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2-Spring18-OcularPharm > Block 5 > Flashcards

Block 5 Flashcards

1
Q

What are the systemic effects of topically administered beta blockers?

A

May cause decrease in HR
Brochospasm
CNS depression

*risky for asthma, lung disease, or vessel spasm patients

Typically used for open-angle glaucoma (non selective b/c you want to block beta 2)

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2
Q

What are the systemic effects of topically administered Muscarinic blockers?

A

May cause increased HR
Dry mouth
Hallucinations
(The sympathetics)

Typically used for cycloplegia (ex. Atropine)

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3
Q

What are the systemic effects of topically administered alpha 2 agonists?

A

Fatigue, lethargy (low sympathetics)

Typically used for open angle glaucoma (ex. Methyldopa)

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4
Q

What is the pH of tears?

A

7.4 (same as blood)

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5
Q

What is the volume of the tear layer?

A

8-10 uL

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6
Q

What is the total volume that can be held for a brief time in the eye if the eyelids are not squeezed after dosing?

A

30 uL

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7
Q

What is the lowest volume of drug delivered by an eye drop?

A

25 uL

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8
Q

What is the normal tear flow rate and what happens to it with age?

A

Normal rate is 0.5-2.2 uL/min

It decreases with age

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9
Q

What does the flow rate have to do with dry eye?

A

Those whose flow rate is at the lower limit

A typical drop of medication is not diluted as much in a dry eye patient thus resulting in greater drug absorption

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10
Q

What 2 things influence drug absorption by the anterior segment of the eye?

A

Tear flow rate

Tear volume

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11
Q

Where is the major site of absorption for topically administered drugs?

A

Cornea

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12
Q

Where is the storage location (depot) for lipophilic drugs?

A

Corneal epithelium

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13
Q

Where is the storage location (depot) for hydrophilic drugs?

A

Corneal stroma

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14
Q

What is an example of a prodrug that is popular for glaucoma?

A

Latanoprost

It’s a PGF2 alpha agonist

When activated to latanprost acid, it concentrates in the aqueous humor and increases fluid drainage to lower IOP

In the eye it lasts 24 hours, systemically it only lasts 17 minutes

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15
Q

What is an example (drug) of an active metabolite? (The parent drug is active and that drug forms an active metabolite)

A

Loteprednol (parent drug is prednisolone)

Rapidly inactivated in the eye thus having fewer side effects than parent drug (less likely to increase IOP)

**this is the case where a shorter acting drug is more beneficial

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16
Q

What structures remove many drugs and metabolites from the vitreous humor and retina?

A

Retinal blood vessels

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17
Q

Which structures remove drugs from the iris and ciliary body?

A

Uveal blood vessels

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18
Q

What are ways to reduce systemic toxicity for topically administered drugs?

A

Store meds away from kids
Wipe excess solution or ointment from the lids and lashes
Use the lowest concentration and minimal dosage frequency
Consider the potential adverse effects of a drug compared to its benefit
Recognize adverse drug reactions

Drugs get into systemic circulation via the conj capillaries, nasal mucosa from lacrimal system, or after swallowing

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19
Q

What are the purpose of preservatives in ocular formulations?

A

Preservatives kill bacteria and fungi that may contaminate drug bottles, however they are harsh chemicals that can harm the cornea and conj epithelial cells

Chronic exposure can lead to dry eye due to poor production of tear film

Most commonly used in ophthalmic solutions is a detergent BAK - causes serious and irreversible side effects in the eye

2nd gen less toxic preservatives being used are oxidizing preservatives

Recently, ionic buffered preservatives are inactivated by the eye and thought to be least toxic

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20
Q

What is the purpose of vehicles in ocular formulations?

A

It is an agent other than the active drug that is added to the formulation to provide proper tonicity, buffering, and viscosity to complement the drug action

High molecular weight polymers increase viscosity and delay washout from the tear film which increases drug bioavailability

Polyionic molecules (oil based ointments) provide longer retention of drugs at the corneal surface

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21
Q

What are the various options for topical drug administration?

A 
Solutions and suspensions (eye drops)
Sprays
Ointments
Lid scrubs
Gels
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22
Q

Which option of topical application tends to last the longest?

A

Ointments - it acts as a reservoir to enhance drug contact time

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23
Q

What are lid scrubs used for?

