Ocular medications in children

Practical use and prescription of ocular medications in children and infants

Optometrists in Australia employ ophthalmic medicines in their paediatric practice to assist clinical diagnosis and to treat ocular conditions. Prior to employing ocular medicines or initiating treatment, it is important to consider the risks versus benefits of ophthalmic medicines and determine the minimum dose required to safely achieve a diagnostic or therapeutic benefit. Instilling drops in infants and young children may require techniques that do not depend on full cooperation, particularly to maintain appropriate dosing and limit the rate of elimination from the eye. Diagnostic cycloplegic agents are highly recommended for the accurate determination of refractive error in infants and young children. Topical atropine is commonly prescribed in paediatric optometry practice in highly variable concentrations. 1% atropine eye drops are used for pharmacological penalisation in management of amblyopia, and, increasingly, low concentration (< 0.1%) atropine is used to manage the progression of childhood myopia. Doses of topical ocular medicines to treat inflammation, infection or glaucoma are generally identical to those use in adults; however, there is potential for increased ocular and systemic side effects with certain medications. It is, therefore, timely to present, summarise and comment on the use of ophthalmic diagnostic and therapeutic agents in children and reference where practitioners can look for more detailed information. The perspective is set in the Australian context of a collaborative approach between paediatric optometry and ophthalmology eye care practitioners for delivery of best practice care in infants and young children. Inclusion of the more complex spectrum of paediatric eye disease in a tertiary ophthalmological setting is provided to build practitioner knowledge of treatment regimens their patients may be using, even though management of these conditions lies outside their scope of practice.

Interventions for preventing ophthalmia neonatorum

BACKGROUND

Ophthalmia neonatorum is an infection of the eyes in newborns that can lead to blindness, particularly if the infection is caused by Neisseria gonorrhoeae. Antiseptic or antibiotic medication is dispensed into the eyes of newborns, or dispensed systemically, soon after delivery to prevent neonatal conjunctivitis and potential vision impairment.

OBJECTIVES

1. To determine if any type of systemic or topical eye medication is better than placebo or no prophylaxis in preventing ophthalmia neonatorum. 2. To determine if any one systemic or topical eye medication is better than any other medication in preventing ophthalmia neonatorum.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and three trials registers, date of last search 4 October 2019. We also searched references of included studies and contacted pharmaceutical companies.  SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials of any topical, systemic, or combination medical interventions used to prevent ophthalmia neonatorum in newborns compared with placebo, no prophylaxis, or with each other.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Outcomes were: blindness or any adverse visual outcome at 12 months, conjunctivitis at 1 month (gonococcal (GC), chlamydial (CC), bacterial (BC), any aetiology (ACAE), or unknown aetiology (CUE)), and adverse effects.  MAIN RESULTS: We included 30 trials with a total of 79,198 neonates. Eighteen studies were conducted in high-income settings (the USA, Europe, Israel, Canada), and 12 were conducted in low- and middle-income settings (Africa, Iran, China, Indonesia, Mexico). Fifteen of the 30 studies were quasi-randomised. We judged every study to be at high risk of bias in at least one domain. Ten studies included a comparison arm with no prophylaxis. There were 14 different prophylactic regimens and 12 different medications in the 30 included studies. Any prophylaxis compared to no prophylaxis  Unless otherwise indicated, the following evidence comes from studies assessing one or more of the following interventions: tetracycline 1%, erythromycin 0.5%, povidone-iodine 2.5%, silver nitrate 1%. None of the studies reported data on the primary outcomes: blindness or any adverse visual outcome at any time point. There was only very low-certainty evidence on the risk of GC with prophylaxis (4/5340 newborns) compared to no prophylaxis (5/2889) at one month (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.24 to 2.65, 3 studies). Low-certainty evidence suggested there may be little or no difference in effect on CC (RR 0.96, 95% CI 0.57 to 1.61, 4874 newborns, 2 studies) and BC (RR 0.84, 95% CI 0.37 to 1.93, 3685 newborns, 2 studies). Moderate-certainty evidence suggested a probable reduction in risk of ACAE at one month (RR 0.65, 95% 0.54 to 0.78, 9666 newborns, 8 studies assessing tetracycline 1%, erythromycin 0.5%, povidone-iodine 2.5%, silver nitrate 1%, colostrum, bacitracin-phenacaine ointment). There was only very low-certainty evidence on CUE  (RR 1.75, 95% CI 0.37 to 8.28, 330 newborns, 1 study). Very low-certainty evidence on adverse effects suggested no increased nasolacrimal duct obstruction (RR 0.93, 95% CI 0.68 to 1.28, 404 newborns, 1 study of erythromycin 0.5% and silver nitrate 1%) and no increased keratitis (single study of 40 newborns assessing silver nitrate 1% with no events).    Any prophylaxis compared to another prophylaxis Overall, evidence comparing different interventions did not suggest any consistently superior intervention. However, most of this evidence was of low-certainty and was extremely limited.

