Preservatives/preservation, ophthalmic

Solutions for external or oral use do not require sterilization but generally contain antimicrobial preservatives. Ophthalmic solutions and parenteral solutions require sterilization (qv). 

Microbiologic culture studies are useful fc>r bacterial identification, especially when an ocular infection foils to respond to treatment. Cultures are often obtained from the eyelids, the conjimctiva, expressed material from the lacrimal sac, and the cornea. Because preserved ophthalmic anesthetics have a bacteriostatic effect, cultures should be obtained if possible before anesthetic instillation. In the case of corneal sampling, it is necessary to provide topical anesthesia for patient comfort. The anesthetic of choice is 0.5% proparacaine because it causes the least bacterial growth inhibition. To enhance the bacterial yield, sterile preservative-free anesthetic may be used. Samples obtained may be inoculated directly onto soUd media plates (e.g., blood agar). Amies without charcoal transport medium (e g., BBL CultureSwab Plus) appears to be an acceptable alternative to direct plating and has the added benefit of convenience. 

Non preserved ophthalmic solutions are preferably delivered in single-dose packaging such as Redipac plastic tubes. In pharmacy preparation alternatives may be ... 

Inactive ingredients may be found in some preparations. Examples of these drugs include preservatives, antioxidants, which prevent deterioration of the product, and drugs that slow drainage of the drug from the eye into the tear duct. Examples of the types of eye preparations are found in the Summary Drug Table Select Ophthalmic Preparations. 

Regardless of the cause, the mainstay of treatment for dry eye is artificial tears. Artificial tears augment the tear film topically and provide relief. If a patient uses artificial tears more than four times daily, recommend a preservative-free formulation. Preservative-free formulations are also appropriate if the patient develops an allergy to ophthalmic preservatives. Artificial tears are available in gel, ointment, and emulsion forms that provide a longer duration of relief and may allow for less frequent instillation. Ointment use is appropriate at bedtime.30... 

In contrast, parenteral suspensions have relatively low solids contents, usually between 0.5 and 5%, with the exception of insoluble forms of penicillin in which concentrations of the antibiotic may exceed 30%. These sterile preparations are designed for intramuscular, intradermal, intralesional, intraarticular, or subcutaneous injection. Syringeability is an important factor to be taken into consideration with injectable dosage forms. The viscosity of a parenteral suspension should be sufficiently low to facilitate injection. Common suspending vehicles include preserved isotonic saline solution or a parenterally acceptable vegetable oil. Ophthalmic and optic suspensions that are instilled into the eye/ear must also be prepared in a sterile manner. The vehicles are essentially isotonic and aqueous in composition. The reader should refer to Chapter 12 for further discussion on parenteral products. 

Sterility testing is conducted on each lot of ophthalmic product by suitable procedures, as set forth in the appropriate pharmacopeia and validated in each manufacturer s laboratory. While the majority of ophthalmic preparations contain preservatives for multiple-dose use, sterile preparations in special containers for individual use on a single patient must be made available. This availability is especially critical for every hospital, office, or other installation where accidentally or surgically traumatized eyes are treated, as well as for patients intolerant to preservatives. 

Although this chapter is directed toward ophthalmic products, it is largely applicable to parenteral and even nonsterile products (solutions, emulsions, and suspensions). The choice of preservative is limited to only a few chemicals that have been found, over the years, to be safe and effective for this purpose. These are benzalkonium chloride, thimerosal, methyl- and propylparaben, phenylethanol, chlorhexidine,... 

Other quaternary ammonium germicides, ben-zethonium chloride and benzalkonium bromide, have been used in several ophthalmic solutions. While these have the advantage of not being a chemical mixture, they do not possess the bactericidal effectiveness of benzalkonium chloride and are subject to the same incompatibility limitations. In addition, the maximum concentration for benzethonium chloride is 0.01%. Several new products that form gels in the eye, like Timolol Gel Forming Solution and Timoptic-XE, employ another quaternary preservative, BDAB, in the formulation. 

Since the organic mercurials offer an alternative to quaternary ammonium preservatives, and since preservative efficacy of ophthalmic solutions is essential, the choice among these alternatives should be based on a benefit-to-risk analysis as long as a ban is not imposed on the use of these organometallic preservatives. 

This aromatic alcohol has been an effective preservative and still is used in several ophthalmic products. Over the years it has proved to be a relatively safe preservative for ophthalmic products [138] and has produced minimal effects in various tests [99,136,139]. In addition to its relatively slower rate of activity, it imposes a number of limitations on the formulation and packaging. It possesses adequate stability when stored at room temperature in an acidic solution, usually about pH 5 or below. If autoclaved for 20-30 minutes at a pH of 5, it will decompose about 30%. The hydrolytic decomposition of chlorobutanol produces hydrochloric acid (HC1), resulting in a decreasing pH as a function of time. As a result, the hydrolysis rate also decreases. Chlorobutanol is generally used at a concentration of 0.5%. Its maximum water solubility is only about 0.7% at room temperature, which may be lowered by active or excipients, and is slow to dissolve. Heat can be used to increase dissolution rate but will also cause some decomposition and loss from sublimation. Concentrations as low as 0.125% have shown antimicrobial activity under the proper conditions. 

