Reversal of cupping em glaucoma juvenil tratado com análogo de prostaglandina tópica / Reversal of cupping in juvenile glaucoma treated with topical prostaglandin analogue

Resumo A reversão da escavação é uma entidade rara que se refere à redução da escavação do disco óptico em resposta à diminuição sustentada dos níveis de pressão intra-ocular (PIO), em cerca de 25% da PIO basal. A ocorrência deste fenômeno apenas com o tratamento clínico é pouco relatada na literatura, Este estudo relata um caso de um paciente com glaucoma juvenil, que apresentou à gonioscopia ângulo aberto e tomografia de coerência óptica (OCT) com uma diminuição significativa na camada de fibras nervosas retinianas em ambos os olhos. Após um ano utilizando análogos de prostaglandina tópica e manutenção de níveis baixos de PIO, ocorreu diminuição da escavação do nervo óptico, que foi confirmada pelos padrões topográficos da OCT. O "reversal of cupping" é um sinal da diminuição da tensão ao nível da lâmina crivosa e está provavelmente associada a uma redução do risco para a progressão do glaucoma a longo prazo, sem melhora da função visual.

Abstract Reversal of cupping is a rare entity, characterized by the reduction of optical disc cupping in response to sustained decrease in intraocular pressure (IOP) levels by 25% of the basal IOP. The occurrence of this phenomenon with clinical treatment is rarely reported in the literature. This study reports a case of a patient with juvenile glaucoma with augmented cupping, significant decrease in the retinal nerve fiber layer in both eyes and altered topografic measures in optical coherence tomography (OCT). After one year using topical prostaglandin analog and keeping low IOP levels, a decrease in optic nerve cupping was detected in rethinography, confirmed by the improvement of OCT topographic measures. Reversal of cupping is a sign of decreased tension at the level of the lamina cribosa and is probably associated with a reduced risk for long-term progression of glaucoma without improvement of visual function.

Comparative evaluation of Latanoprostene Bunod, Timolol Maleate, and latanoprost Ophthalmic Solutions to assess their safety and efficacy in lowering intraocular pressure for the management of Open-Angle Glaucoma

OBJECTIVES: Timolol maleate has been reported to be a safer intraocular pressure (IOP) lowering treatment than latanoprost. The United States Food and Drug Administration approved latanoprostene bunod, a nitric oxide-donating prodrug of latanoprost, for lowering IOP. This study compared the safety and efficacy of latanoprost, latanoprostene bunod, and timolol maleate in patients with open-angle glaucoma. METHODS: Patients who received latanoprost eye drops once daily in the evening were included in the latanoprost Ophthalmic Solutions (LP) cohort (n=104). Those who received latanoprostene bunod eye drops once daily in the evening were included in the Latanoprostene Bunod (LB) cohort (n=94). Those who received timolol eye drops twice daily were included in the Timolol Maleate (TM) cohort (n=115). All treatments were administered to the affected eye(s) for 3 months. Informed Consent has been taken from each participant before the trial. RESULTS: At the end of 3 months of treatment, latanoprost, latanoprostene bunod, and timolol were all successful in reducing IOP. The LB cohort had the highest reduction in IOP, compared to the LP and TM cohorts. All treatments had some common adverse ocular effects. CONCLUSION: Latanoprostene bunod was superior to latanoprost and timolol for the treatment of open-angle glaucoma.

A Case of Lumbar Infantile Hemangioma (SACRAL Syndrome) Accompanied by Spinal Anomaly and Dermal Sinus / 대한피부과학회지

Infantile hemangioma (IH) usually presents solely as a cutaneous manifestation, and rarely accompanies diverse anomalies such as spinal dysraphism. A 2-month-old girl presented with IH on her lumbar skin as a coin-sized red plaque with adjacent depressed skin and a child-palm-sized red plaque on her left ankle since birth. Considering the coexistence of IH and depressed skin on the midline in her lumbosacral area, magnetic resonance imaging of her spine was performed, which showed intraspinal/dermal vascular tumors with spina bifida occulta at the 12th thoracic vertebrae level. Furthermore, no neurologic deficits were observed. She has been taking oral propranolol with topical timolol to prevent neural complications and the lesions clinically improved. However, additional surgery for the intraspinal lesions was considered due to urination/defecation abnormalities since she was 13 months of age. In cases of midline IH, particularly with additional skin lesions, appropriate imaging studies to identify accompanying anomalies should be performed, and referrals to neurosurgical specialists should be considered.