AUTHORS' CONCLUSIONS

There are no data on whether prophylaxis for ophthalmia neonatorum prevents serious outcomes such as blindness or any adverse visual outcome. Moderate-certainty evidence suggests that the use of prophylaxis may lead to a reduction in the incidence of ACAE in newborns but the evidence for effect on GC, CC or BC was less certain. Comparison of individual interventions did not suggest any consistently superior intervention, but data were limited. A trial comparing tetracycline, povidone-iodine (single administration), and chloramphenicol for GC and CC could potentially provide the community with an effective, universally applicable prophylaxis against ophthalmia neonatorum.

Use of topical ocular antibiotics in young children: a Scandinavian drug utilization study

PURPOSE

Acute infectious conjunctivitis is a common disease. While usually self-limiting, children often receive treatment to be accepted back into nursery, day care or school. We aimed to describe trends in the utilization of topical ocular antibiotics in young children aged 0-4 years in Denmark, Norway and Sweden.

METHODS

Using individual-level data from the Danish National Prescription Registry (2000-2015), we provided detailed descriptions of treatment patterns at the individual level, stratified by age (0-1 years, 2-4 years) and antibiotic substance. Aggregate-level data for Danish, Norwegian and Swedish children (0-4 years) were obtained from publicly available data sources (2000-2016).

RESULTS

We identified 107 581 Danish children aged 0-4 years receiving 271 980 treatment episodes. The incidence rate was relatively stable between 2000 and 2010 (on average, 637 and 283/1000 person-years for 0- to 1- and 2- to 4-year-olds, respectively), after which it dropped by 37% until 2015. In the aggregated data, a markedly higher use was seen in Denmark (211/1000 children in 2016) compared with Sweden (42) and Norway (151). The decrease from 2010 onwards was observed in all three countries. Chloramphenicol and fusidic acid were the most commonly used topical ocular antibiotics across Scandinavia. Tobramycin was rarely used in Norway and Sweden (≤1/1000 children in 2016) compared with Denmark (24/1000 children).

CONCLUSION

Considerable variation is seen in the utilization of topical ocular antibiotics among children in Scandinavia, with Denmark having the highest use. Across the Scandinavian countries, however, a decline was noted from 2010 onwards.

