzyme DRUG INTERACTIONS, Hepatic Enzyme InhibitorsInhibitors).).

Anticholinesterases:Anticholinesterases: Concomitant use of anticholinesterase agents and corticosteroids may produce Concomitant use of anticholinesterase agents and corticosteroids may produce

severe weakness in patients with myasthenia gravis. If possible, anticholinesterase severe weakness in patients with myasthenia gravis. If possible, anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid agents should be withdrawn at least 24 hours before initiating corticosteroid therapy.therapy.

Anticoagulants, oral:Anticoagulants, oral: Coadministration of corticosteroids and warfarin usually results in inhibition of Coadministration of corticosteroids and warfarin usually results in inhibition of

response to warfarin, although there have been some conflicting reports. Therefore, response to warfarin, although there have been some conflicting reports. Therefore, coagulationcoagulation indices should be monitored frequently to maintain the desired indices should be monitored frequently to maintain the desired anticoagulantanticoagulant effect. effect.

Antidiabetics:Antidiabetics: Because corticosteroids may increase Because corticosteroids may increase blood glucose blood glucose concentrations, dosage concentrations, dosage

adjustments of antidiabetic agents may be required.adjustments of antidiabetic agents may be required. Antitubercular drugs:Antitubercular drugs:

Serum concentrations of isoniazid may be decreased.Serum concentrations of isoniazid may be decreased.

Cholestyramine:Cholestyramine: Cholestyramine may increase the clearance of corticosteroids.Cholestyramine may increase the clearance of corticosteroids.

Cyclosporine:Cyclosporine: Increased activity of both cyclosporine and corticosteroids Increased activity of both cyclosporine and corticosteroids

may occur when the two are used concurrently. Convulsions may occur when the two are used concurrently. Convulsions have been reported with this concurrent use.have been reported with this concurrent use.

Digitalis glycosides:Digitalis glycosides: Patients on digitalis glycosides may be at increased risk of Patients on digitalis glycosides may be at increased risk of

arrhythmias due to hypokalemia.arrhythmias due to hypokalemia. Estrogens, including oral contraceptives:Estrogens, including oral contraceptives:

Estrogens may decrease the hepatic Estrogens may decrease the hepatic metabolismmetabolism of certain of certain corticosteroids, thereby increasing their effect.corticosteroids, thereby increasing their effect.

Hepatic Enzyme Inducers (e.g., barbiturates, Hepatic Enzyme Inducers (e.g., barbiturates, phenytoin, carbamazepine, rifampin):phenytoin, carbamazepine, rifampin): Drugs which induce cytochrome P450 3A enzyme activity may Drugs which induce cytochrome P450 3A enzyme activity may

enhance the metabolism of corticosteroids and require that enhance the metabolism of corticosteroids and require that the dosage of the corticosteroid be increased.the dosage of the corticosteroid be increased.

Hepatic Enzyme Inhibitors (e.g., ketoconazole, Hepatic Enzyme Inhibitors (e.g., ketoconazole, macrolide antibiotics such as erythromycin and macrolide antibiotics such as erythromycin and troleandomycin):troleandomycin): Drugs which inhibit cytochrome P450 3A4 have the potential Drugs which inhibit cytochrome P450 3A4 have the potential

to result in increased to result in increased plasmaplasma concentrations of corticosteroids. concentrations of corticosteroids.

Ketoconazole:Ketoconazole: Ketoconazole has been reported to decrease the metabolism of Ketoconazole has been reported to decrease the metabolism of

certain corticosteroids by up to 60%, leading to an increased risk certain corticosteroids by up to 60%, leading to an increased risk of corticosteroid side effects.of corticosteroid side effects.

Nonsteroidal anti - inflammatory agents (NSAIDS):Nonsteroidal anti - inflammatory agents (NSAIDS): Concomitant use of aspirin (or other nonsteroidal anti - Concomitant use of aspirin (or other nonsteroidal anti -

inflammatory agents) and corticosteroids increases the risk of inflammatory agents) and corticosteroids increases the risk of gastrointestinal side effects. Aspirin should be used cautiously in gastrointestinal side effects. Aspirin should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. The conjunction with corticosteroids in hypoprothrombinemia. The clearance of salicylates may be increased with concurrent use of clearance of salicylates may be increased with concurrent use of corticosteroids.corticosteroids.

Skin tests:Skin tests: Corticosteroids may suppress reactions to skin tests.Corticosteroids may suppress reactions to skin tests.

