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309 SSAMP > 1- Cycloplegia and Mydriasis > Flashcards

1- Cycloplegia and Mydriasis Flashcards

1
Q

What are the three drug classifications?

A

Pharmacy medication (P)

Prescription only medication (POM)

General sales list (GSL)

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2
Q

What are pharmacy medications

A

Definition: Medicines that do not require a prescription but must be sold under the supervision of a qualified pharmacist in a registered pharmacy.

Examples: Larger packs of painkillers, antihistamines, and certain nasal sprays or eye drops.

Key Points:
Not available in non-pharmacy retailers.
Pharmacist supervision ensures that the medication is appropriate for the buyer.

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3
Q

What are prescription only medications

A

Definition: Medicines that require a valid prescription from a healthcare professional (e.g., doctor, dentist, or nurse practitioner) before they can be dispensed.

Examples: Antibiotics, strong painkillers like morphine, and medications for chronic conditions like high blood pressure or diabetes.

Key Points:
Available only at pharmacies upon presentation of a prescription.
Used for conditions that require professional diagnosis and monitoring.

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4
Q

What are general sales list medications

A

Definition: Medicines that can be sold without a prescription and are available from general retailers, such as supermarkets or convenience stores.

Examples: Paracetamol (in limited quantities), ibuprofen, and some cough syrups.

Key Points:
Can be sold in outlets without a pharmacy.
Pack sizes and dosages are often limited to ensure safety.

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5
Q

Examples of POMs

(ACT)

A

Atropine
Cyclo
Tropicamide

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6
Q

What do atropine, cyclopentolate and tropic amide have in common

A

They are anti muscarinic and allow for mydriasis

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7
Q

What class is phenylephrine

A

P medicine

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8
Q

What does phenylephrine do

A

It’s sympathomimetic- gives mydriasis and has minimal affect on accommodation- just a mydriatic

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9
Q

Literature definition of cycloplegia

A

Millodot defines cycloplegia as the “paralysis of the ciliary muscle resulting in a loss of accommodation.” (Millidot, M. 2018)

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10
Q

What does AcH do

A

Its a neurotransmitter that initiates nerve conduction

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11
Q

What type of drug is needed

A

Need a drug that mimics AcH so that it binds at the receptor site on the post synaptic membrane but we don’t want to initiate nerve conduction

Post receptor sites are blocked with our drug and this gives temporary paralysis of accommodation

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12
Q

Which drug lasts the longest

A

Atropine

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13
Q

Which drug lasts the shortest

A

Tropicamide

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14
Q

What’s the anatomy of the ciliary body, zones and lens

A

The ciliary body is innervated by the parasympathetic nervous system.

Cycloplegic agents temporarily stop this innervation by competing with acetylcholine at the receptor sites on the post-synaptic membrane of the ciliary muscle.

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15
Q

Innervation

A
  • Although the drugs occupy the post-synaptic receptor sites, they do not initiate depolarisation of the neuron.
  • By occupying these sites, acetylcholine is rendered temporarily ineffective
  • The nerve impulse, which was started in the Edinger-Westphal nucleus, travelled via the Third cranial nerve, does not activate the ciliary muscle.
  • This results in the temporary paralysis of accommodation.
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16
Q

What are all cycloplegics

A

Anti- muscarinic

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17
Q

List of synonyms of anti muscarinic

A
  • anticholinergics,
  • cholinergic antagonists,
  • muscarinic antagonists,
  • muscarinic inhibitors,
  • parasympatholytics.
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18
Q

What is AcH

A

The term “anticholinergics” refers to drugs that interfere with the action of acetylcholine (ACh), a key neurotransmitter in the nervous system.

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19
Q

Lysis means…

A

Break down

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20
Q

How is atropine prepared

A

Typically single-dose preparations (Minims) but can be as multi-use bottle (with preservative).

