Ch 26 Drugs Used to treat eye and ear disorders

Question 1

Common eye infections that are treated by primary care providers include:

Answer 1

Bacterial conjunctivitis, viral conjunctivitis, blepharitis, and hordeolum.

Blepharitis is an inflammation of the eyelids in which they become red, irritated and itchy with dandruff-like scales that form on the eyelashes. It is a common eye disorder caused by either bacteria or a skin condition, such as dandruff of the scalp or rosacea.

A stye, also known as a hordeolum, is a bacterial infection of an oil gland in the eyelid. This results in a red tender bump at the edge of the eyelid.

Question 2

True or false: 50 to 75% of cases of conjunctivitis and children are bacterial.

Answer 2

True

Question 3

What are the most common pathogens of pediatric conjunctivitis?

Answer 3

H. Influenzae (29%), and S. pneumoniae (20%)

Question 4

Antibacterial agents for conjunctivitis are:

Answer 4

Bacitracin, erythromycin, azithromycin; and FLOUROQUINOLONES besifloxacin (Besivance), ciprofloxacin (Ciloxan), gatifloxacin (Zymar, Zymaxid), levofloxacin (Iquix), moxifloxacin (Moxeza, Vigamox) norfloxacin (Chibroxin, Noroxin) and ofloxacin (Ocuflox).
COMBINATION DRUGS: Polytrim (polymyxin b/trimethoprim) and Polysporin (polymyxin b/bacitracin).

Question 5

Less commonly used Opthalamic antibiotics used include:

Answer 5

sulfactamide sodium (Bleph-10), tobramycin (Tobrex), and gentamicin (Garamycin, Genoptic). --These are less used because of eye discomfort with use.
Chloromphenicol (Chloroptic) rarely used in primary care because of adverse effects.

Question 6

WHAT IS GLAUCOMA?

Answer 6

Progressive optic neuropathy cause by elevated intraocular pressure (IOP) > 21 mmHg leading to optic nerve damage
Normal IOP 10­-21 mm Hg

Question 7

What are the 2 different types of GLAUCOMA?

Answer 7

1.Open­-angle glaucoma
Silent disease
Obstruction in aqueous humor outflow by obstruction of the trabecular meshwork
Peripheral vision loss

2.Angle­-closure glaucoma aka Narrow-angle glaucoma
Medical emergency
Obstruction of anterior chamber angle resulting in intermittent or acutely elevate IOP with optic nerve damage

Question 8

Symptoms of Open-angle Glaucoma:

Answer 8

“Tunnel vision” and “Blind spots”
Open-angle glaucoma is bilateral with asymmetric disease progression.

Signs:
*Optic disc cupping­
Large cup-­to­-disc ratio
­Diffuse thinning, focal narrowing of the optic nerve

Question 9

Symptoms of Angle-closure Glaucoma:

Answer 9

• *Note** Medical emergency due to high risk for loss of vision.
• Ocular pain
• ­Red eye­
• Blurry vision­
• Halos around lights­
• Systemic symptoms

SIGNS:
*Cloudy cornea
­*Conjunctival hyperemia­
*Pupil semi-dilated and fixed to light­
*Closed eye harder on palpation

Question 10

GLAUCOMA – PHARMACOLOGIC TREATMENT

Answer 10

Eye drops:
Prostaglandin analogs
Alpha­-adrenergic agonists
Beta bockers
Carbonic anhydrase inhibitors
Miotics, cholinesterase inhibitors
Miotics, direct­ acting
Sympathomimetics
Combination products
Rho kinase inhibitors

Mechanism of action (MOA): all work to decrease intraocular pressure (IOP) through various mechanisms

Question 11

Adverse effects of Prostaglandin analogs:
Latanoprost (Xaltan®) 0.005% solution
Bimatoprost (Lumigan®) 0.01% and 0.03% solution
Travoprost (Travatan Z®) 0.004% solution
Tafluprost (Zioptan®) 0.0015% solution

Answer 11

Adverse effects:
Ocular hyperemia (eye redness)
Increased number and length of eyelashes
Changes in eye color (may be permanent)
Rare: uveitis or cystoid macular edema

Warnings/Precautions:
Permanent pigmentation of the iris and/or eyelids, and increase number/length of eyelashes

Question 12

Adverse effects of Glaucoma Beta-Blockers:
Timolol (Timoptic®, Betimol®) 0.25%, 0.5% solution
Betaxolol (Betoptic­S®)0.5% solution (generic) 0.25% suspension (brand)
Levobunol (Betagan®) 0.25%, 0.5% solution
Metipranolol (OptiPranolol®) 0.3% solution

Answer 12

Adverse effects:
Local: eye irritation/stinging
Systemic: headaches, dizziness, bradycardia, masking hypoglycemia

Contraindications:
Bronchial asthma, severe COPD
Sinus bradycardia, 2nd or 3rd degree AV block, heart failure, cardiogenic shock

Warnings/Precautions:
Caution in patients with cardiovascular disease, diabetes, heart failure, myasthenia gravis, respiratory diseases, and thyroid disease

Question 13

The Mechanism of action (MOA): reduce IOP by binding to the FP receptor (subtype of prostaglandin receptor) to increase the outflow of aqueous humor through uveoscleral outflow, applies to which glaucoma drugs:

A) Prostaglandin Analogs
B) Beta-Blockers
C) Alpha-adrenergic Agonists
D) Miotics
E)Sympathomimetics

Answer 13

A) Prostaglandin Analogs (PAs)

PAs work to reduce IOP by binding to the FB recepter to increase the outflow of AH through uveoscleral outflow.

