Pupil dilation with intracameral lidocaine during phacoemulsification

PURPOSE

To evaluate pupil dilation by an intracameral injection of nonpreserved lidocaine 1% during phacoemulsification cataract extraction and compare the results with those using conventional topical mydriatics.

SETTING

Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

METHODS

A prospective comparative case series study was conducted. The study included 57 patients who were given topical mydriatics (30 eyes) or intracameral lidocaine (27 eyes) to dilate the pupil for phacoemulsification and intraocular lens implantation. The topical group received 3 drops of cyclopentolate 1% and phenylephrine 5% given 5 minutes apart starting 60 minutes before surgery. The intracameral group received preservative-free lidocaine 1% (0.2 to 0.3 mL) injected just before the procedure began. No epinephrine was added to the irrigating solution. In both groups, the horizontal pupil diameter was measured before and after pupil dilation using the same caliper. Total surgical time, need for a mydriatic agent during the procedure, and subjective surgical performance were recorded.

RESULTS

The mean age, sex, cataract density, baseline horizontal pupil diameter, and mean duration of the surgery were the same between the topical group and intracameral group. The mean pupil dilation was 4.52 mm +/- 0.08 (SD) in the intracameral group and 4.06 +/- 0.09 mm in the topical group; the difference between groups was statistically significant (P = .001). There was no significant difference between groups in the overall subjective surgical performance (P = .74). No patient in the intracameral group and 2 patients in the topical group required an intracameral mydriatic injection.

CONCLUSION

During phacoemulsification, intracameral preservative-free lidocaine 1% provided rapid, effective mydriasis comparable that of topical mydriatics.

Effect of formulation factors on in-vitro permeation of diclofenac from experimental and marketed aqueous eye drops through excised goat cornea

The effect of formulation factors on permeation of diclofenac from some experimental and marketed aqueous eye drops through excised goat cornea was evaluated. Raising the pH of formulation from 6.0 to 8.0 or diclofenac concentration from 0.05 to 0.15% (w/v) or adjusting tonicity with mannitol or addition of viscolizing agent decreased apparent permeability coefficient (Papp). Formulation (pH 7.4) containing sodium metabisulfite or EDTA or combination of methyl and propyl paraben showed significantly (p<0.05) higher Papp whereas benzalkonium chloride (BAC) had no effect and sorbic acid (SA) had reduced permeation. Surprisingly marketed drops containing BAC or SA, showed significantly (p<0.05) higher Papp and decreased in the order of Difen>Voveran>NSAID>Dicol>Diclolab. Lower pH (7.1-7.3) and surface tension of drops indicating presence of surfactant, could mediate increased permeation and presence of buffer could cause irritation on in vivo instillation. The marketed formulations showed corneal hydration >83% suggesting corneal damaging potential.

In vitro stability of insulin aspart in simulated continuous subcutaneous insulin infusion using a MiniMed 508 insulin pump

BACKGROUND

This study was designed to assess the stability and potency of insulin aspart under experimental circumstances simulating worst-case conditions during clinical use for continuous subcutaneous insulin infusion (CSII).

METHODS

The potency and stability of two batches of U100 insulin aspart, one recently manufactured and one nearing the end of shelf life, were evaluated after storage in a Medtronic (Northridge, CA) MiniMed 508 pump for up to 7 days at 37 +/- 2 degrees C. The pumps were placed on a vibrating platform (30 +/- 3 oscillations/min, 2 +/- 0.5 cm amplitude displacement) for 24 h/day to simulate movement by the pump user. The product remaining in the pump reservoir was tested at days 3, 4, and 7 and compared with control samples.

RESULTS

After 7 days of in-pump use, there was no significant reduction in potency of insulin aspart or difference from reference values with regards to pH, isoAsp(B28), desamido insulin aspart, insulin aspart-related impurities, or high-molecular-weight proteins. The concentration of phenol and m-cresol remained at levels sufficient to ensure preservative efficacy for both control and test samples. There was no evidence of fibrillation or precipitation.