The Effect of a Fixed Combination of 0.0015% Tafluprost-0.5% Timolol in Normal Tension Glaucoma Patients

PURPOSE: This study evaluated the effect of a fixed combination of 0.0015% tafluprost-0.5% timolol (Tapcom®, Santen, Osaka, Japan) in glaucoma patients. METHODS: This study included 23 patients who were diagnosed with normal tension glaucoma and treated with a fixed combination of 0.0015% tafluprost-0.5% timolol as the first therapy. Diurnal intraocular pressure (IOP) was measured every 2 and 0.5 hours between 9:00 am and 4:30 pm. The IOP change with respect to body position (positional IOP) was measured at baseline and at 6 months after eye-drop instillations. IOP fluctuation was defined as the standard deviation of IOP measurements. Throughout the study, all side effects were recorded and monitored by the investigators. RESULTS: The mean reduction in IOP in the 0.0015% tafluprost-0.5% timolol fixed combination-treated eyes was −3.37 ± 2.39 mmHg (−19.70 ± 13.97%) for the right eye and −3.22 ± 2.27 mmHg (-18.81 ± 13.28%) for the left eye (paired t-test, p < 0.001). The mean positional IOP measured at 4 pm at 6 months after 0.0015% tafluprost-0.5% timolol fixed combination instillation showed statistically significant reduction from the mean positional IOP at baseline. There was a significant difference in the number of patients with ≤3 mmHg IOP variation over four time points between baseline and at 6 months in the 0.0015% tafluprost-0.5% timolol fixed combination-treated eyes (McNemar test, p < 0.001). There was no serious adverse event causing ocular damage. CONCLUSIONS: Use of 0.0015% tafluprost-0.5% timolol fixed combination was effective and well tolerated in reducing IOP and in maintaining its effectiveness in glaucoma patients.

Comparison of Allergy Prevalence between Brimonidine/Timolol Fixed Combination and 0.15% Brimonidine in Glaucoma Patients

PURPOSE: To compare the allergy prevalence and clinical manifestations of 0.2% brimonidine/0.5% timolol fixed combination (BTFC) and 0.15% brimonidine in Korean patients with glaucoma. METHODS: We retrospectively analyzed the medical records of 196 glaucoma patients treated with BTFC and 234 glaucoma patients treated with 0.15% brimonidine. We compared sex, age, type of glaucoma, treatment period, allergy history, onset time of ocular allergy and clinical characteristics of allergy in the two groups. RESULTS: Ocular allergy percentages 10.14% in the BTFC group and 22.02% in the 0.15% brimonidine group, and the risk of allergy was approximately 0.4 times lower in patients using BTFC (hazard ratio = 2.5, p = 0.009). The BTFC group developed ocular allergy at a mean of 20.5 months (range: 1.7–51.1 months), and the 0.15% brimonidine group developed ocular allergy at a mean of 7.7 months (range: 0.4–50.8 months). In the BTFC group, 50% of the ocular allergy occurred within 15 months, and within 5 months in the 0.15% brimonidine group. Clinical characteristics of brimonidine allergy involved two types of conjunctival follicles and conjunctival papillae, but there were no significant differences in incidence according to allergy type (p = 0.566). CONCLUSIONS: The prevalence of ocular allergy in the BTFC group was lower than that in the 0.15% brimonidine group in Korean patients with glaucoma. The results of this study are expected to be useful for patient education and compliance improvement using brimonidine.

Síndrome Iridocorneana Endotelial: Relato de Caso da Variante de Chandler / Iridocorneal Endothelial Syndrome: Case Report of Chandler's Variant

Resumo O presente estudo tem por objetivo relatar um raro caso da variante de Chandler da Síndrome Iridocorneana Endotelial em uma paciente de 56 anos. Esta referia baixa acuidade visual em olho direito há 2 anos, acompanhada de fotofobia e prurido. Ao exame oftalmológico, no primeiro atendimento, apresentava em olho direito acuidade visual de conta dedos à 0,5 metro e se observava à biomicroscopia policoria, edema corneano com microcistos e hiperemia conjuntival. O olho esquerdo não apresentava alterações. A pressão intraocular era de 16mmHg no olho direito e 10mmHg no olho esquerdo. Iniciou-se tratamento tópico com dorzolamida, maleato de timolol e dexametasona, sendo então, alcançado o controle da pressão intraocular. Constatou-se no exame de microscopia especular corneana a presença de ice cells. Na biomicroscopia atual, apresenta, no olho acometido, edema corneano com opacidade central, policoria, cristalino não visível e fundo de olho indevassável. Diante da confirmação do diagnóstico de Síndrome de Chandler, pelo quadro clínico compatível e alterações nos exames complementares, a paciente está em acompanhamento no serviço de Oftalmologia do Hospital Federal Servidores do Estado.

Abstract We report in this study a case of Chandler's Syndrome, an Iridocorneal Endhotelial Syndrome variant in a 56 years old patient, female, complaining about low vision in the right side, as well as itching and photophobia in the same side. In the first evaluation, we observed visual acuity of counting fingers at 0,5 meters, corneal swelling with microcystus and conjunctival hyperemia. The left eye was normal. Intraocular pressure was 16mmHg in right eye and 10 mmHg in left eye. We initiated topic treatment with Dorzolamide, Timolol and Dexamethasone, with good control of intraocular pressure. We noticed in corneal specular microscopy the presence of ice cells. In current biomicroscopy it is remarkable the corneal swelling, with central opacity and lens was not visible, as well as the fundoscopy is impossible. We confirmed the diagnosis of Chandler' Syndrome based on the clinical findings, and in abnormalities in complementary exams. Nowadays, the patient is being followed in the Ophthalmology department at Hospital Federal Servidores do Estado.