A

Blepharitis

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24
Q

What are the steps for instilling topical solutions or suspensions?

A

Tilt head back
Gently grasp lower lid and pull away from eye
Place dropper over eye by looking at it
Look up, apply drop
Look down for a few seconds after applying drop
Release lid
Gently close eyes for 2-3 minutes

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25
Q

What are disadvantages of topical solutions?

A

Short ocular contact
Imprecise/inconsistent delivery of drug
Contamination
Risk of injury by dropper tip

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26
Q

Identify periocular routes of administration?

A

Subconjunctival route - right in the conj

Retrobulbar route - right behind the eye but in the muscles

Peribulbar route - much lower behind the eye below the muscles

Intracameral - directly into anterior chamber

Intravitreal - directly into the vitreous

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27
Q

Identify all the parts of a prescription?

A
  1. Patient name and address
  2. Patient age and date
  3. Rx icon is the beginning of your instructions
  4. details of the drug - drug name, drug strength, and drug formulation NO ABBREVIATIONS
  5. Dispensing directions - write out numbers, bottle size, ointment tube size, or number of tablets
  6. Patient use instructions - when to take, how much, route, when to stop, list the diagnosis
  7. Any refills - NEVER leave blank also any special instructions (refrigerate or take with food)
  8. Prescriber’s info and signature
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28
Q

What is the duty to disclose risks for diagnostic and therapeutic agents?

A

In diagnostic agents - informed consent is not necessary unless you are dealing with the very small percent of the population that is at risk for condition (angle closure glaucoma, or allergies to dyes)

Therapeutic agents - ALWAYS inform patients of toxic side effects

Greatest risks for topical steroids, systemic steroids, beta blockers, M agonists for glaucoma, and oral CAIs
Due to the fact that we lack the control over the drug administration (these are the chronic ones)

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29
Q

Describe the categories of drug scheduling for drugs of abuse?

A

1 has the highest potential for abuse and currently no accepted medical use in the US

5 has the lowest potential for abuse

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30
Q

What are the drugs in schedule 1?

A

Ecstasy, LSD, heroin

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31
Q

What are the drugs in schedule 2?

A

Morphine

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32
Q

What are the drugs in schedule 3?

A

Codeine for pain

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33
Q

What are the drugs in schedule 4?

A

Benzodiazepines (anxiety, sleep aids, muscle relaxants)

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34
Q

What are the drugs in schedule 5?

A

Codeine for cough

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35
Q

How are mydriatics different from cycloplegic?

A

Cycloplegic dilate AND knock out accommodation

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36
Q

Why do we use the local anesthetic before instilling mydriatic drops?

A

It facilitates the drug’s effect by affecting the permeability of the epithelium

It does reduce the burning and stinging produced by the mydriatic

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37
Q

What do you have to do before giving dilation drops?

A

You need to warn and document the side effects

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38
Q

Light colored eyes dilate _____?

A

Faster and more completely than darkly pigmented eyes

The pigment sucks up the drug

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39
Q

What are the pupils with poorly controlled diabetes?

A

They have smaller pupils and are slower to dilate

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40
Q

How does age affect dilation?

A

Higher the age the smaller the pupil and a longer time to dilate

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41
Q

The sphincter and the dilator of the iris is under control of which system?

A

Autonomic nervous system

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42
Q

What is the pathway to the dilator?

A

Sympathetic pathway

Hypothalamus
Ciliospinal center of Budge
Superior cervical Ganglion
Dilator muscle

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43
Q

What is the pathway of the sphincter muscle of the iris?

A

Parasympathetic pathway

Pretectal nucleus
E-Westphal nucleus
Ciliary ganglion
Sphincter muscle

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44
Q

What is the MOA of the Anticholinergics/Antimuscarinics?

A

They bind to and inhibit the cholinergic receptors

Inhibit pupillary sphincter (mydriasis(dilate))
Inhibit ciliary body (cycloplegia)

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45
Q

What are the anticholinergics/antimuscarinics used for?

A

Cycloplegic refraction
Pupillary dilation
Management of uveitis

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46
Q

What are the drug names of the anticholinergics/Antimuscarinic?

A

STop ACH

*all have a red cap

Scopolamine
Tropicamide
Atropine
Cyclopentolate
Homatropine
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47
Q

What is the anticholinergic that lasts the longest?

