CMG Flashcards
What are Salutatory exemptions?
Legislations put down by medicine act which exempts Optoms of use & supply, only for Dr & Dentists, but Optometrist can use and supply as long as it within their scope of practice.
In emergency what can Optoms sell & supply?
Cyclo
CLPH- 0.5% & 1%
Fucidic acid
Tropicamide
Additional supply Optoms can sell/supply what medications?
Topica antihistamines
Mast cell stabilisers
NSAIS- Diclofenac sodium
Atroine
Homatrophine
Pilocarpine
Acetylcysteine- (ILUBE) Dry eye drop
What is patient specific direction?
EG: Ophthalmologist & IP working together for intravitreal injections, this is PSD, Ophthalmologist trusts IP to administer these.
Who are at risk groups for prescribing ?
Neonates, elderly, debilitated, pregnancy/ lactation, renal/hepatic (liver) impairment
Why do neonates have a high risk of toxicity to medication?
Immaturity if systems when metabolising and excreting drugs - EG CHLP accumulates in high concentration in tissues in neonates due to reduces hepatic mechanism- can cause grey baby syndrome. But there is a reduced risk in topical application compared to oral.
Why is there an increases risk of perceiving in elderly?
Increased risk of drug reactions due to polypharmacy (Use of multiple drugs) . Due to decreased filtration in elderly there is a reduction in renal drug clearance. Further diseases such as DM & hear failure can worsen renal function, which reduces renal clearance.
Difference between additional supply, supplementary & IP Optoms?
Additional supply do not have the whole range, supplementary can manage and prescribe under the clinical management plan set up of IP, Optom, Pharmacist known as PSD!
What are the 5 drug targets of bacterial that antibacterial drugs have?
1) Cell wall synthesis
2) Bacterial cell membrane
3) Bacterial protein synthesis
4) Bacterial DNA synthesis
5) Bacterial metabolism
What is the target of bacteria for drugs CLPH & Fucidic acid
Bacterial protein synthesis
Discuss CLPH medication- including dosage
Anti-infection, antibacterial. Broad spectrum antibiotic not affective against pseudomonas, usually bacterial conj is due to strep aureus and epidermis can also be due to hempspulius.
Good safety profile but cannot be used in pregnancy or lactation. CL should not be worn during tx.
For eyedrops overage of 2 years old
For ointment 1 month and over.
Some manufacturers’ product information state that chloramphenicol eye drops must not be given to a child less than 2 years old (as they contain boron-based excipients, which may impair future fertility). This does not apply to POM 1% chloramphenicol eye ointment, which does not contain boron-based excipients.
Side effects: Ocular:
transient irritation
transient stinging
transient blurring.
Systemic:
Aplastic anaemia (body stops producing enough new blood cells)
TREATMENT:
Maximum duration of treatment 5 days FOR BACTERIAL CONJUNCTVITIS.
Eye drops 0.5% : one drop into the infected eye every 2 hours for 48 hours. After this period, treatment should be every 4 hours during waking hours. The course of treatment should last for 5 days (even if symptoms improve).
Eye ointment 1%: put a small amount into the affected eye four times a day for 2 days, and then twice a day for 5 days or for 3 days.
Fucidic acid- including dosage
POM- 1% ointment, anti infective, antibacterial. > 1 month old, Use x2 daily for 7 days. Can be used for Bacterial conjunctivitis, off-licence for blepharitis & corneal abrasion, expensive compared to CLPH.
Treatment should be continued for at least 48 hours after the eye returns to normal.
Can use during breastfeeding & pregnancy.
Narrow spectrum gram +
Fusidic acid is particularly active against staphylococcal organisms. But is used as 2nd line tx due to resistance of staph.
NO CL during the tx. Contains benzalkonium chloride as a preservative, which may accumulate in soft lenses and cause irritation.
Ocular side effects include:
transient blurring
transient stinging
transient burning.
Store below 25oC
What is propamaidine
P medicine, licences for ACUTE BACTERIAL CONJUNCTIVITIS ONLY- Antiinfective, antibacterial,- Propamidine isetionate is an aromatic diamidine disinfectant - works against Gram + & less resistance against gram .
X pregnancy, X lactation, X CL.
Ocular side effects include:
transient stinging
transient blurring.
> 2 years old, 1-2 drops x4 a day.
Describe what happens in the Ocular allergy response:
Degranulations of mast cells releasers several mediators including histamines, mediators are the cause of ocular allergies.
There are 2 forms of mediators from mast cells
1) Performed mediatiors- Histamines & Heparin - IMMEDIATE RESPOMSE
2) Newly formed mediators-Prostogladin & Leukotrienes (Short delayed response)
Where are mast cells located
conjunctiva, Uvea, eyelid
What happens when histamines are released?