Manifestações oftalmológicas de Síndrome de Klippel Trenaunay / Ophthalmological manifestation of the Klippel Trenaunay Syndrome

RESUMO A Síndrome de Klippel-Trenaunay (SKT) é uma doença congênita rara, com maior prevalência no sexo masculino e incidência de 2-5:100.000. Apresenta-se, na forma clássica, como a tríade de manchas vinho porto, hipertrofia de membros e malformação venosa e/ou linfática. O diagnóstico é essencialmente clínico e devido à complexidade da síndrome, de natureza progressiva e ampla variedade de apresentações clínicas, os pacientes devem ser tratados de forma individualizada por uma equipe multidisciplinar. Alterações oftalmológicas associadas à SKT incluem anormalidades vasculares da órbita, íris, retina, coroide e nervo óptico. Relato de caso: Paciente de 23 anos, sexo feminino, portadora de SKT, em acompanhamento no Centro da Visão - Universidade Federal do Paraná, com queixa de diminuição da acuidade visual em olho direito. A paciente apresentava manchas vinho porto em dimidio direito e hipertrofia de membros ipsilateral. Foi diagnosticado glaucoma e realizados exames complementares oftalmológicos a fim de avaliar o grau de comprometimento dos campos visuais e o fundo de olho. A visão com a melhor correção foi de 20/100 OD e foi de 20/20 OE. À fundoscopia, constatou-se aumento da escavação do nervo óptico à direita - 0,75 x 0,90 mm. Optou-se por tratamento clínico com Cloridrato de Dorzolamida, Latanoprosta, Brimonidina e Timolol, com bons resultados a longo prazo - a tonometria de aplanação mostrou 19 mmHg OD e 15 mmHg OE, apesar da dificuldade na estabilização da doença. Conclusão: Relatos demonstram que os resultados dos tratamentos clínico e cirúrgico do glaucoma em associação à SKT são insatisfatórios quando comparados a outros tipos de glaucoma - o controle clínico não é possível em cerca de 1/3 dos pacientes, e o manejo cirúrgico tem alto índice de complicações. São necessários estudos mais expressivos que estabeleçam a correlação entre glaucoma e SKT e embasem o tratamento de escolha.

ABSTRACT The Klippel-Trenaunay Syndrome (KTS) is a rare congenital disease, which the prevalence is higher in males, and its incidence of 25:100,000. It is presented in its classic form as the triad of port-wine stains, enlarged limbs and venous and / or lymphatic malformation. The diagnosis is essentially clinical and due to the complexity of the syndrome, the progressive characteristic and the wide variety of clinical presentations, a multidisciplinary team should treat patients individually. The ocular changes associated with KTS include vascular, orbit, iris, retina, choroid and optic nerve abnormalities. Case report: A 23-year-old female patient, carrier KTS, being followed at Vision Center - Federal University of Paraná, complaining of decreased visual acuity in the right eye. The patient had port-wine stains in right hemibody and hypertrophy of ipsilateral members. Glaucoma was diagnosed and eye exams were performed to assess the degree of impairment of visual fields and fundus. The best correction was checked at 20/100 OD and 20/20 OS. At fundoscopy, there was increased excavation of the optic nerve right - 0.75 x 0.90 mm. Clinical treatment was chosen with Dorzolamide Hydrochloride, Latanoprost, Brimonidine and Timolol, presenting good long-term results - the tonometry showed 19 mmHg OD and 15 mmHg OS, despite the difficulty in stabilizing the disease. Conclusion: Reports have shown that the results of clinical and surgical treatments of glaucoma in association with KTS are unsatisfactory compared to other types of glaucoma - clinical control is not possible in about 1/ 3 of patients and the surgical management has a high rate of complications. Significant studies are needed to establish the correlation between glaucoma and KTS, and base the treatment of choice.

Effects of timolol maleate, levobunolol and apraclonidine on intraocular pressure, pupil size, blood pressure and heart rate in beagles / Efeitos do maleato de timolol, do levobunolol e da apraclonidina sobre a pressão intraocular, o diâmetro pupilar, a pressão sanguínea e a frequência cardíaca, em cães da raça Beagle

The aim of this study was to evaluate changes in intraocular pressure (IOP), pupil size (PS), blood pressure (BP), heart rate (HR), and ECG variables (Pms wave PmV, PR interval, QRS complex, RMV wave and QT intervals) over time during the instillation of 0.5% timolol, 0.5% levobunolol and 0.5% apraclonidine in clinically normal dogs. Ten adult beagles were used. Baseline values were measured at 8a.m., 2p.m. and 8p.m., for three consecutive days. A waiting period of 10 days between the administrations of each drug was established. For 15 consecutive days, the drug being tested was instilled in one eye of each dog twice a day (7a.m. and 7p.m.). The parameters were evaluated at the aforementioned times on days 3, 6, 9, 12 and 15. Data were statistically compared using the Bonferroni test and one-way repeated measures analysis of variance (P<0.05). The Pearson test was used to evaluate any correlation between QT interval, HR and BP. The tested drugs did not find a decrease in IOP. A significant decreased in PS was observed in almost all dogs following levobunolol administration, relative to the control eye. A significant decrease in HR was observed on day 3 following levobunolol treatment, while apraclonidine induced an increase on day 15. Blood pressure was reduced in all measurement time points following apraclonidine treatment. A negative correlation between QT interval and HR was only observed in dogs treated with timolol. In conclusion, levobunolol was the only drug that induced significant alterations in PS. Apraclonidine was the only drug that induced systemic hypotension. Timolol was the only drug to that induced a negative correlation between QT and HR.(AU)

