Effect of calcium channel blockers alone and in combination with antiglaucoma medications on intraocular pressure in the primate eye

Influence of Trace Elements on Neurodegenerative Diseases of The Eye-The Glaucoma Model

Glaucoma is a heterogeneous group of chronic neurodegenerative disorders characterized by a relatively selective, progressive damage to the retinal ganglion cells (RGCs) and their axons, which leads to axon loss and visual field alterations. To date, many studies have shown the role of various elements, mainly metals, in maintaining the balance of prooxidative and antioxidative processes, regulation of fluid and ion flow through cell membranes of the ocular tissues. Based on the earlier and current research results, their relationship with the development and progression of glaucoma seems obvious and is increasingly appreciated. In this review, we aimed to summarize the current evidence on the role of trace elements in the pathogenesis and prevention of glaucomatous diseases. Special attention is also paid to the genetic background associated with glaucoma-related abnormalities of physiological processes that regulate or involve the ions of elements considered as trace elements necessary for the functioning of the cells.

Rottlerin acts as a therapeutic in primary open-angle glaucoma by targeting the trabecular meshwork via activation of Rap1 signaling

Primary open-angle glaucoma (POAG) is a leading cause of irreversible blindness worldwide, and elevated intraocular pressure (IOP) is a major risk factor. While IOP is mainly controlled by adjusting the outflow resistance in the trabecular meshwork (TM), drugs that act directly on the TM are rare. In this study, we discovered a novel compound and pathway that acts on the TM and decreases IOP by genomic, proteomic, and bioinformatic analyses of POAG-derived TMs and experimental validation. Overlapping differentially expressed genes of the TM between patients with POAG and normal controls from two independent gene expression profiles in public databases were analyzed and matched by using the Connectivity Map (CMap). Rottlerin was identified as a potential compound. Subsequent experiments confirmed that rottlerin reversed POAG phenotypes in vitro and that it decreased IOP and actin/extracellular matrix accumulation in vivo with no detectable ocular side effects. SwissTargetPrediction in combination with pathway analysis predicted that the effects of rottlerin may be mediated by activation of the Rap1 pathway. Finally, we confirmed that rottlerin upregulated Rap1 and the downstream PI3K/AKT pathway independent of the MAPK/ERK pathway in a dexamethasone-induced POAG cell model.

Ginkgo Biloba Extract in Ophthalmic and Systemic Disease, With a Focus on Normal-Tension Glaucoma

Glaucoma is a neurodegenerative eye disease that results in retinal ganglion cell loss and ultimately loss of vision. Elevated intraocular pressure (IOP) is the most common known risk factor for retinal ganglion cell damage and visual field loss, and the only modifiable risk factor proven to reduce the development and progression of glaucoma. This has greatly influenced our approach and assessment in terms of diagnosis and treatment. However, as many as ≥50% of patients with progressive vision loss from primary open angle glaucoma without IOP elevation (≤22 mm Hg) have been reported in the United States and Canada; 90% in Japan and 80% in Korea. Extensive research is currently underway to identify the etiology of risk factors for glaucoma other than or in addition to elevated IOP (so-called "normal-tension" glaucoma; NTG) and use this knowledge to expand available treatment options. Currently, Food and Drug Administration-approved medications for glaucoma exclusively target elevated IOP, suggesting the need for additional approaches to treatment options beyond the current scope as the definition of glaucoma changes to encompass cellular and molecular mechanisms. This review focuses on alternative medical approaches, specifically Ginkgo Biloba extract, as a potential treatment option for normal-tension glaucoma.

Systems genetics identifies a role for Cacna2d1 regulation in elevated intraocular pressure and glaucoma susceptibility

Glaucoma is a multi-factorial blinding disease in which genetic factors play an important role. Elevated intraocular pressure is a highly heritable risk factor for primary open angle glaucoma and currently the only target for glaucoma therapy. Our study helps to better understand underlying genetic and molecular mechanisms that regulate intraocular pressure, and identifies a new candidate gene, Cacna2d1, that modulates intraocular pressure and a promising therapeutic, pregabalin, which binds to CACNA2D1 protein and lowers intraocular pressure significantly. Because our study utilizes a genetically diverse population of mice with known sequence variants, we are able to determine that the intraocular pressure-lowering effect of pregabalin is dependent on the Cacna2d1 haplotype. Using human genome-wide association study (GWAS) data, evidence for association of a CACNA2D1 single-nucleotide polymorphism and primary open angle glaucoma is found. Importantly, these results demonstrate that our systems genetics approach represents an efficient method to identify genetic variation that can guide the selection of therapeutic targets.

