TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Underreporting and Triggering Factors for Reporting ADRs of Two Ophthalmic Drugs: A Comparison between Spontaneous Reports and Active Pharmacovigilance Databases

(1) Aims of the study: calculating the underreporting ratio for two different medications, a fixed combination of 0.5% timolol + 0.2% brimonidine + 2.0% dorzolamide (antiglaucoma) and a fixed combination of sodium hyaluronate 0.1% + chondroitin sulfate 0.18% (artificial tears) for characterizing the features influencing the reporting of adverse drug reactions (ADRs) in spontaneous reporting. (2) Methods: The underreporting ratio was calculated by comparing the adverse drug reactions reported in the spontaneous reporting database for every 10,000 defined daily doses marketed and the adverse drug reactions from an active surveillance study for every 10,000 defined daily doses used for different drugs (antiglaucoma and artificial tears). The factors related to the report in spontaneous reporting through statistical tests were also determined. (3) Results: The underreporting ratio of spontaneous reporting was 0.006029% for antiglaucoma and 0.003552% for artificial tears. Additionally, statistically significant differences were found for severity, unexpected adverse drug reactions, and incidence of adverse drug reactions in females when compared with spontaneous reporting and active surveillance. (4) Conclusions: The underreporting ratio of ADRs related to ophthalmic medications indicates worry since the cornerstone of pharmacovigilance focuses on spontaneous reporting. Additionally, since underreporting seems to b selective, the role of certain aspects, such as gender, seriousness, severity, and unexpected ADRs, must be considered in future research.

Evaluation of Corneal and Retinal Toxicity in Rheumatoid Arthritis Patients Treated with Hydroxychloroquine

INTRODUCTION

The study aimed to assess the ocular toxicity of hydroxychloroquine (HCQ) by confocal microscopy, multifocal electroretinography (mfERG), and scanning laser polarimetry with variable corneal compensation (GDxVCC) in patients with rheumatoid arthritis (RA).

METHODS

A cross-sectional, comparative case series study was retrospectively conducted on 61 patients under HCQ treatment for RA without fundoscopic anomalies (group 1), 65 RA patients with no HCQ treatment (group 2), and 27 normal subjects (group 3). A comprehensive ophthalmological examination, including confocal microscopy, mfERG, and GDxVCC, was performed in the three groups.

RESULTS

In group 1, the duration of treatment ranged from 19 to 96 months (54.9 ± 15.2 months). The mean cumulative dose of HCQ was 446.1 ± 164.0 g (range 114-864 g). Confocal microscopy revealed hyper-reflective abnormal particles in 45 patients (73.8%) and beaded, tortuous fibers in 34 patients (55.7%) in group 1. No corneal change was observed in the other two groups. The mfERG responses in the 6 concentric rings (R1-R6) among the three groups differed except at R3 (all p < 0.05), and data from R1-R6 were not significantly different between groups 2 and 3. The retinal nerve fiber layer thicknesses were statistically thinner in group 1 than in groups 2 and 3 (all p < 0.05).

CONCLUSIONS

Early signs of corneal and neural retina structure changes were detected in patients with RA treated with HCQ. Whether these findings should be a mark of drug recession still needs further study and more evidence.

A Review of Ocular Complications Associated with Medications Used for Anxiety, Depression, and Stress

This review of commonly prescribed psychotropic drugs aims to update the clinician on possible ophthalmic side effects that may include dry eye, diplopia, mydriasis, and cataracts. This review summarizes our current knowledge of known ocular side effects of psychotropic drugs based on reviews, case reports, case-control studies, a case series, and cross-sectional observational studies reported in the recent literature. The review covers disorders related to depression, anxiety, and stress which are commonly encountered within society and can have debilitating impacts on an individual's quality of life that may require chronic therapeutic management. The main medications used in the treatment and management of these conditions typically target receptors, metabolic enzymes, or transport pumps that alter the pre- and/or post-synaptic levels of neurotransmitters such as serotonin, norepinephrine, dopamine, gamma-aminobutyric acid, and opioids to improve mood and/or relieve pain and anxiety. Novel non-therapeutic options are undergoing clinical trials, and some patients may seek alternative therapies or have associated substance abuse issues to alleviate their symptoms. This review summarizes some of the clinical signs of depression and the main therapeutic options and their reported ocular side effects which may be pertinent today given the rise in use of psychotropic medications used to manage depression, anxiety, and stress.