Question 14

The MOA: interfering with the production of aqueous humor induced by cyclic adenosine monophosphate (cAMP), applies to which glaucoma drugs:

A) Prostaglandin Analogs
B) Miotics
C) Alpha-adrenergic Agonists
D) Sympathomimetics
E) None of the above

Answer 14

E) None of the above

Beta-Blockers work by interfering with the production of AH by cAMP

PAs work to reduce IOP by binding to the FB receptor to increase the outflow of AH through uveoscleral outflow

Miotics work by stimulating cholinergic receptors in the eye causing decreased resistance to the AH outflow, leading to a decrease in intraocular pressure

AAAs Work by decreasing intraocular pressure by reducing aqueous humor production and increasing uveoscleral outflow

Question 15

The Mechanism of action (MOA): stimulates cholinergic receptors in the eye causing decreased resistance to aqueous humor outflow leading to a decrease in intraocular pressure {Also can cause miosis (pupil constriction)}, refers to which glaucoma drugs:

A) Prostaglandin Analogs
B) Miotics
C) Alpha-adrenergic Agonists
D) Sympathomimetics
E) None of the above

Answer 15

B) Miotics

Miotics work by stimulating cholinergic receptors in the eye causing decreased resistance to the AH outflow, leading to a decrease in intraocular pressure

Question 16

The MOA: decrease intraocular pressure by reducing aqueous humor production and increasing uveoscleral outflow, applies to which glaucoma drugs:

A) Prostaglandin Analogs
B) Beta-Blockers
C) Alpha-adrenergic Agonists
D) Miotics
E)Sympathomimetics

Answer 16

C) Alpha-adrenergic Agonists

AAAs Work by decreasing intraocular pressure by reducing aqueous humor production and increasing uveoscleral outflow

Question 17

The MOA: slows the formation of bicarbonate ions, which reduces sodium and fluid transport and leads to decreased production of aqueous humor, applies to which glaucoma drugs:

A) Prostaglandin Analogs
B) Carbonic Anhydrase Inhibitors
C) Alpha-adrenergic Agonists
D) Miotics
E)Sympathomimetics

Answer 17

B) Carbonic Anhydrase Inhibitors work by slowing the formation of bicarbonate ions, which reduces sodium and fluid transport and leads to decrease production of AH

Question 18

Adverse Effects of Carbonic Anhydrase Inhibitors:
Brinzolamide (Azopt®) 1% suspension
Dorzolamide (Trusopt®) 2% solution

Answer 18

Adverse effects:
Dysgeusia (bitter taste) ~25% 
Eye discomfort/burning sensation
Blurred vision
Eyelid irritation/eye redness
Photophobia/headache

Warnings/Precautions:
•Sulfonamide – caution with sulfa allergies, but most patients can tolerate

Question 19

Adverse Effects of Alpha-adrenergic agonists:
Brimonidine (Alphagan P® ) 0.15% 0.15%, 0.2% solution
Brimonidine (Lumify®[OTC]) 0.025% solution
Apraclonidine (Iopidine®) 0.5%, 1% solution

Answer 19

Adverse effects:
Sensation of foreign body in eye
Ocular pain
Drowsiness
Dry eyes 

Contraindications:
Concomitant MAO inhibitor therapy

Warnings/Precautions:
<6 years old (risk of respiratory depression)
Caution in patients with CVD, depression, orthostatic hypotension

Question 20

Adverse Effects of Miotics (Cholinergic Agonists):
Carbachol (Carboptioc®) 1.5%, 3% solution
Pilocarpine (Isopto Carpine®, Diocarpine®) 0.25­10% solution

Answer 20

Adverse effects:
Hyperemia 
Myopia (pupil constriction)
Eye discomfort/burning sensation
Blurred vision
Eyelid irritation/eye redness
Photophobia/headache

Contraindications:
Active inflammation of the eye
Iritis, uveitis, secondary glaucoma

Question 21

Adverse Effects of Rho Kinase Inhibitors:
Netarsudil (Rhopressa®) 0.02% solution

MOA: decreases resistance in the trabecular network to increase aqueous humor outflow

Answer 21

Adverse effects:
Conjunctival hyperemia
Corneal verticillata (corneal deposits forming a golden brown or gray whorl pattern in the inferior cornea; most resolved when treatment was discontinued)
Eye pain, corneal staining, blurred vision, increased lacrimation, eyelid erythema, reduced visual acuity

Question 22

What is the typical primary treatment for Glaucoma?

Answer 22

First­line therapy: topical drugs that lower intraocular pressure (IOP)
Prostaglandin analog monotherapy is preferred for initial treatment
A topical beta blocker, carbonic anhydrase inhibitor, selective alpha2­agonist, or netarsudil could be added or substituted if IOP fails to reach the target range (8­22 mm Hg).