Primary action is vasodilation and increased vascular permeability. Histamine receptors located on blood vessels and sensory nerves, binding of histamine to these receptors causes itch associated w ocular allergies.
What are the 3 antiallergic drugs ?
1) Mast cell stabilisers
2) Antihistamines
3) NSAIDS
Can give corticosteroids in severe cases.
Name different antihistamines you can give for ocular allergies.
Olapatadine- Both MCS & AH
Ketotifen - Both MCS & AH
Epinastine -Both MCS & AH
Azelastine- Both MCS & AH
Antazoline
Name different MSC you can give for ocular allergies.
Sodium Cromogliycate
Lodoxamide
Olapatadine
Name different NSAIDS you can give for ocular allergies.
Diclofenac sodium.
Discuss Antazoline
Topical antihistamine, P medicine,- Example of this is Otrivine 0.5% and also contains Xylometazoline 0.05% this is a vasoconstrictor.
This is an anti-inflammatory, antihistamine drug, Topical.
>12 years old, 1-2 drops x3 a da for maximum of 7 days.
Cautions, X pregnancy, X lactation
Licenced for seasonal & perennial allergic conjunctivitis.
Caution:
Patients on Monoamine oxidase inhibitors (MAOIs) which is an antidepressant, within last 14 days.
Due to containing Xylometazolien(vasoconstrictor) to be avoided in angle closure risk.
Elderly- w cardiovascular diseases etc, CL to worn during tx due to benzaloknium chloride as a preservative.
Normal ocular side effects. \
General side effects: Tachycardia, nausea, headaches, dizziness, drowsiness.
Store below 25oC
AZELASTINE- Discuss
POM-AH & MSC, 0.05% Antiinflammtory, AH,
Licensing for SAC & PAC differes.
SAC, > 4 YEARS
PAC> 12 YEARS.
x1 drop twice a day, can be increased to 4, max duration 6 weeks.
Caution: Benzalkonium Chloride
X PREGNANCY, X LACTATION, X CLS
Ocular side effects are mild, and include:
transient irritation
transient stinging
transient burning
transient blurring.
General side effects include:
bitter taste
very rare allergic reaction (e.g. rash and pruritus
What is Epinastine
AH&MSC, POM, Topic use, Antiinflammtory, AH.
0.05%
SAC
Cautions is CL due to Benzalkonium Chloride, To be used in caution w pregnancy or lactation.
General ocular side effects
General side effects include:
dry mouth
taste disturbance
nasal irritation
headache
itching.
> 12 years, x1 drop x2 a day for up to 8 weeks.
What is Ketotifen
AH & MSC, POM- 0.025% dosage, SAC. Can be used off label for atopic, AAC,
Use in cation with pregnancy & breastfeeding is ok.
Normal ocular side effects.
General side effects include:
headaches
rhinitis
rashes
somnolence.
> 3 years and over, x1 drop x2 a day.
Olapatadine
Due acting agent, AH & MSC.
0.1% eye drop preparation.
> 3 years old, x1 drop 2 a day, max tx duration 4 months.
X PREGANNCY, X LACTATION, X CL.
SAC, but can be used off-licence, atopic keratoconjucntivitis, AAC.
Quite a few general & ocular side effects.
Ocular side effect:
Mydrasis, visual disturbance, eye lid margin crusting.
General side effects include:
headache
taste disturbance
nasal dryness
asthenia (weakness)
dizziness
rhinitis
fatigue
hypersensitivity.
Discuss systemic AH
Loratadine & Cetrazine- P & GSL. Both are 10mg, x1 a day both are non sedative AH. For age of 12 years.
Differs depending on the px age which will be less.
Discuss Lodoxamide
MCS inhibit influx of calcium preventing degranulation, can take 7-14 days for symptomatic relief.
POM, eye drop, 0.1%, MSC, Antiinflammatory, SAC & PAC. but can be used off label, vernal etc. 0.1%, age> 4 years, 1-2 drops x4 daily.
X PREGNANCY, X CL, caution BF.
Normal ocular side effets &general side effects
Discuss sodium Cromoglicate
MCS inhibit influx of calcium preventing degranulation, can take 7-14 days for symptomatic relief.
POM OR P or gsl. 2%, but under age of 6 needs to be checked if more than 14 days use.
POM: For the prophylaxis and symptomatic treatment of acute allergic conjunctivitis, chronic allergic conjunctivitis and vernal keratoconjunctivitis
P: SAC & PAC.
Can use in P & BF.
Adults and children (1 month and over): one or two drops to be administered into each eye four times daily.