Polimedicação em adultos e idosos cadastrados na Estratégia Saúde da Família

Introdução: Verifica-se, no contexto global, a modificação do perfil da morbimortalidade em decorrência das transições demográfica e epidemiológica, relacionadas ao aumento do número de idosos e de doenças crônicas não-transmissíveis. Nesse cenário, a polimedicação tem se tornado frequente e, por conseguinte, seus danos são visualizados. O uso de múltiplos medicamentos amplia o risco de prescrições potencialmente inapropriadas, o que propicia interações farmacológicas, eventos adversos a medicamentos e hospitalizações. Soma-se a isso o ônus ao sistema de saúde e à assistência médica. Objetivo: Identificar os fatores associados à polimedicação em adultos mais velhos e idosos. Métodos: Trata-se de um estudo transversal e quantitativo, realizado em 2018 e 2019, com n=147 adultos (45-59 anos) e n=153 idosos (≥60 anos), cadastrados na Estratégia Saúde da Família (ESF) no município de Três Lagoas/MS. Foram coletados dados de caracterização sociodemográfica, estilo de vida, rede de apoio social e informações sobre saúde. Questionou-se o número de fármacos de uso contínuo tomados por dia, sendo considerada polifarmácia a utilização de cinco ou mais medicamentos. Foi conduzida uma regressão logística binomial para identificar os fatores associados à polifarmácia. Resultados: A prevalência de polifarmácia foi 10,2% (IC95% = [6,3%-16,2%]) para os adultos e 17,0% (IC95% = [11,9%-23,7%]) para os idosos. Estiveram associados à polifarmácia para o grupo de adultos o aumento da idade (OR=1,32; IC95%=1,10-1,59) e não possuir companheiro (OR=6,52; IC95%=1,59-26,81). Já para o grupo de idosos, os fatores associados foram ter sofrido pelo menos uma queda no último ano (OR=3,33; IC95%=1,13-9,85), ser tabagista (OR=5,04; IC95%=1,30-19,62), avaliar a saúde como regular (OR=4,10; IC95%=1,16-14,54) ou ruim/muito ruim (OR=6,59; IC95%=1,31-33,08). O consumo de álcool foi inversamente associado à polifarmácia (OR=0,15; IC95%=0,02-0,98) nos idosos. Conclusões: Diante dos potenciais riscos oferecidos pela polimedicação, torna-se imprescindível a distinção dos grupos em condição de maior vulnerabilidade ao uso de múltiplos medicamentos e um acompanhamento mais cauteloso, a fim de assegurar maior segurança na prescrição de fármacos na atenção primária e o aprimoramento do cuidado.

Stem cell-based retina models

From the early days of cell biological research, the eye-especially the retina-has evoked broad interest among scientists. The retina has since been thoroughly investigated and numerous models have been exploited to shed light on its development, morphology, and function. Apart from various animal models and human clinical and anatomical research, stem cell-based models of animal and human cells of origin have entered the field, especially during the last decade. Despite the observation that the retina of different species comprises endogenous stem cells, most stem cell-related research in the human retina is now based on pluripotent stem cell models. Herein, systems of two-dimensional (2D) cultures and co-cultures of distinctly differentiated retinal subtypes revealed a variety of cellular aspects but have in many aspects been replaced by three-dimensional (3D) structures-the so-called retinal organoids. These organoids not only contain all major retinal cell subtypes compared to the physiological situation, but also show a distinct layering in close proximity to the in vivo morphology. Nevertheless, all these models have inherent advantages and disadvantages, which are expounded and summarized in this review. Finally, we discuss current application aspects of stem cell-based retina models and the specific promises they hold for the future.

Insulin-like growth factor-1 activates PI3K/Akt signalling to protect human retinal pigment epithelial cells from amiodarone-induced oxidative injury

BACKGROUND AND PURPOSE

Amiodarone is one of the most effective anti-arrhythmic drugs available, but its clinical applications are limited by toxic side effects including optic toxicity. The purpose of this study was to investigate the toxic effect of amiodarone on D407 cells (a human retinal pigmented epithelial (RPE) cell line) and the mechanisms of the protective effect of insulin-like growth factor-1 (IGF-1).

EXPERIMENTAL APPROACH

The involvement of the kinases, Akt and ERK, was analysed by Western blot. Intracellular accumulation of ROS was measured using fluorophotometric quantification. A pharmacological approach with inhibitors was used to investigate the pathways involved in the protective action of IGF-1.