Elevated intraocular pressure (IOP) is a heritable risk factor for primary open angle glaucoma. Using forward mouse genetics, cell biology, pharmacology and human genetic data, the authors identify CACNA2D1 as an IOP risk gene that can be therapeutically targeted by the drug pregabalin in animal models.

New directions in the treatment of normal tension glaucoma

Glaucoma is a progressive optic neuropathy that causes characteristic changes of the optic nerve and visual field in relation to intraocular pressure (IOP). It is now known that glaucoma can occur at statistically normal IOPs and prevalence studies have shown that normal tension glaucoma (NTG) is more common than previously thought. While IOP is believed to be the predominant risk factor in primary open angle glaucoma (POAG), IOP-independent risk factors, such as vascular dysregulation, are believed to play an important part in the pathogenesis of NTG. Though certain distinguishing phenotypic features of NTG have been reported, such as an increased frequency of disc hemorrhages, acquired pits of the optic nerve and characteristic patterns of disc cupping and visual field loss, there is much overlap of the clinical findings in NTG with POAG, suggesting that NTG is likely part of a continuum of open angle glaucomas. However, IOP modification is still the mainstay of treatment in NTG. As in traditional POAG, reduction of IOP can be achieved with the use of medications, laser trabeculoplasty or surgery. Studies now show that the choice of medication may also be important in determining the outcomes of these patients. Though it is likely that future treatment of NTG will involve modification of both IOP and IOP-independent risk factors, current efforts to develop IOP-independent neuroprotective treatments have not yet proven to be effective in humans.

Discovery of novel inhibitors for the treatment of glaucoma

INTRODUCTION

Glaucoma is a neurodegenerative disease with heterogeneous causes that result in retinal ganglionic cell (RGC) death. The discovery of ocular antihypertensives has shifted glaucoma therapy, largely, from surgery to medical intervention. Indeed, several intraocular pressure (IOP)-lowering drugs, with different mechanisms of action and RGC protective property, have been developed.

AREAS COVERED

In this review, the authors discuss the main new class of kinase inhibitors used as glaucoma treatments, which lower IOP by enhancing drainage and/or lowering production of aqueous humor. The authors include novel inhibitors under preclinical evaluation and investigation for their anti-glaucoma treatment. Additionally, the authors look at treatments that are in clinics now and which may be available in the near future.

EXPERT OPINION

Treatment of glaucoma remains challenging because the exact cause is yet to be delineated. Neuroprotection to the optic nerve head is undisputable. The novel Rho-associated kinase inhibitors have the capacity to lower IOP and provide optic nerve and RGC protection. In particular, the S-isomer of roscovitine has the capacity to lower IOP and provide neuroprotection. Combinations of selected drugs, which can provide maximal and sustained IOP-lowering effects as well as neuroprotection, are paramount to the prevention of glaucoma progression. In the near future, microRNA intervention may be considered as a potential therapeutic target.

Prolonged mydriasis after inadvertent topical administration of the calcium channel antagonist amlodipine: implications for glaucoma drug development

CONTEXT

Calcium channel inhibitors are being investigated as potential therapeutic adjuncts to reduce painful ciliary muscle spasm and control intraocular pressure in glaucoma. Relatively little is known about the effect of topical administration of calcium channel blockers in humans.

OBJECTIVE

(1) To describe prolonged fixed pupil dilation resulting from exposure to topical amlodipine (2) to review the evidence that links calcium channel blockers with mydriasis and (3) to discuss the implications for glaucoma pharmacotherapy.

DESIGN

Single interventional case report, literature review (including human and animal studies) and analysis of reported adverse drug reactions (ADRs) records in the USA and UK.

CASE

A 35-year-old female doctor presented to eye casualty with blurred vision and bilateral, fixed, dilated pupils. A history of exposure to liquid amlodipine while preparing a paediatric chemotherapy regimen for a neuroblastoma patient was elicited. The patient was reassured and observed.

RESULTS

Pupil function returned to normal within 48 h. A multi-national review of adverse drug reactions reports was conducted, as well as an extensive literature search for case reports and experimental studies. To the authors' knowledge this is the first report of amlodipine causing mydriasis and we discuss the potential molecular mechanism.