Pediatric Glaucoma: Pharmacotherapeutic Options

Childhood glaucoma is a major therapeutic challenge for pediatric ophthalmologists and glaucoma specialists worldwide. Management depends on the etiology and age at presentation. A variety of drugs are available for the control of intraocular pressure in children; however, none of these drugs have been licensed by the regulatory agencies for use in children. Furthermore, evidence gained from randomized controlled trials in the pediatric population is sparse, and little is known regarding the use of newer anti-glaucoma preparations. This evidence-based review aims to discuss the available pharmacotherapeutic options for glaucoma in children. Topical adrenoceptor blockers, topical and systemic carbonic anhydrase inhibitors, prostaglandin (PG) analogs, adrenoceptor agonists, parasympathomimetics, and combined preparations are available for use in children, but usually as an off-label indication. Therefore, it is important to recognize that serious side effects have been reported, even with topical drops, and measures to reduce systemic absorption should be taken. Most drugs have been shown to have comparable ocular hypotensive effects, with the lowest occurrence of systemic side effects with PG analogs. Whereas a newly introduced prostaglandin analog, tafluprost, and some other preservative-free preparations have shown promising results in adult glaucoma patients, no pediatric reports are available as yet. Future studies may describe their role in treating pediatric glaucoma. This review also shares some suggested treatment pathways for primary congenital glaucoma (PCG), juvenile open angle glaucoma (JOAG), developmental glaucoma, aphakic/pseudophakic glaucoma, and uveitic glaucoma.

Effects of dosing protocol on distribution of propranolol in periocular tissues after topical ocular instillation

PURPOSE

Our previous study demonstrated that topical ocular instillation can deliver effective concentrations of propranolol in the periocular tissues, and may be superior to oral propranolol in the treatment of periocular capillary hemangiomas. The objective of this study was to investigate the effects of dosing protocol on the distribution of propranolol in the periocular tissues and plasma after topical ocular instillation.

METHODS

Each rabbit received propranolol 0.5% ophthalmic solution using one of the following dosing protocols: three drops of 50 μL, one drop of 50 μL, or one drop of 25 μL. The periocular tissues (e.g. eyelids and extraocular muscles) and blood were collected and assayed for propranolol at 1 h after dosing.

RESULTS

Decreasing the concentration of eye drops (1% to 0.5%), decreasing the number of eye drops during dosing (three drops to one drop), or decreasing the instilled volume (50 µL to 25 µL) generally lowered the concentration of propranolol in the periocular tissues. Nevertheless, therapeutic levels of propranolol (> 0.4 μg/g) were delivered to the periocular tissues at 1 h after dosing using any of the three protocols examined. Dose-dependent concentrations in some periocular tissues and plasma were observed over the dose range of 0.125 mg to 1.5 mg. The plasma concentration of propranolol was not measurable when a single 25 μL of propranolol 0.5% was instilled in the eye.

CONCLUSIONS

The dosing protocol of topical ocular instillation can be tailored to achieve the desired therapeutic concentrations of propranolol in the periocular tissues while minimizing systemic exposure.

Can ophthalmic drops cause central nervous system depression and cardiogenic shock in infants?

Topical ocular medications have been widely prescribed and successfully used in children for the management of different ophthalmic disorders. We present 2 infants admitted to our pediatric intensive care unit who developed altered state of consciousness, hypotonia, hypothermia, bradycardia, and apnea after instillation of ophthalmic drops. The second infant also had hypotension and broncho-obstruction. Few days before admission, both infants were diagnosed with congenital glaucoma, and topical antiglaucoma treatment was initiated. Ophthalmic drops with brimonidine and brinzolamide were prescribed to both patients, whereas the second infant also received topical timolol. After elimination of other possible causes, the diagnosis of intoxication with topical antiglaucoma medications was established. After discontinuation of eye drops and vigorous symptomatic treatment, both infants recovered without sequels. Topically applied ophthalmic drops may cause life-threatening systemic adverse effects in infants, such as central nervous system depression and cardiogenic shock. Moreover, these 2 patients illustrate the importance of careful evaluation of all topical medications and their consideration as possible causes of the derangements in critically ill infants.

Ocular medicines in children: the regulatory situation related to clinical research

Background

Many ocular medications are prescribed for paediatric patients, but the evidence for their rational use is very scant. This study was planned to compare the availability and the licensing status of ocular medications marketed in Italy, the United Kingdom (UK), and the United States of America (USA) related to the amount of published and un-published RCTs testing these drugs in the paediatric population.