KEY RESULTS

Amiodarone concentration-dependently augmented the production of ROS, lipid peroxidation and apoptosis in D407 cells. IGF-1 time- and concentration-dependently reversed these effects of amiodarone and protected D407 cells from amiodarone-mediated toxicity. Amiodarone inhibited the pAkt but not pErk, and IGF-1 reversed this inhibitory effect of amiodarone. However, IGF-1 failed to suppress amiodarone-induced cytotoxicity in the presence of PI3K/Akt inhibitor LY294002 suggesting the direct involvement of the PI3K/Akt pathway. Furthermore, in vivo rat flash electroretinogram (FERG) recordings showed that IGF-1 reverses the amiodarone-induced decrease in a- and b-waves. The immunocytochemistry findings confirmed that vitreous IGF-1 injections promote the survival of RPE cells in rat retina treated with amiodarone.

CONCLUSION AND IMPLICATIONS

IGF-1 can protect RPE cells from amiodarone-mediated injury via the PI3K/Akt pathway in vivo and in vitro. IGF-1 has potential as a protective drug for the prevention and treatment of amiodarone-induced optic toxicity.

A Single Drop in the Eye - Effects on the Whole Body?

Introduction:

Although the local adverse effects of ophthalmic drugs, including allergic reactions, are well recognized, less is known about the systemic side- effects of eye drops, especially during pregnancy, breast-feeding and early childhood. Ophthalmologists should also be aware of unusual, in some cases even life-threatening, effects of commonly used eye drops.

Conclusion:

This brief review outlines the routes of systemic absorption and the kinetics of active components present in eye drops, and identifies the clinically relevant systemic adverse effects.

Pharmacokinetic aspects of retinal drug delivery

Drug delivery to the posterior eye segment is an important challenge in ophthalmology, because many diseases affect the retina and choroid leading to impaired vision or blindness. Currently, intravitreal injections are the method of choice to administer drugs to the retina, but this approach is applicable only in selected cases (e.g. anti-VEGF antibodies and soluble receptors). There are two basic approaches that can be adopted to improve retinal drug delivery: prolonged and/or retina targeted delivery of intravitreal drugs and use of other routes of drug administration, such as periocular, suprachoroidal, sub-retinal, systemic, or topical. Properties of the administration route, drug and delivery system determine the efficacy and safety of these approaches. Pharmacokinetic and pharmacodynamic factors determine the required dosing rates and doses that are needed for drug action. In addition, tolerability factors limit the use of many materials in ocular drug delivery. This review article provides a critical discussion of retinal drug delivery, particularly from the pharmacokinetic point of view. This article does not include an extensive review of drug delivery technologies, because they have already been reviewed several times recently. Instead, we aim to provide a systematic and quantitative view on the pharmacokinetic factors in drug delivery to the posterior eye segment. This review is based on the literature and unpublished data from the authors' laboratory.

Advances in the Pharmacogenomics of Adverse Drug Reactions

Rapid developments in pharmacogenomics have been noticeable in recent years, and much of this knowledge has improved understanding of adverse drug reactions. This improved knowledge has largely been the result of improved sequencing technologies and falling costs in this area, as well as improved statistical techniques to analyse the data derived from studies. While the genetic reasons behind adverse drug reactions are becoming better understood, translation of this knowledge, particularly in terms of biomarkers that might be clinically applicable at the bedside, has been more difficult. Understanding of the technologies and their application is limited among practising clinicians. The cost of some of the technologies available may also be prohibitive in stretched healthcare economies. As education about the potential for applying pharmacogenomics improves and costs fall, understanding of adverse drug reactions and application of this knowledge in a clinical setting should improve.

Amiodarone-Induced Retinal Neuronal Cell Apoptosis Attenuated by IGF-1 via Counter Regulation of the PI3k/Akt/FoxO3a Pathway

Amiodarone (AM) is the most effective antiarrhythmic agent currently available. However, clinical application of AM is limited by its serious toxic adverse effects including optic neuropathy. The purpose of this study was to explore the effects of AM and to assess if insulin-like growth factor-1 (IGF-1) could protect retinal neuronal cells from AM-induced apoptosis, and to determine the molecular mechanisms underlying the effects. Accordingly, the phosphorylation/activation of Akt and FoxO3a were analyzed by Western blot while the possible pathways involved in the protection of IGF-1 were investigated by application of various pathway inhibitors. The full electroretinogram (FERG) was used to evaluate in vivo effect of AM and IGF-1 on rat retinal physiological functions. Our results showed that AM concentration dependently caused an apoptosis of RGC-5 cells, while IGF-1 protected RGC-5 cells against this effect by AM. The protective effect of IGF-1 was reversed by PI3K inhibitors LY294002 and wortmannin as well as the Akt inhibitor VIII. AM decreased p-Akt and p-FoxO3a while increased the nuclear localization of FoxO3a in the RGC-5 cells. IGF-1 reversed the effect of AM on the p-Akt and p-FoxO3a and the nuclear translocation of FoxO3a. Similar results were obtained in primary cultured retinal ganglia cells. Furthermore, FERG in vivo recording in rats showed that AM decreased a-wave and b-wave of FERG while IGF-1 reversed the effects of AM. These data show that AM induced apoptosis of retinal neuronal cells via inhibiting the PI3K/Akt/FoxO3a pathway while IGF-1 protected RGC-5 cells against AM-induced cell apoptosis by stimulating this pathway.

