Ophthalmology clinics of North America最新文献

The past 10 years have seen dramatic changes in the pharmacologic treatment of glaucoma. The treatment of glaucoma has changed from surgical to primarily medical. These treatments have improved the effectiveness and safety of lowering the intraocular pressure to prevent progressive vision loss and blindness, but no cure for glaucoma or reversal of blindness is available yet. Research is progressing and can hopefully achieve these final goals sometime in the future.

Significant advances have been made in developing new treatments and refining existing treatments for the prevention of scarring after disease, trauma, or surgical prevention. The advent of new technologies in addition to traditional chemical drugs such as dendrimers, antibodies, aptamers, ribozymes, gene therapy with viral vectors, and RNA interference, opens the door to a whole new generation of therapies to prevent fibrosis in the eye. The ability to control fibrotic processes in the eye offers many tantalizing prospects, including prevention of corneal blindness from scarring to "20/5 vision" with perfect corneal wound healing after wavefront refractive surgery prevention of PCO to fully accommodative lens implants, 100% success of glaucoma surgery with pressure at approximately 10 mmHg associated with < 5% progression over a decade, to no failure of retinal detachment surgery and minimal visual loss from AMD. Finally, most exciting is the prospect that neutralizing the fibrotic response to disease and injury will allow us to revert to the "fetal" mode when regeneration is the normal process, such as shown in the recent report that demonstrated that induction of bcl-2 gene expression together with downregulation of gliosis results in axonal regeneration in mice.

This article discusses the newest antibiotics, antivirals, and antifungals and their application in ophthalmology. The literature is reviewed to present the latest research on topical antibiotics, with particular attention to the newest classes of fluoroquinolones, new oral and topical antifungals, and new oral antivirals. Data comparing in vitro susceptibilities and minimum inhibitory concentrations of the antibiotics and antifungals are presented in tabular form.

Compliance with medication regimens is critical in assessing the effectiveness of treatments. As new drugs are approved for marketing and prescribed to diverse patient populations, the FDA now recommends further observational studies to continuously monitor unforeseen side effects or efficacy. More research is needed to develop valid and reliable tools to assess adherence of patients to treatment recommendations and adherence of patients to treatment guidelines, when applicable. Information on adherence is a relevant to physicians and their patients as it is to insurers and payers, who need to implement cost-effective disease management programs. This review also has highlighted examples in the adherence literature specific to glaucoma medications and based on longitudinal survival analyses of claims data. Such results may be best complemented by primary, survey-based data collected from patients in observational studies.

Although most medications for ophthalmic disease are administered locally, systemic absorption occurs as the drug passes into the nasopharynx by way of the nasolacrimal duct and may lead to a significant exposure. Knowledge of the mechanism of action of the drug, extent of systemic exposure, and its corresponding risks are important factors that must be considered before prescription of any ophthalmic agent. The relative risk in turn depends on the agent prescribed, plasma levels achieved, and individual susceptibility factors. Judicious use of pharmacotherapy in the management of ophthalmic disease should minimize the risk-benefit ratio.

Ocular allergy is a common hypersensitivity disorder that affects 15%-20% of the population in developed nations. This disorder can be divided into several categories: seasonal and perennial allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and drug-induced allergic conjunctivitis. Giant papillary conjunctivitis often is included among these classifications of allergy; however, it is not a true allergy, but rather the result of a chronic mechanical irritation. This article reviews these subtypes of ocular allergy, with particular emphasis on the pathophysiology, diagnosis, and treatment of seasonal and perennial allergic conjunctivitis. These are the most common varieties, representing more than 95% of the ocular allergy cases in the United States.

Although neuroprotective strategies and pharmaceutical agents have been initiated in the treatment of numerous disorders of the central and peripheral nervous systems, including trauma, epilepsy, stroke, Huntington disease, amyotrophic lateral sclerosis,and AIDS dementia, none have yet been applied to the treatment of glaucoma. A prospective, placebo-controlled, multi-institutional trial of memantine is underway. One would not expect the treatment modalities that form the bases of nonpharmaceutical, traditional medical systems to be used to lower IOP. Glaucoma was unknown when these medicinal treatments were developed over the centuries. Their primary use is in improving the cardiovascular and immune systems and in what is now called neuro-protection. Rather than single compounds that target a specific receptor and have demarcated side effects in other systems, plant products are a blend of many compounds and, according to those most versed in them, they achieve a balanced therapy, helping in specific symptomatic complexes while reducing side effects through ameliorating effects in other areas. It is not insignificant that, now that the rain forests are rapidly dwindling, together with their inhabitants and the knowledge of medicinal plants (especially in South America), the pharmaceutical companies are spending large amounts of money in a sudden, almost frantic attempt to gather the knowledge about rainforest plants before all has been completely lost. Proof of effects clinically in a chronic disease such as glaucoma remains largely lacking, and controlled trials are unlikely to be initiated, except perhaps through the National Institutes of Health, because these compounds have been in the public domain for many years. Perhaps those as yet unknown or un-recorded are patentable and perhaps these include drugs known only to small surviving communities of hunter-gatherers, which explains the pharmaceutical interest in these areas. When more accurate and rapid means of assessment of progression of glaucomatous damage than perimetry and optic nerve head photography are eventually developed and trials can be reduced in time, number of subjects, or even the use of nonhuman subjects for the bulk of studies, studies could be done for verification of effect of various compounds and also comparative studies. At the present time, GBE is the best documented of all the complementary medicinal agents and seems to have the greatest potential value. Ginkgo biloba extract has numerous properties that theoretically should be beneficial in treating non-IOP-dependent mechanisms in glaucoma. Its multi-ple beneficial actions, including increased ocular blood flow, antioxidant activity, platelet activating factor inhibitory activity, nitric oxide inhibition, and neuroprotective activity, combine to suggest that GBE could prove to be of major therapeutic value in the treatment of glaucoma.

Anti-VEGF therapy is a promising new avenue for the treatment of ocular neovascular diseases. Early preclinical data and recent clinical data support the efficacy and safety of several novel anti-VEGF for NVAMD. Whether these novel biologics are used on their own, in combination with previously available therapies, or with newly developing therapies, they represent a new avenue in treatment. These agents are highly selective in their targeted approaches, and when administered appropriately , offer treatment with minimal damage to retinal tissue. In the future, biotherapeutic agents will certainly play a powerful role in the treatment of human choroidal neovascular membrane formation.

Glaucoma is the most common optic neuropathy. Preventing visual loss is being studied with neuroprotective therapies. Visual restoration requires a restoration of retinal ganglion cells and their axons, ie, neurorepair and neuroregeneration. This review surveys recent developments in neuroprotection and regeneration from the standpoint of eventual applicability to treatment of patients who have glaucoma.