Methods

A quantitative analysis was performed to evaluate the number of ocular medications with a paediatric license in Italy, the UK, and the USA. A literature search was also performed in MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) on ophthalmic pharmacological therapy in children aged < 18 years, published up to December 2010. A search in the international clinical trial registries, the list of paediatric investigation plans (PIPs) approved by European Medicines Agency (EMA), and the table of medicines with new paediatric information approved by Food and Drug Administration (FDA) was also performed.

Results

In all, of 197 drugs identified, 68 (35%) single drugs are licensed for paediatric use at least in one considered country, while 23 (12%) were marketed in all three countries. More specifically, in Italy 43 single drugs (48% of those marketed) had a paediatric license, while 39 (64%) did in the UK and 22 (54%) did in the USA. Only 13 drugs were marketed with a paediatric license in all countries.

The percentage of drugs licensed for paediatric use and for which at least one RCT had been performed ranged between 51% in Italy and 55% in the USA. No published RCTs were found for 11 (48%) drugs licensed for paediatric use in all three countries. In all, 74 (35%) of the retrieved RCTs involved mydriatic/cycloplegic medications.

A total of 62 RCTs (56% completed) on 46 drugs were found in the international clinical trial registries. Cyclosporin and bevacizumab were being studied in many ongoing trials. Twenty-six drugs had new paediatric information approved by FDA based on new paediatric clinical trials, while only 4 PIPs were approved by EMA.

Conclusions

There is a pressing need for further research and clinical development in the pediatric ophthalmic area, where effective up-to-date treatments, and additional research and education on use in children, remain priorities.

Acute infectious conjunctivitis in childhood

OBJECTIVE

To review the etiology, clinical features and management of acute infectious conjunctivitis in children after the newborn period.

DATA SOURCES

Articles obtained from MEDLINE published before March 2000.

DATA SELECTION AND EXTRACTION

Representative articles on the etiology and clinical features were selected. Twenty-four clinical trials were also selected. From these articles, the main findings from three placebo controlled trials and two comparative clinical trials involving children are summarized in detail. The main findings from 19 comparative clinical trials in adults are briefly summarized.

DATA SYNTHESIS AND CONCLUSIONS

Acute infectious conjunctivitis caused by bacteria or viruses is a very common problem in children after the neonatal period. The most common bacterial pathogens are nontypable Haemophilus influenzae and Streptococcus pneumoniae. Diagnostic microbiology tests are not indicated for uncomplicated cases but may be useful for very young or very ill children if there is no response to initial therapy; for nosocomial cases; for cases suspected to be caused by sexually transmitted pathogens; and for outbreaks. Conjunctivitis is usually a mild, self-limited disease, but topical antibiotics are superior to placebo in reducing the duration and severity of symptoms. Most topical agents have equivalent efficacy; therefore, the selection of first-line agents should include inexpensive drugs with few adverse effects. Good choices include polymyxin/gramicidin, polymyxin/trimethoprim or sulfacetamide. Referral to an ophthalmologist should be considered in situations in which the diagnosis of uncomplicated conjunctivitis is in doubt or if there is no prompt response to therapy.

The safety and efficacy of glaucoma medication in the pediatric population

Topical glaucoma medications are widely used for childhood glaucoma, although little is known concerning the use of the newer glaucoma medications in this population. The majority of the references cited were extracted from PubMed. A literature review of all English language reports related to glaucoma medication in the pediatric population since 1980 was performed. Medical therapy of pediatric glaucoma contains four groups of drugs: beta-blockers (timolol and betaxolol), carbonic anhydrase inhibitors (dorzolamide), alpha2-agonists (brimonidine), and prostaglandin analogs (latanoprost). Timolol is the first choice in pediatric glaucoma. In cases with insufficient reduction of the intraocular pressure (IOP), the combination of timolol once a day and dorzolamide twice a day brings about a good control of the IOP. Both medications are effective and well tolerated. The alpha2-agonists have more and potentially serious adverse effects in children and are contraindicated for children younger than 2 years of age. Latanoprost tends to be less effective in lowering IOP in children than in adults. However, no studies are reported where latanoprost is used in monotherapy. Additional study may further delineate this drug's role in treating pediatric glaucoma. The safety profile of latanoprost in children appears excellent.