Alternatives: laser trabeculoplasty and surgery

Question 23

CONJUNCTIVITIS is:

Answer 23

Definition: inflammation of the conjunctiva

Types:

Non-infections:
Allergic
Mechanical/irritative/toxic
Immune-­mediated
Neoplastic

Infections:
Viral
Bacterial

Question 24

ALLERGIC CONJUNCTIVITIS:

Bilateral red eyes and itching

Answer 24

Causes: environmental allergens (e.g., pollen, dander, dust, etc.)

Treatment: remove and avoid allergens
•Artificial tears (1st line), topical antihistamines, systemic

Goal of treatment: to provide symptomatic relief

Question 25

VIRAL CONJUNCTIVITIS:
“Pink­eye”
•Unilateral or bilateral, red eyes, itching, watery discharge

Answer 25

Cause: Adenovirus most common pathogen

Treatment: cold compresses, proper hygiene, artificial tears

Usual self ­limiting and resolves w/in 2 weeks

Question 26

BACTERIAL CONJUNCTIVITIS:

Unilateral or bilateral purulent discharge

Answer 26

Cause: Common pathogens: S. pneumonia, H. influenza, S. aureus

Treatment: ophthalmic antibiotics

Mild form: usual self­ limiting in adults
Severe: may persist without treatment

Question 27

Ophthalmic vasoconstrictors are contraindicated for which individuals:
A) Ages 6 and under
B) Ages 6 and under and 65 and older
C) Pregnant and breastfeeding mothers
D) Individuals with narrow-angle glaucoma and pregnant women

Answer 27

D) Individuals with narrow-angle glaucoma should avoid ophthalmic vasoconstrictors because increased vasoconstriction could lead to an angle closure attack which could result in blindness.

Ophthalmic vasoconstrictors have not been established as safe to use during pregnancy and therefore are considered to be a Pregnancy C category.

Question 28

For which of the following diagnoses would you use ophthalmic corticosteroids as a primary treatment?
A) Glaucoma
B) Macular Degeneration
C) Conjunctivitis
D) None of the above

Answer 28

D) none of the above

Corticosteroids are helpful with decreasing inflammation that occurs with conjunctivitis, however, are not a first line therapy choice. First line therapy for bacterial conjunctivitis would be ophthalmic antibiotics, and for viral and allergic: artificial tears

Question 29

Fluoroquinolone eye preparations are effective against which organism?
1. Staphylococcus aureus

2. Streptococcus pneumoniae
3. Moraxella
4. Neisseria gonorrhoeae

Answer 29

Answer 2. Streptococcus pneumoniae

Rationales
Option 1:
Erythromycin is active against Staphylococcus aureus.
Option 2:
The fluoroquinolones are active against staphylococci, S. pneumoniae, H. influenzae, K. pneumoniae, Proteus species, Enterobacter species, and Pseudomonas aeruginosa.
Option 3:
Tobramycin is active against Moraxella species.
Option 4:
Sulfacetamide is active against Neisseria gonorrhoeae.

Question 30

Which organism is most commonly implicated in bacterial conjunctivitis caused by dacryostenosis?

1. Moraxella species
2. Haemophilus influenzae
3. Neisseria gonorrhoeae
4. Streptococcus pneumoniae

Answer 30

4. Streptococcus pneumoniae

Rationales
Option 1:
Moraxella species are not the most commonly implicated organisms in bacterial conjunctivitis caused by dacryostenosis.
Option 2:
H. influenzae is the second most common organism implicated in bacterial conjunctivitis caused by dacryostenosis.
Option 3:
Neisseria gonorrhoeae is not the most commonly implicated organism in bacterial conjunctivitis caused by dacryostenosis.
Option 4:
Bacterial conjunctivitis caused by dacryostenosis is most commonly S. pneumoniae (35%).

Question 31

Why is erythromycin ophthalmic ointment indicated in the treatment of blepharitis?

1. Ointment is preferred in the treatment of blepharitis due to the possibility of a secondary bacterial infection.
2. Ointment is preferred in the treatment of blepharitis due to the possibility that it is caused by adenovirus.
3. Ointment is preferred in the treatment of blepharitis due to the possibility of a fungal infection.
4. Ointment is preferred in the treatment of blepharitis due to the increased contact with the ocular tissue.

Answer 31

4. Ointment is preferred in the treatment of blepharitis due to the increased contact with the ocular tissue.

Rationales
Option 1:
Risk of secondary bacterial infection is not the reason for use of ointment in the treatment of blepharitis.
Option 2:
Adenovirus is not the reason for use of ointment in the treatment of blepharitis.
Option 3:
Risk of fungal infection is not the reason for use of ointment in the treatment of blepharitis.
Option 4:
Use of ointment increases contact with the ocular tissue.