O objetivo deste estudo foi avaliar as mudanças na pressão intraocular (PIO), no diâmetro pupilar (DP), na pressão sanguínea (PS), na frequência cardíaca (FC) e nas variáveis eletrocardiográficas (onda Pms, PmV, intervalo PR, complexo QRS, onda RmV e intervalo QT), ao longo do tempo da instilação do timolol 0,5%, do levobunolol 0,5% e da apraclonidina 0,5% em cães clinicamente normais. Dez Beagles adultos compuseram o estudo. Valores basais foram mensurados às oito,, 14 e 20 horas, durante três dias consecutivos. Foi instituído um período de espera de 10 dias entre a administração de cada fármaco. Durante 15 dias consecutivos, um olho de cada animal recebeu uma gota de cada um deles, a intervalos de 12 horas (às sete e às 19 horas). Os parâmetros foram avaliados nos momentos acima referidos, nos dias três, seis, nove, 12 e 15. Os dados foram comparados estatisticamente empregando-se o teste de Bonferroni após análise de variância para medidas repetidas (P<0,05). Teste de Pearson foi utilizado para correlação entre o intervalo QT com a FC e a PS. Não se encontrou diminuição da PIO. Observou-se redução significativa do DP na quase totalidade dos animais que receberam levobunol, relativamente ao olho controle. Diminuição significativa da FC foi vista ao terceiro dia após a administração do levobunolol, enquanto apraclonidina induziu aumento no 15º dia. A pressão arterial foi reduzida em todos os momentos com a apraclonidina. Observou-se correlação negativa entre o intervalo QT e a FC apenas nos indivíduos tratados com o timolol. Em conclusão, levobunolol foi o único fármaco que induziu alterações significativas no DP. A apraclonidina foi o único fármaco que induziu hipotensão sistêmica significativa. O timolol foi o único a ensejar correlação negativa entre o intervalo QT e a FC.(AU)

Tratamento de hemangioma da infância com maleato de timolol tópico / Treatment of infantile hemangioma with topical timolol maleate

Introdução: o hemangioma da infância é uma proliferação neoplásica benigna de células endoteliais, decorrente de um desequilíbrio na angiogênese. Atinge 10 a 12% das crianças com menos de ano de vida, sendo, portanto, o tumor mais comum da infância. O tratamento, geralmente, é expectante, mas são utilizados, em alguns casos, propranolol oral, corticosteroides, interferon alfa-2a, laserterapia, embolização, imunomoduladores e cirurgia. Descrição do caso: criança do sexo masculino com hemangioma em couro cabeludo de 3 cm de diâmetro. Utilizou-se maleato de timolol 0,5%, solução oftálmica, três gotas duas vezes ao dia na superfície da lesão, durante dois anos. Após um ano de tratamento, a lesão apresentava-se praticamente plana, com involução quase completa e alopecia residual. Nenhum efeito colateral foi observado durante o período de tratamento. Discussão: o hemangioma da infância possui amplo espectro clínico e graus variados de gravidade, o que torna o seu manejo difícil e controverso. Diante do alto número de efeitos colaterais descritos para os tratamentos convencionais, o timolol tópico tem se tornado excelente alternativa para os casos não complicados. Conclusão: o timolol tópico vem sendo uma nova opção terapêutica eficaz e desprovida de efeitos colaterais para o tratamento do hemangioma da infância, sendo capaz de acelerar sua involução e prevenir complicações. Entretanto, é necessário que sejam realizados estudos que padronizem a dosagem terapêutica mais segura e avaliem o real risco x benefício do uso do fármaco no tratamento desse tipo de tumor.(AU)

Introduction: Infantile hemangioma is a benign neoplastic proliferation of endothelial cells, resulting from an imbalance in angiogenesis. Reaches 10-12% of children under one year old, therefore it is the most commom tumor of childhood. Treatment is usually expectant, but in some cases can be used oral propranolol, corticosteroids, interferon alpha-2a, laser therapy, embolization, immunomodulators and surgery. Case report: Male child with scalp hemangioma of 3 cm diameter. It was used eye drop solution of timolol maleate 0.5%, three drops, twice daily, on the surface of the lesion, during two years. After one year, it was almost plane and completely involuted with residual alopecia. No side effects were observed during the treatment. Discussion: Infantile hemangioma has a wide spectrum of clinical presentation and varying degrees of severity, which make it difficult and controversial management. Due to the high number of side effects reported for conventional treatments, topical timolol has become an excellent alternative for uncomplicated cases. Conclusion: Topical timolol has been an effective therapeutic option devoid of side effects for treatment of infantile hemangioma, being able to accelerate tumors involution and to prevent complications. Still, it is necessary studies to standardize the safest therapeutic dose and evaluate the actual risk-benefit ratio of timolol use in treatment of this tumor.(AU)