Diclofenac Sodium
POM- Antiinflammatory, non steroidal anti-inflammatory. Anti-inflammatory potency without the side effects of corticosteroids. NSAIDS are formed of family compounds called eicosanoids which act as a potent anti-inflammatory mediators. Principle eicosanoids as found in the short delayed respond of ocular allergy.
Licences for SAC & PAC & corneal abrasion.
0.1% x1 drop x4 a day as long as required
For ocular pain- x1 drop x4 a day for 2 days.
NSAIDs can result in Keratitis. due to eptelial breakdown, corneal thinning, ulceration etc…
Can cause MO, IOP,vasodilation, misses.
Discuss AAC.
This is a self limiting reaction to an allergen which comes into contact with conjunctiva provoking an immediate (Type 1) IGE mediated response, common in Children, Allergens are grass pollen, animal dander
Predisposing factors: Hx of allergic diseases.
Reassure, disappears in few hours, usually unilateral if direct contact.
Antihistamines as prophylactic
Sodium cromoglicate 2% (as POM), or gutt lodoxamide 0.1%, or dual-acting antihistamine/mast cell stabiliser, e.g. gutt. olopatadine 0.1% (off-label use), or gutt ketotifen 0.025% (off-label use)
SAC & PAC
Aetiology:
Type I hypersensitivity (IgE-mediated) reaction to specific airborne allergens.
Conjunctival mast cell degranulation liberates histamine and other inflammatory mediators into the tissues and tear film, causing dilatation of conjunctival vessels (→red eye), increased permeability of blood vessels (→oedema), itch
Seasonal allergic conjunctivitis (hay fever conjunctivitis)
caused by seasonal allergens, especially grass pollen
onset of symptoms associated with seasonal production of allergens, e.g. tree pollen: spring; grasses: early summer; weeds and fungal spores: late summer
condition not sight-threatening, but reduces quality of life and is associated with a significant economic burden
Perennial allergic conjunctivitis (PAC)
caused by non-seasonal allergens such as house dust mite or animal dander
symptoms throughout the year; may be seasonal exacerbations
less common and usually less severe than SAC
Often associated with allergic rhinitis (between 30–71% of patients with allergic rhinitis also have allergic conjunctivitis or conjunctival symptoms).
Predisposing factors:
Atopic disposition
Personal history of allergic disease (hay fever, asthma, eczema, food or drug allergy)
Family history of allergic disease
Exposure to allergens
Managent:
Identify allergen(s). Requires thorough history and possible use of symptom diary matching to pollen calendars
Advise avoidance of allergen(s)
Cool compresses for symptomatic relief
Advise against eye rubbing (causes mechanical mast cell degranulation)
Worse scenarios can use a steroid: Flurometolone, Lotepresdnol POMS
No management BUT can refer to immunologist if recurrent & no helps routine- B1.
LODOXAMIDE, OLOPATADINE, KERAFINE, SODIUMCROMOGLIGATE.
Discuss Atopic Keratoconjunctivitis
Aetiology: Severe and potentially sight-threatening allergic eye disease characterised by chronic inflammation of the ocular surface
Complex immunopathology which is type 1 & type 4, including T-cell mediated (type 4 hypersensitivity)
Symptoms of AKC typically begin in the late teens or early twenties and can persist until the fourth or fifth decade of life. The peak incidence of AKC occurs between the ages of 30 and 50 years
VKC as a child more prone to AKC as adults.
Predisposing factors:
There is a strong association with staphylococcal lid margin disease
Atopic dermatitis.
SIGNS & SYMPTOMS:
Bilateral, all year round w exacerbations
SIGNS:
Crusting of eye lids, chronic staphylococcal blepharitis,
Limbal inflammation
conjunctival hyperima
Tarsal giant papillae.
These px increased risk of developing HSK, Atopic Cataract, RD, Keraotocnous,
Corneal involvement- may start as Punctate epitheliopathy, can progress to macro erosion (widespread loss of the corneal epithelium ) and a plaque, sub epithelial scarring, neovas/pannus, thinning and rarely perforation.
Corneal mucous plaques are a collection of mucus, epithelial cells, lipid, and proteinaceous debris, which are firmly adhered to the underlying corneal epithelium
LODOXAMIDE, OLOPATADINE, KERAFINE, SODIUMCROMOGLIGATE.
Management:
A3, URGENT referral within 1 week to Ophthalmologist for corneal involvement, including plaque or macro erosion.
B1- Milder cases, Routine referral.
Multidisciplinary management: with dermatology & immunology.
What is vernal keratoconjunctivitis?
