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Toronto Notes 2019 Common Medications WET AGE-RELATED MACULAR DEGENERATION MEDICATIONS
VEGF Inhibitors (Anti-VEGF)
• blockVEGFwhichpreventsocularangiogenesisandfurtherdevelopmentofchoroidal neovascularization
• administered via intravitreal injections
• pegaptanib(Macugen®)isaselectiveanti-VEGFtargetingVEGFisoform165
■ no longer widely used
• alflibercept(Eylea®)isaVEGF“trap”agentthatbindsVEGF-Aandplacentalgrowthfactor
• ranibizumab (Lucentis®) is a monoclonal Fab fragment and non-selective anti-VEGF agent
• bevacizumab(Avastin®)isrecombinanthumanizedmonoclonalantibodyandnon-selectiveanti-VEGF
agent
■ FDA approved only for metastatic breast cancer, colorectal cancer, and non-small cell lung cancer;
therefore, its widespread ophthalmologic use is off-label
TOPICAL OCULAR THERAPEUTIC DRUGS
NSAIDs
• usedforlessseriouschronicinflammatoryconditions
• e.g.ketorolac(Acular®),diclofenac(Voltaren®),nepafenac(Nevanac®)drops
Anti-Histamines
• usedtorelieveredanditchyeye,oftenincombinationwithdecongestants • sodiumcromoglycate–stabilizesmembranes
Decongestants
• weakadrenergicstimulatingdrugs(vasoconstrictor)
• e.g.naphazoline,phenylephrine(IsoptoFrin®)
• reboundvasodilationwithoveruse;rarelycanprecipitateangleclosureglaucoma
Antibiotics
• indications:bacterialconjunctivitis,keratitis,orblepharitis
• commonlyastopicaldropsorointments,maygivesystemically
• e.g.sulfonamide(sodiumsulfacetamide,sulfisoxazole),gentamicin(Garamycin®),erythromycin,
tetracycline, bacitracin, polymyxin B, fluoroquinolones (ciprofloxacin [Ciloxan®], ofloxacin [Ocuflox®], moxifloxacin [Vigamox®], gatifloxacin [Zymar®])
Corticosteroids
• e.g.fluorometholone(FML®),betamethasone,dexamethasone(Maxidex®),prednisolone(Predsol®0.5%, Pred Forte® 1%), rimexolone (Vexol®), loteprednol etabonate 0.5% (Lotamax®), difluprednate (Durezol®)
• primarycarephysiciansshouldavoidprescribingtopicalcorticosteroidsduetoriskofglaucoma, cataracts, and reactivation of HSV keratitis
• complications
■ potentiates HSV keratitis and fungal keratitis as well as masking symptoms ■ increased IOP, more rapidly in steroid responders (within weeks)
■ posterior subcapsular cataract (within months)
Ophthalmology OP43
Intravitreal Bevacizumab Versus Ranibizumab for Treatment of Neovascular Age-Related Macular Degeneration: Findings from a Cochrane Systematic Review
Ophthalmology 2016; 123(1):70-77
Summary: In 6 RCTs with 2809 participants, there were no important differences in effectiveness or safety between bevacizumab and ranibizumab, despite a significant cost difference.
Antiplatelet and Anticoagulant Drugs Do Not Affect Visual Outcome in Neovascular Age-Related Macular Degeneration in the BRAMD Trial
Am J Ophthalmol 2018;187:130-137
Summary: In 330 NVAMD patients receiving either bevacizumab or ranibizumab treatment, use of anti-coagulant and anti-platelet agents was not associated with visual decline or occurrence of ocular hemorrhages.