Use of Video-oculography in the Diagnosis of Superior Oblique Myokymia

PURPOSE: Superior oblique myokymia is intermittent spontaneous contractions of the superior oblique muscle presenting as rapid and small-amplitude intorsions and depressions of the eye. The authors report a case of superior oblique myokymia that was objectively and quantitatively diagnosed with slit lamp examination and video-oculography and completely resolved with medical treatment. CASE SUMMARY: A 44-year-old woman presented with a seven-year history of intermittent oscillopsia which continued for few seconds. She had no history of head trauma or systemic ocular disease, and the anterior segment and fundus examination were unremarkable. Right eye intorsion lasting for a few seconds as detected by slit lamp examination. Eye movements were recorded using video-oculography, which showed a torsional nystagmus of 5 to 10 degrees with 2 to 5 vertical components in the right eye. Based on these findings, the patient was diagnosed with superior oblique myokymia. The patient was prescribed topical timolol ophthalmic solution, one drop twice per day, but the symptoms persisted. Timolol ophthalmic solution was stopped and replaced with carbamazepine, 200 mg twice a day, which resolved her symptoms. CONCLUSIONS: Slit lamp examination and video-oculography can be used as objective and quantitative diagnostic tools in order to confirmed a diagnosis and lead to proper treatment.

A clinical study of Timolol Maleate Eye Drops for the treatment of superficial infantile hemangiomas / 中华整形外科杂志

<p><b>OBJECTIVE</b>To dicuss the clinical efficacy of Timolol Maleate Eye Drops in the treatment of superficial infantile hemangiomas. Methods From April 2012 to May 2014, 210 patients with superficial infantile hemangiomas were included. According to the parents' choice, a total of 176 cases were treated with Timolol Maleate Eye Drops as the treatment group, and the 34 cases who received the treatment of "wait and see" was included in the control group. In the treatment group, the gauzes were dipped into the eye drops and putted evenly on the surface of the hemangioma, 3-4 times daily and lasted for more than 20 minutes. The gauze should completely cover the surface of the tumor. The follow-up periods were 3 weeks and 6 months after treatment with the pictures to record the treatment effect. The therapeutic effect was graded as: grade I (unable to control the growth of the hemangioma), II (the growth of the hemangioma stagnated), III (hemangioma significantly subsided), IV (the hemangioma completely disappeared). The effective rate included the cases with grade II and above grade II . The cure cases included the cases with grade IV. The data was analyzed with the statistical software SPSS 17.0 and the Chi-square test (P < 0.05).</p><p><b>RESULTS</b>3 cases in the treatment group showed eczema action. Tumor ulcer happened in 1 case in treatment group. The side effect rate was 2.3% . The results at 3 weeks following in the treatment group showed that the growth of the hemangioma were stagnated in 154 cases. The color of hemangioma became darker in different degrees than before, and the texture of the hemangioma became soft in majority of children, and the thickness of hemangioma became thinner in some cases. However, only 4 cases showed the hemangiomas were subsided, 18 cases showed the color of the part of the hemangiomas were brighter than before, and 12 cases of the hemangiomas remained original state in the control group. The results of 6 weeks following the treatment showed that 18 patients in the treatment group reached the standard of the grade IV, 84 patients reached the standard of the grade III, 60 patients achieved in the standard of grade II, and only 14 patients showed the volume of hemangiomas were increased as grade I. The effective rate was 58. 0% , and the cure rate was 10. 2% in treatment group. In control group, no children reached the standard of the grade IV, 4 cases reached the standard of grade III, 13 cases who remained original state reached the standard of grade II, and 17 cases showed the volume of hemangiomas continued to increase as grade I . The effective rate was 11. 8% , and the cure rate was 0. By comparison, the effective rate and the cure rate in the control group were relatively lower than those in the treatment group (P < 0.05).</p><p><b>CONCLUSIONS</b>The efficacy of Timolol Maleate Eye Drops in the treatment of superficial infantile hemangioma is exact, especially in the proliferative phase of the infantile hemangioma. It is safe and easy to perform with mild side effect. It should be selected as first-line treatment.</p>

Electrocardiographic evaluation of healthy dogs treated with ophthalmic solution of timolol maleate 0.5%: preliminary study / Avaliação eletrocardiográfica de cães clinicamente hígidos sob tratamento com solução oftálmica de maleato de timolol 0.5%: estudo preliminar

Timolol maleate 0.5% is a drug recommended for glaucoma treatment in dogs. After administration, it is absorbed to systemic circulation and being an antagonist of beta adrenergic receptors it has important systemic side effects on cardiac electrical conduction. The present study evaluated the modification caused by ophthalmic timolol 0.5% in the electrocardiogram. Six clinically normal dogs were selected to participate in two different ophthalmic treatments: in the first one, a placebo (hypromellose 0.5%) was used and in the second one, timolol 0.5% was administered. Each solution was applied twice a day, for 14 days. The electrocardiographic parameters were measured in times: zero, 10, 60, 120, 240, 360 and 720 min after ocular solution instillation in first, seventh and 14th days of each treatment. The differences found in electrocardiogram were more evident between 120 and 240 min after instillation of timolol 0.5% when compared with placebo treatment. The rhythm was irregular, with sinus arrhythmia and sinus bradycardia moments. The RR and PR intervals lengthen notoriously (p 0.05) from the first day of timolol administration, and are more expressive in the 14th day of treatment. The QT interval demonstrated a few changes, just lengthening noticeably (p 0.05) in the 14th day of timolol application. The QTc interval did not show expressive change. Despite the changes in the electrocardiogram, no clinical manifestation related to beta-adrenoceptor antagonists were observed. One must consider, however, that the animals studied were healthy and thus, clinical signs could result from the changes implied by the use of timolol in animals with pre-existing heart disease. Therefore, cardiac assessment of patients prior to prescription of ophthalmic timolol is recommended.

