Systemic Effects of Ocular Medications II. Age-related Macular Degeneration

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Systemic Effects of Ocular Medications II. Age-related Macular Degeneration - #28

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Review systemic effects of ocular medications for age related macular degeneration.

Assessment

PDF of Table

Ophthalmologic Condition: Age-Related Macular Degeneration (also in treatment of diabetic retinopathy)

Drug Class/Mode of administration

Systemic Effect

Contraindications

Corticosteroids - Intravitreal injection Example: Triamcinolone acetonide

CNS/behavioral changes, glycosuria, hypertension, hyperglycemia, 8

Hypersensitivity, cerebral malaria, idiopathic thrombocytopenia, systemic fungal infections8

IV infusion with local activation of drug by infrared light - Photodynamic Therapy

Example: Verteporfin

Transient back pain and photosensitivity in eyes and skin8

Not for use in patients with porphyria8

AREDs* Vitamins – Oral

Example: AREDs formulations (Ivites, Ocuvite PreserVision)

No known significant toxicity 10

Beta carotene formulations not for use in active/recently quit smokers due to increased incidence of lung cancer10

Vascular endothelial growth factor(VEGF) inhibitors - Intravitreal Injection

Example: Afilbersept, Bevacizumab, Pegaptanib sodium Ranibizumab

Rare but serious side effect profile:

  • Non-ocular hemorrhage (ecchymosis, GI bleed, hematoma, subdural hematomas, among others)
  • Hypertension 2, 8, 9
  • Serious thromboembolic events (CVA, MI, death)
  • Pregnancy
  • Hypersensitivity reaction, ocular/periocular infections
  • Bevacizumab is currently used off label8, 9

 

*Age-Related Eye Disease Study (AREDS)

Context

Elderly patients being treated or evaluated for common ophthalmic disorders.

Action

Identify common systemic side effects and contraindications for common ophthalmic medications.

Incidence / Prevalence

Blinding disorders such as glaucoma and macular degeneration increase in prevalence with aging. The high prevalence of these potentially treatable or preventable conditions necessitates frequent ophthalmic examinations and treatments for the geriatric population. Age-related macular degeneration (AMD) is the leading cause of vision loss in Americans > 60 years of age, with prevalence increasing sharply with age. Approximately 2% of people ages 40-49 have intermediate AMD, while 12% of people 70-79 and almost 24% of people over the age of 80 are affected. 1

Underlying Sciences

Topically applied ophthalmic medications and Intravitreal injections are commonly used in the geriatric population. Topical: Absorption of topically applied drugs into the eye requires higher drug concentration. The combination of a small corneal surface area for absorption and limited tear sac volume results in a large percentage of the drug solution being drained into the tear drainage system, with direct access to the nasopharyngeal mucosal surface. Absorption through this highly vascularized tissue results in direct systemic spread without first pass hepatic metabolism. Strategies to reduce systemic absorption and side effects include following contraindication guidelines, punctual occlusion, smaller drop volumes, gel formulations, and waiting 5-10mins between drops to allow for maximal local absorption of each medicine. Intravitreal Injections: While small volumes are used, pharmacologic agents still pass through the blood-retinal barrier into systemic circulation where they are ultimately metabolized and excreted. Compared to intravenously administered agents, the systemic concentrations are miniscule and side effects are much less, but still present in rare cases.

Science Principles

Immunosenescense
Impaired homeostasis
Post-mitotic tissue and age related degeneration

Objectives

To identify systemic complications and contraindications of ophthalmic medications commonly used in the geriatric population.

Keywords/Tags

References

  1. http://www.nei.nih.gov/eyedata/amd.asp
  2. Drugs for Some Common Eye Disorders Treatment Guidelines from The Medical Letter 8(89) 2010.
  3. Lama, PJ Systemic Reactions Associated with Ophthalmic Medications, Ophthalmol Clin N Am 2005(18) 569-584.
  4. Fraunfelder, FT Drug Induced Ocular Side Effects. Boston: Butterworth-Heinemann. 2001.
  5. Labetoulle,M, Frau E, LeJeunne C. Systemic adverse effects of topical ocular treatments Presse Med 2005 (34) 589-95.
  6. Brocklehurst’s textbook of geriatric medicine and gerontology. Philadelphia, PH: Saunders/Elsevier. 2010.
  7. Havener’s Ocular Pharmacology. St. Louis: Mosby, 1994.
  8. Goodman and Gilman’s The Pharmacological basis of Therapeutics. New York: McGraw-Hill Medical. 2011.
  9. Tolentino, M Systemic and Ocular Safety of Intravitreal Anti-VEGF Therapies for Ocular Neovascular Disease Surv Ophthalmol 2011 56(2) 95-113.
  10. Evans, JR Antioxidant vitamin and mineral supplements for slowing the progression of Age-Related Macular Degeneration Cochrane Review 2006 Apr 19(2).
This GFF ___ my competence in geriatrics.

Authors

Kathryn Barbieri, Jonathan Skarie PhD, MD, Cristin Subramanian MD, Bhavna Sheth MD, Edmund Duthie MD

Author Affiliation

Medical College of Wisconsin, Milwaukee, Wisconsin

Copyright

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