A

Atropine

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48
Q

What is the anticholinergic that is the shortest?

A

Tropicamide

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49
Q

What is the use for scopolamine?

A

NOT usually used - only if patients are allergic to others

**remember it is used as a motion sickness patch, so if someone comes in with a patch on and a dilated eye, that is normal

50
Q

What are the systemic side effects of scopolamine?

A

CNS toxicity!! It penetrates the BB barrier

***this is important! Always pick scopolamine for CNS toxicity

Watch in elderly, small children, and Down’s patients specifically

51
Q

What is the drug of choice for routine mydriasis?

A

Tropicamide

Fastest onset and shortest duration

52
Q

What are the side effects for tropicamide?

A

NONE

These one is very well tolerated

53
Q

What is the most potent mydriatic and cycloplegic?

A

Atropine

54
Q

Which drug should you use as an alternative to amblyopia occlusion?

A

Atropine

Very common b/c you only have to drop once a week or so

55
Q

What are the side effects of atropine?

A

It is safe when the correct dosage is used, however never give to elderly, small children, or Down’s patients

6 cases of death

56
Q

What is the drug of choice for cycloplegic refraction?

A

Cyclopentolate

Faster cycloplegia with less residual accommodation

57
Q

What is the standard drug for treating anterior uveitis?

A

Homatropine

Also useful for pain and prevention of posterior synechiae

58
Q

What is the MOA of phenylephrine?

A

Stimulates the alpha adrenergic receptors causing mydriasis only! Also vasoconstriction

NO cycloplegia!

59
Q

What are uses for phenylephrine?

A

Dilation without cycloplegia

**differentiates scleritis and episcleritis
If redness goes away its episcleritis

Used to break posterior synechiae

60
Q

What is posterior synechiae?

A

Attachment of iris to lens

61
Q

What is anterior synechiae?

A

Attachment of iris to cornea

62
Q

What are contraindications of phenylephrine?

A

Do not use in patients taking MAO inhibitors, tricyclics antidepressants, or methyldopa

Or patients with Graves’ disease

63
Q

What is Paremyd?

A

It is a mixture of hydroxyamphetamine and tropicamide

MOA: causes release of Norepinephrine from adrenergic nerve terminals and possibly inhibits its reuptake (indirect alpha adrenergic agonist)

Inhibits the response of iris sphincter and ciliary body muscles via acetylcholine receptors inhibit

64
Q

What is the use for paremyd?

A

Dilation without cycloplegia

Conjunctival blanching

Utilized after cocaine or apraclonidine to determine lesion location in Horner’s syndrome
*acts on postganglion neuron to release NE and dilation will occur - if no dilation, that means postganglionic neuron is damaged

65
Q

What are the contraindications of paremyd?

A

Do not give to patients taking MAO inhibitors, or antidepressants or with Grave’s disease

May be slightly safer than phenylephrine in high risk patients

66
Q

What are the side effects of paremyd?

A

Less stinging than phenylephrine

Little or no elevation of IOP in glaucoma patients

67
Q

What are the uses for ophthalmic anesthetics?

A

Minor eye trauma, removal of superificial foreign bodies, measuring IOP, nasalacrimal tract irrigation and probing, cataract surgery

68
Q

Local anesthetic is used for _____% of cataract operations/

A

95%

69
Q

When is general anesthetic most appraise in ocular surgery?

A

Children and younger cataract patients

Or people who have trouble keeping still due to tremor or confusion/distress

70
Q

What is the MEC? Maximum effective concentration

A

Concentration where there is no further increase in activity

71
Q

Which type are the most commonly used topical ocular anesthetics?

A

Esters

72
Q

Why is there a contraindication of the combination of 2 or more local anesthetics?

A

There is an increased toxic risk

73
Q

What are the commonly used topical anesthetics in ocular surgery?

A

Benoxinate hydrochloride with fluorescein sodium
Benoxinate hydrochloride with flourexon sodium
Proparacaine hydrochloride
Proparacaine hydrochloride with fluorescein sodium

74
Q

What is the ophthalmic use of cocaine?

A

For otolaryngologist purpose in Horner’s syndrome (10% solution)

75
Q

When is cocaine contraindicated?

