Metipranolol-associated granulomatous iritis

Binge eating disorder

Binge eating disorder (BED) is characterized by regular binge eating episodes during which individuals ingest comparably large amounts of food and experience loss of control over their eating behaviour. The worldwide prevalence of BED for the years 2018-2020 is estimated to be 0.6-1.8% in adult women and 0.3-0.7% in adult men. BED is commonly associated with obesity and with somatic and mental health comorbidities. People with BED experience considerable burden and impairments in quality of life, and, at the same time, BED often goes undetected and untreated. The aetiology of BED is complex, including genetic and environmental factors as well as neuroendocrinological and neurobiological contributions. Neurobiological findings highlight impairments in reward processing, inhibitory control and emotion regulation in people with BED, and these neurobiological domains are targets for emerging treatment approaches. Psychotherapy is the first-line treatment for BED. Recognition and research on BED has increased since its inclusion into DSM-5; however, continuing efforts are needed to understand underlying mechanisms of BED and to improve prevention and treatment outcomes for this disorder. These efforts should also include screening, identification and implementation of evidence-based interventions in routine clinical practice settings such as primary care and mental health outpatient clinics.

Pharmacologically induced uveitis

Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.

Uveitis and glaucoma: new insights in the pathogenesis and treatment

Glaucoma is a potentially blinding complication of uveitis, where intraocular inflammation, secondary corticosteroid response, and varying types and degrees of angle abnormalities contribute to its pathogenesis. Management of uveitic glaucoma remains challenging. Treatment is targeted at reducing the inflammation and lowering the intraocular pressure. Recent studies have highlighted the role of viruses, such as cytomegalovirus, herpes simplex virus, and more recently Ebola virus, in the pathogenesis of uveitic glaucoma. Antiviral therapy may be beneficial in eyes with detectable viral DNA. The success of glaucoma surgery is decreased in eyes with uveitic glaucoma, and surgical interventions are associated with a higher incidence of postoperative complications. Novel glaucoma surgical and laser treatments may improve the predictability of surgery for uveitic glaucoma, but these require further evaluation.

Drug-induced uveitis

A number of medications have been associated with uveitis. This review highlights both well-established and recently reported systemic, topical, intraocular, and vaccine-associated causes of drug-induced uveitis, and assigns a quantitative score to each medication based upon criteria originally described by Naranjo and associates.

Cardiovascular and respiratory considerations with pharmacotherapy of glaucoma and ocular hypertension

Glaucoma and ocular hypertension are highly prevalent conditions in individuals over the age of 40 and are commonly seen together in patients with cardiovascular disease. Many of the antiglaucoma medications, when systemically absorbed, affect the sympathetic and parasympathetic nervous systems of patients and can cause cardiovascular toxicity. Such adverse effects are frequently associated with the long-term use of potentially toxic agents in elderly people, who are most prone to chronic eye disease. Moreover, patients may not associate their symptoms with the topical eye medications, and consequently may not report adverse drug effects. Drug-drug interactions can also occur when patients are taking medications for both cardiovascular disease and glaucoma. In this review, the systemic toxicity of these agents is reviewed, along with possible drug-drug interactions. Mention is made of other antiglaucoma medications used alone and in combination with topical beta-blockers. Identification of genetic loci-a bold new step toward glaucoma treatment-is mentioned briefly at the end of the article.

Management of glaucoma: focus on pharmacological therapy

Glaucoma represents a major cause of vision loss throughout the world. Primary open-angle glaucoma, the most common form of glaucoma, is a chronic, progressive disease often, though not always, accompanied by elevated intraocular pressure (IOP). In this disorder, retinal ganglion cell loss and excavation of the optic nerve head produce characteristic peripheral visual field deficits. Patients with normal-tension glaucoma present with typical visual field and optic nerve head changes, without a documented history of elevated IOP. A variety of secondary causes, such as pigment dispersion syndrome and ocular trauma, can result in glaucoma as well. Treatment of all forms of glaucoma consists of reducing IOP. With proper treatment, progression of this disease can often be delayed or prevented. Treatment options for glaucoma include medications, laser therapy and incisional surgery. Laser techniques for the reduction of IOP include argon laser trabeculoplasty and selective laser trabeculoplasty. Both techniques work by increasing outflow of aqueous humour through the trabecular meshwork. Surgical options for glaucoma treatment include trabeculectomy, glaucoma drainage tube implantation and ciliary body cyclodestruction. While each of these types of procedures is effective at lowering IOP, therapy usually begins with medications. Medications lower IOP either by reducing the production or by increasing the rate of outflow of aqueous humour within the eye. Currently, there are five major classes of drugs used for the treatment of glaucoma: (i) cholinergics (acetylcholine receptor agonists); (ii) adrenoceptor agonists; (iii) carbonic anhydrase inhibitors (CAIs); (iv) beta-adrenoceptor antagonists; and (v) prostaglandin analogues (PGAs). Treatment typically begins with the selection of an agent for IOP reduction. Although beta-adrenoceptor antagonists are still commonly used by many clinicians, the PGAs are playing an increasingly important role in the first-line therapy of glaucoma. Adjunctive agents, such as alpha-adrenoceptor agonists and CAIs are often effective at providing additional reduction in IOP for patients not controlled on monotherapy. As with any chronic disease, effective treatment depends on minimising the adverse effects of therapy and maximising patient compliance. The introduction of a variety of well tolerated and potent medications over the past few years now allows the clinician to choose a treatment regimen on an individual patient basis and thereby treat this disorder more effectively.