CONCLUSIONS

The data indicate that storage in the plastic pump reservoir under temperature and vibration conditions simulating worst-case conditions during clinical use for CSII did not affect the stability or potency of insulin aspart significantly, and support an in-pump-use time of 7 days in the MiniMed 508 pump.

Conjunctival Provocation Test for the Diagnosis of Ocular Hypersensitivity to Chlorobutanol

PURPOSE

Conjunctival provocation test (CPT) is a useful tool for the determination of the reagent in patients with allergic conjunctivitis. Our aim is to present an unusual reaction of ocular hypersensitivity to chlorobutanol by using this technique.

METHODS

This case describes a 56-year-old woman who presented intense ocular pruritus and conjunctival hyperemia with each instillation of Colircusi Fluotest (Alcon, El Masnou, Spain). Skin tests and CPTs were considered.

RESULTS

Skin tests were all negative. CPTs were performed with commercially available ophthalmic products that were selected for their compositions. Chlorobutanol was presumed as the reagent through elimination. Positive CPT with purified chlorobutanol confirmed this hypothesis.

CONCLUSION

CPT performed with commercially available products can be a useful, accessible, and inexpensive technique to orient the diagnosis of suspected ocular hypersensitivity to a pharmacologic component. To our knowledge, this is the first report of ocular hypersensitivity to chlorobutanol.

Long-term Retinal Toxicity of Intravitreal Commercially Available Preserved Triamcinolone Acetonide (Kenalog) in Rabbit Eyes

PURPOSE

To investigate whether intravitreal Kenalog (IVTK; Bristol Meyers Squibb Company, Princeton, NJ) produces histologic or electroretinographic changes in the rabbit retina up to 3 months after injection.

METHODS

Ten Dutch-belted rabbits were injected with 4 mg/0.1 mL Kenalog in one eye and 0.1 mL physiologic salt solution (PSS) in the fellow eye. Simultaneous bilateral dark-adapted electroretinography was performed 2 weeks and 12 weeks after injection in 10 and 6 rabbits, respectively. Saturated a-wave amplitude, maximal scotopic b-wave amplitude, and individual a-wave and b-wave amplitudes of IVTK-injected and control eyes were compared at 2 and 12 weeks after injection. Light microscopy was performed on both eyes of three animals 3 months after injection. Immunohistochemistry was performed with antibodies recognizing vimentin and human alveolar macrophage (HAM)-56, markers of glial cells and macrophages, respectively.

RESULTS

No significant difference was observed in the saturated a-wave or maximal scotopic b-wave amplitudes between the PSS-injected eyes and the IVTK-injected eyes at 2 weeks (P = 0.95 and P = 0.56, respectively) and 12 weeks (P = 0.82 and P = 0.17) after injection. Light microscopy and immunohistochemistry disclosed only rare macrophages in the vitreous of IVTK-injected eyes. Retinal layers, retinal pigment epithelium, and choriocapillaris in treatment and control eyes were unremarkable.

CONCLUSIONS

No demonstrable electroretinographic or histologic changes occurred to suggest immediate or delayed widespread retinal toxicity of IVTK.

Topical 2% cyclosporine A in preservative-free artificial tears for the treatment of vernal keratoconjunctivitis

BACKGROUND

A double-masked, placebo-controlled trial to evaluate the short-term efficacy and safety of topical 2% cyclosporine A in preservative-free artificial tears for patients with vernal keratoconjunctivitis.

METHODS

Twenty patients with severe vernal keratoconjunctivitis were included in the study. All were treated with topical 2% cyclosporine A eye drops. One eye of each patient was administered 2% cyclosporine A in preservative-free artificial tears; the fellow eye received the placebo (vehicle) for the first 2 weeks, in a double-masked, placebo-controlled trial. Thereafter, the placebo eye received cyclosporine A (open trial). Symptoms and signs were scored on the day of enrollment and at the end of week 2, 4, and 14.