O maleato de timolol 0,5% é um fármaco recomendado para tratamento de glaucoma em cães. Após instilação, e absorvido para a circulação sistêmica e por ser um antagonista beta-adrenérgico pode promover efeitos colaterais sistêmicos importantes sobre a condução elétrica cardíaca. No presente estudo, foi avaliada a alteração causada pelo timolol 0,5% oftálmico no eletrocardiograma. Foram selecionados seis cães hígidos para participar de dois tratamentos oftálmicos diferentes: no primeiro foi instilado placebo (hipromelose 0,5%) e no segundo utilizou-se timolol 0,5%. O colírio foi instilado a cada 12 horas por 14 dias. Os parâmetros eletrocardiográficos foram mensurados nos tempos: zero, 10, 60, 120, 240, 360 e 720 minutos após instilação da solução ocular nos dias primeiro, sétimo e décimo quarto de cada tratamento. As alterações eletrocardiográficas foram mais evidentes entre 120 e 240 minutos pós-instilação de timolol 0,5% quando comparado com o tratamento placebo. O ritmo foi irregular, com momentos de arritmia sinusal e bradicardia sinusal. Os intervalos RR e PR prolongaram significativamente (p 0,05) desde o primeiro dia de instilação de timolol, sendo o prolongamento mais expressivo no décimo quarto dia de tratamento. O intervalo QT demonstrou pouca variação, apenas prolongando significativamente (p 0,05) no décimo quarto dia de aplicação de timolol. O intervalo QTc não demonstrou alteração significativa (p > 0,05). Apesar das alterações encontradas, não foram observadas manifestações clínicas relacionadas ao timolol nos animais estudados. Deve-se considerar, porém, que os animais em questão eram hígidos e, portanto, as alterações decorrentes do uso do timolol em animais com cardiopatias preexistentes poderiam promover sinais clínicos, sendo recomendada a avaliação cardíaca de pacientes previamente à prescrição do timolol oftálmico.

Comparison of intraocular pressure lowering effect of Latanoprost and Timolol combination versus Latanoprost alone in Primary Open Angle Glaucoma

To compare the intraocular pressure [IOP] lowering effect of topical drug combination [Latanoprost and Timolol] with Latanoprost alone in patients of Primary Open Angle Glaucoma [POAG]. Randomized controlled Trials [RCT]. Armed Forces Institute of Ophthalmology [AFIO] Rawalpindi from December 2009 to May 2011. A total of 240 eyes of 120 patients [68 males and 52 females] were included in the study. The patients were randomized into two groups of 60 each using random numbers table. Group A [60 patients, 12Q eyes] were put on topical drug combination of Latanoprost and Timolol eye drops and Group B [60 patients, 120 eyes] were treated with topical Latanoprost eye drops alone. IOP assessments were done at baseline, 2 weeks, 4 weeks and 8 weeks intervals after initiation of treatment. Both the groups were age matched with mean age in Group A was 56.39 +/- 8.50 years and in Group B was 55.61 +/- 8.95 years [p=0.09]. Both groups showed significant IOP decrease from the baseline at each follow up interval. However after 8 weeks of start of treatment, pressure lowering effect in group A [14.73 +/- 2.50 mmHg] was significantly more as compared to Group B [9.10 +/- 2.51 mmHg] [p<0.001]. Combination therapy of Latanoprost and Timolol is more effective as compared to monoyherapy with Latanoprost in lowering IOP of patients with POAG

Comparison of Cytotoxic Effects on Rabbit Corneal Endothelium between Preservative-free and Preservative-containing Dorzolamide/timolol

PURPOSE: To evaluate and compare the toxic effects of eyedrops containing a fixed combination of 2.0% dorzolamide and 0.5% maleate timolol with or without preservatives on rabbit corneal endothelium. METHODS: This study was performed with 22 eyes of New Zealand white rabbits. Dorzolamide/timolol eyedrops with preservative (Cosopt group) or without preservative (Cosopt-S group) were diluted with a balanced salt solution at a 1 : 1 ratio. We injected 0.1 mL of diluted Cosopt into the anterior chamber of left eyes and an equal volume of diluted Cosopt-S into the anterior chamber of right eyes. Corneal thickness, corneal haze, and conjunctival injection were measured before and 24 hours after treatment. Endothelial damage was compared between both eyes by vital staining (alizarin red/trypan blue staining), live/dead cell assay, TUNEL assay, and scanning electron microscopy. RESULTS: Corneal endothelial damage was severe in the Cosopt group. Cosopt-treated eyes exhibited remarkable corneal edema and prominent apoptosis of endothelial cells. In addition, the live/dead cell assay revealed many dead cells in the endothelium, and scanning electron microscopy analysis showed that corneal endothelial cells exhibited a partial loss of microvilli on the surface as well as extensive destruction of intercellular junctions. However, in the Cosopt-S group, corneal edema was mild and the damage to the corneal endothelium was minimal. CONCLUSIONS: The main cause of corneal endothelial toxicity was due to the preservative in the dorzolamide/timolol fixed combination eyedrops, and not the active ingredient. Thus, it appears to be safer to use preservative-free eyedrops during the early postoperative period.