Are there any benefits of Betoptic S (betaxolol HCl ophthalmic suspension) over other beta-blockers in the treatment of glaucoma?

The cardioselective beta-blocker, betaxolol, is an effective ocular antihypertensive agent. Its mode of action in lowering intraocular pressure is similar to that of the nonselective blockers, by suppressing the flow of aqueous humor. The most frequent adverse reaction to betaxolol is stinging upon administration, which is minimised by an ocular suspension with a similarly effective twofold reduced concentration (Betoptic S, 0.25%). The extent of beta 1-adrenoceptor occupancy of topically applied betaxolol in the systemic circulation is less than that of the nonselective blockers and beta 2-receptor occupancy is negligible, providing a better safety profile in patients with cardiopulmonary disease. Experimental studies have revealed that the drug reaches the retina after topical administration and displays a voltage-dependent L-type calcium channel blocking activity, which probably allows betaxolol to improve retinal perfusion and to serve as a neuroprotective agent recommendable in various forms of glaucoma.

Metoprolol responding uveitis

BACKGROUND

Noninfectious uveitis is usually managed by topical and systemic corticosteroids and in refractory cases by immunosuppressive drugs.

OBJECTIVE

To describe a patient with noninfectious anterior and posterior uveitis, refractory to corticosteroids, and immunosuppressive therapy, which responded to systemic metoprolol.

PATIENT AND METHODS

A 49-year-old patient was treated for 3 years with topical and systemic corticosteroids and systemic cyclosporin A for a bilateral anterior and posterior uveitis of unknown origin. The treatment did not result in resolution of the uveitis. A bilateral uveitic glaucoma developed and necessitated neodymium : YAG laser iridotomies and antiglaucoma medications. A systemic beta-blocker, metoprolol tartrate 50 mg b.i.d., was administered for palpitations because of idiopatic paroxysmal supraventricular tachycardia and short ventricular tachycardia.

RESULTS

Following administration of metoprolol tartrate, the bilateral uveitis resolved. The corticosteroids and the cyclosporin A were withdrawn after 6 weeks without any recurrence. A trial to discontinue metoprolol after 6 months resulted in flare-up of the disease and only following its readministration the inflammation resolved. The patient is currently under metoprolol for a year without flare-ups.

CONCLUSIONS

The use of metoprolol tartrate in this patient resulted in resolution of bilateral noninfectious uveitis. This is the first report of non-antiinfectious, antiinflammatory, or immunosuppressive drug effective for uveitis. It is possible that a subgroup of resistant uveitis may respond to drugs other than the traditional drugs, such as metoprolol, and that other forms of uveitis of unidentified origin exist.

Putative side effects of prostaglandin analogs

Anecdotal case reports describe the occurrence of cystoid macular edema, iritis, herpes simplex keratitis, periocular skin darkening, and headaches in patients treated with prostaglandin analogs for glaucoma. The purpose of this article is to critically analyze these anecdotal case reports in light of a few well-controlled, randomized clinical studies to determine whether conclusions can be made about a causal relationship between the use of prostaglandin analogs and the occurrence of these side effects. None of these putative side effects has been proven to be causally related to latanoprost therapy using valid scientific methodology. These possible side effects occur rarely. Cystoid macular edema, iritis, and herpes simplex keratitis occur in eyes with risk factors. To scientifically establish a causal relationship between drug therapy and rare side effects, repeated rechallenging with masked controls is required. With rare exception, such methodology has not been used with any of these putative side effects. Nevertheless, even without firm establishment of a causal relationship, caution is advised with the use of prostaglandin analogs in eyes with risk factors for cystoid macular edema, iritis, and herpes simplex keratitis until properly designed, large, controlled studies provide more definitive information.