RESULTS

At the end of week 2, no statistically significant decrease was noted from baseline in mean scores of either signs (p = 0.18) or symptoms (p = 0.50) in the eyes that received placebo. On the other hand, a statistically significant decrease was observed in both sign and symptom scores (p < 0.001, for both) of eyes that received cyclosporine A. Significant differences were also noted at 2 weeks in mean scores of both signs and symptoms (p < 0.001, for both) between the eyes that received cyclosporine A and those that received placebo. At week 4 and 14, statistically significant decreases in both sign scores and symptom scores were noted compared with baseline in the eyes that received cyclosporine A and in the eyes that had initially received placebo (p < 0.001, for all).

INTERPRETATION

Topical 2% cyclosporine A in preservative-free artificial tears is effective in alleviating signs and symptoms of patients with severe vernal keratoconjunctivitis and had no observed side effects over the course of the study.

Stability of lyophilized and reconstituted plasma/albumin-free recombinant human factor VIII (ADVATE rAHF-PFM)

Traditionally the serum protein albumin has been used to stabilize lyophilized recombinant factor VIII (rFVIII) products. Advanced rFVIII products have now been developed that employ other stabilizers. ADVATE antihaemophilic factor (recombinant), plasma/albumin-free method (rAHF-PFM) utilizes trehalose and mannitol as stabilizers in the lyophilized preparation. An extensive in vitro evaluation was conducted on the stability of rAHF-PFM as measured by retained activity over time. Both lyophilized and reconstituted rAHF-PFM were analysed, and the full range of available potencies were tested under varying temperature conditions. Lyophilized rAHF-PFM exhibited a high degree of stability under a range of conditions. The mean retained activity of 15 rAHF-PFM lots (ranging from low to maximal potency) at 5 degrees C for 30 months was 91.6% (95% CI, 88.9-94.3%) of initial potency. rAHF-PFM also remained highly stable after storage at room temperature for 18 months, with 82.0% (95% CI, 79.2-84.9%) of initial activity retained at 25 degrees C and 79.1% (95% CI, 76.2-81.9%) at 30 degrees C. All other parameters, including moisture, appearance, solubility, pH and aggregation remained within the established product specifications. The mean retained activity after 1 month of storage at 40 degrees C was 94.0% (95% CI, 92.4-95.6%). A high temperature excursion to 40 degrees C for 2 weeks did not compromise subsequent stability of the lyophilized powder either under refrigeration or at room temperature. Reconstituted samples from 11 rAHF-PFM lots retained an average of 92.0% (95% CI, 89.8-94.3%) activity after 24 h. The present study provides evidence of good stability at differing temperatures of an albumin-free formulated rFVIII product.

Increasing importance of dry eye syndrome and the ideal artificial tear: consensus views from a roundtable discussion

BACKGROUND

Dry eye syndrome is a highly prevalent, yet largely under diagnosed, condition that can substantially affect quality of life. Left untreated, dry eye is associated with chronic eye pain and increased risk of ocular surface disease. Current demographic changes and lifestyle factors indicate that the dry eye syndrome patient population will increase significantly, ensuring that general practitioners and ophthalmic clinicians alike will experience more patients presenting with dry eye symptoms. Greater public and practitioner awareness of emerging research, technologies, and therapies is crucial to ensuring appropriate interventions to meet specific patient needs and result in clinically favorable outcomes.

ROUNDTABLE ASSEMBLY

In August 2005, a team of ocular surface experts convened for a 1-day roundtable session to discuss the latest information on diagnosing and treating dry eye syndrome and real-world issues in artificial tear therapy, including preservative use.

ROUNDTABLE DISCUSSION

The discussion centered on the mild to moderate dry eye patient and critical features of the ideal artificial tear, which are preservative-free formulation, protection from microbial contamination, cost-effective, non-blurring, and easy to use. Products that match this profile have the advantage of being able to benefit the myriad of patients who comprise the dry eye syndrome population. Ocular surface health should always remain a top priority. Preferred Practice Pattern Dry Eye Syndrome Medical Treatment guidelines should be modified to recommend the use of preservative-free formula artificial tear products for all levels of dry eye conditions in consideration of the medical benefit they offer to dry eye syndrome sufferers.