CONCLUSIONS

This case is the first to suggest that calcium channel blockers can cause prolonged mydriasis. These agents have been investigated as potential adjuncts in glaucoma therapy. As accidental topical exposure to amlodipine can cause prolonged pupil dilation, it could precipitate angle closure in predisposed patients.

Effect of Topical Calcium Channel Blockers on Intraocular Pressure in Steroid-induced Glaucoma

Purpose: To evaluate the effect of 0.125% verapamil and 0.5% diltiazem eye drops on intraocular pressure (IOP) in steroid-induced glaucoma in rabbit eyes.

Methods: A total of 18 rabbits with steroid-induced glaucoma were divided into three groups (A, B and C; n = 6 each). Right eyes in groups A, B and C received 0.5% diltiazem, 0.125% verapamil and 0.5% timolol eye drops twice daily for 12 days, respectively; whereas, left eyes received distilled water. IOP was measured with Tono-pen XL at baseline, day 4, day 8, and day 12 of treatment.

Results: Both 0.5% diltiazem and 0.125% verapamil eye drops significantly reduced IOP compared to control eyes (p < 0.05). Reduction of IOP by 0.5% diltiazem, 0.125% verapamil eye drops were comparable to 0.5% timolol. No surface toxicity or systemic side effects were noted during the study period.

Conclusion: Calcium channel blockers, verapamil, and diltia-zem significantly reduced IOP in rabbiteyes. This group of drugs may have a potential role in treatment of glaucoma

How to cite this article: Ganekal S, Dorairaj S, Jhanji V, Kudlu K. Effect of Topical Calcium Channel Blockers on Intraocular Pressure in Steroid-induced Glaucoma. J Current Glau Prac 2014;8(1):15-19.

Calcium channels and their blockers in intraocular pressure and glaucoma

Several factors besides high intraocular pressure assumed to be associated with the development and progression of glaucoma, and calcium channel blockers (CCBs) have been an anticipated option for glaucoma treatment by improving ocular perfusion and/or exerting neuroprotective effects on retinal ganglion cells with safety established in wide and long-term usage. Decrease in IOP has been reported after topical application of CCBs, however, the effect is much smaller and almost negligible after systemic application. Various CCBs have been reported to increase posterior ocular blood flow in vivo and to exert direct neuroprotection in neurons in vitro. Distribution of the drug at a pharmacologically active concentration in the posterior ocular tissues across the blood-brain barrier or blood-retina barrier, especially in the optic nerve head and retina where the ganglion cells mainly suffer from glaucomatous damage, is essential for clinical treatment of glaucoma. Improved visual functions such as sensitivity in the visual field test have been reported after administration of CCBs, but evidences from the randomized studies have been limited and effects of CCBs on blood flow and direct neuroprotection are hardly distinguished from each other.

Medical treatment of glaucoma: present and future

INTRODUCTION

In the last decades, the therapy of glaucoma has largely shifted from surgery to medical treatment thanks to the introduction of strongly effective formulations, that is, prostaglandin analogs and fixed combinations. This clinical scenario may dramatically change in the future thanks to the progresses in biochemistry, genetics and drug delivery technology.

AREAS COVERED

This review covers the strategies currently used to achieve effective medical reduction of intraocular pressure in clinical practice; treatments that are currently been experimented in humans and that may be clinically available in the next few years; treatments at preclinical stages; and future goals of glaucoma treatment (gene therapy, ocular implants and neuroprotection).

EXPERT OPINION

Apart from an adequate reduction of intraocular pressure, effective glaucoma treatments should guarantee other characteristics: good tolerability, low problems of adherence and, possibly, multiple ways of action. From this viewpoint, a crucial clinical role may be played by drugs remodeling the trabecular meshwork (i.e., ROCK inhibitors, metalloproteinases). Other strategies such as the use of ocular implants for drug delivery, neuroprotection or gene therapy could renew glaucoma management in the future, but need long-term rigorous verification of safety and efficacy.

