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Background: Currently, diabetic retinopathy is the leading cause of permanent visual loss in workingage adults in industrialized nations. The chronic microangiopathic changes associated with diabetic retinopathy lead to the most common causes of severe permanent visual loss: diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Multiple studies have evaluated different pharmacotherapies for different levels of retinopathy. Methods: A review of the pathophysiology of diabetic retinopathy and current and emerging pharmacotherapies for diabetic retinopathy. Results: Historically, DME has been the primary focus of treatment in patients with nonproliferative diabetic retinopathy (NPDR). Due to the rapidly increasing number of agents and treatment options, management algorithms for DME have become increasingly complex. Furthermore, spectral domain optical coherence tomography (OCT) has allowed unparalleled sensitivity and specificity for detecting macular edema. All available intravitreal vascular endothelial growth factor (VEGF) inhibitors have demonstrated efficacy in the treatment of patients with DME and PDR. Intravitreal triamcinolone acetonide has also proven beneficial in diabetic retinopathy. Most recently, various corticosteroids have been designed as sustained-release intraocular implants in order to reduce the burden and risks associated with retreatment. Current research is focused on providing new agents that target alternate pathways and signaling molecules to provide patients with additional therapeutic tools, especially in patients who have an incomplete response to the current medications. Conclusion: Anti-VEGF therapy has revolutionized the medical management of diabetic retinopathy. The most important existing challenges in the treatment of diabetic retinopathy are improving visual outcomes and decreasing the treatment burden associated with repeated intravitreal injections. Combination therapy with anti-VEGF and corticosteroids with other previously available treatments, such as panretinal photocoagulation, may be a reasonable clinical strategy to reduce the intravitreal injections burden. Many exciting novel drugs that target newly discovered pathways hold clinical promise. The results of ongoing randomized clinical trials will answer the important concerns surrounding new drugs and delivery devices: safety and visual outcomes.

Background: Myopic choroidal neovascularization (CNV) is a common cause of central visual loss in patients with high myopia, and the most common form of CNV in younger individuals. Pharmacologic therapy is the current mainstay of treatment of these patients. Methods: Review of pharmacological treatment options for myopic CNV, which primarily involves intravitreal administration of anti-vascular endothelial growth factor (anti-VEGF) agents. Results: At this time, anti-VEGF therapy agents are the first-line therapy in these patients. Comparative trials have not identified any major differences in treatment outcomes between aflibercept, bevacizumab, and ranibizumab. Only ranibizumab is approved for this indication in the US. Best visual outcomes are associated with younger age, smaller lesion size, and absence of chorioretinal atrophy. Conclusion: Anti-VEGF therapy is generally very effective in the treatment of myopic CNV.

Background: Acute-onset postoperative endophthalmitis is an uncommon but potentially serious complication of cataract surgery. Since there are relatively few randomized clinical trials comparing the timing and administration of prophylactic antibiotics, there are wide variations in prevention practices around the world. Methods: Literature review. Results: Antibiotics may be used before surgery, during surgery, or after surgery in an attempt to decrease the rates of endophthalmitis. Antibiotics may be delivered by various routes, including topical, subconjunctival, in the irrigating solution, or by bolus intracameral injection. Polymerase chain reaction and other DNA identification techniques for bacterial isolates and their antibiotic sensitivity profiles will play an important role in future management strategies. Conclusion: There is no consensus regarding the precise use of antibiotics in the perioperative period. Because of increased multidrug-resistant bacteria, evolving strategies are needed to address these issues.

Age-related macular degeneration (AMD) is a leading cause of irreversible visual loss and is primarily treated with nutritional supplementation as well as with anti-vascular endothelial growth factor (VEGF) agents for certain patients with neovascular disease. AMD is a complex disease with both genetic and environmental risk factors. In addition, treatment outcomes from nutritional supplementation and anti-VEGF agents vary considerably. Therefore, it is reasonable to suspect that there may be pharmacogenetic influences on these treatments. Many series have reported individual associations with variants in complement factor H (CFH), age-related maculopathy susceptibility 2 (ARMS2), and other loci. However, at this time there are no validated associations. With respect to AMD, pharmacogenetics remains an intriguing area of research but is not helpful for routine clinical management.

Several medications are associated with retinal vascular toxicity. These include intraocular aminoglycosides, oral contraceptives, interferon alpha, several other agents, and talc, which occurs as a vehicle in some oral medications that may be abused intravenously. As a group, these entities represent a small but clinically relevant category of retinal toxicity from medications. Some of the manifestations (e.g., retinal vascular occlusion) are nonspecific, but others are more specific, including clinically visible talc emboli in retinal vessels. Toxicity may be asymptomatic or may cause irreversible visual loss. By maintaining a high index of suspicion, the correct diagnosis can usually be made.

Acute-onset postoperative endophthalmitis after cataract surgery remains a rare but important cause of visual loss. There is no global consensus regarding the optimal strategies for prophylaxis of endophthalmitis and practices vary substantially around the world, especially with respect to the use of intracameral antibiotics. The European Society of CataractRefractive Surgeons in a randomized clinical trial (2007) reported an approximately 5-fold reduction in endophthalmitis rates associated with the use of intracameral cefuroxime. Despite this report, the use of intracameral antibiotics has not been universally adopted.Various endophthalmitis prophylaxis patterns around the world (including the United States, Canada, Australia/New Zealand, Japan, China, India, Indonesia, South Africa, Argentina, Russia, Sweden and Mexico) are compared. Each contributing author was asked to provide similar information, including endophthalmitis rates based on published studies, current practice patterns, and in some cases original survey data. Various methods were used to obtain this information, including literature reviews, expert commentary, and some new survey data not previously published.Many different practice patterns were reported from around the world, specifically with respect to the use of intracameral antibiotics.There is no worldwide consensus regarding endophthalmitis prophylaxis with cataract surgery.

Endophthalmitis following intravitreal injection is uncommon. There are currently no randomized clinical trials evaluating the role of prophylactic topical antibiotics in this setting. Many large series have reported that topical antibiotics do not decrease, and may in fact increase the rate of endophthalmitis. The reason for this apparent paradoxical finding is unknown but may be due to changes in conjunctival flora due to repeated exposure to antibiotics. At this time, antiseptics (specifically povidone-iodine), rather than antibiotics, are preferred for the majority of patients undergoing intravitreal injections.