Vaccines:Vaccines: Patients on prolonged corticosteroid therapy may exhibit a Patients on prolonged corticosteroid therapy may exhibit a

diminished response to toxoids and live or inactivated vaccines diminished response to toxoids and live or inactivated vaccines due to inhibition of due to inhibition of antibodyantibody response. Corticosteroids may also response. Corticosteroids may also potentiate the potentiate the replicationreplication of some organisms contained in live of some organisms contained in live attenuatedattenuated vaccines. Routine administration of vaccines or vaccines. Routine administration of vaccines or toxoids should be deferred until corticosteroid therapy is toxoids should be deferred until corticosteroid therapy is discontinued if possible discontinued if possible

PREVENTIONPREVENTION In patients with an infectious cause of In patients with an infectious cause of

optic neuritis, eradication of the optic neuritis, eradication of the underlying infection will usually prevent underlying infection will usually prevent further episodes. further episodes.

In patients with a known immune disorder In patients with a known immune disorder such as systemic lupus or vasculitis, such as systemic lupus or vasculitis, treatment of the underlying disorder will treatment of the underlying disorder will usually prevent further episodes. usually prevent further episodes.

In patients with known multiple sclerosis, In patients with known multiple sclerosis, treatment of the multiple sclerosis may treatment of the multiple sclerosis may decrease the incidence of future attacks of decrease the incidence of future attacks of multiple sclerosis, including optic neuritis. multiple sclerosis, including optic neuritis.

Retinitis Pigmentosa Retinitis Pigmentosa Retinitis pigmentosa is the most common of a Retinitis pigmentosa is the most common of a

group of hereditary progressive retinal group of hereditary progressive retinal degenerations or dystrophies. There is degenerations or dystrophies. There is considerable variation and overlap among the considerable variation and overlap among the various forms of retinitis pigmentosa.various forms of retinitis pigmentosa.

Common to all of them is progressive Common to all of them is progressive degeneration of the retina, specifically of the degeneration of the retina, specifically of the light receptors, known as the rods and cones. light receptors, known as the rods and cones. The rods of the retina are involved earlier in the The rods of the retina are involved earlier in the course of the disease, and cone deterioration course of the disease, and cone deterioration occurs later. occurs later.

In this progressive degeneration of the retina, In this progressive degeneration of the retina, the peripheral vision slowly constricts and central the peripheral vision slowly constricts and central vision is usually retained until late in the disease. vision is usually retained until late in the disease.

Retinitis pigmentosa lasts a lifetime, Retinitis pigmentosa lasts a lifetime, with blindness often occurring if one with blindness often occurring if one lives long enough.lives long enough.

Cataracts occur at a higher incidence Cataracts occur at a higher incidence in RP patients. in RP patients.

The ultimate complication of RP is The ultimate complication of RP is blindness from loss of retinal function. blindness from loss of retinal function.

CAUSE OF RETINITIS CAUSE OF RETINITIS PIGMENTOSAPIGMENTOSA

Retinitis pigmentosa is an inherited Retinitis pigmentosa is an inherited condition which involves both eyes. If condition which involves both eyes. If it starts in one eye, the other eye it starts in one eye, the other eye usually develops the same condition usually develops the same condition in a number of years. in a number of years.

SYMPTOMS AND SIGNSSYMPTOMS AND SIGNS

Decreased vision at night or in Decreased vision at night or in low lightlow light

Loss of side (peripheral) visionLoss of side (peripheral) vision

Loss of central vision (in Loss of central vision (in advanced cases)advanced cases)

DIAGNOSISDIAGNOSIS

It is primarily diagnosed by examination. It is primarily diagnosed by examination. The ophthalmologist observes relatively The ophthalmologist observes relatively

characteristic bone spicule pigment characteristic bone spicule pigment during the fundus examination (looking at during the fundus examination (looking at the back layers of the eye with the the back layers of the eye with the ophthalmoscope, an instrument allowing ophthalmoscope, an instrument allowing the visualization of the back of the eye by the visualization of the back of the eye by looking through the pupil). looking through the pupil).

Two tests are essential in the diagnosis and the Two tests are essential in the diagnosis and the follow-up exams.follow-up exams.