Optic neuritis complicating herpes zoster ophthalmicus in an immunocompetent patient / Zoster optic neuritis in immunocompentent

A 58-year-old woman presented with rash over the left side of the face and intense acute uveitis. Following careful review of the symptoms and dilated fundus examination unilateral optic neuritis was discovered. The rash was typical of varicella zoster dermatitis. Patients presenting with herpes zoster ophthalmicus should always undergo dilated fundus examination, as there is a potential risk of unexpected posterior segment inflammation. Early diagnosis and prompt treatment can avoid visual sequelae.

Paciente de 58 anos de idade apresentando erupção cutânea no lado esquerdo da face e intensa uveíte unilateral. Após cuidadosa revisão dos sintomas e exame de fundo do olho foi detectada neurite óptica. O rash era típico de dermatite por varicella zoster. Pacientes apresentando quadro de herpes zoster oftálmico devem ser submetidos ao exame de fundo do olho devido ao risco de inesperada inflamação do segmento posterior. Diagnóstico precoce e tratamento imediato podem evitar danos visuais.

Desarrollo tecnológico de dorzolamida 2 % más timolol 0, 5 % solución oftálmica / Techological development of 2 % dorzolamide plus 0. 5 % timolol as eye solution

OBJETIVO: desarrollar una solución oftálmica de dorzolamida 2 % más timolol 0,5 % que cumpla con todos los requerimientos de calidad para proporcionar el efecto terapéutico deseado sin efectos adversos al paciente. MÉTODOS: se prepararon tres ensayos preliminares en los que se utilizaron clorhidrato de dorzolamida y maleato de timolol, una solución tampón que consistió en ácido cítrico monohidratado/citrato trisódico dihidratado, cuyo pH estuviese en el rango de 5 y 6, cloruro de benzalconio, y HPMC F4M (hidroxipropilmetilcelulosa) al 10 %. Se usaron estos componentes en sustitución de los recomendados en la literatura. Se estudió la estabilidad química y física de la formulación durante 3 meses en cuanto a las características organolépticas, concentración del ingrediente activo, el pH, así como las propiedades fluidimétricas, irritabilidad oftálmica y efectividad del preservo. Con la formulación de estudio se desarrolló y se validó la técnica analítica en el Centro de Investigación y Desarrollo de Medicamentos. Se determinó la linealidad, precisión, especificidad y exactitud de método. Se elaboraron tres lotes pilotos de 5 L cada uno. Se utilizó como material de envase frascos plásticos de polietileno de baja densidad con Master Batch de 5 mL de capacidad. RESULTADOS: los ingredientes activos, clorhidrato de dorzolamida y maleato de timolol, y los excipientes de calidad farmacéutica y el material de envase utilizado cumplieron con las especificaciones de calidad informados en la USP 33. Los análisis fisicoquímicos realizados a los tres lotes del escalado piloto e industrial cumplieron con las especificaciones de calidad de la técnica analítica desarrollada por el Departamento de Estabilidad del Centro de Investigación y Desarrollo de Medicamentos y con los análisis microbiológicos informados en la USP 33. CONCLUSIONES: los resultados obtenidos permiten la introducción industrial y sustituir la importación del referido medicamento.

OBJECTIVE: to develop a 2 % dorzolamide plus 0.5 % timolol eye drop solution with all the quality requirements to provide adequate therapeutic effect without adverse reactions for the patients. METHODS: three preliminary trials were prepared with dorzolamide chlorhydrate and timolol maleate, a buffer solution based on monohydrated citric acid/dehydrated trisodic citrate with pH range 5-6, benzalkonium chloride and 10 % HPMC F4M (hydroxypropilmetylcellulose). These components replaced those recommended in the literature review. The chemical and physical stability of this formulation was studied for three months in terms of organoleptic characteristics, active ingredient concentration, pH, fluidmetric properties, eye irritability and effectiveness of preserver. The study formulation allowed developing and validating the analytical technique of the Center for the Drug Research and Development. Linearity, precision, specificity and accuracy of the method were determined. Three 5 L pilot batches were prepared. Master Batch 5 mL low-density polyethylene plastic bottles were used for packing. RESULTS: active ingredients, dorzolamide chlorhydrate and timolol maleate, the pharmaceutical quality excipients and the packing material met the quality specifications according to USP 33. The physical and chemical analysis of the three batches at pilot and industrial scales met the quality specifications of the analytical technique devised by the Department of Stability of the Center for Drug Research and Development and the microbiological analysis reported in USP 33. CONCLUSIONS: the achieved results allowed introducing the formulation at industrial scale and replacing the imported drug.

