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Phacoanaphylaxis Medication

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 14, 2016
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. See Medical Care.

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Cycloplegics

Class Summary

Cyclopentolate, atropine sulfate, homatropine, and scopolamine break or prevent formation of posterior synechiae; stabilize the blood-aqueous barrier, leading to reduced leakage of plasma proteins; increase uveoscleral outflow; and provide mild relief of ciliary spasm pain. The stronger the inflammatory reaction, the more frequently applied or stronger the cycloplegic.

Cyclopentolate hydrochloride 0.5%, 1%, 2% (Cyclogyl, AK-Pentolate, I-Pentolate)

 

Blocks muscle of ciliary body and sphincter muscle of iris from responding to cholinergic stimulation, thus causing mydriasis and cycloplegia.

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Corticosteroids

Class Summary

Block formation of arachidonic acid from cell membrane precursors by inhibiting action of phospholipase-A2. Corticosteroids frequently are used in uveitis therapy. Topical corticosteroids are given in dosages ranging from once daily to hourly. They also can be given in an ointment form. Periocular corticosteroids generally are given as depot-steroid injections when a more prolonged effect is needed or when a patient is noncompliant or poorly responsive to topical administration.

Prednisolone ophthalmic (AK-Pred, Econopred Plus, Pred Forte)

 

Treats acute inflammations following eye surgery or other types of insults to eye.

Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.

In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely.

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Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

Inhibit cyclooxygenase pathway that controls prostaglandin biosynthesis. NSAIDs have both topical analgesic and anti-inflammatory effects. Although NSAIDs currently do not have a significant role in uveitis therapy beyond the treatment of macular edema, they may have a synergistic effect with topical corticosteroids, and, because of minimal adverse effects, they often are used in cases of intraocular inflammation.

Diclofenac ophthalmic (Voltaren)

 

Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases formation of prostaglandin precursors. May facilitate outflow of aqueous humor and decreases vascular permeability.

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Beta-adrenergic blocking agents

Class Summary

Decrease production of aqueous humor by the ciliary epithelium, resulting in decreased intraocular pressure. Beta-blockers reduce aqueous formation by 24-48%.

Timolol maleate 0.25-0.5% (Timoptic, Betimol)

 

Ocular hypotensive medication that lowers intraocular pressure by reducing aqueous humor production. Reduces cardiac output, decreases heart rate and blood pressure, produces beta-adrenergic receptor blockade in bronchi and bronchioli, and has little or no effect on pupil size and accommodation.

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Alpha2-adrenergic agonists

Class Summary

Potent inhibitors of aqueous production, reducing it by 35-40%.

Brimonidine tartrate 0.2% (Alphagan)

 

Relatively selective alpha2-adrenergic agonist. Has dual mechanism of action by reducing aqueous humor production and increasing uveoscleral outflow.

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Carbonic anhydrase inhibitors

Class Summary

These agents are nonbacteriostatic sulfonamides that inhibit enzyme carbonic anhydrase (eg, topical dorzolamide, brinzolamide, systemic methazolamide, acetazolamide). This action reduces the rate of aqueous humor production, resulting in decreased intraocular pressure.

Dorzolamide 2% (Trusopt)

 

Formulated for topical ophthalmic use. Inhibition of carbonic anhydrase in ciliary processes decreases aqueous humor secretion, presumably by slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport. The result is decreased intraocular pressure.

Acetazolamide (Diamox, Diamox Sequels)

 

Used for adjunctive treatment of glaucoma. Reduces aqueous humor formation by 20-40% with no significant change in outflow facility. Approximately 90% is bound to plasma proteins and excreted by urine largely unmetabolized. Maximal effect is noted 2-4 h after oral administration and 10-15 min after IV administration.

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Contributor Information and Disclosures
Author

Robert H Graham, MD Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, Arizona Ophthalmological Society, American Medical Association

Disclosure: Partner received salary from Medscape/WebMD for employment.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Retina Society, American College of Healthcare Executives, American Uveitis Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Acknowledgements

Charles C Barr, MD Retina Service Director, Professor, Department of Ophthalmology, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Judith Mohay, MD Director of Primary Care Center Eye Clinic, Instructor, Department of Ophthalmology, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

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Gross photomicrograph for eye enucleated with penetrating injury.
Gross photomicrograph for eye enucleated with penetrating injury. Note marked inflammatory reaction consisting of polymorphonuclear cells around lens capsule and lens fibers (hematoxylin and eosin X100).
Low (X25) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).
High (X50) photomicrograph of phacoanaphylactic reaction to lens protein in eye enucleated with penetrating injury. Note polymorphonuclear leucocytes around lens protein (hematoxylin and eosin).
Phacoanaphylactic reaction to penetrating injury of lens. This patient was a 25-year-old woman whose eye was penetrated with a 27-gauge needle during an attempt to anesthetize the eyelid for chalazion removal. One week later, a marked uveitis was present. Notice perforation site and posterior synechiae.
Same patient as in Media file 5. Notice cortical cataract at perforation site.
Typical clinical picture of retained lens material following cataract surgery. White cortical material is easily visible in the pupillary space.
Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Eye is white and quiet with anterior chamber lens.
Patient with persistently elevated intraocular pressure after cataract surgery was found to have retained lens material and low-grade inflammation. Retained lens material is visible in retroillumination on downgaze.
Typical appearance of retained lens fragments in posterior vitreous cavity. Lens material is a whitish substance that obscures fundus details.
Another view of a retained lens fragment, noted inferiorly.
 
 
 
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