Visual field testing will find defects in the peripheral Visual field testing will find defects in the peripheral (side vision) with the degree of loss related to defects (side vision) with the degree of loss related to defects in relation to the damage occurring in this disease. in relation to the damage occurring in this disease. Over time, the visual field may reduce to a small Over time, the visual field may reduce to a small central island of vision causing "tunnel vision." The central island of vision causing "tunnel vision." The final progression may be the complete loss of the final progression may be the complete loss of the remaining central vision. remaining central vision.

Electrophysiological testing by the ophthalmologist Electrophysiological testing by the ophthalmologist (often by referral to a university ophthalmology (often by referral to a university ophthalmology department, since very few private offices would have department, since very few private offices would have this equipment) is often diagnostic. Responses to this equipment) is often diagnostic. Responses to flashes of light are measured via electrodes placed on flashes of light are measured via electrodes placed on the surface of the eye. It is a painless test. The the surface of the eye. It is a painless test. The electroretinogramelectroretinogram (ERG), in conjunction with the (ERG), in conjunction with the visual field exam, will usually make the diagnosis. This visual field exam, will usually make the diagnosis. This will also determine if there is any cone involvement.will also determine if there is any cone involvement.

Recently, gene testing for defects is being done to Recently, gene testing for defects is being done to clarify the basic cause for RP and assist in ultimately clarify the basic cause for RP and assist in ultimately finding a treatment. finding a treatment.

TREATMENTTREATMENT As of now there is no specific cure for retinitis As of now there is no specific cure for retinitis

pigmentosa. pigmentosa. For years, vitamin A therapy has been For years, vitamin A therapy has been

recommended for many RP patients.recommended for many RP patients. Another study among adult patients with RP has Another study among adult patients with RP has

shown that an shown that an omega-3-rich dietomega-3-rich diet containing containing docosahexaenoic acid can further slow disease docosahexaenoic acid can further slow disease progression. progression.

Such a diet includes one to two 3-ounce servings per Such a diet includes one to two 3-ounce servings per week of oily fish such as salmon, tuna, herring, week of oily fish such as salmon, tuna, herring, mackerel, or sardines. mackerel, or sardines.

Researchers estimated that the combination of Researchers estimated that the combination of vitamin A plus this diet could provide almost 20 vitamin A plus this diet could provide almost 20 additional years of useful vision for adults who start additional years of useful vision for adults who start the regimen in their 30s. the regimen in their 30s.

AQUASOL A® ParenteralAQUASOL A® Parenteralwater-miscible vitamin A water-miscible vitamin A

PalmitatePalmitate AQUASOL A® ParenteralAQUASOL A® Parenteral (water- (water-

miscible vitamin A Palmitate) provides miscible vitamin A Palmitate) provides 50,000 USP Units of vitamin A per mL 50,000 USP Units of vitamin A per mL as as retinolretinol (C20H30O) in the form of (C20H30O) in the form of vitamin A palmitate, a light yellow to vitamin A palmitate, a light yellow to amber oil.amber oil.

THIS IS A STERILE PRODUCT FOR THIS IS A STERILE PRODUCT FOR INTRAMUSCULAR INJECTIONINTRAMUSCULAR INJECTION

STRUCTURE:STRUCTURE:

Ordinarily oil-Ordinarily oil-soluble, the soluble, the vitamin A in this vitamin A in this product has been product has been water solubilized water solubilized by special by special processingprocessing..


Vitamin A injection is effective for the Vitamin A injection is effective for the treatment of treatment of vitamin A deficiencyvitamin A deficiency..

The parenteral administration is indicated The parenteral administration is indicated when the oral administration is not feasible when the oral administration is not feasible as in as in anorexiaanorexia, , nauseanausea, vomiting, pre- and , vomiting, pre- and postoperativepostoperative conditions, or it is not conditions, or it is not available as in the "available as in the "MalabsorptionMalabsorption Syndrome" with accompanying steatorrhea.Syndrome" with accompanying steatorrhea.

Pediatric Use:Pediatric Use: Vitamin A treatment for Vitamin A treatment for deficiency states has been recognized as deficiency states has been recognized as an especially effective and important an especially effective and important therapy in the pediatric population.therapy in the pediatric population.


For intramuscular use.For intramuscular use. I. AdultsI. Adults

100,000 Units daily for three days followed by 50,000 daily for two 100,000 Units daily for three days followed by 50,000 daily for two weeks.weeks.

II. Pediatric patients 1 to 8 years oldII. Pediatric patients 1 to 8 years old 17,500 to 35,000 Units daily for 10 days.17,500 to 35,000 Units daily for 10 days.