Determination of enantiomeric impurity of timolol maleate in bulk substances and eye drops / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To determine the enantiomeric impurity contents of domestic timolol maleate in bulk drugs and eye drops.</p><p><b>METHODS</b>Enantiomer impurity of timolol was assayed by chiral high performance liquid chromatography. The chromatographic conditions were as follows:chiralcel OD chiral column (4.6 mm ×150 mm, 5μm), detection wavelength:297 nm, mobile phase:hexane-isopropanol-diethylamine (480:20:1), column temperature:25 ℃, flow rate:1.0 ml/min, sample injection volume:5 μl.</p><p><b>RESULTS</b>The resolution between R- and S-timolol was more than 4. The enantiomeric impurity contents were less than 0.67% on average in two batches of timolol maleate bulk drugs, and 0.31% on average in three batches of timolol maleate eye drops.</p><p><b>CONCLUSION</b>Enantiomeric impurity contents in each batch of products all meet European Pharmacopoeia criteria, which can be used as references in Chinese Pharmacopoeia criteria.</p>

Comparison of timolol alone with fixed combination of latanoprost/ timolol to control intra-ocular pressure in primary open angle glaucoma

To evaluate the effectiveness of Timolol only and fixed combination Latanoprost- Timolol in lowering intraocular pressure in patients with primary open angle glaucoma. Comparative Randomized Controlled trial This study was conducted at Institute of Ophthalmology, Mayo Hospital, Lahore over a period of one year from January 2012 to December 2012. Total 80 patients were selected by Non-Probability Purposive Sampling technique after fulfilling inclusion and exclusion criteria. After informed consent these patients were divided into two groups by random number table. Group-I consisted of 40 patients which were put on topical Timolol therapy one drop in each eye twice daily. Group-II consisting of 40 patients was put on topical fixed combination Latanoprost-Timolol therapy, one drop once daily in both eyes. On each follow-up visit all patients were assessed by monitoring intraocular pressure with Goldmann Applanation Tonometer. The follow up examinations were scheduled at one week, one month, and three months from the start of therapy. Later on, all patients were followed for at least 6 months and according to requirement they underwent modification in medication or surgical procedure. At the end of study, mean reduction of intraocular pressure from baseline in Group- I [using 0.5% Timolol twice daily] was 6.7 mm of Hg [27.57%] and the mean reduction of intraocular pressure in Group-II [using Fixed Combination Timolol-Latanoprost once daily] was 7.9 mm of Hg [32.24%]. The effectiveness i.e. reduction of intraocular pressure by 30% from baseline was noted among 32.5% patients in Group-I and 70% patients in Group-II. Latanoprost-Timolol fixed combination is well tolerated, convenient and an effective ocular hypotensive agent than Timolol alone in lowering IOP in primary open angle glaucoma

Comparing the Efficacy of Latanoprost (0.005%), Bimatoprost (0.03%), Travoprost (0.004%), and Timolol (0.5%) in the Treatment of Primary Open Angle Glaucoma

PURPOSE: To compare the efficacy and safety of latanoprost, bimatoprost, travoprost and timolol in reducing intraocular pressure (IOP) in patients with primary open angle glaucoma. METHODS: This was a prospective study conducted at a tertiary-care centre. One hundred and forty patients with newly diagnosed primary open angle glaucoma were randomly assigned to treatment with latanoprost (0.005%), bimatoprost (0.03%), travoprost (0.004%) or timolol gel (0.5%); 35 patients were assigned to each group. All patients were followed for 2, 6, and 12 weeks. The main outcome measure studied was the change in IOP at week 12 from the baseline values. Safety measures included recording of adverse events. RESULTS: The mean IOP reduction from baseline at week 12 was significantly more with bimatoprost (8.8 mmHg, 35.9%) than with latanoprost (7.3 mmHg, 29.9%), travoprost (7.6 mmHg, 30.8%) or timolol (6.7 mmHg, 26.6%) (ANOVA and Student's t-tests, p < 0.001). Among the prostaglandins studied, bimatoprost produced a maximum reduction in IOP (-2.71; 95% confidence interval [CI], -2.25 to -3.18) followed by travoprost (-1.27; 95% CI, -0.81 to -1.27) and latanoprost (-1.25; 95% CI, -0.79 to -1.71); these values were significant when compared to timolol at week 12 (Bonferroni test, p < 0.001). Latanoprost and travoprost were comparable in their ability to reduce IOP at each patient visit. Ocular adverse-events were found in almost equal proportion in patients treated with bimatoprost (41.3%) and travoprost (41.9%), with a higher incidence of conjunctival hyperemia (24.1%) seen in the bimatoprost group. Timolol produced a significant drop in heart rate (p < 0.001) at week 12 when compared to the baseline measurements. CONCLUSIONS: Bimatoprost showed greater efficacy when compared to the other prostaglandins, and timolol was the most efficacious at lowering the IOP. Conjunctional hyperemia was mainly seen with bimatoprost. However, the drug was tolerated well and found to be safe.