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21
Q

Atropine class and age appropriate

A

POM
3 months to 17 years

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22
Q

Cautions for atropine use

A
  • Pigmented irides.
  • Narrow angles- risk of angle occlusion
  • Neonates
  • Big amounts can cause death and illness
  • Single dose have no preservatives
  • Can cause allergy, hypersensitivity
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23
Q

Cons of atropine

A
  • more expensive
  • May need to instill more drugs if not absorbed
  • Risk of systemic side effects with more doses
  • Atropine comes from plant deadly night shade- can be toxic
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24
Q

Note for Atropine

A
  • Close the angle due to the trabecular meshwork and allow the aqueous to drain- causes acute glaucoma if closed angle
  • Dilation makes all iris tissue to be dragged back towards the angle- risk of angle occlusion
  • Assess risk using Van Hericks
  • If in doubt ask doctor or nurse praticiconer to view structures in the angle to decide if risk is too high
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25
Q

Atropine interactions

A
  • Typically, other drugs which have antimuscarinic effects but also levodopa (used in Parkinson’s disease) as atropine can reduce the absorption of levodopa.
  • Phenylephrine; atropine increases the risk of severe hypertension.
  • Use with phenylephrine increases risk of severe hypertension
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26
Q

Atropine side effects

A
  • Photophobia, stinging- caused by mydriasis
  • confusion
  • constipation
  • dizziness
  • drowsiness
  • dry mouth
  • Dyspepsia- acid reflux
  • If child swallows atropine must go to A and E
  • As body weight affects how drug is metabolized
  • Atropine can shut down the brain if drank
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27
Q

More atropine side effects

A
  • flushing
  • headache
  • nausea
  • palpitations
  • skin reactions
  • tachycardia
  • urinary disorders
  • vision disorders
  • vomiting
  • Instillation procedure must minimize systemic affects
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28
Q

Atropine percentage

A

1%

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29
Q

Cyclopentolate percentage

A

0.5% and 1%

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30
Q

Who is cyclo not recommended for

A
  • Not recommended in children under 3 months due to risk of amblyopia.
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31
Q

How is cyclo prepared

A

Typically, both are in the form of Minims but can be as multi-use bottle (Eg. Mydrilate)

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32
Q

Cyclo class and age

A

It’s a POM

3months to 12 years 1%.
Over 12s 0.5%.

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33
Q

Cautions of cyclo

A

Pigmented irides. Narrow angles. Neonates.

34
Q

Cyclo interactions

A
  • Other muscarinic drugs
  • Levodopa (used in Parkinson’s disease) cyclo reduces the absorption
    -Clozapine; risk of developing intestinal obstruction
35
Q

Side effects of tropicamide

A
  • eye erythema- redness
  • eye irritation (on prolonged administration)
  • eye pain; headache
  • hypotension- low blood pressure
  • nausea
  • Syncope- fainting
  • vision blurred
36
Q

Clinical uses of tropicamide

A
  • Paediatric refraction
  • Amblyopia therapy
  • Uveitis- stops or reduces formation of posterior synechiae
  • Alleviation of ciliary spasm
37
Q

What is the gold standard for paediatric refraction

A

Atropine was the gold standard

Today Cyclopentolate 1% is the preferred choice

38
Q

Benefits of atropine for paediatric refraction

A

-knocks about tonic accommodation
-gives full cycloplegia

39
Q

Disadvantages of atropine for paediatric refraction

A

-toxicity
-slow acting and long lasting
-not preferred for pediatric refraction

40
Q

What are the components needed for ideal refraction

A
  • fast-acting
  • give adequate cycloplegia
  • last long enough for the refraction to take place
  • have no local or systemic side-effects.
41
Q

Drawbacks of cyclopentoloat for refraction

A

It’s adequate but not a perfect drug. This is because it stings and causes allergy.

42
Q

Local side effects of cyclopentolate

A

Ocular stinging
Allergy

43
Q

Systemic side effects of cyclopentolate

A

CNS disturbances such as ataxia, Incoherent speech
Restlessness
Hallucinations
Hyperactivity
Disorientation.

44
Q

What should be done after instilling cyclopentolate

A

monitor child for 45 minutes post instillation

45
Q

Optical penalisation study PEDIG

A

Study: Multi-centre RCT with 419 children.

Groups: Patching vs. Atropine.

Outcome: After 6 months, no significant difference in visual acuity improvement.

Key Finding: Both treatments are equally effective; patching is daily, atropine is twice weekly.

46
Q

How is atropine used for amblyopia

A

Atropine 1% is placed into the better seeing eye, thereby preventing that eye from having a clear stimulus at near and forcing the amblyopic eye to read.

47
Q

Advantages of atropine for amblyopia

A

It can reduce any hyperopic correction in the better seeing eye to also cause blur at distance.

