Over-the-Counter Ocular Decongestants in the United States - Mechanisms of Action and Clinical Utility for Management of Ocular Redness

Efficacy in myopia control-The impact of rebound

PURPOSE

When myopia control treatment is discontinued, progression will increase, but does it revert to expected values based on the age and race of the child or does it accelerate further? The latter scenario is considered a rebound.

METHODS

A PubMed search was conducted with the words 'rebound' and 'myopia control', identifying further papers from reviews. Inclusion was limited to prospective studies with ≥6 months of treatment, ≥3 months of data following cessation and with axial length data, which allowed calculation of rebound. Nineteen studies were identified, comprising 24 treatment groups. In 10 studies, untreated control children were followed both throughout the treatment and cessation periods, allowing for a concurrent comparison group. In three studies, a control group was followed for 1 or 2 years and thereafter received the treatment under evaluation. Later, treatment ceased in the originally treated children. Finally, six studies were cross-over designs. For these latter two study designs, initial axial elongation and myopia progression in the control group were extrapolated to the cessation period, accounting for annual slowing. Values from durations of <1 year were annualised.

RESULTS

The mean annualised rebound was +0.05 ± 0.10 mm and -0.09 ± 0.24 D for axial length and myopia progression, respectively, and these were correlated (r2 = 0.59, p < 0.001). Rebound was associated with 1-year treatment efficacy (r2 = 0.43, p < 0.001). The mean annualised rebound with optical corrections was -0.01 ± 0.03 mm. Five of the six highest rebound values (≥0.14 mm) were from red light therapy and atropine studies. Rebound ranged from +0.03 to +0.14 mm for overnight orthokeratology.

CONCLUSIONS

Consistent with previous statements, no evidence for rebound was found for myopia control spectacles and soft contact lenses. Future research should explore the influence of age and magnitude of treatment efficacy on rebound.

Neurokinin-1 Receptor Antagonism Reduces Nonallergic Ocular Redness in a Rabbit Model

Purpose: To evaluate the therapeutic efficacy of topical application of a neurokinin-1 receptor (NK1R) antagonist in a rabbit model of nonallergic ocular redness. Methods: Nonallergic ocular redness was induced in rabbits by a single, topical application of dapiparzole hydrochloride eye drops (0.5%, 1%, 2%, or 5%). The NK1R antagonist L-703,606 was topically applied to the eye at the same time of induction or 20 min after induction, and phosphate buffered saline (PBS) treatment served as the control. Superior bulbar conjunctival images were taken every 30 s for the first 2 min, followed by every 4 min for 8 min, and then every 10 min until 1 h. The severity of ocular redness was evaluated on the images using ImageJ-based ocular redness index (ORI) calculations. Results: The ORI scores were significantly increased after the application of 0.5%, 1%, 2%, or 5% dapiparzole at each time point evaluated, with the most severe redness induced by the 5% dapiprazole that led to a maximal mean increase in ORI score of 14 at 20 min post-induction and thus used for subsequent evaluation of therapeutic efficacy of NK1R antagonism. Topical L-703,606, when applied at the same time as dapiprazole induction, significantly suppressed the increase of ORI scores at all time points (∼40% decrease). Furthermore, when applied at 20 min after dapiprazole induction, L-703,606 rapidly and effectively suppressed the increase of ORI scores at 30, 40, 50, and 60 min (∼30% decrease). Conclusions: Topical blockade of NK1R effectively prevents and alleviates nonallergic ocular redness in a novel animal model.

Diagnostic Uses of Common Eye Drops

Medicated eye drops may have dual therapeutic and diagnostic uses that form part of the ophthalmic assessment paradigm. In this review article, commonly administered and prescribed eye drops were analyzed for their use as a diagnostic tool. It examines the common categories of eye drops-antimicrobial agents, topical anesthetics, mydriatics, and ocular anti-hypertensives, with respect to their therapeutic and diagnostic applications. Knowledge of the pharmacological effects of eye drops is an important aspect in performing clinical duties. Diagnostic tests by utilization of eye drops are safe, efficient, noninvasive, and informative to the eye care professional.