Vasodilator effects of flunarizine on retinal blood vessels in anesthetized rats

The aim of this study was to investigate the effects of intravenous administration of flunarizine on the diameter of retinal blood vessels and blood pressure in anesthetized rats and to compare the effects of this antagonist with those of nicardipine and nifedipine. Retinal vascular images were captured with a fundus camera system for small animals and the diameter of retinal blood vessels contained in the images was measured using image-processing softwares on a personal computer. Blood pressure was continuously measured. Flunarizine [1-30 microg/kg, intravenously (i.v.)] dose-dependently increased the diameter of retinal blood vessels without significantly changing systemic blood pressure. Nicardipine (1-30 microg/kg, i.v.) increased the retinal blood vessel diameter but decreased blood pressure in a dose-dependent manner. Nifedipine (10-100 microg/kg, i.v.) failed to dilate the retinal blood vessels, although it produced comparable depressor responses as those to nicardipine. These results suggest that flunarizine selectively acts on the retinal blood vessels rather than on the peripheral resistance vessels. Flunarizine could therefore be considered as a candidate for therapeutic drugs to treat diseases associated with disorders of retinal circulation without severe cardiovascular side-effects.

Comparative study of topical application of timolol and verapamil in patients with glaucoma within 6 months

INTRODUCTION

As glaucoma is one of the most significant causes of blindness, and administration of calcium channel blockers is effective in reducing intraocular pressure (IOP) in rabbits and patients with normotensive glaucoma, we administered topical verapamil 0.25% in the human eye to compare its effect with timolol 0.5% in reducing IOP.

PURPOSE

To compare the effect of timolol 0.5% and topical verapamil 0.25% in patients with open-angle glaucoma.

METHODS

It was a double-blinded study in which 118 eyes (59 individuals) were chosen and divided into 2 groups (30 individuals related to timolol and 29 individuals related to verapamil). Patients who used drugs (systemic or topical) that could alter IOP and those with IOP <22 mmHg were excluded from the study (19 eyes). We chose patients who did not use any drugs 24 h prior to the study. Then applanation tonometry was done exactly before the administration of drugs and 90 min later and the results were compared.

RESULTS

In timolol group, mean intraocular pressure in 52 eyes (27 right eyes and 25 left eyes) decreased from 32.545 to 30.230 and mean pressure in verapamil group decreased from 33.195 to 30.835.

CONCLUSION

It seems that topical verapamil has a similar effect to timolol in patients with open-angle glaucoma, so it can be considered as a lowering intraocular pressure agent in glaucoma patients.

Cyclic mechanical stress and trabecular meshwork cell contractility

PURPOSE

Ocular pulse decreases outflow facility of perfused anterior segments. However, the mechanism by which conventional outflow tissues respond to cyclic intraocular pressure oscillations is unknown. The purpose of the present study was to examine responses of trabecular meshwork (TM) cells to cyclic biomechanical stress in the presence and absence of compounds known to affect cell contractility.

METHODS

To model flow in the juxtacanalicular region of the TM and to measure changes in transendothelial flow, human TM cell monolayers on permeable filters were perfused at a constant flow rate until reaching a stable baseline pressure and then were exposed to cyclic stress with an average amplitude of 2.7 mm Hg peak to peak at a 1-Hz frequency for 2 hours in the presence or absence of compounds known to affect cell contractility (isoproterenol, Y27632, pilocarpine, and nifedipine). Pressure was recorded continuously. Immunocytochemistry staining was used to determine filamentous actin stress fiber content, whereas Western blot analysis was used to measure the extent of myosin light chain (p-MLC) phosphorylation and ratio of filamentous to globular actin.

RESULTS

Human TM cells respond to cyclic pressure oscillations by increasing mean intrachamber pressure (decreasing hydraulic conductivity) (126.13% +/- 2.4%; P < 0.05), a response blocked in the presence of Y27632, a rho-kinase inhibitor (101.35 +/- 0.59; P = 0.234), but not isoproterenol, pilocarpine, or nifedipine. Although mechanical stress appeared to have no effect, Y27632 decreased phosphorylated myosin light chain, filamentous/globular actin ratio, and stress fiber formation in TM cells.

CONCLUSIONS

Human TM cells respond to cyclic mechanical stress by increasing intrachamber pressure. Pulse-mediated effects are blocked by Y27632, implicating a role for Rho-kinase-mediated signaling and cellular contractility in ocular pulse-associated changes in outflow facility.