CONCLUSION

The growing prevalence of dry eye syndrome demands increased attention. Further research, enhanced diagnostic tests, increased use of preservative-free artificial tear formulations as first-line therapy, greater patient-practitioner interaction, and patient education are warranted.

Assessment of corneal epithelial integrity after acute exposure to ocular hypotensive agents preserved with and without benzalkonium chloride

The corneal toxicity of 2 intraocular pressure-lowering agents was compared in a rabbit cornea model with New Zealand White rabbits. Corneal epithelial morphology and cell size were assessed by in vivo confocal microscopy. Baseline microscopic examinations were performed on 1 eye of each animal. Two weeks later, the eyes were bathed for 3 min in travoprost 0.004% preserved without benzalkonium chloride (BAK( or latanoprost 0.005% preserved with 0.02% BAK; the eyes were then rinsed with balanced salt solution, and the corneas were again examined by confocal microscopy (n=4/group). A second group of animals was exposed to the medications through a dosing regimen of 1 drop/min (lpar3 drops total) (n=4/group). In eyes treated with travoprost without BAK (3-min bath), superficial epithelial cells were similar to baseline, as indicated by their visible cell borders and bright nuclei. In contrast, the surface cells in eyes treated with latanoprost were significantly smaller and brighter and had less distinct borders. Surface cell size was significantly smaller as compared with baseline size and as compared with rabbits treated with travoprost without BAK for 3 min. Similar effects on corneal epithelial cell morphology were observed with the 1-drop/min dosing regimen. In this rabbit model, travoprost 0.004% preserved without BAK did not cause corneal epithelial toxicity; latanoprost 0.005% induced superficial cell loss, most likely caused by the presence of a relatively high concentration of BAK (0.02%).

Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP)

This report updates the 2005 recommendations by the Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine and antiviral agents (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2005;54[No. RR-8]:1--44). The 2006 recommendations include new and updated information. Principal changes include 1) recommending vaccination of children aged 24-59 months and their household contacts and out-of-home caregivers against influenza; 2) highlighting the importance of administering 2 doses of influenza vaccine for children aged 6 months--<9 years who were previously unvaccinated; 3) advising health-care providers, those planning organized campaigns, and state and local public health agencies to a) develop plans for expanding outreach and infrastructure to vaccinate more persons than the previous year and b) develop contingency plans for the timing and prioritization of administering influenza vaccine, if the supply of vaccine is delayed and/or reduced; 4) reminding providers that they should routinely offer influenza vaccine to patients throughout the influenza season; 5) recommending that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United States until evidence of susceptibility to these antiviral medications has been re-established among circulating influenza A viruses; and 6) using the 2006-07 trivalent influenza vaccine virus strains: A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. For the A/Wisconsin/67/2005 (H3N2)-like antigen, manufacturers may use the antigenically equivalent A/Hiroshima/52/2005 virus; for the B/Malaysia/2506/2004-like antigen, manufacturers may use the antigenically equivalent B/Ohio/1/2005 virus. A link to this report and other information can be accessed at http://www.cdc.gov/flu.

Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients having laser in situ keratomileusis

PURPOSE

To evaluate dry-eye signs, symptoms, and refractive outcomes in patients with dry-eye disease having laser in situ keratomileusis (LASIK).

METHODS

In this randomized parallel double-masked prospective clinical trial, 42 eyes of 21 myopic patients (mean spherical equivalent -4.3 diopters [D], range -1.00 to -10.63 D) with dry-eye disease were treated with unpreserved artificial tears or cyclosporine 0.05% ophthalmic emulsion twice a day beginning 1 month before LASIK. Treatment with the study drug was discontinued for 48 hours post surgery and then resumed for 3 additional months. Both groups used additional artificial tears as needed. Study visits occurred pretreatment (baseline), before surgery, and at 1 week and 1, 3, 6, and 12 months after surgery.

