Cyclopegics Flashcards
what is the primary purpose for using cycloplegics
temporary paralysis of accommodation
why can a hyperopic patients vision fluctuate
due to accommodation
list 3 optometric reasons why cycloplegics are used
- assessment of refractive error (latent hyperopia), as child can use accommodation to focus during sight test
- penalisation
- adaptation to spectacles (rare)
list 3 other ophthalmological uses of cycloplegics in addition to optometric reasons
- anterior uveitis (to prevent posterior synaechiae)
- corneal abrasion
- amblyopia - may blur the good eye if could is non-compliant to patching
list the 2 optometric indications for using cycloplegics from H and S, from symptoms
- asthenopia
- reading difficulties
list the optometric indications for using cycloplegics from H and S, from history
manifest deviations
list the 2 optometric indications for using cycloplegics from H and S, from family history
- refractive error at an early age
- manifest deviations
list the 2 optometric indications for using cycloplegics from clinical tests, from finding a binocular vision anomaly
- manifest eso deviation
- sometimes if latent deviation
list the 2 optometric indications for using cycloplegics from clinical tests, following a fluctuating ret
- if theres a large different between subjective and objective
- poor fixation
why will you find your ret results fluctuating on a child
because the child is accommodating and looking at something closer i.e. the ret, so the rx becomes more myopic than it is supposed to be
apart from binocular vision analogies and fluctuating ret, when else will you need to use cycloplegics on a px, from findings in your clinical tests
- accommodative anomalies
- if visual acuity is reduced
list the 6 ideal properties of a cycloplegic
- rapid onset
- adequate depth of cycloplegia (not much residual accommodation)
- adequate duration
- no stinging
- no mydriasis (but it is a side effect)
- no toxic effects, local or systemic
name an unnatural condition which may occur after cycloplegic installation
pupils can change shape
what occurs initially after instillation of cycloplegics, prior to cycloplegia and why
mydriasis
because the iris is located anteriorly and close to the ciliary muscle
list the 3 effects of cycloplegics
- initially mydriasis
- cycloplegia
- reduced tear secretion
what occurs within the eye in order to cause cycloplegia
relaxation of the ciliary muscle, increasing tension on suspensory ligaments
list the 3 things that muscarinic agonists such as cycloplegics affect
- lacrimal gland
- iris sphincter muscle
- ciliary body
list the 5 pieces of advice you will give to a parent before instilling cycloplegics into their child’s eye
- explain the need to use
- onset
- duration
- expected side effects
- caution
what advice will you give to a child before instilling cycloplegics into their eye
- explain that they might feel the drop on the eye
- use one drop of proxymetacaine first?
why may you want to use proxymetacaine before instilling a cycloplegic
- child will not feel the stinging sensation
- it helps the cyclo go through as the cornea is more permeable
what must you do if consent for cycloplegics is denied for the child by the parent/guardian
- explain the advantages and disadvantages
- note refusal on the record
- if concern for the child is great then refer to the GP
what must you do is consent or cycloplegics is denied by the child themselves
- Gillick competent (if the child is sure about their decision even though they’re below the age of 16)
- record all discussions on notes
- if concern for the child is great, then refer to the GP
what 2 things may be a helpful way of instilling cycloplegic drops
the patient lying down or sometimes drop onto the eyelashes
which 2 ways can you check for cycloplegia
- measure accommodation
- check ret reflex
what sign does not indicate that cycloplegia has been achieved and why
mydriasis
as the rate that the pupil dilates and the rate of cycloplegia is different
why may you ask the px to fixate upon the ret light during cycloplegic retinoscopy
to ensure that retinoscopy is conducted upon axis
what is there no need to do when carrying out cycloplegic retinoscopy (which you will usually do normally)
no need to fog the other eye
when will you occlude one eye when carrying out cycloplegic retinoscopy
if the child has strabismus, in order to align the other eye
what must you observe whilst doing cycloplegic retinoscopy and what must you ignore