Question 32

Upon examination of an 18-year-old patient with otitis media, the APN notes that the tympanic membrane is perforated. Which medication would be appropriate to prescribe?
1. Cortisporin otic suspension

2. Cortisporin otic solution
3. Ciprofloxacin HC otic suspension
4. Hydrocortisone-neomycin-colistin solution

Answer 32

1. Cortisporin otic suspension

Rationales
Option 1:
Cortisporin otic suspension may be used if the tympanic membrane is perforated.
Option 2:
Cortisporin otic solution is contraindicated if the tympanic membrane is perforated.
Option 3:
Aminoglycoside-containing products are contraindicated if the tympanic membrane is perforated.
Option 4:
Aminoglycoside-containing products are contraindicated if the tympanic membrane is perforated.

Question 33

Which information would the APN include when educating the patient on viral conjunctivitis?

1. The course of viral conjunctivitis runs 12 to 15 days.
2. The course of viral conjunctivitis runs 8 to 10 days.
3. The course of viral conjunctivitis runs 10 to 12 days.
4. The course of viral conjunctivitis runs 15 to 18 days.

Answer 33

1. The course of viral conjunctivitis runs 12 to 15 days.

Rationales
Option 1:
The course of the viral conjunctivitis runs 12 to 15 days.
Option 2:
The course of the viral conjunctivitis runs longer than 8 to 10 days.
Option 3:
The course of the viral conjunctivitis runs longer than 10 to 12 days.
Option 4:
The course of the viral conjunctivitis runs shorter than 15 to 18 days.

Question 34

Which anti-infective agent can be prescribed to infants and children of all ages?

1. Polymyxin B
2. Erythromycin
3. Moxifloxacin
4. Azithromycin

Answer 34

2. Erythromycin

Rationales
Option 1:
Polymyxin B should not be prescribed to infants younger than 2 months.
Option 2:
Erythromycin and tobramycin are safe and effective in children.
Option 3:
Moxifloxacin (Moxeza) is only approved for children 4 months of age and older.
Option 4:
The safety of azithromycin in children younger than age 1 has not been established.

Question 35

If a patient presents to the clinic with symptoms consistent with an adverse effect from an ophthalmic antiglaucoma medication, the primary care provider should take which action?

1. Prescribe another antiglaucoma medication.
2. Facilitate a referral back to the ophthalmologist.
3. Instruct the patient to stop taking the medication.
4. Instruct the patient to continue taking the medication and return to see the primary care provider in 2 weeks.

Answer 35

2. Facilitate a referral back to the ophthalmologist.

Rationales
Option 1:
Antiglaucoma medications are prescribed by ophthalmologists.
Option 2:
If the patient is experiencing adverse effects from the medication, the primary care provider can facilitate a referral back to the ophthalmologist.
Option 3:
Abruptly stopping the medication can increase adverse effects.
Option 4:
If the patient is experiencing adverse effects from the medication, the primary care provider can facilitate a referral back to the ophthalmologist.

Question 36

There can be a cross-sensitivity between individual aminoglycosides and which antibiotic class?

1. Macrolide
2. Sulfacetamide
3. Trimethoprim
4. Fluoroquinolones

Answer 36

4. Fluoroquinolones

Rationales
Option 1:
A bacteriostatic macrolide antibiotic can be active against a wide range of organisms. There is no cross-reactivity with aminoglycosides.
Option 2:
Sulfacetamide is a synthetic sulfonamide that has no cross-sensitivity with fluoroquinolones.
Option 3:
Trimethoprim inhibits bacterial dihydrofolate reductase. There is no known cross-sensitivity with fluoroquinolones.
Option 4:
There may be cross-sensitivity between the individual aminoglycosides (tobramycin and gentamicin). The same is found with the fluoroquinolones.

Question 37

An adverse drug reaction to which ophthalmic anti-infective preparation can cause temporary blurred vision?

1. Bacitracin
2. Aminoglycosides
3. Sulfacetamide
4. Fluoroquinolones

Answer 37

1. Bacitracin

Rationales
Option 1:
Bacitracin may cause blurred vision, which usually lasts only a few minutes.
Option 2:
Aminoglycosides can cause localized ocular toxicity and hypersensitivity.
Option 3:
Sulfacetamide can cause hypersensitivity.
Option 4:
Fluoroquinolones can cause a white crystalline precipitate.

Question 38

Which of these is the antibiotic treatment of choice for a patient with hyper-purulent gonococcal conjunctivitis?

1. Azithromycin PO
2. Penicillin intramuscular (IM)
3. Ceftriaxone intramuscular (IM)
4. Augmentin PO

Answer 38

3. Ceftriaxone intramuscular (IM)

Rationales
Option 1:
Azithromycin is not the antibiotic treatment of choice for hyperpurulent gonococcal conjunctivitis.
Option 2:
Treatment consists of parenteral antibiotics (ceftriaxone 1 g IM in a single dose). There can be high levels of resistance to other antibiotics.
Option 3:
Intramuscular (IM) ceftriaxone is indicated for treatment of gonococcal conjunctivitis in the newborn.
Option 4:
Amoxicillin-clavulanate (Augmentin) with amoxicillin dosed at 80 to 90 mg/kg/d is the first-line drug of choice for patients with conjunctivitis-otitis syndrome.

Question 39

The treatment for vernal conjunctivitis includes use of a mast cell stabilizer such as which medication?