RESULTS

Statistically significant increases from baseline were found in Schirmer scores for artificial tears at 1 month (P = .036) and for cyclosporine 0.05% before surgery and 1 week, 1 month, and 6 months after surgery (P<.018). There were no significant differences from baseline or between groups in responses to the Ocular Surface Disease Index questionnaire or best corrected visual acuity (BCVA), nor were there significant between-group differences in superficial punctate keratitis or uncorrected visual acuity. Mean refractive spherical equivalent in cyclosporine-treated eyes was significantly closer to the intended target at 3 and 6 months after surgery than in artificial-tears-treated eyes (P = .007). A greater percentage of cyclosporine eyes was within +/-0.5 D of the refractive target 3 months after surgery than artificial tears eyes (P = .015).

CONCLUSION

Successful outcomes after LASIK were achieved for dry-eye disease patients. Treatment with cyclosporine 0.05% provided greater refractive predictability 3 and 6 months after surgery than unpreserved artificial tears.

Biocidal activity of a bioactive glass-protected, preservative-free tattooing solution

BACKGROUND

The number of people obtaining a tattoo has increased markedly in recent years Tattooing is known to present a risk of transfer of bacterial/fungal pathogens and possibly also viral pathogens. Colorants used for tattooing purposes can be heavily contaminated with bacteria, thus presenting a risk for infections. Concerted efforts are being made to remove this threat, including the production and use of cleaner dyes and pigments with enhanced antimicrobial properties.

METHODS

Challenge tests were used to assess the survival characteristics of bacteria, bacterial endospores, fungal hyphae/spores, and bacteriophage in tattooing colorants.

RESULTS

Bacteria were able to grow to high numbers in some colorants. A recently marketed, preservative-free colorant was shown to have a good hygienic quality and rapidly inactivated added bacteria and fungal spores. Activity against bacterial endospores was also demonstrated. Bacteriophage survived in the product during the 28-day test period.

CONCLUSION

The present study is the first to document the survival characteristics of vegetative bacteria and endospores, fungi, and bacteriophage (as virus surrogate) in tattooing solutions. The results of the present study readily explain the previously reported high numbers of bacteria in some tattooing colorants. A preservative-free colorant, which was designed in response to recent recommendations of the European Council with respect to chemical content, was also adequately self-preserving with respect to bacterial and fungal growth.

Carboxymethylcellulose as a new carrier substance for intravitreal injection of reproducible amounts of triamcinolone

BACKGROUND

Intravitreal application of triamcinolone acetonide has become increasingly popular for the treatment of various retinal disorders. However, dosage, mode of preparation and application differ worldwide. The aim of this study was to find a safe vehicle that would allow intravitreal injection of an exact amount of triamcinolone acetonide without potentially retinotoxic preservatives.

METHODS

Solutions of triamcinolone acetonide with a theoretical concentration of 4 mg/0.2 ml were prepared following one sedimentation (A) and two filtration (B, C) methods. In addition, a filtration method using carboxymethylcellulose 2% as a carrier (D) was established. During processing and after injection into an eye model, the crystals were quantified by weight and high-performance liquid chromatography (HPLC), and, hence, the rate of crystal loss during this process was determined.

RESULTS

The initial preparation contained 93-106% of the calculated quantity. Method A, containing the entire vehicle, delivered 45%+/-7.3% of the target quantity to the eye model, whereas the vehicle-free methods B and C delivered 15%+/-6.9% and 11%+/-3.2%, respectively. Using carboxymethylcellulose 2% as a preservative-free vehicle, we found 93%+/-3.7% of the calculated amount in the eye model. The missing crystals were mainly sticking to the walls of the syringes and needles used for transfer.

CONCLUSION

Common methods for preparing triamcinolone acetonide vary in the amount of drug actually injected intravitreally. Carboxymethylcellulose is an ideal carrier substance for intravitreal application of an exact dose of triamcinolone acetonide without preservatives.