This preservative is comparatively new to ophthalmic preparations and is a polymeric quaternary ammonium germicide. Its advantage over other quaternary ammonium seems to be its inability to penetrate ocular tissues, especially the cornea. It has been used at concentrations of 0.001-0.01% in contact lens solutions as well as dry eye products. At clinically effective levels of preservative, POLYQUAD is approximately 10 times less toxic than benzalkonium chloride [87,137], Various in vitro tests and in vivo evaluations substantiate the safety of this compound [137,141,142], This preservative has been extremely useful for soft contact lens solutions because it has the least propensity to adsorb onto or absorb into these lenses, and it has a practically nonexistent potential for sensitization. Its ad-sorption/absorption with high water and high ionic lenses can be resolved by carefully balancing formulation components [143],... 

This preservative is also comparatively new to ophthalmic formulations and has been used as a disinfectant in contact lens solutions. Polyaminopropyl biguanide (polyhexamethyl biguanide) also is a polymeric compound that has a low toxicity potential at the concentrations generally used in these solutions [141, 149, 150]. 

In general, aqueous ophthalmic solutions are manufactured by methods that call for the dissolution of the active ingredient and all or a portion of the excipients into all or a portion of the water and the sterilization of this solution by heat or by sterilizing filtration through sterile depth or membrane filter media into a sterile receptacle. If incomplete at this point, this sterile solution is then mixed with the additional required sterile components, such as previously sterilized solutions of viscosity-imparting agents, preservatives, and so on, and the batch is brought to final volume with additional sterile water. 

Surfactants. The use of surfactants is greatly restricted in formulating ophthalmic solutions. The order of surfactant toxicity is anionic > cationic >> nonionic. Several nonionic surfactants are used in relatively low concentrations to aid in dispersing steroids in suspensions and to achieve or to improve solution clarity. Those principally used are the sorbitan ether esters of oleic acid (Polysorbate or Tween 20 and 80), polymers of oxyethylated octyl phenol (Tyloxapol), and polyoxyl 40 stearate. The lowest concentration possible is used to perform the desired function. Their effect on preservative efficacy and their possible binding by macromolecules must be taken into account, as well as their effect on ocular irritation. The use of surfactants as cosolvents for an ophthalmic solution of chloramphenicol has been described [271]. This com-... 

An erodible insert developed as a potential ocular drug-delivery system is marketed as a prescription drug for the lubricant properties of the polymer base. Lacrisert is a sterile ophthalmic insert used in the treatment of moderate to severe dry eye syndrome and is usually recommended for patients unable to obtain symptomatic relief with artificial tear solutions. The insert is composed of 5 mg of hydroxypropylcellulose in a rod-shaped form about 1.27 mm diameter by about 3.5 mm long. No preservative is used, since it is essentially anhydrous. The quite rigid cellulose rod is placed in the lower conjunctival sac and first imbibes water from the tears and after several hours forms a... 

Although some types of pharmaceutical products, like ophthalmic and injectable preparations, are sterilized by physical methods, including autoclaving, dry heat, or by bacterial filtration during their manufacture, many of them additionally require the presence of an antimicrobial preservative to maintain their aseptic condition throughout the period of their storage and use. Other types of preparations that are not sterilized during their... 

Bacterial keratitis Bacterial keratitis associated with the use of multiple-dose containers of topical ophthalmic products has been reported. Serious damage to the eye and subsequent loss of vision may result from using contaminated preparations. Benzalkonium chloride Benzalkonium chloride is a preservative used in some of these products that may be absorbed by soft contact lenses. Patients wearing soft... 

Ophthalmic Solution 0.15% (Alphagan P) (contains Purite 0.005% as preservative]. Indications and Dosages ... 

Contraindications Ophthalmic solutions (both strengths) of phenylephrine HCl are contraindicated in patients with anatomically narrow angles or narrow-angle glaucoma, severe arteriosclerotic cardiovascular or cerebrovascular disease, use during intraocular operative procedures when the corneal epithelial barrier has been disturbed, and in persons with a known sensitivity to phenylephrine, sulfites, or any of its components including preservatives. The 10% solution is contraindicated in patients with aneurysms. 

Many researchers have demonstrated that some preservatives significantly increase the corneal permeability of ophthalmic drugs [53 56]. 

Burton, G.D., and R.M. Hill. 1981. Aerobic responses of the cornea to ophthalmic preservatives, measured in vivo. Invest Ophthalmol Vis Sci 21 842. 

Pfister, R.R., and N. Burstein. 1976. The effects of ophthalmic drugs, vehicles, and preservatives on corneal epithelium A scanning electron microscope study. Invest Ophthalmol 15 246. 

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