48
Q

How is atropine instilled

A

1% atropine was instilled every day, and the children were provided with sunglasses and advised to wear a hat

48
Q

Disadvantages of atropine for amblyopia

A

Emmetropic patients will have significant blur at near

49
Q

How is atropine used for amblyopia

A

Dosage: Weekend or twice-weekly atropine 1%.

Monitoring: Check adherence via pupil dilation (dynamic retinoscopy).

Non-response: Consider conventional patching.

Advantage: Long-lasting action preferred over cyclopentolate.

50
Q

Anterior uveitis (iritis)

A

Definition: Inflammation of the iris and ciliary body.

Presentation: Young adults with a painful, red, uniocular eye, photophobia, and vision changes.

Association: May have systemic inflammatory diseases (e.g., rheumatoid arthritis).

Common: Often affects young adults.

51
Q

How is the slit lamp used for examining uveitis

A

Cornea: Check for keratic precipitates.

Anterior Chamber: Assess for cells and flare (signs of inflammation).

Iris: Look for nodules or irregularities.
Lens: Examine for posterior synechiae.

Technique: Use focused beams to evaluate specific structures in detail.

52
Q

What is used to treat posterior synechiae

A

steroids

53
Q

How is uveitis managed

A

Acute/Chronic: Both types require medical evaluation.

Cyclopentolate 1%: Prevents/breaks synechiae and reduces pain by paralyzing ciliary movement.

Steroids: Prednisolone 1% (Pred Forte) to reduce inflammation.

Chronic Uveitis: Associated with juvenile arthritis.

54
Q

Alleviating ciliary spasm

A
  • In some cases of corneal abrasion, the ciliary muscle can go into a spasm which is extremely uncomfortable.
  • Cyclopentolate 1% can be administered to alleviate this spasm through cycloplegia.
55
Q

What do all anti muscarinics cause

A

Pupil dilation (mydriasis)

This is because the sphincter papillae of the iris receives parasympathetic innervation.

56
Q

More on mydriasis and pupils

A
  • Therefore, stopping this muscle from working leaves the dilator papillae to exert it’s affect without competition and the pupil will dilate.
  • Therefore, stopping this muscle from working leaves the dilator papillae to exert it’s affect without competition and the pupil will dilate.
  • If one stimulates the dilator papillae using an adrenergic agonist (sympathomimetic) then this will result in mydriasis.
57
Q

What innervation does the iris get

A

Sympathetic and parasympathetic innervation

Sympathetic- fight or flight response

Neurotransmitter for sympathetic system- noradrenaline

58
Q

What is sympathetic innervation

A

fight or flight response

59
Q

What are the parasympathetic innervations

A

Accommodation, pupil myosis

60
Q

What action do anti muscarincs affect

A

the action of the sphincter on the iris – cause mydriasis

61
Q

What are all cycloplegia drops

A

Mydriatics

62
Q

Summary about all cycloplegia drops being mydriatics

A
  • To dilate the pupil a drop that doesn’t affect the parasympathetic system can be used- this mimics noradrenaline and allows dilator to be amplified
  • Sympathomimetic system is mimicked e.g. phenylephrine and can give mydriasis without affecting accomodation
  • adrenergic system is aided – amplifies
  • To achieve best mydriasis a combination is used
63
Q

Why are drug combinations often used

A

Drugs from separate classes are often used to create mydriasis

e.g. phenylephrine 2.5% and tropicamide 1%.

64
Q

Which cases is a drug combination typically used

A

Assessing infants for signs of ROP (need full mydriasis for this)

Assessing adults when the peripheral retina needs to be seen in suspected retinal detachment.

In eye casualty need to use combination to visualize all the way to ora serrata

65
Q

What is the best drug combination for mydriasis

A

phenylephrine 2.5% and tropicamide 1%.