Ingestion of Fluids of the Ocular Surface Containing Eye Drops of Imidazole Derivatives-Alpha Adrenergic Receptor Agonists as Paragons

Accidental poisonings by ingesting conjunctival fluid mixed with eye drops commonly involve alpha-2 adrenergic receptor agonists and tetrahydrozoline. These substances are recognized in commonly reported ingestions. Victims of all ages, otherwise in good health, often present as pale and lethargic to the emergency department (ED) after unintentionally ingesting topical eye medication. While eye drop poisoning cases in childhood include accidents during the play and poisonings in adults mean either suicide attempts or side effects caused by the systemic absorption of the substance, fluid of the ocular surface is a risk to all age groups. With this in mind, this study aimed to summarize data in the literature on tetrahydrozoline and alpha-2 adrenergic receptor agonists as dangerous medications, even when administered in low-bioavailability forms, such as eye drops. With this aim, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of relevant studies was conducted. A search of PubMed, Scopus, Web of Science, and EBSCOhost yielded nine studies that met the rigorous inclusion criteria. The primary studies were subject to a meta-analysis once a quality appraisal of the studies and a narrative synthesis of the extracted data had been conducted. The author hopes that this information will provide observations that will lead to better designs for over-the-counter eye drops, off-label drug usage policies, and parental attention.

Novel Deliberately Sensitive and Selective Tetrahydrozoline Voltammetric Sensors Integrated with a Copper Oxide Nanoparticle/Zeolite Platform

The present study introduced a novel disposable screen-printed carbon electrodes (SPCEs) modified with copper oxide/zeolite nanostructures for eco-friendly selective differential pulse voltammetric quantification of tetrahydrozoline (THZ) in eyedrop samples and biological fluids. Modification of the electrode matrix with copper oxide nanoparticles/zeolite nanostructures (CuONPs/ZY) with their effective and synergistic electrocatalytic activity enhanced the electrode performance against electrooxidation of THZ at 0.960 V in BR at pH 9.0 with a diffusion-controlled reaction mechanism. The tentative oxidation mechanism based on molecular orbital calculations postulates the oxidation of THZ molecules through oxidation of a nitrogen atom five-membered ring and the participation of two electrons/protons in the electrode reaction. Linear calibration curves were illustrated within a wide THZ concentration range from 0.24 to 57.2 μg mL-1 recording a limit of detection (LOD) value of 0.0799 μg mL-1. The CuONPs/ZY/SPEs exhibited improved performance compared with the sole reported THZ sensor-based gold film-plated carbon paste electrodes, in addition to their high reproducibility of fabrication and measurement and prolonged shelf lifetime. Tetrahydrozoline was successfully assayed in the presence of excipients, degradation products, and chloramphenicol. The presented voltammetric sensor can be considered as an eco-friendly and reliable analytical approach for monitoring THZ residues in eye drop samples and biological fluids with high recovery compared with the official pharmacopeial analytical protocol. The presented sensors were assessed according to an EcoScale tool and also compared with the reported THZ sensor.

Improvement of objective ocular redness measured with Keratograph 5M in glaucoma patients after instilling brimonidine drops

OBJECTIVE

To compare objective ocular redness measured using OCULUS Keratograph 5 M before and after 0.2% brimonidine instillation in glaucoma patients under topical hypotensive treatment.

METHODS

60 eyes from 60 subjects diagnosed with glaucoma or ocular hypertension under hypotensive ocular topical treatment were analyzed. Basal Ophthalmological examination was performed.Outcome variables were OCULUS Keratograph 5 M redness scores (RS) before and after 0.2% brimonidine instillation; overall, bulbar temporal (BT), bulbar nasal (BN), limbar temporal (LT), and limbar nasal (LN); non-invasive average tear film breakup time (Nia-BUT), non-invasive first tear film breakup time (Nif-BUT) and meibography. In addition, the following clinical data were collected: intraocular pressure, type, duration, amount, and preservatives/or not of hypotensive treatment, fluorescein corneal staining score and lower tear meniscus height.

RESULTS

All eyes were under topical medication. All redness scores were reduced after brimonidine instillation, mean RS differences were BT 0.82 ± 0.62, BN hyperemia 1.03 ± 0.55, LN hyperemia 0.84 ± 0.49, LT hyperemia 0.71 ± 0.50 and total hyperemia 0.91 ± 0.52 (all p < 0.001). 30 min after brimonidine instillation mean overall RS reduction was 47.97 ± 12.39% (p < 0.001) and after 1 h there was a persistent reduction of overall RS of 45.92 ± 14.27% (p < 0.001). Hyperemia reduction was significant and comparable between preservative and preservative-free group 0.12 ± 0.14 (p > 0.392) and between patient with combination therapy and monotherapy 0.16 ± 0.14 (p > 0.258).

CONCLUSION

A significant reduction of conjunctival hyperemia was objectively found in glaucoma patients under topical hypotensive treatment before and after brimonidine instillation. Its fast and long-lasting effect may be useful preoperatively in glaucoma patients to reduce intraoperative bleeding and associated complications.

