Medication Summary
Definitive management of vitreous wick syndrome, also known as vitreous touch syndrome, is primarily surgical. Medical therapy is limited to broad-spectrum topical antibiotics for uncomplicated cases.
Antibiotics
Class Summary
Antimicrobial therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Vancomycin
Vancomycin is used as empiric therapy for gram-positive organisms. It has excellent gram-positive coverage and possesses the added advantage of providing better coverage against resistant organisms. It is bactericidal against most organisms and bacteriostatic for enterococci. Inhibits cell wall biosynthesis, interfering with cell membrane permeability and RNA synthesis.
Vancomycin is the drug of choice for intravitreal and systemic administration. After systemic administration, it penetrates most tissues, including vitreous, especially if the blood-ocular barrier is compromised. In patients with renal impairment, the dosage is adjusted on the basis of creatine clearance.
Moxifloxacin ophthalmic (Vigamox, Moxeza)
Moxifloxacin is indicated for treating bacterial conjunctivitis. It inhibits topoisomerase II (DNA gyrase) and IV enzymes. DNA gyrase is essential in bacterial DNA replication, transcription, and repair. Topoisomerase IV plays a key role in chromosomal DNA portioning during bacterial cell division.
Ofloxacin ophthalmic (Ocuflox)
Ofloxacin is a pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. It inhibits bacterial growth by inhibiting DNA gyrase. It is indicated for superficial ocular infections of conjunctiva or cornea due to susceptible microorganisms.
Polymyxin B and trimethoprim (Polytrim)
This combination is used for ocular infection of the cornea or conjunctiva caused by susceptible microorganisms. It is available as a solution (polymyxin/trimethoprim) and as an ointment (polymyxin/bacitracin).
Ciprofloxacin ophthalmic (Ciloxan)
Ciprofloxacin has activity against Pseudomonas and Streptococcus species, methicillin-resistant Staphylococcus aureus (MRSA), S epidermidis, and most gram-negative organisms; it has no activity against anaerobes.
Norfloxacin ophthalmic (Noroxin)
Norfloxacin has activity against susceptible gram-negative and gram-positive bacteria. Antibiotics in this class inhibit bacterial DNA synthesis and thus growth by inhibiting DNA gyrase.
Erythromycin ophthalmic (Romycin, Ilotycin)
Erythromycin is indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Sulfacetamide ophthalmic (Bleph-10)
This agent interferes with bacterial growth by inhibiting bacterial folic acid synthesis by competitively antagonizing para-aminobenzoic acid. It is available in solution, ointment, and lotion form.
Tobramycin ophthalmic (Tobrex)
Tobramycin is an aminoglycoside that interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, causing a defective bacterial cell membrane. It is available in solution, ointment, and lotion form.
Gentamicin ophthalmic (Gentak, Garamycin)
Gentamicin is an aminoglycoside antibiotic that covers gram-negative bacteria.
Nonsteroidal Anti-inflammatory Drugs
Class Summary
The inhibition of prostaglandin synthesis results in vasoconstriction, a decrease in vascular permeability, leukocytosis, and a decrease on intraocular pressure (IOP). However, these agents have no significant effect on IOP.
Ketorolac ophthalmic (Acular, Acular LS, Acuvail)
Ketorolac ophthalmic inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase. This results in decreased formation of prostaglandin precursors, which, in turn, results in reduced inflammation.
Diclofenac ophthalmic (Voltaren)
Diclofenac ophthalmic is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. It may facilitate outflow of aqueous humor and decrease vascular permeability. Any equivalent topical NSAID also can be used.
Flurbiprofen ophthalmic (Ocufen)
Flurbiprofen ophthalmic facilitates outflow of aqueous humor by inhibiting prostaglandin synthesis, causing a subsequent decrease in vascular permeability.
Nepafenac ophthalmic (Nevanac, Ilevro)
Nepafenac is a pro-drug of amfenac, a potent NSAID. Nepafenac undergoes amide hydrolysis by intraocular hydrolases to form the pharmacologically active amfenac. Amfenac inhibits both cyclooxygenase COX-1 and COX-2 activity.Therefore, its effects are intraocular (CME) and have less effect (or side-effect) on the ocular surface.
Corticosteroids
Class Summary
Corticosteroids are used for pseudomembranes and decreased vision and/or glare due to subepithelial infiltrates. They have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Prednisolone ophthalmic (Omnipred, Pred Forte, Pred Mild)
Prednisolone is used to treat acute inflammation following eye surgery or other insults to the eye. It decreases inflammation and corneal neovascularization, suppresses migration of polymorphonuclear leukocytes, and reverses increased capillary permeability.
In cases of bacterial infection, concomitant use of anti-infective agents is mandatory. If signs and symptoms do not improve after 2 days, the patient should be reevaluated. Dosing may be reduced, but patients should be advised not to discontinue therapy prematurely.
Dexamethasone ophthalmic (Maridex, Ozurdex)
Dexamethasone is used for various allergic and inflammatory diseases. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Fluorometholone ophthalmic (FML, Flarex, FML Forte)
This agent suppresses the migration of polymorphonuclear leukocytes and reverses capillary permeability.
Rimexolone 1% (Vexol)
Rimexolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Loteprednol ophthalmic (Alrex, Lotemax)
This agent decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. It is a topical ester steroid eye drop that poses a decreased risk of glaucoma. It is available in 0.2% and 0.5% concentrations.
Cholinergic Agent
Class Summary
Cholinergic agonists add to the effects of beta-blockers, carbonic anhydrase inhibitors, and sympathomimetics as an adjunctive therapy.
Pilocarpine ophthalmic (IsoptoCarpine, Pilopine HS)
Pilocarpine for ophthalmic administration is a sterile solution containing a direct-acting cholinergic parasympathomimetic agent that acts through direct stimulation of muscarinic neuroreceptors and smooth muscle (eg, in the iris and secretory glands). Pilocarpine produces miosis through contraction of the iris sphincter, causing increased tension on the scleral spur and opening of the trabecular meshwork spaces to facilitate outflow of aqueous. Outflow resistance is thereby reduced, lowering intraocular pressure.
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Externalized vitreous with a peaked pupil. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
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Cellulose sponge teasing the vitreous wick. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
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Castroviejo sweep performed with a cyclodialysis spatula. Image courtesy of Manolette Roque, MD, MBA, Roque Eye Clinic.