III. Infants III. Infants 7,500 to 15,000 Units daily for 10 days.7,500 to 15,000 Units daily for 10 days.

Follow-up therapy with an oral therapeutic multivitamin Follow-up therapy with an oral therapeutic multivitamin preparation, containing 10,000 to 20,000 Units vitamin A for adults preparation, containing 10,000 to 20,000 Units vitamin A for adults and for pediatric patients over 8 years old, and 5,000 to 10,000 and for pediatric patients over 8 years old, and 5,000 to 10,000 Units for infants and other pediatric patients under 8 years old, is Units for infants and other pediatric patients under 8 years old, is recommended daily for two months. Low birth-weight infants may recommended daily for two months. Low birth-weight infants may require additional vitamin A though the exact dosing in these require additional vitamin A though the exact dosing in these pediatric patients has not been established. In malabsorption, the pediatric patients has not been established. In malabsorption, the parenteral route must be used for an equivalent preparation.parenteral route must be used for an equivalent preparation.

Poor dietary habits should be corrected and an abundant and well-Poor dietary habits should be corrected and an abundant and well-balanced dietary intake should be prescribed.balanced dietary intake should be prescribed.

DRUG INTERACTIONSDRUG INTERACTIONSWomen on oral contraceptives have Women on oral contraceptives have

shown a significant increase in plasma shown a significant increase in plasma vitamin A levels.vitamin A levels.

Carcinogenesis: Carcinogenesis: There are no studies There are no studies that show that administration of that show that administration of vitamin Avitamin A will cause or prevent cancer. will cause or prevent cancer.

Nursing Mothers: Nursing Mothers: The U.S. The U.S. Recommended Daily Allowance (RDA) of Recommended Daily Allowance (RDA) of vitamin A (5,000 Units) is recommended vitamin A (5,000 Units) is recommended for nursing mothers.for nursing mothers.

RETINOBLASTOMARETINOBLASTOMA

Retinoblastoma is a malignant tumor Retinoblastoma is a malignant tumor on the retina, the light-sensing part on the retina, the light-sensing part of the eye, and is highly curable if of the eye, and is highly curable if treated early. This type of cancer can treated early. This type of cancer can be present in one or both eyes.be present in one or both eyes.

Retinoblastoma occurs most often in Retinoblastoma occurs most often in children 5 years and under. It rarely children 5 years and under. It rarely occurs in adults. occurs in adults.

CAUSECAUSE Our eyes begin to develop very early in the Our eyes begin to develop very early in the

womb. womb. Rapidly growing cells in the eye, called Rapidly growing cells in the eye, called

retinoblasts, will eventually mature and form retinoblasts, will eventually mature and form the retina, the light-sensing part of the eye that the retina, the light-sensing part of the eye that is located in the back of the eye. is located in the back of the eye.

Sometimes, these specialized cells do not stop Sometimes, these specialized cells do not stop reproducing and form a tumor on the retina. reproducing and form a tumor on the retina. These tumors may continue to grow, filling These tumors may continue to grow, filling almost the entire vitreous humor (the jellylike almost the entire vitreous humor (the jellylike substances the fills the eyeball). substances the fills the eyeball).

These tumors can also break off and spread to These tumors can also break off and spread to other parts of the eye, and eventually outside to other parts of the eye, and eventually outside to lymph nodes and other organs lymph nodes and other organs

Symptoms of Retinoblastoma Symptoms of Retinoblastoma Symptoms of retinoblastoma include:Symptoms of retinoblastoma include:

A pupil that appears white when light is A pupil that appears white when light is shone into it, called leucocoria, may mean shone into it, called leucocoria, may mean that a retinal tumor is present. Blood that a retinal tumor is present. Blood vessels in the back of the eye will normally vessels in the back of the eye will normally reflect red. reflect red.

The eyes may not move or focus in the The eyes may not move or focus in the same direction. same direction.

Eye pain Eye pain The pupil is constantly dilated. The pupil is constantly dilated. Red eye(s) Red eye(s)

DIAGNOSISDIAGNOSIS

An eye exam and imaging test given An eye exam and imaging test given by an eye doctor can diagnose by an eye doctor can diagnose retinoblastoma.retinoblastoma.