SAFETY AND PHARMACOKINETICS OF A PRESERVATIVE-FREE TRIAMCINOLONE ACETONIDE FORMULATION FOR INTRAVITREAL ADMINISTRATION

PURPOSE

The safety and pharmacokinetics of a triamcinolone acetonide (TA) preservative-free (TA-PF) formulation were investigated after intravitreal administration in rabbits.

METHODS

A TA-PF formulation was prepared as a sterile 40-mg/mL or 160-mg/mL suspension in single-use vials by adding TA powder to 0.5% hydroxypropyl methylcellulose in normal saline. TA-PF (4-mg and 16-mg doses) and Kenalog (Bristol-Myers-Squibb, Princeton, NJ) (4-mg dose) were injected into the vitreous of separate groups of rabbits, and drug levels were measured in the vitreous over time with HPLC. Ocular toxicology (clinical examination, serial electroretinography, and histopathologic analysis) was evaluated in a separate group of animals after intravitreal TA-PF injection.

RESULTS

The half-lives of the injection amount in the vitreous, 4-mg TA-PF, 16-mg TA-PF, and 4-mg Kenalog, were found to be 24 days, 39 days, and 23 days, respectively. There were no signs of toxicities by clinical examination after TA-PF injection. Serial electroretinograms of rabbits receiving either 4-mg or 16-mg intravitreal TA-PF injections remained normal over time. Histopathologic analysis showed normal ocular tissues in animals receiving either 4-mg or 16-mg intravitreal TA-PF injections.

CONCLUSION

The half-life of TA in the vitreous after a 4-mg injection of either TA-PF or Kenalog was comparable. A 16-mg dose of TA-PF produced a long vitreous half-life, and this may be of clinical benefit in patients requiring 6 months of drug exposure in the eye for a chronic disease.

Comparison of Two Pressure Ulcer Preventive Dressings for Reducing Shear Force on the Heel

OBJECTIVE

We compared the shear forces exerted over the heel between a pressure ulcer preventive dressing and a thin-film dressing in a clinical setting. Interface pressures were measured as well.

DESIGN

Quasi-experimental clinical trial.

SETTING AND SUBJECTS

Participants were 30 elderly patients (5 men, 25 women; mean age, 86.4 +/- 8.0 years) hospitalized in a geriatrics hospital in Japan; all had a Braden score of less than 14 (mean, 10.1 +/- 1.1). Informed consent was obtained from all the patients.A shear force and pressure sensor including a strain gauge, and an oval airbag-type pressure sensor were used.

METHODS

The sensor was attached to one heel using double-sided tape; then the target dressing was applied over the sensor and on the opposite heel to avoid the influence of the opposite heel on the shear force measurement. Interface pressures were measured with the patient in a stationary supine position; shear force was then measured at 0.2-second intervals, while the sheet was manually pulled at a velocity of around 5 cm/second. Shear force was determined by averaging the stable shear force lasting for 10 measurement points.

RESULTS

The mean interface pressures with the PPD and the film dressings were 70.7 +/- 16.5 and 70.2 +/- 15.2 mmHg, respectively; this difference was not statistically significant. The shear force produced during the pulling of the sheet was 2.2 +/- 1.4 and 11.7 +/- 5.8 N, respectively (P < .001, Wilcoxon signed-rank test).

CONCLUSIONS

The results of this study suggest that a dressing with a low-friction external surface (such as the pressure ulcer preventive dressing) can significantly reduce shear force. However, results also suggest that external dressings do not significantly reduce interface pressures and cannot be used as a substitute for heel elevation in an immobile patient.

