INTRAVITREAL INTRAVITREAL DRUGSDRUGS

Dr.Prathibha.M.ChachadiDr.Prathibha.M.Chachadi

How to giveHow to give ? ?

Informed consentInformed consent Dilated pupilDilated pupil Opd/operation theatreOpd/operation theatre Aseptic measuresAseptic measures Anaesthetic dropsAnaesthetic drops Lid speculumLid speculum Mark the site of injectionMark the site of injection Loading the drugLoading the drug Injecting the drugInjecting the drug Post injection precautions & medicationsPost injection precautions & medications

Drug used & its IndicationsDrug used & its Indications Antimicrobials Antimicrobials Acute post operative endophthalmitisAcute post operative endophthalmitisDelayed onset post operative endophthalmitisDelayed onset post operative endophthalmitisConjunctival bleb related endophthalmitisConjunctival bleb related endophthalmitisAcute retinal necrosisAcute retinal necrosisCytomegalovirus retinitisCytomegalovirus retinitis Anti –VEGFAnti –VEGFChoroidal neovascular membraneChoroidal neovascular membraneDiabetic macular edemaDiabetic macular edema Silicon oil & GasSilicon oil & GasRetinal detachmentRetinal detachment TpaTpavein occlusions-CRVOvein occlusions-CRVO Steroids Steroids Refractory CMERefractory CMEMacular edema+CRVOMacular edema+CRVOExudative macular degenerationExudative macular degeneration

AntimicrobialsAntimicrobials DrugDrug Dosage -mg/0.1mlDosage -mg/0.1ml

gentamicingentamicin 0.10.1

tobramycintobramycin 0.10.1

amikacinamikacin 0.40.4

cefazolincefazolin 2.252.25

cefatazidimecefatazidime 2.252.25

ciprofloxacinciprofloxacin 0.10.1

vancomycinvancomycin 11

Amphotericin-BAmphotericin-B 0.005[5microg]0.005[5microg]

AcyclovirAcyclovir 0.08[80microg]0.08[80microg]

ganciclovirganciclovir 400-2000microg400-2000microg

Preparation of intravitreal dosePreparation of intravitreal dosedrugdrug Vial sizeVial size InitialInitial

concentrconcentrationation

aliquotaliquot Add nsAdd ns Dose Dose mg/0.1mlmg/0.1ml

½-life½-life

amikacinamikacin 100mg/2ml100mg/2ml 50mg/ml50mg/ml 0.2ml0.2ml 2.3ml2.3ml 0.40.4 20-40hrs20-40hrs

Cefazolin Cefazolin &ceftazidim&ceftazidimee

500mg/2ml500mg/2ml 250mg/ml250mg/ml 0.1ml0.1ml 0.9ml0.9ml 2.52.5 15-38hrs15-38hrs

vancomycinvancomycin 5oomg/10ml5oomg/10ml 50mg/ml50mg/ml 0.2ml0.2ml 0.8ml0.8ml 11 22-54hrs22-54hrs

GentamycinGentamycin 80mg/2ml80mg/2ml 40mg/ml40mg/ml 0.1ml0.1ml 1.9ml1.9ml 0.20.2

AmphotericiAmphotericin-Bn-B

50mg/10ml50mg/10ml 5mg/ml5mg/ml 0.1ml0.1ml 0.9ml0.9ml 5microg5microg

ganciclovirganciclovir 500mg/10ml500mg/10ml 50mg/ml50mg/ml 0.8ml0.8ml 0.2ml0.2ml 800microg800microg

SteroidsSteroids

drugdrug Dosage[mg/0.1ml]Dosage[mg/0.1ml]

Dexamethasone[25]Dexamethasone[25] 0.40.4

Triamcenalone Triamcenalone acetate[5]acetate[5]

4 4 [half life- [half life- 18.6days;complete 18.6days;complete elimination-3 months]elimination-3 months]

Anti VEGFAnti VEGF

DrugDrug DosageDosage

Bevacizumab[ Bevacizumab[ avastiavasti

nn]]1.25 to 2.25mg1.25 to 2.25mg

Ranibizumab[Ranibizumab[lucentislucentis

]]0.3mg or 0.5mg0.3mg or 0.5mg

Pegabtanib[Pegabtanib[macugenmacugen]] 0.3mg0.3mg

PharmacodynamicsPharmacodynamics Therapeutic windowTherapeutic window Blood ocular barriersBlood ocular barriers Factors affecting absorption of a drugFactors affecting absorption of a drugPhPhLipid solubilityLipid solubilityMol wtMol wtProtein bindingProtein bindingInflammationInflammationothersothers

Distribution & eliminationDistribution & eliminationDosage usedDosage used

Extent & volume of distributionExtent & volume of distribution

Rate of elimination- apparent volume of distribution Rate of elimination- apparent volume of distribution & ½ life of drug& ½ life of drug

Route of elimination- anterior/posteriorRoute of elimination- anterior/posterior

Complications of intravitreal injectionComplications of intravitreal injection

Due to procedureDue to procedure Due to drugsDue to drugs Antibiotics Antibiotics Steroids-cataract, increased IOPSteroids-cataract, increased IOP Anti-VEGF-systemic complicationsAnti-VEGF-systemic complications

Retinal toxicityRetinal toxicity

gentamicingentamicin c/f- macular infarction, retinal c/f- macular infarction, retinal necrosis,vascular occlusion,retinal necrosis,vascular occlusion,retinal detachment,detachment,

vancomycinvancomycin Vitreous clouding, retinal opacificationVitreous clouding, retinal opacification

ceftazidimeceftazidime Macular cysts, holes, outer retinal damageMacular cysts, holes, outer retinal damage

clindamycinclindamycin At higher doses disorganisation of retinal At higher doses disorganisation of retinal layers ;papillitis; optic atrophylayers ;papillitis; optic atrophy

Amphotericin -Amphotericin -BB

Vitreous inflammation, retinal haemorhages, Vitreous inflammation, retinal haemorhages, retinal detatchment, retinal necrosis, retinal detatchment, retinal necrosis, chorioretinal scarringchorioretinal scarring

ganciclovirganciclovir Retinal opacification, peripapillary Retinal opacification, peripapillary haemorhages,RPE changes, vascular sclerosishaemorhages,RPE changes, vascular sclerosis

Drug interactionsDrug interactions Combination of drugsCombination of drugs Repetition of injectionsRepetition of injections

ReferencesReferences

Text book of ophthalmology-Dutta,vol 3Text book of ophthalmology-Dutta,vol 3 Posterior segment complications- P.N.NagpalPosterior segment complications- P.N.Nagpal