observe central movement
ignore movement in the periphery
which types of aberration are more common during cycloplegic retinoscopy and what risks do they cause
positive aberrations more common
this makes the peripheral area more myopic and causes a risk of over prescribing minus
which types of aberration is more rare during cycloplegic retinoscopy and what risks do they cause
negative aberrations more rare
this makes the peripheral area more hyperopic and causes a risk of over prescribing positive
list the 4 types of cycloplegics and their available doses
- atropine 1%
- homatropine 1%
- cyclopentolate 0.5% and 1%
- tropicamide 1%
which 2 cycloplegic drugs are additional supply or independent prescriber status
atropine and homatropine
which cycloplegic is the weakest drug and which group of patients are they only effective in
tropicamide 1% only effective in adults
which cycloplegic is the most commonly used
cyclopentolate
what type of compound is atropine sulphate and where is it extracted from
a naturally occurring compound extracted from “belladonna” deadly nightshade
what type of agent is atropine sulphate
toxic
what was atropine sulphate the first of
first muscarine antagonist used in medicine
which category of medicine is atropine sulphate
POM
for use and supply by additional supply optometrists
used and prescribed by independent prescribing optometrists
what doses is atropine sulphate eye drops available in
- 0.5%
- 1%
what dose is atropine sulphate eye ointment available in
1% atropine sulphate (non-proprietary)
how much of atropine sulphate can be enough to kill a child
a 3ml tube of ointment
what dose is atropine sulphate minims available in
1% atropine sulphate Bausch and Lomb
which 3 forms is atropine sulphate available in
- eye drops
- eye ointment
- minims
what degrees must you store atropine sulphate below
25 degrees celsius and protect from light
what dose of atropine eye drops and for how many days prior to refraction must an adult or child > 3 months take
1 drop of 1% twice per day for 1-3 days before refraction
what dose of atropine ointment and for how many days prior to refraction must an adult or child > 3 months take
2 times a day for 1-3 days before refraction
give this to the parent with a leaflet
what must you ask parents who have received atropine sulphate ointment to do on day of refraction examination
to return the unused ointment to practice
when does mydriasis commence after instilling 1 drop or 1% of atropine
in 10-15 mins
when is maximal mydriasis achieved after instilling 1 drop or 1% of atropine
30-40 mins
when does mydriasis recover after instilling 1 drop or 1% of atropine
in 3-7 days
when does mydriasis recover after instilling 3x of atropine twice daily
after 10-14 days
when does cycloplegia commence after instilling 1 drop or 1% of atropine
in 30 mins
when is maximal cycloplegia achieved after instilling 1 drop or 1% of atropine
in 1-3 hours, not complete
when does cycloplegia recover after instilling 1 drop or 1% of atropine
in 3-7 days
when does cycloplegia recover after instilling 3x of atropine twice daily
after 7-10 days
when does adequate near vision recover after instilling 3x of atropine twice daily
after 4-5 days
what tones does the ciliary muscle have
a dependent and an independent tone
what needs to be made for the dependent tone after atropine instillation and how
an allowance - where the spherical power only needs to be adjusted in the less positive direction
what amount of allowance needs to be made for dependent tone following atropine for low myopes and hyperopes (
-1.00DS
what amount of allowance needs to be made for dependent tone following atropine for moderate and high myopes
0.00DS
which drugs is allowance for dependent tone not applicable
cyclopentolate and tropicamide
why has atropine dependent tonus allowance been abolished
because theres a risk of over plussing the patient
list 3 possible contraindications to atropine
- a known allergy to atropine or component of the preparation
- narrow angles?
in children?
list the 7 types of people who need to be cautioned when using atropine
- children
why must you take caution with a child
it can cause amblyopia from stimulus deprivation
why must you take caution with atropine on someone who has a intermittent manifest deviation
as the accommodation is paralysed for so long, deviation may become permanent
list 4 immediate ocular side effects that can occur when taking atropine
- transient stinging
- blurring
- photophobia
- raised IOP?
