How should patients be counseled about stinging with hypertonic saline (Muro 128)?

Stinging with Muro 128 is common and reflects its hypertonic mechanism. Discomfort is usually brief, and bedtime ointment is often better tolerated than frequent daytime drops.

Which patients are good candidates for Upneeq?

Upneeq fits mild to moderate acquired ptosis when Müller’s muscle function is intact and dermatochalasis or neurogenic causes are not dominant. It is not a substitute for surgery when levator issues or field loss are significant.

How significant is retinal detachment risk with pilocarpine?

Pilocarpine carries a small increased risk of retinal breaks or detachment, especially in high myopes or eyes with lattice. Consider a baseline dilated exam and give clear return precautions before ongoing use.

What are common side effects patients notice with pilocarpine drops?

Pilocarpine can cause brow ache or headache, transient blur, and dimmer vision in low light due to miosis. Counsel patients about night-driving impact and give return precautions for flashes or floaters.

Other Ophthalmic Medications

Hyperosmotics, miotics, and specialty agents used in eye care

Specialty Ophthalmic Therapies: Edema, Ptosis, and Miotics

Hypertonic saline for corneal edema: Sodium chloride 5% (Muro 128)

Sodium chloride 5% (Muro 128) is a standard hypertonic agent used to reduce epithelial corneal edema. By creating a hypertonic tear film, it draws fluid out of the cornea via osmosis. Patients often notice the most benefit when edema is worst on waking.

Common uses include Fuchs' endothelial dystrophy to improve morning vision and recurrent corneal erosion (RCE) as part of a regimen intended to support epithelial adhesion. Ointment is often preferred at bedtime for longer contact time, with drops used during the day as tolerated.

Pharmacologic ptosis therapy: Oxymetazoline 0.1% (Upneeq)

Oxymetazoline 0.1% (Upneeq) is an alpha-adrenergic agonist that stimulates Müller's muscle, producing a modest upper eyelid elevation in many patients. It is indicated for acquired blepharoptosis and is most useful for mild to moderate cases when Müller's muscle function is intact. It does not correct dermatochalasis, true levator dehiscence, or most neurogenic causes of ptosis. Because systemic absorption is low but not zero, review cardiovascular history, blood pressure control, and concomitant adrenergic medications when considering long-term use.

Pilocarpine: targeted indications and key counseling points

Pilocarpine stimulates the iris sphincter (miosis) and the ciliary muscle (increased trabecular outflow). Although routine glaucoma management often relies on newer classes, pilocarpine remains clinically relevant in several focused scenarios:

LPI preparation in narrow angles: Pre-treatment miosis can help tighten the peripheral iris in pupillary block or narrow-angle eyes.
Adie's tonic pupil testing: Low-dose pilocarpine (for example 0.125%) may demonstrate denervation supersensitivity.
Presbyopia drops: Low-concentration pilocarpine can increase depth of focus via a pupil-size effect, often used selectively based on symptoms and patient tolerance.

Counseling should include expected brow ache or headache in some patients, possible dimming in low light due to smaller pupil size, and return precautions for new flashes or floaters in higher-risk patients.

Miscellaneous Ophthalmic Agents

Brand	Generic	Dosing	Amount	Ages	Pregnancy	Mechanism
Latisse Generic	bimatoprost 0.03%	qd	3mL (70 applicators)5mL (140 applicators)	NA	C	prostagladin analogue
Lumify OTC	brimonidine 0.025%	qd-qid	2.5/7.5mL	>5 years	B	α-2 agonist
Muro-128 GenericOTC	sodium chloride 5%	q3-4h	15/30mL (gtt)3.5/7g (ung)	NA	C	hyperosmotic
Natacyn Generic	natamycin 5%	q1-2h x3d, then q3-4h x14-21d	15mL	NA	NA	antifungal
Qlosi	pilocarpine 0.4%	qd-bid	30/60 vial carton	NA	NA	cholinergic muscarinic agonist
Upneeq	oxymetazoline 0.1%	qd	30 vial carton	>13 years	NA	α-adrenergic agonist
Vizz	aceclidine 1.44%	qd	25 vial carton	NA	NA	cholinergic muscarinic agonist
Vuity	pilocarpine 1.25%	qd-bid	2.5mL	NA	NA	cholinergic muscarinic agonist
Xdemvy	lotilaner 0.25%	bid	10mL	>18 years	NA	γ-aminobutyric acid (GABA)-gated chloride channel inhibitor

Specialty Medication FAQs

How should patients be counseled about stinging with hypertonic saline (Muro 128)?: Stinging or burning is common with hypertonic sodium chloride. The high salt concentration creates an osmotic gradient that draws water out of the corneal epithelium, and that surface shift can cause brief discomfort as the eye equilibrates. Patients can be told the burning is usually short, often around a minute or two. Bedtime ointment is often better tolerated than frequent daytime drops in sensitive eyes.
Which patients are good candidates for Upneeq?: Upneeq is best suited for mild to moderate acquired ptosis when Müller's muscle function is intact and there is not a dominant mechanical cause such as heavy dermatochalasis. It does not correct true levator dehiscence, third-nerve palsy, or most neurogenic ptosis, and it should not be viewed as a substitute for surgical repair when superior field loss or cosmesis warrant a procedural approach. Before prescribing, review cardiovascular status, blood pressure control, and concomitant adrenergic medications, and document baseline lid position and symptom impact.
How significant is retinal detachment risk with pilocarpine?: Pilocarpine causes ciliary muscle contraction and can increase traction on the vitreous base and peripheral retina. A small increased risk of retinal tears or detachment has been reported, particularly in high myopes or eyes with lattice degeneration or prior peripheral pathology. For higher-risk patients, a documented dilated fundus examination before ongoing miotic therapy, clear return precautions for flashes and floaters, and coordination with retina colleagues when indicated are prudent safeguards.
What are common side effects patients notice with pilocarpine drops?: Common effects include brow ache or headache from ciliary muscle contraction, transient blur, and dimming in low-light settings due to smaller pupil size. Some patients also notice increased myopia or difficulty with night driving. Patients should be counseled on expected visual changes and instructed to seek care promptly for new flashes, floaters, or a curtain-like shadow.