Zentralnervöse Atemdepression als Komplikation der Behandlung des kongenitalen Glaukoms mit Brominidin-Augentropfen

We report the case of a premature newborn (gestational age 33 weeks) with congenital glaucoma. After a trabeculotomy high intraocular pressure persisted, leading to adjuvant treatment with timolol and--when the infant was 3 weeks old--with brimonidine. After the first application of topical brimonidine the infant developed such severe apnoeic spells that intubation and temporary ventilation were necessary. A review of the literature reveals that when used in young infants brimonidine eye drops can potentially have toxic effects on the central nervous system (e.g. respiratory depression). The use of topical brimonidine is therefore not advised in this age group.

Transient paralytic ileus following the use of cyclopentolate-phenylephrine eye drops during screening for retinopathy of prematurity

Cyclopentolate-phenylephrine eye drops are commonly used for mydriasis during routine screening for retinopathy of prematurity in preterm infants. Although systemic absorption is minimal, it can result in side effects. We report two cases of transient paralytic ileus associated with transient oxygen desaturation and hypertension following the use of cyclopentolate-phenylephrine eye drops.

Penetration of topically administered ofloxacin and trimethoprim into aqueous humor

Ocular penetration of two topical antibiotics used to treat bacterial conjunctivitis was assessed in adult volunteers scheduled for cataract surgery. In this randomized, parallel-group study, patients instilled trimethoprim sulfate 0.1%/polymyxin B (n = 23) or ofloxacin 0.3% (n = 25) QID for 3 days, plus 4 instillations in the hour before surgery. Analysis of aqueous humor samples obtained during surgery showed a 2.4-fold greater concentration of ofloxacin over trimethoprim (1.135 micro g/ml vs 0.470 micro g/ml; P <.0001). The greater concentration of ofloxacin in ocular tissue coupled with its superior antibacterial activity profile supports its use as an alternative to trimethoprim/polymyxin B for treatment of bacterial conjunctivitis.

Corneal ulceration in pediatric patients: a brief overview of progress in topical treatment

Pediatric microbial keratitis is a rare but potentially devastating condition. The condition is similar to adult microbial keratitis, but is often characterized by a more severe inflammatory response. The micro-organisms that cause microbial keratitis in children are similar to the causative agents in adults, with herpes simplex and bacteria being the predominant causative agents, and fungi being less frequent. Of the bacterial pathogens, Pseudomonas aeruginosa, Staphylococcus aureus and alpha-hemolytic streptococci are common. The risk factors for pediatric keratitis include colonization of the eyes during birth and trauma to the cornea. Certain microbial factors involved in microbial keratitis are common to all micro-organisms, including adhesion to the cornea, penetration into the cornea, destruction of the corneal stroma (usually by microbial and/or host proteases), and recruitment of white blood cells to help defend the eye. Specific inflammatory responses that occur during pediatric microbial keratitis are not known in detail, but it is likely that cytokines and polymorphonuclear leucocytes are major factors, as they are in adult microbial keratitis. Treatment for pediatric microbial keratitis is usually the same as treatment for adult microbial keratitis; topical application of antimicrobial agents initially, followed by application of anti-inflammatory agents. With pediatric microbial keratitis, extra care must be taken to ensure nontoxicity due to blood adsorption. New microbial keratitis treatments are being developed and these mainly focus on new antimicrobials, antivirulence agents (such as vaccination against microbial toxins) or specific anti-inflammatory agents. There remains a clear need for increased research into the specific responses during microbial keratitis in children which will help progress new therapies as well as the development of new antimicrobials, especially new antifungal therapies.