Effect of flunarizine, a calcium channel blocker, on intraocular pressure and aqueous humor dynamics in monkeys

PURPOSE

To evaluate the effects of flunarizine, a nonselective calcium channel blocker, on intraocular pressure (IOP) in monkeys with laser-induced unilateral glaucoma and on aqueous humor dynamics in normal monkeys.

METHODS

The IOP was measured before and hourly for 6 hours after single-dose administration of 0.5%, 1%, or 2% flunarizine to the glaucomatous eye of 8 monkeys with unilateral laser-induced glaucoma. In a separate multiple-dose study, 0.5% flunarizine was applied twice daily for 5 consecutive days to the glaucomatous eye of the same 8 monkeys. IOP was measured at untreated baseline, after treatment with vehicle only, and on treatment days 1, 3, and 5. Tonographic outflow facility and fluorophotometric flow rates of aqueous humor were measured in 7 normal monkeys before and after the fifth dose of twice-daily treatment with 0.5% flunarizine.

RESULTS

Unilateral application of 50 microL of 0.5%, 1%, or 2% flunarizine reduced IOP bilaterally. In the treated glaucomatous eyes, flunarizine reduced the IOP for 2, 3, or 5 hours, with a maximum reduction of 2.5+/-0.5 (mean+/-SEM) mm Hg (9%), 3.0+/-0.4 mm Hg (10%), and 5.0+/-0.8 mm Hg (18%) following the 0.5%, 1%, and 2% concentrations, respectively (P<0.01). The maximum reductions in IOP in the contralateral untreated eyes were 1.3+/-0.5 mm Hg, 1.5+/-0.3 mm Hg, and 2.9+/-0.7 mm Hg following the 0.5%, 1%, and 2% concentrations, respectively (P<0.05). Both the magnitude and duration of the ocular hypotensive effect of 0.5% flunarizine were enhanced with twice-daily administration for 5 days. Outflow facility in normal monkey eyes was increased (P<0.05) by 39% in the treated eyes compared with vehicle-treated contralateral eyes and by 41% compared with baseline values, and aqueous humor flow rates were unchanged (P>0.30).

CONCLUSIONS

Flunarizine reduces IOP in a dose-dependent manner when administered to glaucomatous monkey eyes, but also has an ocular hypotensive effect on the contralateral untreated eyes. An increase in tonographic outflow facility seems to account for the IOP reduction in normal monkey eyes.

Migrainous scintillating scotoma and headache is ocular in origin: A new hypothesis

Brain neuronal dysfunction has been implicated in pathogenesis of migraine but direct evidence is lacking. Scintillating scotoma of migraine is generally believed to originate at the visual cortex. While cortical spreading depression is a relatively late physiological alteration in migraine, its protective role in neuronal ischaemia is increasingly being recognized. Atenolol, nadolol, or verapamil prevent migraine but do not readily cross the blood-brain barrier or critically influence any brain or peripheral neuronal function. Typical migraine headache, aura, or scintillating scotoma has not been reported following enucleation or evisceration of the eye. In humans, pain and temperature fibres from only the ophthalmic division of the trigeminal nerve reach the upper cervical spinal segments. Pain in migraine attacks including occipital and nuchal discomfort reflects selective involvement of the ophthalmic nerve. Photophobia is largely a retinal reflex involving the ophthalmic division of the trigeminal nerve. Key clinical features of the migrainous scintillating scotoma are consistent with retinal origin. Spreading depression in the retina is well-established. A subtle regional ocular sympathetic deficit prevails in migraine patients and possibly impairs regulation of intraocular choroidal blood volume and intraocular pressure. Several first-line migraine prophylactic agents lower the intraocular pressure. The neuro-ophthalmological basis for a monocular origin of migrainous scintillating scotomata due to mechanical deformation of the posterior segment of the corneo-scleral envelope consequent to choroidal venous congestion and rise in intraocular pressure is presented. Study of distribution and displaceability of the migrainous scintillating scotoma can settle its site of origin. Headache of migraine possibly arises from a similar mechanical deformation of the anterior eye segment followed by antidromic discharge in the trigeminovascular system. Lateralizing negative deficits such as homonymous hemianopia probably reflect vasospastic complications of migraine. A rational explanation for the most characteristic clinical features of migraine and a new template to elucidate the pharmacological basis of anti-migraine drugs is offered.

