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eye disease and therapeutics > Cycloplegics > Flashcards

Cycloplegics Flashcards

1
Q

What happens as get older

A

Accommodation reduces

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2
Q

What does duanes classical curve show

A

Amplitude or width of accommodation as changing with age = declines as older

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3
Q

Why use cylcoplegics

A

Optometric uses
*Assessment of refractive error - latent hyperopia = accommodative muscles are used to increase the eyes focusing power
*Penalisation - instead of occlusion
*Adaptation to spectacles (rare) – vision clear only with glasses

Additional ophthalmological uses
*Anterior uveitis – dilating pupil and alleviating ciliary spasm
*Corneal abrasion - alleviate ciliary spasm

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4
Q

What optometric indications would make you want to use cyloplegics

A

From H and S
- Symptoms
- Asthenopia = fatigue, blurred vision, pain in eyes
- Reading difficulties
- History
- Manifest deviations
- Family history
- Refractive error at an early age
-Manifest deviations

From clinical tests:
- Binocular vision anomaly
- Manifest eso deviation Sometimes if latent deviation
- Fluctuating ret
- Large difference between subjective and objective
- Poor fixation
- Accommodative anomalies
- Visual acuity reduced

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5
Q

Properties of a cycloplegic

A
  • Rapid onset
  • Adequate depth of cycloplegia
  • Adequate duration
  • No stinging
    -No mydriasis
  • No toxic effects – Local AND systemic
  • Large pupil
  • Drops sting / duration of onset of cycloplegia
  • Unnatural conditions
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6
Q

Effects of cycloplegia - how is cycloplegia caused

A
  • Initially mydriasis
    - Iris located anteriorly to ciliary muscle
    - Unnecessary side effect
  • Cycloplegia
    • Paralysis of the ciliary muscle, resulting in loss of accommodation
      - Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on near objects
  • Reduced tear secretion = dry eye
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7
Q

Which parts of eye does antimuscarinic agents affect

A
  • Lacrimal gland
  • Iris sphincter muscle
  • Ciliary body
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8
Q

Advice before instillation

A

Advice for parent/guardian
* Explain need to use
* Onset
* Duration
* Expected side effects = temporary blurred vision until effects wear off
* Caution

Advice for child
* Explain might feel drop on eye
* 1dropof proxymetacaine first?
– RCOguidelines

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9
Q

What happens if consent is denied

A

Parent/Guardian:
* Explain advantages and disadvantages
* Note refusal on record
* If concern for child great refer to GP
Child
* Gillick competent = child agrees
* Record all discussions on notes
* If concern for child great refer to GP

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10
Q

How to instil drops

A
  • Instillation-lying down may help.
  • Sometimes drop onto eyelashes can help
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11
Q

Checking for cycloplegia

A

*Measure accommodation
*Check ret reflex

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12
Q

Cycloplegic Retinoscopy

A
  • Sit younger child on parent’s knee
  • Can ask px to fixate upon light of ret
    – Ensures retinoscopy is conducted upon axis
  • No need to fog other eye
  • Can try using lens rack
  • Observe central movement – 3-4mm
  • Ignore movement in periphery
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13
Q

Examples of cycloplegic drugs

A

Strongest to weakest:
- Atropine 1%
- Additional supply or independent prescriber status
- Associated with numerous side effects
- Cyclopentolate
- 0.5 and 1%
- Most commonly used
-Homatropine 1%
- Additional supply or independent prescriber status
- Tropicamide 1%
- Weakest drug only effective in adults
- Used mainly as mydraitic

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14
Q

Features of atropine sulphate

A
  • Naturally occurring compound “Belladonna” deadly nightshade
  • First muscarinic antagonist used in medicine
  • Toxic agent
  • POM = For use and supply by additional
    supply optometrists and used and prescribed by independent prescribing optometrists
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15
Q

Atropine- Preparations

A
  • Atropine Sulphate: eye drops, (non-proprietary)
    – 0.5% atropine sulphate
    – 1.0% atropine sulphate
  • Atropine Sulphate: eye ointment
    – 1% atropine sulphate (non- proprietary)
  • Minims
    - 1% atropine sulphate (Bausch &
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16
Q

Atropine- Dose

A

Adults and children > 3 months
*Eye drops
– 1 drop (1%) twice per day for 1-3 days before refraction
*Ointment
– 2 times a day for 1-3 days before refraction