Increased retest reactivity by both patch and use test with methyldibromoglutaronitrile in sensitized individuals

Hyperreactivity on re-exposure of previous allergic contact dermatitis skin areas has been previously demonstrated. This study aimed to investigate in methyldibromoglutaronitrile (MDBGN) allergic patients whether skin with previous allergic dermatitis from MDBGN showed an augmented response on re-exposure by both a patch test challenge and a use test with a liquid soap preserved with MDBGN. MDBGN dermatitis was elicited on the back and arms of sensitized individuals. One month later the previously eczematous areas were challenged with MDBGN. On the back, the test sites were patch-tested with a serial dilution of MDBGN and a use test was performed on the arms with an MDBGN-containing soap. A statistically significant increased response was seen on the areas with previous dermatitis on the back. Eight of the nine patients who developed dermatitis on the arms from the MDBGN-containing soap had an augmented response on areas with prior allergic contact dermatitis. Even though the allergic dermatitis appeared to be healed, an increased reactivity to allergen re-exposure was demonstrated both by patch test and use test challenge.

Safety considerations in IGIV utilization

One of the primary patient concerns about IGIV infusions is safety. Patients and physicians are both concerned about transmission of infectious agents and product tolerability. Since the documented transmission of hepatitis C virus in 1994, the manufacturers of IGIV products have added additional steps to remove and/or deactivate viruses. There are numerous different methods employed to accomplish this goal. It is desirable to utilize methods that are separate and additive to decrease the likelihood of viral or prion transmission with the infusion of IGIV products. This article describes the different methods and the impact on enveloped and non-enveloped viruses and prions. IGIV tolerability is impacted by the pharmaceutical differences in these products. Different stabilizers such as sugars, amino acids and sodium chloride affect the osmolality of the products and their potential for adverse events. Patients with co-morbid conditions including age and impaired renal status could require a change in product, concentration and rate of administration.

Infectious and noninfectious endophthalmitis after intravitreal high-dosage triamcinolone acetonide

PURPOSE

To evaluate the rate of infectious and noninfectious endophthalmitis after intravitreal injection of a high-dosage of triamcinolone acetonide.

DESIGN

Clinical interventional case-series study.

METHODS

The study included 1135 intravitreal injections of approximately 20 mg triamcinolone performed for 915 eyes with diabetic macular edema (n = 257), exudative age-related macular degeneration (n = 561), retinal vein occlusions (n = 82), and other reasons. Among the injections were 220 reinjections. Triamcinolone was filtered to remove the solvent agent. Mean follow-up was 8.1 +/- 7.4 months.

RESULTS

In none of the eyes, signs of an infectious or noninfectious endophthalmitis were observed such as noncrystalline hypopyon, cellular infiltration, or amorphous opacification of the vitreous, retinal infiltration, or pain. One patient developed infectious endophthalmitis 2 days after a traumatic rupture of a previous corneoscleral cataract incision.

CONCLUSIONS

The rate of infectious or noninfectious endophthalmitis after an intravitreal high-dosage triamcinolone injection may be approximately 1:1000, if the solvent agent was removed.

A stability-indicating HPLC method for medroxyprogesterone acetate in bulk drug and injection formulation

A stability-indicating HPLC assay method has been developed and validated for medroxyprogesterone acetate (MPA) in bulk drug and injectable suspension. An isocratic RP-HPLC was achieved on a Hichrom C(18) column (150 mm x 4.6mm i.d., 5 microm) utilizing a mobile phase of methanol 0.020 M acetate buffer pH 5 (65:35, v/v) and a photodiode array detector at 245 nm. The stress testing of MPA was carried out under acidic and alkaline hydrolysis, and oxidation conditions. MPA was well resolved from its degradation products, a main related substance (megestrol acetate) and two preservatives (methyl paraben and propyl paraben) with the resolution >or=2. The proposed method was validated for selectivity, linearity, accuracy, precision and solution stability. The method was found to be suitable for the quality control of MPA in bulk drug and injections as well as the stability-indicating studies.

Microbial contamination of preservative free eye drops in multiple application containers

BACKGROUND/AIMS

The majority of eye drops used in the United Kingdom contain preservatives and are bottled in plastic containers. Preservative free drops are used to avoid ocular irritation and allergies in certain individuals. The aim of this study was to investigate the incidence of microbial contamination of preservative free drops dispensed from multiusage containers.