A

It blocks reuptake of NE so it is contraindicated in patients with systemic hypertension or taking adrenergic agonists

76
Q

What are the major ocular side effects of cocaine?

A

Visible grayish pits and irregularities

Loosening of the corneal epithelium resulting is large erosions

Systemic toxicity (10 drops of 4% soln) causes irregular pulse, dilated pupil, abdominal pain, delirium, convulsion

77
Q

What is tetracaine?

A

Topical anesthetic which is an ester of PABA

Use for tonometry, cataract surgery, intraocular lens implantation

78
Q

What are major ocular side effects of tetracaine?

A

Overdose if administered in higher doses than 1.5mg/kg of body weight

Structural damage to cell membrane
Loss of microviili and desquamtion of superficial epithelial cells
Produces moderate stinging or burning sensation after topical instillation
May develop local allergy
Cross sensitivity with proparacaine

79
Q

Drug that is only available in combination of Na-fluorescein and Na-fluorexon(vital dye solution) aka flurasafe or fluress

A

Benoxinate

It does NOT stain hydrogel contact lenses

80
Q

What is the use of benoxinate?

A

Applanation tonometry

Has significant antimicrobial properties

81
Q

What are side effects of benoxinate?

A

Sensation of stinging or burning

Very low or rare allergic potential therefore replaces tetracaine

82
Q

This drug is in 0.5% with or without Na-fluorescein and Na-fluorexon

Causes less pain or irritation compared to tetracaine

A

Proparacaine

83
Q

What are the side effects of proparacaine?

A

Fewer side effects but may cause hypersensitivity reaction or allergic contact dermatitis on the fingertips

84
Q

Upon administration, what is the comparison between proparacaine and tetracaine

A

Proparacaine stings less but tetracaine produces a better anesthesia

Warn the patient for brief stinging

85
Q

What are side effects of anesthetic drops?

A

Stinging
Keratitis if overdosed
Specifically tetracaine inhibits corneal epithelial cell healing

Don’t use if know hypersensitive and use caution with hypertensive patients

86
Q

What are common injected anesthetics?

A

Lidocaine hydrochloride (most common)
Bupivacaine
Cocaine

87
Q

Where are anesthetics injected?

A 
Subcutaneous
Subconjuunctival
Sub-tenon** safest
Peribulbar
Retrobulbar

(Last 2 have higher risk)

88
Q

What are the the ocular side effects of injected anesthetics

A

Peribulbar and retrobulbar injections are trickier and can result in retrobulbar hemorrhage, globe puncture, optic nerve damage, muscle palsy, and 7th cranial nerve complications

Systemic side effects are rare but can occur if a very large dose is injected

89
Q

What are the risks of local anesthetics?

A

Localized self limiting hemorrhage
Sight limiting complications are rare

Patients on anticoagulants or antiplatelet agents are as increased risk for minor complications

Drop LAs do not block muscular action - this can be an issue in procedures where movements of millimeter or less can have serious consequences

90
Q

What are some agents added to LA and why?

A

Fluorescein - dye combined with lidocaine or proparacaine drops to enable visualization of corneal epithelial defectes

Adrenaline (epinephrine) - diminishes blood flow, so it decreases systemic absorption and prolongs local effect (very low concentrations are used)
-when epi is subjected to heat it loses its potency, used specifically for injected LAs and not added to eye drops

Hyaluronidase - added to increase tissue permeability to injected fluid, usual concentration of 15 units/mL

91
Q

Most LAs are what?

A

Bactericidal

92
Q

Compare benoxinate, proparacaine, tetracaine, cocaine

A

Benoxinate - 1-20 minutes - only combined with vital dye
Minor irritation and side effects
Rare allergies

Proparacaine - 1-20 minutes - stand alone or combined with vital dye
Discoloration

Tetracaine - 10-30 minutes - significant corneal toxicity
Moderate stinging
More allergic reaction

Cocaine - 20+ minutes - significant corneal toxicity
Abuse potential

93
Q

What are some ophthalmic NSAIDs used?