Short- and long-term safety of glaucoma drugs

Glaucoma, a leading cause of blindness worldwide, is a chronic neurodegenerative disorder. Patients with glaucoma may require long-term administration of intraocular pressure (IOP)-lowering medications. These medications belong to several classes of molecules including beta-adrenergic blockers, cholinergic agents, alpha-adrenergic agonists, carbonic anhydrase inhibitors and ocular hypotensive lipids. Most adverse effects associated with IOP-lowering medications are mild and ocular in nature; however, several of them are associated with systemic risks as well as serious ocular effects, especially following chronic use. The following review discusses the acute and long-term effects of commonly used IOP-lowering medications.

Transscleral diode laser cyclophotocoagulation for the treatment of refractory glaucoma secondary to inflammatory eye diseases

BACKGROUND

Inflammatory glaucoma is still a diagnostic and therapeutic dilemma and surgical intervention is always associated with a high risk of failure or reactivation of the inflammatory disease. In this study we prospectively examined the value of transscleral diode laser cyclophotocoagulation (TDLC) for the treatment of refractory inflammatory glaucoma.

METHODS

22 eyes of 20 consecutive patients with inflammatory, medically uncontrollable, glaucoma secondary to chronic uveitis/trabeculitis (n = 18), chemical injury (n = 2), episcleritis (n = 1), and necrotising scleritis with inflammation (n = 1) were treated by TDLC. Nine eyes (41%) had had previous failed glaucoma surgery (trabeculectomy, cyclocryocoagulation) and 15 eyes (68.2%) had had previous anterior segment surgery. All patients were followed for 1 year after the initial treatment.

RESULTS

Within 12 months of the first treatment the intraocular pressure was controlled in 77.3% of all eyes (72.2% of those with uveitic glaucoma). No serious side effects such as activation of the inflammatory process, phthisis bulbi or persistent hypotonia were observed, except one patient with a temporary fibrin reaction. More than one treatment was necessary in 63.6% of the patients. The use of systemic carbonic anhydrase inhibitors was reduced from 68.2% before treatment to 27.3% after 1 year.

CONCLUSION

TDLC seems to be a safe and effective procedure for the treatment of inflammatory glaucoma and may become an alternative to trabeculectomy with antimetabolites in uveitic glaucoma. TDLC may become the surgical procedure of choice in treating secondary glaucoma caused by chemical injury and also in scleritis associated glaucoma, using reduced parameters for application.

Incidence of ocular side effects of topical beta blockers in the Netherlands

BACKGROUND

Several ocular side effects including uveitis, have been reported following topical beta blocker treatment for glaucoma and ocular hypertension. The incidence of these side effects was investigated in the Netherlands.

METHODS

A prospective observational design was used whereby monthly questionnaires were sent to all practising ophthalmologists in the Netherlands during 3 consecutive months. Questionnaires were returned at the end of each month. Any patient whose topical beta blocker therapy was altered because of an ocular reaction was noted on this questionnaire. Ophthalmologists who did not return their questionnaires were interviewed by telephone at the end of the study period. The number of patients using topical beta blockers was derived from drug sales figures.

RESULTS

70% (328/467) of the ophthalmologists in the Netherlands participated in the study. During the 3 month study period 34 cases were reported: 15 patients had periorbital dermatitis, in eight patients eyelids and conjunctiva were affected, in seven patients the conjunctiva was affected, and four patients had punctate keratitis. The calculated incidence of ocular side effects during topical beta blocker therapy was 1.51 cases/1000 patient years.

CONCLUSION

Topical beta blocker therapy is associated with few clinically important ocular side effects. No cases of uveitis were reported.