Ocular complaints and diagnoses in spaceflight

The NASA human system risk board (HSRB) has long focused on trauma and acute medical illness as a key contributor to high level in-flight medical risk. However, ocular issues, trauma, and complaints during spaceflight are poorly characterized. In a retrospective case series, the NASA data from the life sciences data archieve (LSDA) and the lifetime surveillance of astronaught health (LSAH) was queried for eye related complaints and conditions in spaceflight across international space station (ISS) missions and space shuttle (STS) missions. The ISS dataset included missions from the year 2000 to 2020, and the STS dataset included missions from 1981 to 2011. Data were reviewed and segmented into categories of ocular complaints. 135 STS missions and 63 ISS missions were included in this analysis. Ocular events were only noted across 83 STS missions (61.5%) and 41 ISS missions (65.1%). Overall, the most common ocular complaints were eye irritation (n = 80, 33.1%), ocular foreign body or foreign body sensation (n = 55, 22.7%), dry eye syndromes (n = 38, 15.7%), epiphora or excessive tearing (n = 19, 7.85%). Of all ocular complaints or diagnoses, 9 (3.72%) were considered higher severity (keratitis, corneal ulcer, chemical exposure, and corneal abrasion). However, seemingly none required evacuation from mission. Improved depiction of ocular symptoms and diagnoses, and a more standard classification system and process to describe ocular symptoms, diagnoses, and treatments in space is crucial to provide more effective and comprehensive treatments.

The Effect of Half Percent Oxymetazoline Nasal Drops on Post-Tonsillectomy Cough, Sore Throat and Bleeding in Children; A Double-Blind Randomized Clinical Trial

Background

Considering the high prevalence of tonsillectomy in children and concerns of postoperative management, this study was conducted with the aim of evaluating the effects of oxymetazoline on bleeding, cough, and sore throat in children undergoing tonsillectomy.

Materials and Methods

The current double-blind clinical trial study was conducted on 88 tonsillectomy candidate patients. These patients were randomly divided into two groups. In the first group, oxymetazoline 0.05% nasal spray (OXY group) and in the second group, distilled water spray (Control group) was prescribed as one puff in each nostril immediately after anesthesia induction., the nasal spray was prescribed again in both nostrils at 12 h after tonsillectomy. Then the hemodynamic parameters, post-tonsillectomy hemorrhage (PTH) and sore throat were evaluated.

Results

The mean of the sore throat of children was not significantly different between the two groups in any of the follow-up times (P value >0.05). PTH in recovery and in the ward in the OXY group with the mean of 57.60 ± 71.82 ml and 22.11 ± 22.50 ml, respectively, was significantly lower than the control group (83.50 ± 113.64 ml and 27.52 ± 35.11 ml) (P value < 0.05). Also, the frequency of cough in the ward in the OXY group with 27.3% was significantly lower than the control group with 56.8% (P value = 0.005).

Conclusion

Regarding the results of the present study, sore throat and hemodynamic parameters did not change significantly with the administration of oxymetazoline. But this drug has played a significant role in reducing PTH and cough in children.

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.

Naphazoline and oxymetazoline are superior to epinephrine in enhancing the cutaneous analgesia of lidocaine in rats

This study observed the cutaneous analgesic effect of adrenergic agonists when combined with lidocaine. We aimed at the usefulness of four adrenergic agonists and epinephrine as analgesics or as tools to prolong the effect of local anesthetics using a model of cutaneous trunci muscle reflex (pinprick pain) in rats. We showed that subcutaneous four adrenergic agonists and epinephrine, as well as the local anesthetic bupivacaine and lidocaine, developed a concentration-dependent cutaneous analgesia. The rank order of the efficacy of different compounds (ED₅₀ ; median effective dose) was epinephrine [0.013 (0.012-0.014) μmol] > oxymetazoline [0.25 (0.22-0.28) μmol] > naphazoline [0.42 (0.34-0.53) μmol] = bupivacaine [0.43 (0.37-0.50) μmol] > xylometazoline [1.34 (1.25-1.45) μmol] > lidocaine [5.86 (5.11-6.72) μmol] > tetrahydrozoline [6.76 (6.21-7.36) μmol]. The duration of full recovery caused by tetrahydrozoline, oxymetazoline, or xylometazoline was greater (P < 0.01) than that induced via epinephrine, bupivacaine, lidocaine, or naphazoline at equianesthetic doses (ED₂₅ , ED₅₀ , and ED₇₅ ). Co-administration of lidocaine (ED₅₀ ) with four adrenergic agonists or epinephrine enhanced the cutaneous analgesic effect. We observed that four adrenergic agonists and epinephrine induce analgesia by themselves, and such an effect has a longer duration than local anesthetics. Co-administration of lidocaine with the adrenergic agonist enhances the analgesic effect, and the cutaneous analgesic effect of lidocaine plus naphazoline (or oxymetazoline) is greater than that of lidocaine plus epinephrine.