list 4 ocular side effects that can occur when using atropine repeatedly
- hyperaemia
- oedema
- itching, irritation
- follicular conjunctivitis
what are the 3 general body side effects of atropine
- toxic effects
- tachycardia
- death from respiratory depression
list the 4 different toxic effects atropine has on the body
- dry as a bone: dry mouth and skin due to decreased secretion of salivary and sweat glands
- red as a beetroot: flushing, increased body temperature, as cannot cool body by sweating
- blind as a bat: cycloplegia
- mad as a hatter: CNS effects - ataxia, hallucinations, confusion, difficulty in speaking
which type of patients is most likely to die from respiratory depression as a side effect of taking atropine
children, who take a 3 gram tube of atropine
can be fatal to small children who ingest it
what is an additional use of atropine, and how is it used
used to treat amblyopia
- instilled into better eye
- prevents accommodation
- used when child will not tolerate patching or used as a first choice
- excellent results
what is the full name for cyclopentolate
cyclopentolate hydrochloride
what type of compound is cyclopentolate
synthetic drug
what dose of cyclopentolate is more useful as a mydriatic
0.5%
what type of medicine is cyclopentolate
POM for use and supply by all optometrists
what doses is cyclopentolate multi use eye drops available in and what are they called
- 0.5%
- 1.0%
called mydrilate (intrapharm)
at what temperature must cyclopentolate multi use eye drops be stored
between 2-8 degrees celsius
what doses is cyclopentolate minims available in
- 0.5%
- 1%
at what temperature must cyclopentolate minims be stored
below 25 degrees celsius and protect from light
what forms is cyclopentolate available in
- eye drops
- minims
what dose of cyclopentolate is used on children up to 12 years old
1%
what dose of cyclopentolate is used if iris pigmentation is light
0.5%
after how long does cycloplegia commence from cyclopentolate
after a few minutes
after how long is maximal cycloplegia achieved with cyclopentolate
30-60 minutes
after how long is maximal mydriasis achieved with cyclopentolate
30-60 minutes
after how long is recovery from cycloplegia with cyclopentolate
24-48 hours
how much of residual accommodation is there with cyclopentolate
1.50D or less
what amount of rx will you give after using cyclopentolate
always give full rx found
at what 2 exceptions will you not give the full rx following a cycloplegic refraction using cyclopentolate
- hyperopia and exo deviation
- myopia and eso deviation
what are the 6 types of people who have to use cyclopentolate with caution
- young children
- debilitated patients
- elderly
- avoid over dosage in darkly pigmented eyes
- pregnancy and lactation: unknown use only if risk to mother outweighs risk to foetus
- hallucinations and CNS effects reported with concentrations (a marked risk only with over dose)
list the 5 immediate ocular side effects from cyclopentolate
- transient stinging
- transient blurring
- photophobia (due to mydriasis)
- raised IOP - only in older px
- conjunctival hyperaemia and oedema
list 4 ocular side effects of cyclopentolate after prolonged administration
- irritation
- hyperaemia
- oedema
- conjunctivitis
list the 7 general body side effects from cyclopentolate
- dose related in children
- CNS effects
- dry mouth
- flushing
- tachycardia
- urinary symptoms
- GI symptoms
similar to atropine but at a much lower scale
what is an additional use of cyclopentolate, and how is it used
adaptation to spectacles as patient won’t be accommodating through new spectacles
- children almost always adapt well to hyperopic prescription, so is used on children who have myopic prescriptions
- use 1% cyclopentolate daily for 2/52 weeks
- accommodation is abolished
- clear vision is only obtained via spectacle wear
- the child then usually accepts the spectacle wear
what is another 3 additional uses to cyclopentolate other than adaptation to spectacles
- mydriasis
- for anterior and posterior uveitis and posterior synechiae breakdown
- for alleviation of ciliary spasm
how is cyclopentolate used to treat anterior and posterior uveitis and posterior synechiae breakdown
1-2 drops of 1% cyclopentolate is instilled every 6-8 hours (only used my ophthalmologist in hospital)
how is cyclopentolate used for alleviation of ciliary spasm
1 drop is 1% cyclopentolate used 2-3 times a day
what is the full name for homatropine
homatropine hydrobromide
what category of medicine is homatropine
POM
additional supply or independent prescriber
what for is homatropine available in
1% multi dose containers (non-proprietary)
at what temperature must homatropine be stored at
below 25 degrees celsius and protect from light
after how long is mydriasis achieved with homatropine
30-40 minutes
after how long is recovery of mydriasis achieved with homatropine
24-48 hours
what is the full name for tropicamide
tropicamide hydrochloride
what 2 things is the degree of cycloplegia dependent upon with tropicamde
- age
- iris pigmentation
when is mydriasis used for cycloplegia in relation to age
it is only indicated for cycloplegic refraction in older patients
after using 2 drops of 1% tropicamide, when does mydriasis occur after
15 minutes (quicker than cyclopentolate)
after using 2 drops of 1% tropicamide, when does mydriasis recover after
8-9 hours
after using 2 drops of 1% tropicamide, when does maximal cycloplegia occur after
30 minutes
after using 2 drops of 1% tropicamide, when does cycloplegia recover after
6 hours