Pharmacological therapy for glaucoma: a review

For some time the medical treatment of glaucoma has consisted of topical beta-blockers, adrenergic agents, miotics and oral carbonic anhydrase inhibitors (CAIs). However, the therapeutic arsenal available for the medical treatment of glaucoma has recently extended with new classes of ocular hypotensive agents i.e. prostaglandins, local CAIs and alpha2-adrenergic agents. Beta-blockers are still the mainstay in glaucoma treatment and are first line drugs. However, even if they are applied once daily, as with timolol in gel forming solution and levobunolol, the possible cardiopulmonary adverse effects of beta-blockers remain a cause for concern. When monotherapy with beta-blockers is ineffective in reducing intraocular pressure (IOP) or is hampered by adverse effects, a change of monotherapy to prostaglandins, local CAIs, alpha2-adrenergic agonists (brimonidine) or to dipivalyl epinephrine is advised. Prostaglandins, local CAIs and alpha2-adrenergic agonists, such as brimonidine, may in time become first line drugs because they reduce IOP effectively and until now systemic adverse effects have rarely been reported with these agents. The development of a pro-drug of either a local CAI or an alpha2-adrenergic agonist with a sustained and continuous effect on IOP level, which could be applied once a day is suggested. Because of these new developments, miotics, i.e. pilocarpine and carbachol, are recommended as second or third line drugs. The cholinesterase inhibitors are considered third line drugs as better agents with fewer local and systemic adverse effects have become available. Oral CAIs may be used temporarily in patients with elevated IOPs e.g. postsurgery or post-laser, or continuously in patients with glaucoma resistant to other treatment. Combining ocular hypotensive drugs is indicated when the target pressure for an individual patient cannot be reached with monotherapy. Combination therapy of beta-blockers is additive with prostaglandins, topical CAIs and miotics. Prostaglandins such as latanoprost can be combined with beta-blockers, adrenergic agents, local CAIs and miotics. Combinations with brimonidine or local CAIs need further investigation. Treatment of glaucoma with the new ocular hypotensive agents, either in monotherapy or combination therapy, may provide lower IOPs and delay or postpone the need for surgery.

Antiglaucoma medications: a review of safety and tolerability issues related to their use

BACKGROUND

Much experience has been gained with the use of older classes of antiglaucoma agents--topical beta-adrenergic-receptor antagonists, nonselective adrenergic-receptor agonists, oral carbonic anhydrase inhibitors, and cholinergic agents. In the past decade, new drugs and classes of drugs used to treat glaucoma have become available, including topical carbonic anhydrase inhibitors, prostaglandin analogues, and alpha2-adrenergic-receptor agonists. Extensive community-based use of antiglaucoma medications has led to an increased understanding of the acute and long-term safety and tolerability issues associated with their use.

OBJECTIVE

This paper reviews the side effects associated with the various classes of topical antiglaucoma drugs, with a particular focus on long-term safety issues.

Endophthalmitis

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

Anterior uveitis associated with latanoprost

PURPOSE

To report the association of anterior uveitis with the use of latanoprost.

METHODS

We studied four patients with complicated open-angle glaucoma who had anterior uveitis associated with the use of latanoprost. The uveitis was unilateral and occurred only in the eye receiving latanoprost in three patients. In one patient, latanoprost was used in both eyes, and the uveitis was bilateral. Four of five eyes had a history of prior inflammation and/or prior incisional surgery. All patients were rechallenged with the drug.

RESULTS

The uveitis improved after cessation of latanoprost with or without topical corticosteroids. It recurred after rechallenging with latanoprost in all eyes.

CONCLUSION

There is a possible association between latanoprost and anterior uveitis. Topical prostaglandin analogs may be relatively contraindicated in patients with a history of uveitis or prior ocular surgery. This association may also be possible in eyes that have not had previous uveitis or incisional surgery.

Drug-induced uveitis

Uveitis has been reported in association with a variety of topical, intraocular, periocular, and systemic medications. To establish causality of adverse events by drugs, in 1981, Naranjo and associates proposed seven criteria, which are related to the frequency and documentation of the event; circumstances of occurrence, recovery, and recurrence; and coexistence of other factors or medications. Rarely does a drug meet all seven criteria. The authors review reports of drug-associated uveitis, applying the seven criteria and examining possible mechanisms. Only systemically administered biphosphonates and, perhaps, topical metipranolol meet all seven criteria. Systemic sulfonamides, rifabutin, and topical glucocorticoids fulfill at least five criteria.

Metipranolol-associated nongranulomatous anterior uveitis

PURPOSE

To describe the findings in a patient with a nongranulomatous anterior uveitis, presumed to be induced by metipranolol.

METHOD

A 69-year-old woman developed bilateral, nongranulomatous, anterior uveitis while undergoing treatment with metipranolol 0.3% for primary open-angle glaucoma. Four months after resolution of the initial episode, the patient was challenged with metipranolol 0.3% in the right eye.

RESULT

On reinstituting metipranolol 0.3%, the patient once again developed a unilateral, nongranulomatous, anterior uveitis in the challenged eye.

CONCLUSION

Metipranolol 0.3% eyedrops, used to treat primary open-angle glaucoma, appear to cause a nongranulomatous anterior uveitis.