A 
Bromfenac
Diclofenac sodium
Flurbiprofen sodium
Ketorolac 0.5%
Ketorolac 0.4%
Ketorolac 0.5% PF 
Nepafenac
94
Q

This drug is used for temporary relief of pain and photophobia in patients

A

Diclofenac sodium

95
Q

Which drug is used for ocular itching, ,seasonal allergic conjunctivitis

Treatment of post op inflammation in cataract extraction patient

A

Ketorolac 0.5%

96
Q

Drug used for reduction of ocular pain, burning, stinging after surgery

A

Ketorolac 0.4%

97
Q

Drug for reduction of photophobia, pain associated with surgery

A

Ketorolac 0.5% PF

98
Q

What do prostaglandins in the eye cause?

A

Increased IOP
Miosis (pupil constriction)
Increased vascular permeability

99
Q

What is the MOA of ophthalmic NSAIDs?

A

Inhibits COX1 and COX2 which limits prostaglandin production and provides both analgesic and anti inflammatory activity

Topical ophthalmic NSAIDs are preferred over systemic NSAIDs b/c they produce higher ocular drug concentrations while avoiding some of the systemic adverse events

100
Q

This drug inhibits the adherence of Stapp. Epidermidids to the soft lens material

A

Diclofenac

101
Q

Drug with its greatest advantage being less initial stinging on instillation?

A

Bromfenac

102
Q

This drug is combined with cyclosporine A for treatment of chronic dry eye disease

A

Ketorolac

103
Q

This drug is a prodrug, it penetrates the cornea and is converted by ocular tissue hydrolases to its active form amfenac

This allows it to reach higher intraocular concentrations than other topical NSAIDs and provides longer lasting inhibition of PG synthesis

A

Nepafenac

104
Q

What are some inflammatory complications that occur after cataract surgery that are treated with NSAIDs?

A 
Posterior synechiae 
Chronic uveitis
Secondary glaucoma
Cystoid macular edema
Pain
105
Q

What is Cystoid macular edema? CME

A

Appears as multiple cyst like areas of accumulated fluid in the macula causing retinal swelling or edema

Can present as blurred or impaired central vision

It is the most common cause of reduced vision after cataract surgery

106
Q

What are the side effects of ketorolac 0.5%?

A

<40 burning/stinging

Ocular irritation

Corneal edema

Slight vision change

107
Q

What are the side effects of ketorolac 0.4%?

A

30-40 burning/stinging

Ocular irritation

Corneal edema

No vision change

108
Q

What ar the side effects of ketorolac 0.5% PF?

A

20 burning/stinging

Ocular irritation

Corneal edema

Vision changes

109
Q

What is the side effects of nepafenac 0.1%?

A

Vision changes

110
Q

What are the complications of NSAIDs?

A

Bromfenac - contains sodium sulphite and is contraindicated in patients with sulphite hypersensitivity

Cross hypersensitivity in patients with aspirin and other NSAIDs - prolonged bleeding times and healing

May cause keratitis - epithelial breakdown, corneal thinning, erosion, and ulceration

Impaired healing if in combo with ophthalmic steroids

111
Q

What are the side effects of topical antibiotics?

A

Stinging, burning, redness, blurry vision

112
Q

Which is the only antibiotic that does not treat pseudomonas?

A

Neomycin

113
Q

What is the drug of choice for pseudomonas?

A

Ciprofloxacin

114
Q

Which topical antibacterial drop is yellow?

A

Moxifloxacin

Moxeza or Vigamox

115
Q

When is betadine most useful?

A

When treating epidemic keratoconjunctivitis during the acute, red state

116
Q

What is the dosage for oral acyclovir?

A 
HSV = 400mg 5x per day 14-21 days 
HZV = 800mg 5x per day 7-10 days
117
Q

What is the dosage for oral valacyclovir?

A

HSV 500mg TID 14-21 days

HZV 1000mg TID 7 days

118
Q

What is the dosage for oral Famciclovir?

A

HSV 250mg BID 14-21 days

HZV 500mg TID 7 days

119
Q

When is the oral drugs for herpes simplex and zoster the most effective?

A

Within 72 hours of the rash

120
Q

What did the HEDS-1 study find?

A

Stromal diseases are best managed by topical steroids

Oral acyclovir didn’t do anything

121
Q

What did the HEDS-2 study find?

A

Recurrent keratitis can be reduced by 45% with lifetime treatment of acyclovir 400 mg BID, famciclovir 250mg QD, or valacyclovir 500mg QD

2-Spring18-OcularPharm (1 decks)

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