Elvitegravir/cobicistat-associated toxic optical neuropathy in an HIV-infected patient: a call for caution?

Ocular toxicity may not only be caused by medication overdoses and drug-drug interactions, but also by chronic administration of medications at recommended doses. We describe a case of an HIV-infected patient who experienced significant and sustained bilateral visual loss 2 months after starting treatment with elvitegravir/cobicistat/tenofovir/emtricitabine. Given the absence of any evidence of tenofovir- or emtricitabine-induced optical neuropathy after several years of clinical use, the antiretroviral therapy was promptly changed to tenofovir/emtricitabine plus atazanavir/ritonavir, which led to a progressive improvement in visual acuity. However, visual evoked potentials never returned to normal amplitudes. This is the first report of toxic optical neuropathy associated with the use of elvitegravir/cobicistat. It is imperative to recognize any signs of possible eye toxicity as rapidly as possible, and refer affected patients to an ophthalmologist promptly because early detection and the withdrawal of the offending agent are crucial in reversing this adverse ocular event.

Ocular toxicity assessment of chronic sildenafil therapy for pulmonary arterial hypertension

PURPOSE

The aim of this study was to investigate possible functional and structural ocular changes caused by chronic sildenafil therapy to treat pulmonary arterial hypertension (PAH).

METHODS

Case-control study included patients with pulmonary arterial hypertension: chronically using sildenafil and without sildenafil treatment. A comprehensive ophthalmologic exam including ectoscopy, extrinsic ocular motility, logMAR visual acuity measurement, contrast sensitivity test, color test, anterior segment biomicroscopy, Schirmer test 1, intraocular pressure, fundus exam under pupil dilation, fundus pictures, time domain and spectral domain optical coherence tomography, ocular Doppler ultrasound were performed. Full-field electroretinography (ERG) was tested for each eye in a subgroup of sildenafil-treated patients.

RESULTS

Twenty patients from each group were tested. Bilateral severe keratitis was found in seven (35 %) patients under sildenafil therapy. Lacrimal film break-up time (BUT) was significantly reduced (p = 0.006 respectively) and Doppler ultrasound showed a reduced resistance index of the central retinal artery in the group of sildenafil users (p = 0.019). No diffuse retinal functional abnormalities were found in ERG in treated patients. Visual acuity, contrast sensitivity and color discrimination were normal in both groups. No abnormalities were found in both time-domain and spectral-domain OCT for retinal parameters.

CONCLUSIONS

One-third of the treated PAH group showed severe bilateral keratitis. This finding could be related to connective tissue abnormalities usually present in patients with this condition that might be exacerbated with the sildenafil usage. The resistance index of the central retinal artery was diminished in the chronic users group and it could be associated to the vasodilation caused by the medication in the choroidal vessels. An ophthalmic assessment for these patients is recommended to diagnose and treat possible ocular surface and choroidal blood flow abnormalities caused by sildenafil.

Prediction of Ocular Drug Distribution from Systemic Blood Circulation

Systemically circulating drugs may distribute to ocular tissues across the blood-ocular barriers. Ocular distribution is utilized in the treatment of ocular diseases with systemic medications, but ocular delivery of systemic drugs and xenobiotics may also lead to adverse ocular effects. Ocular distribution after systemic drug administration has not been predicted or modeled. In this study, distribution clearance between vitreous and plasma was obtained from a previous QSPR model for clearance of intravitreal drugs. These values were used in a pharmacokinetic simulation model to describe entry of unbound drug from plasma to vitreous. The simulation models predicted ocular distribution of 10 systemic drugs in rabbit eyes within 1.96 mean fold error and the distribution of cefepime from plasma to vitreous in humans. This is the first attempt to predict ocular distribution of systemic drugs. Reliable predictions were obtained using systemic concentrations of unbound drug, computational value of ocular distribution clearance, and a simple pharmacokinetic model. This approach can be used in drug discovery to estimate ocular drug exposure at an early stage.