1. Ketotifen
2. Levocabastine
3. Cromolyn sodium
4. Azelastine

Answer 39

3. Cromolyn sodium

Rationales
Option 1:
The ophthalmic H1 blocker ketotifen can be prescribed for allergic conjunctivitis and ocular pruritus and is an antihistamine.
Option 2:
Levocabastine is another prescription ophthalmic H1 blocker and is an antihistamine.
Option 3:
Vernal conjunctivitis refers to conjunctivitis that occurs primarily in the spring, usually because of an allergen. The mast cell stabilizer cromolyn sodium may be used to treat vernal conjunctivitis.
Option 4:
Azelastine is another prescription ophthalmic H1 blocker and is an antihistamine.

Question 40

Which agent is first-line treatment of a patient with conjunctivitis-otitis syndrome?

1. Penicillin IV
2. Augmentin PO
3. Azithromycin PO
4. Erythromycin ointment

Answer 40

2. Augmentin PO

Rationales
Option 1:
Penicillin is not first-line treatment of a patient with conjunctivitis-otitis syndrome.
Option 2:
Amoxicillin-clavulanate (Augmentin) with amoxicillin dosed at 80 to 90 mg/kg/d is the first-line drug of choice.
Option 3:
Azithromycin is not first-line treatment of a patient with conjunctivitis-otitis syndrome.
Option 4:
If systemic antibiotics are prescribed, topical ophthalmic treatment is usually not needed.

Question 41

Facial nerve palsies can be noted with which condition?

1. Acute otitis externa
2. Malignant otitis externa
3. Chronic otitis externa
4. Inflammatory otitis externa

Answer 41

2. Malignant otitis externa

Rationales
Option 1:
Acute otitis externa, “swimmer’s ear,” can cause deafness, but facial nerve palsy is not a complication.
Option 2:
Malignant otitis externa is a rare but potentially lethal infection that occurs mainly in older adults with diabetes. It can extend, causing osteomyelitis of the base of the skull and purulent meningitis, accompanied by multiple cranial nerve palsies.
Option 3:
Chronic otitis externa can have inflammatory components and chronic itching. Multiple nerve palsies are not a complication of chronic otitis externa.
Option 4:
Inflammatory otitis externa is a form of chronic otitis externa, and chronic itching can be a complication. Multiple nerve palsies are not a complication of inflammatory otitis media.

Question 42

Otitis externa (OE) is an acute painful condition of the external auditory canal. It is also referred to as which of the following?

1. Otomycosis
2. Tinnitus
3. Swimmer’s ear
4. Cholesteatoma

Answer 42

3. Swimmer’s ear

Rationales
Option 1:
Otomycosis is the infection of the external ear canal caused by a fungus
Option 2:
Tinnitus is a ringing in the ears.
Option 3:
OE is an acute, painful inflammatory condition of the external auditory canal, commonly known as swimmer’s ear.
Option 4:
Cholesteatoma is characterized by abnormal growth of skin in the middle ear. It is usually caused by chronic infection.

Question 43

A 40-year-old male who was prescribed antiglaucoma ophthalmology medication comes to see the APN for a routine physical examination. He states that he develops a bitter taste in his mouth after taking his eye drops. Which medication is the most likely cause?

1. Acetazolamide
2. Pilocarpine
3. Timolol
4. Netarsudil

Answer 43

1. Acetazolamide

Rationales
Option 1:
Many patients (about 25%) report dysgeusia, or a bitter taste in the mouth, after ocular administration of carbonic anhydrase (CA) inhibitors, including acetazolamide.
Option 2:
Pilocarpine is a miotic. With miotics, patients may have systemic anticholinergic effects if excessive absorption occurs. These symptoms include headache, hypertension, salivation, sweating, nausea, and vomiting.
Option 3:
Headaches and dizziness may occur with the use of beta blockers, including timolol. Patients may exhibit systemic beta blocker effects with the use of ophthalmic preparations. Symptoms include bradycardia, hypotension, bronchospasm, and, rarely, atrioventricular block.
Option 4:
In addition to discomfort and hyperemia, netarsudil may cause corneal staining, blurred vision, increased lacrimation, corneal verticillata, and reduced visual acuity with instillation.

Question 44

Polysporin Ophthalmic contains which antibiotics?

1. Polymyxin B and trimethoprim
2. Polymyxin B and gentamicin
3. Polymyxin B and bacitracin
4. Trimethoprim and bacitracin

Answer 44

3. Polymyxin B and bacitracin

Rationales
Option 1:
Polytrim is an ophthalmic antibacterial preparation that combines polymyxin B and trimethoprim.
Option 2:
There are no preparations that contain these two antibiotics.
Option 3:
Polysporin Ophthalmic contains polymyxin B and bacitracin.
Option 4:
There are no preparations that contain these two antibiotics.

Question 45

Which organism most commonly causes ophthalmia neonatorum?