The Management of Chemosis after Blepharoplasty

Chemosis is a common, though typically temporary complication of both upper and lower blepharoplasty surgery, though it is much more common after the latter. It occurs due to extravasation of fluid into the subconjunctival space precipitated by desiccation, inflammation, and manipulation of the conjunctiva and associated lymphatic drainage. Intraoperatively, minimizing surgical exposure and manipulation as well as maintaining a moist ocular surface can reduce the risks. Postoperatively, we propose a stepwise approach, starting with lubricants and escalating to increasingly potent anti-inflammatories with compression bandaging and surgery reserved for persistent cases.

Brimonidine tartrate ophthalmic solution 0.025% for redness relief: an overview of safety and efficacy

INTRODUCTION

Ocular redness, or conjunctival hyperemia, is a common ophthalmic sign associated with reduced quality of life. For redness without apparent underlying pathology, topical ophthalmic decongestants have been widely used.

AREAS COVERED

Brimonidine tartrate was approved in 2017 as a topical vasoconstrictor at a 0.025% concentration for relief of ocular redness. Since then, investigators have reported on efficacy and safety findings from studies evaluating low-dose brimonidine for reducing ocular redness.

EXPERT OPINION

Brimonidine is highly selective for α₂-adrenergic receptors. Clinical trials have so far shown that the drug in low doses significantly reduces ocular redness in comparison to vehicle for up to 8 hours. Brimonidine-treated eyes did not present side effects of other vasoconstrictors, such as hypotension, cardiac arrhythmia or drowsiness. Ocular adverse events such as allergic reactions and redness rebound were also minimal. In this review, we examine in detail published literature on the mechanism of brimonidine tartrate and its efficacy and safety in relieving conjunctival hyperemia.

Can bleeding in trabeculectomy be decreased? Effectiveness of brimonidine pre-treatment

PURPOSE

To evaluate the efficacy of preoperative topical brimonidine use to maintain visibility during trabeculectomy and control intraoperative bleeding and postoperative subconjunctival hemorrhage.

METHODS

The first group comprised 35 eyes of 34 patients administered brimonidine tartrate 0.15% (Brimogut, Bilim Ilac, Turkey) eye drops 6 and 3 min before surgery, and 33 eyes of 31 patients who received no medication for vasoconstriction formed the second group. Preoperative and postoperative photographs and operation video images were taken and vision analysis software used. Black-and-white images were obtained to identify the blood vessel and surface hemorrhage areas. The surface area of the hemorrhage was calculated by counting the black pixels with Image J software.

RESULTS

There was no significant difference between two groups in terms of baseline (preoperative) eye redness (p > 0.05). In the first group, the eye redness values were 344.7 ± 19.5 pixels preoperatively and 244.1 ± 23.3 pixels at the beginning of the surgery, respectively (p < 0.001). However, no significant change was observed in the second group in eye redness (348.2 ± 17.5 pixels preoperatively and 360.7 ± 26.8 pixels at the beginning of the surgery, p > 0.05). Cautery was used for an average of 11.91 ± 1.96 s in the first group and 25.57 ± 4.66 s in the second to control intraoperative bleeding (P < 0.001).

CONCLUSION

Preoperative topical brimonidine use in trabeculectomy surgery significantly decreased intraoperative bleeding and postoperative subconjunctival hemorrhage and facilitated bleeding control.

Factors Determining Plasticity of Responses to Drugs

The plasticity of responses to drugs is an ever-present confounding factor for all aspects of pharmacology, influencing drug discovery and development, clinical use and the expectations of the patient. As an introduction to this Special Issue of the journal IJMS on pharmacological plasticity, we address the various levels at which plasticity appears and how such variability can be controlled, describing the ways in which drug responses can be affected with examples. The various levels include the molecular structures of drugs and their receptors, expression of genes for drug receptors and enzymes involved in metabolism, plasticity of cells targeted by drugs, tissues and clinical variables affected by whole body processes, changes in geography and the environment, and the influence of time and duration of changes. The article provides a rarely considered bird’s eye view of the problem and is intended to emphasize the need for increased awareness of pharmacological plasticity and to encourage further debate.