Aetiology: Type 1 & Type 4 complex hypersensitivity reaction, very uncommon allergic disorder of children-
Vernal keratoconjunctivis characterised by chronic inflammation of the ocular surface
More common in some other parts of the world, e.g. Mediterranean region, parts of Africa, Indian sub-continent
Complex immune reaction
Onset usually before 10 years of age; M:F = 2-4:1 and typically resolves during puberty
Symptoms typically bilateral & symmetrical in both eyes
Palpebral
hyperaemia and chemosis of conjunctiva when active
macro or giant tarsal papillae (1mm or greater in diameter; ‘cobblestone’ appearance)
Limbal
hyperaemic, oedematous, thickened limbus
Trantas’s Dots (discrete white superficial accumulations of eosinophils and degenerating epithelial cells)
limbal phenotype may be unilateral
Corneal (usually in upper third)
punctate epithelial keratopathy
macro-erosion (coalescent epithelial loss)
plaque (deposited on Bowman’s layer, preventing re-epithelialisation); ‘shield ulcer’ in US terminology
subepithelial scarring (often ring-shaped)
Management Generally needs referral for multidisiplinary management.
No referral if no sight threading concerns, w antihistamines, Sodum Cromo or lodoxamide, or Olopatadine (off label)
Giant papillary conjunctivitis
Mixed hypersensitivity reaction, type 1 & type 4.
CL released or due to ocular prosthetics, exposure sutures, scleral bucklers, filtration blebs, floppy eye lid syndrome.
Mixed hypersensitivity reaction, type 1 & type 4.
Type 1 - immediate hypersensitivity reaction mediated by iGE-
Possible allergens include
1)protein on lens surface
2) bacterial cell wall constitutes
3) other lens contaminants
reaction cause of deregulation of mast cells
Type v- delated hypersensitivity medicated by T cells
- amplifies the inflammatory response.
Pharmacological management:
Type 1 sensitivity reation- MCS, AH. Lodoxamide & Sodium Cromoglicate
Off label, Olapatadine & Ketoifen for 6 weeks for GPC only.
In cases where MSC & AH do not work can use non penetrating topical steroid such as Flurometheolone & Loteprednol - this can manage the type 4 sensitivity reaction too for 6 weeks.
Papillae VS Follicles
Follicles:
hyperplasia of lymphoid tissue
generally seen in viral or chlamydial conditions
smooth, pale, pink-to-yellow, elevated lesions
surrounded by displaced vessels, dome shaped, small,
GREY, WHITE DOME SHAPED W SURROUNDING BV, base of bump & periphery is red.
Papillae:
thickened irregular epithelium
usually more discrete and more red than follicles
side walls of papillae appear perpendicular to tarsal plate
contain vascular core visible at apex as vascular tuft
Full of inflammatory cells.
Block, flat topped shapes, vascular centre,
What is Loteprednol
POM, eye drop, 0.5%, Anti-inflammatory, corticosteroid, Use following ocular surgery but off-licence, in keratoconjunctvitis sicca, ptregiyum, pingeculi, gpc.
Cautions:
Loteprednol, as with other corticosteroids, can cause ocular hypertension and should be used with caution in patients with glaucoma.
Risk of CSR
Prolonged use of corticosteroids may suppress host–immune responses and increase the possibility of secondary ocular infection. In diseases causing thinning of the cornea or sclera, corticosteroids have been associated with perforations.
XCL
Use in caution w Pregnancy & BF.
Licenced for adults only.
Can cause increase IOP, need to take pressure readings @ beginning of tx, 2 weeks end of tx.
Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
Chemical irritation of ocular and/or adnexal tissues by a topically applied drug contact lens care product or cosmetic, or by environmental or occupational substances
or
Delayed hypersensitivity (cell-mediated) response to a topically applied drug, preservative or other excipient, or cosmetic
Preservatives in contact lens care products e.g. polyquaternium compounds (e.g. PQ-1) and biguanides (e.g. PHMB)
- can cause reaction
Can give steroids for relief, prednisolone preservative free
Discuss Chlamydial conjunctivitis.
Chronic follicular conjunctivitis caused by the sexually transmitted microorganism Chlamydia trachomatis (serotypes D-K), an obligate intracellular parasite (i.e. it cannot replicate outside a host cell). Spread by direct contact or fomites.
Predisposing factos: Adult hood, genital infection w C Trachoma’s
Symptoms: More than 2 weeks, gritty, sticky, dropping upper lid
Lid and other features
oedema +/- ptosis (‘mechanical’)
non-tender pre-auricular lymph node swelling (may or may not be present)
Conjunctival features
hyperaemia and chemosis
mucopurulent conjunctivitis
large follicles in upper and lower fornices (double eversion of lid needed to view upper fornix)
limbal and/or bulbar follicles may also be present
Corneal features
epithelial keratitis, usually superior
subepithelial infiltrates, similar to those seen in adenovirus KC
marginal infiltrates
superior pannus
Management: X CL wear, ocular lubricants
Referral to GP for Genito urinary clinic