1. Chlamydial
2. Staphylococcal
3. Streptococcal
4. Herpes simplex virus (HSV)

Answer 45

1. Chlamydial

Rationales
Option 1:
Ophthalmia neonatorum is defined as conjunctivitis occurring within the first 4 weeks of life. Infection is usually transmitted during passage through the birth canal, although ascending infection can occur. Chlamydia is the most common organism to cause ophthalmia neonatorum.
Option 2:
Staphylococcal origin can be seen in ophthalmia neonatorum, but it is a less common organism identified and is a non–sexually transmitted bacteria.
Option 3:
Streptococcal origin can be seen in ophthalmia neonatorum, but it is a less common organism identified and is a non–sexually transmitted bacteria.
Option 4:
HSV origin can be seen in ophthalmia neonatorum, but it is a less common organism identified and is a non–sexually transmitted bacteria.

Question 46

Which is a common antiviral agent?

1. Trifluridine
2. Erythromycin
3. Bacitracin
4. Sulfacetamide

Answer 46

1. Trifluridine

Rationales
Option 1:
Commonly used antiviral agents are ganciclovir, trifluridine, and vidarabine.
Option 2:
Erythromycin is not an antiviral medication.
Option 3:
Bacitracin is not an antiviral medication.
Option 4:
Sulfacetamide is not an antiviral medication.

Question 47

Bacteriostatic ophthalmic antibiotics are effective through which mechanism of action?

1. Inhibiting movement of bacteria
2. Inhibiting bacteria from multiplying
3. Inhibiting viral DNA
4. Inhibiting DNA gyrase

Answer 47

2. Inhibiting bacteria from multiplying

Rationales
Option 1:
Bacteriostatic ophthalmic antibiotics do not inhibit the movement of bacteria.
Option 2:
Ophthalmic antibiotics may be bacteriostatic or bactericidal. Bacteriostatic eye drops do not kill bacteria; they just stop bacteria from multiplying.
Option 3:
Bacteriostatic ophthalmic antibiotics do not inhibit viral DNA.
Option 4:
Bacteriostatic ophthalmic antibiotics do not inhibit DNA gyrase.

Question 48

Which macrolide antibiotic eye drop is active against both gram-positive and gram-negative organisms?

1. Azithromycin
2. Tobramycin
3. Gentamicin
4. Sulfacetamide

Answer 48

1. Azithromycin

Rationales
Option 1:
Azithromycin is a macrolide antibiotic that is active against both gram-positive and gram-negative organisms.
Option 2:
Tobramycin is a broad-spectrum aminoglycoside.
Option 3:
Gentamicin is a broad-spectrum antibiotic. It is active against both gram-positive and gram-negative organisms.
Option 4:
Sulfacetamide is a synthetic sulfonamide.

Question 49

Sulfacetamide is a synthetic sulfonamide eye drop that inhibits bacterial dihydrofolate synthetase. It is active against which susceptible organism?

1. Corynebacterium diphtheriae
2. Escherichia coli
3. Haemophilus influenzae
4. Moraxella species

Answer 49

2. Escherichia coli

Rationales
Option 1:
Corynebacterium diphtheriae is susceptible to erythromycin, but not sulfacetamide.
Option 2:
Sulfacetamide is a synthetic sulfonamide that inhibits bacterial dihydrofolate synthetase. It is active against the following susceptible organisms: streptococci, staphylococci, Escherichia coli, Klebsiella pneumoniae, Pseudomonas pyocyanea, Neisseria gonorrhoeae, and C. trachomatis.
Option 3:
Tobramycin is active against staphylococci, streptococci, Corynebacterium species, K. pneumoniae, Moraxella species, Proteus species, beta-hemolytic streptococci, and Haemophilus influenzae.
Option 4:
Tobramycin is active against staphylococci, streptococci, Corynebacterium species, K. pneumoniae, Moraxella species, Proteus species, beta-hemolytic streptococci, and Haemophilus influenzae.

Question 50

Which ophthalmic preparation is incompatible with products containing silver salts, including silver nitrate?

1. Gentamicin
2. Erythromycin
3. Sulfacetamide
4. Polymyxin B

Answer 50

3. Sulfacetamide

Rationales
Option 1:
There are no drug interactions reported for ophthalmic preparations of bacitracin.
Option 2:
There are no drug interactions reported for ophthalmic preparations of erythromycin.
Option 3:
Sulfacetamide is incompatible with silver-containing preparations and should not be used in conjunction with ophthalmic products containing silver salts, including silver nitrate.
Option 4:
There are no drug interactions reported for ophthalmic preparations of polymyxin B.

Question 51

Erythromycin is a bacteriostatic macrolide antibiotic that is active against a wide range of organisms. Which mechanism of action makes it effective?

1. The mechanism of action is unknown.
2. The mechanism of action involves inhibiting bacterial dihydrofolate synthetase.
3. The mechanism of action is achieved by inhibiting bacterial protein synthesis.
4. The mechanism of action involves binding to cell membranes with high affinity.

Answer 51

3. The mechanism of action is achieved by inhibiting bacterial protein synthesis.

Rationales
Option 1:
The mechanism of action for erythromycin is known.
Option 2:
Sulfacetamide is a synthetic sulfonamide that inhibits bacterial dihydrofolate synthetase, not erythromycin.
Option 3:
Erythromycin is a bacteriostatic macrolide antibiotic that is active against a wide range of organisms. It binds to the 50S ribosomal subunit, inhibiting bacterial protein synthesis.
Option 4:
Polymyxin B binds to cell membranes with high affinity, which is not true of erythromycin.