The effects of antiglaucoma and systemic medications on ocular blood flow

Based on the body of evidence implicating ocular blood flow disturbances in the pathogenesis of glaucoma, there is great interest in the investigation of the effects of antiglaucoma drugs and systemic medications on the various ocular vascular beds. The primary aim of this article was to review the current data available on the effects of antiglaucoma drugs and systemic medications on ocular blood flow. We performed a literature search in November 2002, which consisted of a textword search in MEDLINE for the years 1968-2002. The results of this review suggest that there is a severe lack of well-designed long-term studies investigating the effects of antiglaucoma and systemic medications on ocular blood flow in glaucomatous patients. However, among the 136 articles dealing with the effect of antiglaucoma drugs on ocular blood flow, only 36 (26.5%) investigated the effects of medications on glaucoma patients. Among these 36 articles, only 3 (8.3%) were long-term studies, and only 16 (44.4%) were double-masked, randomized, prospective trials. Among the 33 articles describing the effects of systemic medications on ocular blood flow, only 11 (33.3%) investigated glaucoma patients, of which only one (9.1%) was a double-masked, randomized, prospective trial. Based on this preliminary data, we would intimate that few antiglaucoma medications have the potential to directly improve ocular blood flow. Unoprostone appears to have a reproducible antiendothelin-1 effect, betaxolol may exert a calcium-channel blocker action, apraclonidine consistently leads to anterior segment vasoconstriction, and carbonic anhydrase inhibitors seem to accelerate the retinal circulation. Longitudinal, prospective, randomized trials are needed to investigate the effects of vasoactive substances with no hypotensive effect on the progression of glaucoma.

Pharmacokinetic profile of topical flunarizine in rabbit eye and plasma

The purpose of this study was to determine the aqueous humor, cornea, iris-ciliary body, retina and plasma levels and pharmacokinetics of a new topical formulation containing 0.05% flunarizine upon single drop application. Albino rabbits were used and tissue samples were collected at 15, 30, 60, 120 and 240 min after instillation. Drug concentrations in ocular tissues and plasma were measured by gas chromatography assay. After single dose application peak levels of drug were achieved at 15 min in cornea and at 30 min in aqueous humor, iris-ciliary body and retina. Unilateral topical flunarizine caused a significant reduction of intraocular pressure in rabbits. The pharmacokinetic profile showed a good ocular bioavailability of the drug providing that the new topical formulation containing 0.05% flunarizine reach the target tissues at effective concentrations and therefore may be use in the treatment of glaucoma.

Ocular hypotensive action of topical flunarizine in the rabbit: role of sigma 1 recognition sites

In a previous study we ascertained the presence of sigma1 and sigma2 recognition sites in the rabbit iris-ciliary body, an ocular structure involved in aqueous humor production and drainage. We characterized the sigma1 sites using the preferential ligand (+)-pentazocine, which caused a significant reduction of intraocular pressure (IOP). In the present study, flunarizine, a calcium channel blocker with a complex pharmacological profile, bound to sigma1 sites expressed in the iris-ciliary body with moderate affinity (K(i) = 68 nM). Unilateral topical flunarizine (0.01-0.1%) caused a dose-related reduction of IOP in ocular normotensive rabbits and in the alpha-chymotrypsin model of ocular hypertension, without altering the IOP of the contralateral eye. This activity was blocked by the sigma1 site antagonist NE-100 [N,N-dipropyl-2-[4-methoxy-3-(2-phenylethoxy)phenyl]ethylamine HCl] which, by itself, had no effect on IOP. Detection of flunarizine in rabbit iris-ciliary body homogenates, after topical instillation, showed that it adequately penetrates the rabbit eye. To investigate mechanisms that may contribute to ocular hypotension induced by sigma1 agonists, we carried out in vitro studies on the isolated rabbit iris-ciliary body. Flunarizine (IC50 = 5. 96 nM) and (+)-pentazocine (IC50 = 3. 81 nM) inhibited [3H]norepinephrine release. Moreover, flunarizine (IC50 = 6.34 nM) and (+)-pentazocine (IC50 = 27.26 nM) also antagonized isoproterenol-induced cAMP accumulation. The action of flunarizine and (+)-pentazocine was sensitive to NE-100 antagonism; however, this latter compound partially prevented their effect on [3H]norepinephrine and cAMP accumulation. These findings indicate that flunarizine and (+)-pentazocine interact with ocular sigma1 sites and may prove effective in the control of ocular hypertension.