66
Q

Is atropine used as a mydriatic

A
  • Rarely used as a mydriatic due to long time of onset, long lasting effect and potential toxicity.
  • Only used if other drops ineffective or allergy. Eg heavily pigmented irides. POM
67
Q

Is cyclopentolate used as a mydriatic

A
  • Cyclopentolate is more frequently used than atropine but its not the drug of choice as the cycloplegic affect is too great and lasts too long
  • Cyclo is used in case of ineffective dilation with tropicamide or an allergy (POM)
68
Q

Is tropic amide used as a mydriatic

A
  • Sufficient to produce 6mm pupil diameter in young healthy adults (Siderov and Nurse, 2005)
  • Usually tolerated better than the above due to rapid onset and faster recovery and usually leaves some residual accommodation.
69
Q

Phenylephrine 2% summary

A

Available as Minim

It’s a pharmacy medicine (P)

70
Q

What are the cautions when using phenylephrine

A

Asthma
Long standing diabetes
Corneal epithelial damage
Darkly pigmented iris is more resistant to pupillary dilatation and caution should be exercised to avoid overdosage

71
Q

What are the cautions when using phenylephrine 10%

(7)

A
  • It is a vasoconstrictor
  • Can do same in lungs
  • Caution in asthmatics
  • mydriasis can precipitate acute angle-closure glaucoma in the very few children who are predisposed to the condition because of a shallow anterior chamber
  • neonates are at an increased risk of systemic toxicity (in neonates);
  • ocular hyperaemia
  • susceptibility to angle-closure glaucoma
  • cardiothoracic, breathing and heart complications- rarely used and if used has many issues
72
Q

Phenylephrine drug interactions

A

Amitriptyline
Apraclonidine
Monoamine Oxidase Inhibitors (MAOIs)
Beta-adrenergic Blockers
Alpha-2 Adrenergic Agonists (e.g., clonidine)
Tricyclic Antidepressants
Ergot Alkaloids
Corticosteroids
Norepinephrine Reuptake Inhibitors (e.g., atomoxetine)
Alpha-adrenergic Blocking Agents (e.g., chlorpromazine)
Calcium Channel Blockers
Angiotensin-Converting Enzyme (ACE) Inhibitors
Benzodiazepines
Oxytocic Drugs
Atropine Sulfate
Sympathomimetic Agents
Acetaminophen (Paracetamol)
Antihistamines
Digoxin

73
Q

Phenylephrine side effects

A
  • Conjunctivitis allergic
  • eye discomfort
  • Systemic hypertension
  • myocardial infarction (usually after use of 10% strength in patients with pre-existing cardiovascular disease)
  • periorbital pallor
  • vision disorders
74
Q

Clinical use of phenylephrine

A

0.5% Tropicamide and 2.5% phenylephrine are used in all healthy adults.

It is important to take a careful medical history prior to instilling these drops

75
Q

Risks of using phenylephrine

A
  • Precipitating angle closure glaucoma in susceptible individuals and assessment of the potential to close should be carried out on all patients.
  • In particular, older, phakic (original lens in place) female hypermetopes of East Asian descent are particularly at risk.
  • Because iris is being pulled there is a risk of angle closure
  • Females more at risk of angle closure than males
  • Hypermetropes- more at risk because of small eyes
  • East Asian- can cause angle closure
76
Q

Why is a Van hericks assessment done and what is the grading

A

Van Herick’s Grading is a slit-lamp technique used to estimate the anterior chamber angle and assess the risk of angle-closure glaucoma:

Grade 4: Angle width >1:1 (Wide open, no risk of angle closure).
Grade 3: Angle width ~1:1 (Open, low risk of angle closure).
Grade 2: Angle width ~1:4 (Narrow, moderate risk of angle closure).
Grade 1: Angle width ~1:16 or less (Very narrow, high risk of angle closure).
Grade 0: No visible gap (Angle closed or very high risk).

77
Q

Further clinical use of van hericks assessment

A

This method is essential in glaucoma risk assessment, especially in identifying primary angle-closure glaucoma (PACG).

Regular monitoring or further evaluation with gonioscopy is needed for narrow angles.

78
Q

Which patients need dilation

A

-Indirect viewing techniques such as Volk lens examination with a slit lamp or headset mounted binocular indirect ophthalmoscopy.
-When viewing the peripheral fundus, commonly needed to check for retinal tears following posterior vitreous detachment (PVD).
-Ensuring adequate mydriasis is essential but using too much of any of the agents mentioned here increases the risk of systemic absorption and raises the possibility of systemic effects.

79
Q

More on patients who need dilation

A
  • The risk of missing ocular pathology outweighs the risk of inducing angle closure.

-Tropicamide is safe to use but patients must be advised if symptoms of angle closure
present. (Pandit & Taylor, 2000)

  • Long term diabetic has higher risk of disease
  • Sudden onset of flashes and floaters in myope

309 SSAMP (3 decks)

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