Real-Life Active Surveillance of a Naphazoline/ Hypromellose Fixed Combination's Safety Profile in Peruvian Population

Objective

Identifying the adverse reactions and the possible risks associated with the use of naphazoline 0.1% + hypromellose 0.5% (NAPH), thereby evaluating its tolerability and safety profile.

Methods

A total of 236 Peruvian patients were included in an active pharmacovigilance study drug event monitoring consisting in 2 phone calls conducted in order to register adverse drug reactions (ADRs), the product’s tolerability and to assess the risk concerning specific clinical and demographic characteristics using a binary logistic regression model.

Results

A total of 54 ADRs (one per patient) were reported after the use of NAPH; classified (according to the Medical Dictionary for Regulatory Activities) into two groups of System Organ Class (SOC): eye disorders and nervous system disorders; and four groups of preferred term (PT): eye irritation, vision blurred, eye pruritus and headache. All ADRs were expected, mild and not serious. No risk factors related to the clinical and demographic characteristics of the patients were identified.

Conclusion

The low incidence of ADRs, their short recovery time, and their categorization as “mild” and “not serious” demonstrates the high tolerability in the studied population; therefore, according to the study, the safety profile for NAPH seems to be adequate, with a suitable tolerability.

Safety of Once-Daily Oxymetazoline HCl Ophthalmic Solution, 0.1% in Patients with Acquired Blepharoptosis: Results from Four Randomized, Double-Masked Clinical Trials

Purpose

An oxymetazoline 0.1% ophthalmic solution was recently approved for treatment of acquired blepharoptosis in adults. This study's objective was to evaluate the safety profile of oxymetazoline 0.1% when administered once daily for 14-84 days.

Patients and Methods

Pooled analysis examined safety outcomes from four randomized, double-masked, placebo-controlled clinical trials conducted at 6, 16, 27, and 35 sites, respectively, in the United States. In total, 568 participants with acquired blepharoptosis were evaluated. Median age was 66 years and 74.8% of participants were female. Overall, 375 participants self-administered oxymetazoline 0.1% to both eyes once/day and 193 self-administered placebo (vehicle) daily. Treatment-emergent adverse event (TEAE) rates, severity, and causality were evaluated in the overall population and within participant subgroups defined based on age, race, and ethnicity. Vital signs and ophthalmic findings were evaluated at predefined study visits. Patient-reported treatment tolerability was recorded at study end.

Results

TEAE incidence was similar among participants using oxymetazoline 0.1% (31.2%) or vehicle (30.6%). Nearly all TEAEs were mild-to-moderate, and most were not suspected of being treatment related. Serious TEAEs occurred in four participants receiving oxymetazoline 0.1% and one participant receiving vehicle. Nine and two participants in the oxymetazoline 0.1% and vehicle groups, respectively, discontinued due to a TEAE. Ocular TEAEs occurring in ≥2% of participants receiving oxymetazoline 0.1% were punctate keratitis, conjunctival hyperemia, dry eye, blurred vision, instillation site pain, and corneal vital dye staining, with none occurring in >3.5% of participants. TEAE rates were similar across subgroups based on age, race, and ethnicity. No clinically significant mean changes in vital signs or ophthalmologic findings occurred, and >98% of participants rated oxymetazoline 0.1% as causing no/mild discomfort.

Conclusion

Once-daily oxymetazoline 0.1% was safe and well tolerated in participants with acquired blepharoptosis when used for 14-84 days. Safety did not appear to differ based on age, race, or ethnicity.

A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options

Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact quality of life. While there are several known forms of congenital ptosis, acquired ptosis (appearing later in life, due to a variety of causes) is the predominant form of the condition. This review summarises the prevalence, causes, identification, differential diagnosis, and treatment of acquired ptosis. Particular attention is paid to the differential diagnosis of acquired ptosis and emerging treatment options, including surgical and pharmacologic approaches.

Conceptual Model for Using Imidazoline Derivative Solutions in Pulpal Management

Alpha-adrenergic agonists, such as the Imidazoline derivatives (ImDs) of oxymetazoline and xylometazoline, are highly effective hemostatic agents. ImDs have not been widely used in dentistry but their use in medicine, specifically in ophthalmology and otolaryngology, warrants consideration for pulpal hemostasis. This review presents dental healthcare professionals with an overview of ImDs in medicine. ImD solutions have the potential to be more effective and biocompatible than existing topical hemostatic compounds in pulpal management. Through a comprehensive analysis of the pharmacology of ImDs and the microphysiology of hemostasis regulation in oral tissues, a conceptual model of pulpal management by ImD solutions is presented.