Other tests may be conducted to Other tests may be conducted to determine the stage of the determine the stage of the retinoblastoma, or how far it has retinoblastoma, or how far it has spread. These tests include ultrasound, spread. These tests include ultrasound, MRI scans, CT scans, bone scans, MRI scans, CT scans, bone scans, spinal tap, and bone marrow tests spinal tap, and bone marrow tests

Stages of Retinoblastoma Stages of Retinoblastoma

Intraocular retinoblastoma.Intraocular retinoblastoma. The earliest stage of retinoblastoma, found The earliest stage of retinoblastoma, found

in one or both eyes. It has not yet spread to in one or both eyes. It has not yet spread to tissue outside of the eye. tissue outside of the eye.

Extraocular retinoblastoma.Extraocular retinoblastoma. This type of cancer has either spread This type of cancer has either spread

outside of the eye or to other parts of the outside of the eye or to other parts of the body. body.

Recurrent retinoblastoma.Recurrent retinoblastoma. The cancer has come back or spread in the The cancer has come back or spread in the

eye or to other parts of the body after being eye or to other parts of the body after being treated. treated.

TREATMENTTREATMENT Because it is usually found before it spreads outside of the sclera Because it is usually found before it spreads outside of the sclera

(white of the eye), retinoblastoma is highly curable. There are (white of the eye), retinoblastoma is highly curable. There are also many types of treatment that can save sight in the eye also many types of treatment that can save sight in the eye affected by retinoblastoma. affected by retinoblastoma.

Treatments are selected based on the stage of cancer at the time Treatments are selected based on the stage of cancer at the time of diagnosis. Options include:of diagnosis. Options include: Photocoagulation.Photocoagulation. A laser is used to kill blood vessels that feed the A laser is used to kill blood vessels that feed the

tumor. tumor. Cryotherapy.Cryotherapy. Extremely low temperatures are used to kill cancer Extremely low temperatures are used to kill cancer

cells. cells. Chemotherapy.Chemotherapy. Chemotherapy is a treatment given Chemotherapy is a treatment given

intravenously (injected into the vein), orally, or is injected into the intravenously (injected into the vein), orally, or is injected into the fluid that surrounds the brain and spinal cord, called intrathecal fluid that surrounds the brain and spinal cord, called intrathecal chemotherapy. These powerful doses of cancer-killing medication chemotherapy. These powerful doses of cancer-killing medication help kill or slow the growth of multiplying cancerous cells. help kill or slow the growth of multiplying cancerous cells.

Radiation therapy.Radiation therapy. Radiation may be given externally or Radiation may be given externally or internally. External-beam radiation therapy uses X-rays to kill internally. External-beam radiation therapy uses X-rays to kill cancer cells. Internal, or local radiation therapy, involves placing cancer cells. Internal, or local radiation therapy, involves placing small amounts of radioactive material inside of or near the tumor small amounts of radioactive material inside of or near the tumor to kill cancer cells. to kill cancer cells.

Enucleation.Enucleation. Surgery to remove the eye. Surgery to remove the eye.

PREVENTIONPREVENTION Because heredity and age play such large roles in Because heredity and age play such large roles in

retinoblastoma, the best prevention is through early retinoblastoma, the best prevention is through early detection. All babies should have a general eye detection. All babies should have a general eye exam at birth and then again at six months. exam at birth and then again at six months.

The chance is 1 in 2 that a parent will pass on the The chance is 1 in 2 that a parent will pass on the DNA mutation that causes retinoblastoma. A blood DNA mutation that causes retinoblastoma. A blood test can be used to determine if this mutation is test can be used to determine if this mutation is present.present.

For adults, prevention means getting a thorough For adults, prevention means getting a thorough regular eye examination at least once a year and regular eye examination at least once a year and more often, as recommended by your more often, as recommended by your ophthalmologist, if you have a personal or family ophthalmologist, if you have a personal or family history of eye disorders or diabetes.history of eye disorders or diabetes.

CYTOXAN®CYTOXAN®(cyclophosphamide) for (cyclophosphamide) for

Injection, USPInjection, USP It is a sterile white It is a sterile white

powder containing powder containing cyclophosphamide cyclophosphamide monohydrate. monohydrate. Cyclophosphamide is a Cyclophosphamide is a synthetic antineoplastic synthetic antineoplastic drug chemically related drug chemically related to the nitrogen to the nitrogen mustards. mustards. Cyclophosphamide is a Cyclophosphamide is a white crystalline white crystalline powder.powder.