Question 52

Which ophthalmic preparation may cause a rare adverse reaction called Stevens–Johnson syndrome?

1. Bacitracin
2. Sulfacetamide
3. Aminoglycosides
4. Fluoroquinolones

Answer 52

2. Sulfacetamide

Rationales
Option 1:
Bacitracin may cause blurred vision, which usually lasts only a few minutes.
Option 2:
Sulfacetamide ophthalmic preparations may cause a hypersensitivity reaction in patients who have previously exhibited sensitivity to sulfonamides. Stevens–Johnson syndrome is a rare adverse reaction that has been reported with sulfacetamide ophthalmic ointment use.
Option 3:
Aminoglycosides may cause localized ocular toxicity and hypersensitivity.
Option 4:
Fluoroquinolones may cause a white crystalline precipitate to form in the superficial portion of the cornea.

Question 53

Gentamicin is a broad spectrum aminoglycoside that is effective against which type of organisms?

1. Fungal organisms
2. Parasitic organisms
3. Gram positive and negative organisms
4. Viral organisms

Answer 53

3. Gram positive and negative organisms

Rationales
Option 1:
Gentamicin does not contain antifungal properties.
Option 2:
Gentamicin does not contain antiparasitic properties.
Option 3:
Gentamicin is a broad-spectrum antibiotic that is active against a wide range of gram-positive and gram-negative organisms.
Option 4:
Gentamicin does not contain antiviral properties.

Question 54

Which is an antiviral ophthalmic agent?

1. Ganciclovir
2. Ciprofloxacin
3. Erythromycin
4. Gentamicin

Answer 54

1. Ganciclovir

Rationales
Option 1:
Antiviral ophthalmic agents are ganciclovir (Zirgan), vidarabine (Vira-A), and trifluridine (Viroptic).
Option 2:
Ciprofloxacin is a fluoroquinolone antibiotic.
Option 3:
Erythromycin is a macrolide antibiotic.
Option 4:
Gentamicin is a broad-spectrum antibiotic.

Question 55

Which medication is used for the treatment of simple viral conjunctivitis caused by adenovirus?

1. Azithromycin 1% solution
2. Polytrim ointment
3. Sulfacetamide 10% solution
4. Erythromycin ointment 0.5%

Answer 55

3. Sulfacetamide 10% solution

Rationales
Option 1:
Azithromycin 1% ophthalmic solution is indicated for treatment of uncomplicated bacterial conjunctivitis and blepharitis.
Option 2:
Uncomplicated bacterial conjunctivitis may be treated with trimethoprim/polymyxin B (Polytrim).
Option 3:
Viral conjunctivitis is usually caused by an adenovirus, herpes simplex virus (HSV), or herpes zoster. Simple viral conjunctivitis caused by adenovirus is treated with sulfacetamide 10% solution or ointment.
Option 4:
Erythromycin is a bacteriostatic macrolide antibiotic that is active against a wide range of organisms. It does not, however, have any viral infection indication.

Question 56

Which macrolide antibiotic eye drop is active against both gram-positive and gram-negative organisms?

1. Azithromycin
2. Tobramycin
3. Gentamicin
4. Sulfacetamide

Answer 56

1. Azithromycin

Rationales
Option 1:
Azithromycin is a macrolide antibiotic that is active against both gram-positive and gram-negative organisms.
Option 2:
Tobramycin is a broad-spectrum aminoglycoside.
Option 3:
Gentamicin is a broad-spectrum antibiotic. It is active against both gram-positive and gram-negative organisms.
Option 4:
Sulfacetamide is a synthetic sulfonamide.

Question 57

A patient presents with a purulent bacterial ocular infection. The APN knows that treatment is which of these?

1. Corticosteroid eye drops
2. Ocular anti-allergic agents
3. Prostaglandin analogues
4. Referral to an ophthalmologist

Answer 57

4. Referral to an ophthalmologist

Rationales
Option 1:
Corticosteroid eye medications should not be administered to patients with acute, untreated purulent bacterial, viral, or fungal ocular infection.
Option 2:
Ocular anti-allergic agents are not indicated for a purulent bacterial ocular infection.
Option 3:
Prostaglandin analogues are not indicated for a purulent bacterial ocular infection.
Option 4:
Referral to an ophthalmologist is warranted for patients who appear to need corticosteroid therapy.

Question 58

Dorzolamide is contraindicated in patients with which allergy?

1. Penicillin
2. Ragweed
3. Codeine
4. Sulfonamide

Answer 58

4. Sulfonamide

Rationales
Option 1:
Penicillin does not have a cross reactivity with dorzolamide.
Option 2:
Ragweed does not have a cross reactivity with dorzolamide.
Option 3:
Codeine does not have a cross reactivity with dorzolamide.
Option 4:
Dorzolamide contains sulfonamide and is absorbed in amounts great enough to cause hypersensitivity reactions in patients with sulfonamide sensitivity.

Question 59

Which pathogen is common in pediatric conjunctivitis?

