Preparation of fortified eye drops Dr Sushmita G Shah DNB(Sankara Nethralaya), FICO, FLVPEI Fellow Cornea – Mass. Eye & Ear Infirmary, Boston, USA Consultant Cornea & Anterior Segment Surgeon Eye Life Eye Hospital, Khar(W), Mumbai Netra Mandir, Mumbai No financial interests

Purpose Fortification – dictionary meaning the act, art, or science of fortifying or strengthening Fortification of antibiotics may be required To achieve the MIC levels for pathogens which may be difficult with the usual 0.3% / usual strength topical antibiotics Drug resistant cases In large and severe ulcers Drug is available in parenteral form and not as topical drops

Drawbacks of fortification Gokhale NS. Ind J Ophthalmol

General instructions Should be done by doctor or pharmacist inside a laminar air hood under aseptic precautions conditions Disposable syringe should be used All drops should be labelled Date of preparation and date of expiry should be mentioned Prescription describing frequency of application etc should also be given to the patient Storage instructions should also be given

Fortified Aminoglycosides Fortified Rx ADD Final Concentration Storage Shelf life Tobramycin (1.4%) Tobramycin 0.3% eye drop - 15mg in 5 ml Inj. Tobramycin-2ml/80mg 95 mg in 7 ml – 1.4% 4deg C 1 week in Fridge 4 days in room temperature Gentamycin Gentamicin 0.3% eye drop Inj. Gentamicin-2ml/80mg Gentamicin 95 mg in 7 ml - 1.4%

Fortified Aminoglycosides Fortified Rx Add Final concentration Temperature Stability Amikacin 2.5% Inj Amikacin 250mg/2ml 8ml artificial tears Amikacin 250mg/10ml – 2.5% 4deg C 7 days

Fortified Cephalosporins Drug ADD Fortified Cefazolin 5% Inj. Cefazolin – 5oomg 10 ML artificial tears 500mg in 10 ml – 5% Fortified Cefazolin 4 deg C 1 week Fortified Ceftazidime 5% Inj Ceftazidime 500mg Fortified Ceftazidime

Topical Linezolid 0.2% Lancure / Adlid /Rapidline IV infusion 200mg/100ml Topical ophthalmic dosage – 0.2%(2mg/ml) Indications – Methicillin resistant Staphylococcus aureus keratitis Corneal surface toxicity less than topical Vancomycin Tas T. Cornea 2013

Topical Vancomycin 5% Available as Inj Vancomycin HCL – 500mg Add 2ml sterile water for reconstitution Add 8ml artificial tears 50mg/ml – 5% Vancomycin Stabilty – 28 days at 4deg C Methicillin resistant Staphylococcus aureus keratitis Corneal surface toxicity – greatest drawback

Topical colistin 0.19% Inj Xylistin – Colistimethate sodium powder 1million IU/75mg Added to 10ml distilled water – 75mg/ml(0.75%) 1ml of above solution + 3ml distilled water – 0.19% Colistin drops For pandrug/multidrug resistant Pseudomonas aeruginosa keratitis

Topical Imipenem-cilastin 1% Inj. Imipenem(500mg) + Inj Cilastin (500mg) Add 10ml sterile water – 50mg/ml Take 1 ml of this solution and add 4 ml sterile water Topical Imipenem 1% - 1mg/ml Store in amber coloured bottles Stability – 3 days at 2-8 deg C

Topical Voriconazole 1% 200mg of Voriconazole powder Add 19ml normal saline Voriconazole 1% eye drop Stable – 30days at 4deg C or room temperature Intracameral voriconazole inj. - 10µgm/ml to 10mg/ml concentration of Voriconazole has been described. Also available from Aurolab

Intrastromal Voriconazole 50 µgm/0.1ml From1% solution, take 0.5ml, add 0.5ml sterile water 5mg/ml – take 0.1ml,add 0.9ml – 0.5mg/ml 0.5mg/ml – take 0.1ml, add 0.9ml – 0.05mg/ml

Topical Amphotericin B 0.15% 50mg Amphotericin B powder Add 10ml sterile water – 5mg/ml Take 3ml of this solution and add 7ml artificial tears – 1.5mg/ml = 0.15% Storage – 7 days at 4deg C

Intracameral Amphotericin 5 -10 µgm/0.1ml injected Reconstituition in 5% Dextrose or sterile water From 5mg/ml solution – take 0.1ml solution Add 0.9ml 5%Dextrose / sterile water Again take 0.1ml and add 0.9ml 5%Dextrose/Sterile water 5 µgm/0.1ml Same concentration is used for intrastromal injection

Thank you sushmitagshahin@gmail.com