INDICATIONSINDICATIONS Malignant DiseasesMalignant Diseases CYTOXAN, although effective alone in susceptible malignancies, CYTOXAN, although effective alone in susceptible malignancies,

is more frequently used concurrently or sequentially with other is more frequently used concurrently or sequentially with other antineoplastic drugs. The following malignancies are often antineoplastic drugs. The following malignancies are often susceptible to CYTOXAN treatment:susceptible to CYTOXAN treatment: Malignant lymphomas.Malignant lymphomas. Multiple myeloma.Multiple myeloma. Leukemias.Leukemias. Mycosis fungoides (advanced disease).Mycosis fungoides (advanced disease). Neuroblastoma (disseminated disease).Neuroblastoma (disseminated disease). Adenocarcinoma of the ovary.Adenocarcinoma of the ovary. Retinoblastoma.Retinoblastoma. Carcinoma of the breast.Carcinoma of the breast.

Nonmalignant DiseaseNonmalignant Disease Biopsy Proven "Minimal Change" Nephrotic Syndrome in Biopsy Proven "Minimal Change" Nephrotic Syndrome in

ChildrenChildren CYTOXAN is useful in carefully selected cases of biopsy proven CYTOXAN is useful in carefully selected cases of biopsy proven

"minimal change" nephrotic syndrome in children but should not "minimal change" nephrotic syndrome in children but should not be used as primary therapy. be used as primary therapy.


Treatment of Malignant DiseasesTreatment of Malignant Diseases

Adults and ChildrenAdults and Children When used as the only oncolytic drug therapy, When used as the only oncolytic drug therapy,

the initial course of CYTOXAN for patients with the initial course of CYTOXAN for patients with no hematologic deficiency usually consists of 40 no hematologic deficiency usually consists of 40 to 50 mg/kg given intravenously in divided to 50 mg/kg given intravenously in divided doses over a period of 2 to 5 days. Other doses over a period of 2 to 5 days. Other intravenous regimens include 10 to 15 mg/kg intravenous regimens include 10 to 15 mg/kg given every 7 to 10 days or 3 to 5 mg/kg twice given every 7 to 10 days or 3 to 5 mg/kg twice weekly.weekly.

Oral CYTOXAN dosing is usually in the range of 1 Oral CYTOXAN dosing is usually in the range of 1 to 5 mg/kg/day for both initial and maintenance to 5 mg/kg/day for both initial and maintenance dosing.dosing.

Treatment of Nonmalignant DiseasesTreatment of Nonmalignant Diseases

Biopsy Proven "Minimal Change" Biopsy Proven "Minimal Change" Nephrotic Syndrome In ChildrenNephrotic Syndrome In ChildrenAn oral dose of 2.5 to 3 mg/kg daily for a An oral dose of 2.5 to 3 mg/kg daily for a

period of 60 to 90 days is recommended. In period of 60 to 90 days is recommended. In males, the incidence of oligospermia and males, the incidence of oligospermia and azoospermia increases if the duration of azoospermia increases if the duration of CYTOXAN treatment exceeds 60 days. CYTOXAN treatment exceeds 60 days. Treatment beyond 90 days increases the Treatment beyond 90 days increases the probability of sterility. Adrenocorticosteroid probability of sterility. Adrenocorticosteroid therapy may be tapered and discontinued therapy may be tapered and discontinued during the course of CYTOXAN therapy. during the course of CYTOXAN therapy.


The rate of metabolism and the leukopenic activity of The rate of metabolism and the leukopenic activity of cyclophosphamide reportedly are increased by cyclophosphamide reportedly are increased by chronic administration of high doses of phenobarbital.chronic administration of high doses of phenobarbital.

Cyclophosphamide treatment, which causes a marked Cyclophosphamide treatment, which causes a marked and persistent inhibition of cholinesterase activity, and persistent inhibition of cholinesterase activity, potentiates the effect of succinylcholine chloride.potentiates the effect of succinylcholine chloride.

AdrenalectomyAdrenalectomy Ajustment of the doses of both replacement Ajustment of the doses of both replacement

steroids and cyclophosphamide may be necessary steroids and cyclophosphamide may be necessary for the adrenalectomized patient.for the adrenalectomized patient.

Wound HealingWound Healing Cyclophosphamide may interfere with normal Cyclophosphamide may interfere with normal

wound healing.wound healing.

Health & Medicine

Pharmacology eye disorders