METHODS

Eye drop bottles were collected from patients attending the Tennent Institute of Ophthalmology outpatient and inpatient departments. The bottles were collected on day 3 (for inpatients) and day 7 (for outpatients) of use. The drops were inoculated onto different culture plates (chocolate agar, blood agar, fungal culture media, and enriched media) and the resulting microbial growth was identified using standard microbial identification techniques.

RESULTS

95 eye drop bottles were collected, containing a variety of 10 different eye drops. Significant bacterial growth was found in eight bottles. In total, seven different types of organism were identified from the eye drops. The organisms identified were Staphylococcus aureus, coagulase negative staphylococcus, Bacillus spp, Serattia spp, Klebsiella oxytoca, Enterobacter cloacae, and alpha streptococcus. Staph aureus was the commonest microbial organism.

CONCLUSION

Preservative free eye drops in multiple application containers are at risk of contamination by potentially pathogenic micro-organisms.

Low incidence of paradoxical bronchoconstriction in asthma and COPD patients during chronic use of Respimat soft mist inhaler

Respimat Soft Mist Inhaler (SMI) is a new-generation inhaler that offers improved lung deposition compared with chlorofluorocarbon metered dose inhalers (CFC-MDIs). Bronchodilators administered via Respimat SMI are preserved and stabilised with low concentrations of benzalkonium chloride and ethylene diamine tetra-acetic acid, both of which have been reported to cause dose-related paradoxical bronchoconstriction. The aim of this analysis was to compare the incidence of paradoxical bronchoconstriction after chronic use of bronchodilators via Respimat SMI and CFC-MDI. Data from three clinical trials, in which patients with asthma or chronic obstructive pulmonary disease (COPD) received ipratropium bromide alone or in combination with fenoterol hydrobromide, or placebo via Respimat SMI or CFC-MDI for 12 weeks, were included in the analysis. In order to evaluate the risk of paradoxical bronchoconstriction, we identified four respiratory events that might have occurred within 30 min of inhalation on four test days; these were: 'bronchospasm', 'other respiratory adverse events', 'rescue medication use' and 'asymptomatic drop in FEV(1) 15% from baseline'. In total, 631 asthma and 1538 COPD patients participated in the three studies. No occurrences of bronchospasm were reported with Respimat SMI on any test day. Overall, the incidence of respiratory events possibly indicative of paradoxical bronchoconstriction was low and similar for both devices. There was no increase in the incidence of events during 12 weeks' treatment. Delivery of bronchodilators by Respimat SMI is safe with regard to paradoxical bronchoconstriction during chronic use in patients with asthma or COPD.

In-use study of potential bacterial contamination of ophthalmic moxifloxacin

PURPOSE

To determine the contamination rate of topical moxifloxacin 0.5% (Vigamox) after clinical use for preoperative and postoperative prophylaxis for cataract surgery.

SETTING

Bascom Palmer Eye Institute, Miami, Florida, USA.

METHODS

A total of 61 bottles of moxifloxacin were collected in a 2-month time period after use preoperatively by patients (n = 21, mean 2.2 days), postoperatively by patients (n = 16, mean 7.2 days), or by nurses in the operating room (n = 24). For each bottle, cultures of the cap, tip, external thread, and solution were inoculated onto chocolate agar plates and incubated at 35 degrees for 7 days. A total of 13 bottles of benzalkonium chloride (BAC)-preserved gatifloxacin ophthalmic solution (Zymar) were also cultured in a similar manner for comparison.

RESULTS

No organisms were found by cultures of the cap, tip, or solution from any bottle in the study. One colony of coagulase-negative Staphylococcus was recovered from the thread of 1 Vigamox bottle. This bottle had negative cultures from its cap, tip, and solution.

CONCLUSIONS

The only contaminant found in this study was cultured from the bottle thread. This is a location with a high rate of skin contact and minimal solution contact. The remaining cultures from this bottle were negative, showing the solution's ability to self-preserve. These data demonstrate that BAC-free Vigamox can be treated no differently than BAC-preserved solutions by patients and medical staff, without concern for solution contamination.