1. Neisseria gonorrhoeae
2. Haemophilus influenzae
3. Corynebacterium diphtheriae
4. Klebsiella pneumoniae

Answer 59

2. Haemophilus influenzae

Rationales
Option 1:
N. Gonorrhoeae is a species of gram-negative diplococci bacteria. It can cause infection in the genitals, throat, and eyes.
Option 2:
H. influenzae is a common pathogen in pediatric conjunctivitis.
Option 3:
Corynebacterium diphtheriae is the bacterium that causes the disease diphtheria.
Option 4:
Klebsiella is a type of bacteria found in nature. Klebsiella pneumonia infections are acquired in the hospital setting or in long-term care facilities.

Question 60

In choosing an antibiotic that provides good coverage for the common organisms that cause bacterial conjunctivitis, the provider should consider which antibiotic?

1. Sulfacetamide
2. Polysporin
3. Fluoroquinolones
4. Ganciclovir

Answer 60

2. Polysporin

Rationales
Option 1:
A determination of the suspected organism guides the choice of an ophthalmic antibiotic. If H. influenzae is high on the list of suspected organisms, then sulfacetamide should not be the first choice for treatment because it has poor coverage for H. influenzae.
Option 2:
A combination product such as Polysporin or Polytrim provides good coverage for the common organisms that cause bacterial conjunctivitis.
Option 3:
Fluoroquinolones are more expensive, up to 10 times the cost of erythromycin and other antibiotics with good coverage.
Option 4:
Ganciclovir covers antiviral organisms and is not the first choice.

Question 61

Which of these is the leading cause of blindness in the world?

1. Cataracts
2. Herpes keratitis
3. Ophthalmia neonatorum
4. Glaucoma

Answer 61

4. Glaucoma

Rationales
Option 1:
The risk of cataracts increases with each decade of life starting around age 40. By age 75, half of white Americans have cataracts. By age 80, 70% of whites have a cataract compared with 53% of African Americans and 61% of Hispanic Americans. It is not the leading cause of blindness.
Option 2:
Herpes keratitis is a potentially serious consequence of infection with herpes simplex virus (HSV) but is not a leading cause of blindness.
Option 3:
Conjunctivitis occurring within the first 4 weeks of life is defined as ophthalmia neonatorum. Gonococcal conjunctivitis is the most serious cause of ophthalmia neonatorum owing to concerns about the bacteria causing blindness, but it is not the leading cause of blindness in the world.
Option 4:
In the United States, glaucoma affects 3 million people and is the leading cause of blindness in the world.

Question 62

Which agent can be prescribed only by specialists due to concerns regarding systemic absorption and complications of chronic conditions?

1. Ophthalmic antiglaucoma agents
2. Ophthalmic anti-infective agents
3. Ophthalmic antiviral agents
4. Ophthalmic anti-inflammatory agents

Answer 62

1. Ophthalmic antiglaucoma agents

Rationales
Option 1:
Ophthalmic antiglaucoma medications are absorbed, and systemic levels are reached in sufficient amounts to cause complications of chronic conditions.
Option 2:
Ophthalmic anti-infective agents generally penetrate the ocular fluid and tissues. Systemic absorption is minimal, although there may be enough absorption for sensitization to occur.
Option 3:
Ophthalmic antiviral agents can cause burning and irritation upon instillation but are not systemically absorbed.
Option 4:
Ophthalmic anti-inflammatory agents have limited systemic absorption.

Question 63

Ocular NSAIDs have an analgesic, antipyretic, and anti-inflammatory activity. This occurs by which mechanism?

1. Inhibition of histamine-stimulated vascular permeability
2. Inhibition of the production of aqueous humor
3. Inhibition of prostaglandin biosynthesis
4. Inhibition of viral DNA replication

Answer 63

3. Inhibition of prostaglandin biosynthesis

Rationales
Option 1:
Ocular histamines block the H1 histamine receptors and inhibit histamine-stimulated vascular permeability in the conjunctiva.
Option 2:
Beta-adrenergic antagonists interfere with the production of aqueous humor induced by cyclic adenosine monophosphate (cAMP) through the ciliary processes in the eye.
Option 3:
The ocular NSAIDs have analgesic, antipyretic, and anti-inflammatory activity. The ophthalmic NSAIDs reduce prostaglandin E2 in aqueous humor by inhibition of prostaglandin biosynthesis.
Option 4:
Vidarabine inhibits viral DNA replication, although the exact mechanism of action is not known. Vidarabine has antiviral activity against herpes simplex virus (HSV) types 1 and 2, varicella-zoster virus, cytomegalovirus, vaccinia, and hepatitis B.

Question 64

A 2½-year-old child presents to the clinic with allergic conjunctivitis, and the APN wants to prescribe an ophthalmic antiallergic agent. Which agent would the APN prescribe?

1. Emedastine
2. Cromolyn
3. Nepafenac
4. Lodoxamide

Answer 64

4. Lodoxamide

Rationales
Option 1:
The safety of emedastine in children younger than age 3 years has not been established.
Option 2:
Cromolyn sodium ophthalmic can be prescribed to children older than age 4 years.
Option 3:
Nepafenac is not recommended for children younger than age 10 years.
Option 4:
Lodoxamide is safe in children as young as age 2 years.