17
Q

Why is atropine ointment preferable

A

– Systemic toxic effects
– Prolonged contact with eye

18
Q

Atropine -Timing

A

After instilling 1 drop of 1%:
Mydriasis
–Commences in 10-15 mins
–Maximal in 30 – 40 mins
–Recovers in 3 – 7 days
Cycloplegia
–Commences in 30 mins
–Maximal in 1 – 3 hours
–Recovers in 3 - 7 days

After 3x twice daily instillations
Mydriasis
–Recovers after 10 – 14 days
Cycloplegia
–Recovers after 7 – 10 days
–Adequate near vision recovers after 4 – 5 day

19
Q

Atropine-Tonus allowance

A
  • Ciliary muscle has dependant and independent tone
  • Allowance needs to be made for dependent tone - Spherical power only needs to be adjusted in less
    positive direction
  • -1.00DS for low myopes and hyperopes
  • 0.00DS for moderate and high myopes
20
Q

Atropine - Cautions

A

Contraindications
- Known allergy to atropine or component of the preparation
- Narrow angles - not so present in children
Cautions
- Children < 3 months
- Elderly or debilitated
- Down’s syndrome
- Children with brain damage
- Hypersensitivity
- Soft contact lenses = multi-dose containers contain benzalkonium chloride – do not use if lenses worn Intermittent manifest deviations

Pregnancy and Lactation Interactions

21
Q

Atropine Sulphate side effects on eye

A
  • Transient stinging
  • Blurring
  • Photophobia
  • RaisedIOP?
  • Repeated use
    – Hyperaemia
    – Oedema
    – Itching, irritation
    – Follicular conjunctivitis
22
Q

Atropine Sulphate side effects on body

A
  • Toxic effects
    – Dry as a bone: Dry mouth and skin
    – Red as a beetroot: Flushing, Increased body temperature
    – Blind as a bat: Cycloplegia
    – Mad as a hatter: CNS effects –ataxia, hallucinations, confusion, difficulty in speaking
  • Tachycardia
  • Death from respiratory depression = more likely in children. 3 gram tube can be fatal to a small children
23
Q

Atropine - additional uses

A
  • Used to treat amblyopia = instead of occlusion
  • Instilledinto“better eye”
  • Preventsaccommodation
  • Used when child will not tolerate patching/ first choice?
  • Excellent results
24
Q

Features of Cyclopentolate Hydrochloride

A
  • Commonly used cycloplegic
  • Synthetic drug
  • Not commonly used as a mydriatic by Optometrists
    *0.5% more useful as a mydriatic
    *Ophthalmologists
  • Stings
25
Q

Cyclopentolate- Preparations

A
  • POM for use and supply by all optometrists
  • Mydrilate: eye drops
    – Mydrilate (Intrapharm)
    – 0.5% cyclopentolate HCL
    – 1.0% cyclopentolate HCL
    – Stored between 2 - 8°C
  • Minims
    – 0.5% cyclopentolate HCL
    – 1% cyclopentolate HCL
    – Store below 25°C, protect from light
26
Q

When would you use 1% or 0.5% cyclopentolate

A

Up to age 12 yrs– usually 1%, if iris pigmentation is light then 0.5% may be suitable
CAUTION-very young px

27
Q

Cyclopentolate - Timing

A

Cycloplegia:
- Commences after a few minutes, maximal in 30-60 minutes
- Recovery 4-12 hours

Mydriasis:
-Commensces after 30 mins
-Recovery 24-48 hours
- Residual accommodation ≤1.50D
- Time scale variable

28
Q

Cyclopentolate – Tonus allowance

A
  • No tonus allowance made
  • Almost always give full Rx found
  • Exception
    – Hyperopia and exo deviation
    – Myopia and eso deviation
29
Q

Cyclopentolate - Cautions - which px’s

A
  • Young children
  • Debilitated patients
  • Elderly
  • Avoid over dosage in darkly pigmented eyes
    – Compressing the lacrimal sac for 2-3 mins after instillation of the drops to make sure maximum amount of drug in eye
  • Pregnancy and lactation
    – Unknown use only if risk to mother outweighs risk to foetus
  • Hallucinations and CNS effects reported with concentrations
30
Q

Cyclopentolate side effects

A

Ocular:
- Transient stinging
- Transient blurring
- Photophobia
- Raised IOP?
- Conjunctival hyperaemia and oedema
- After prolonged administration = irritation, hyperaemia, oedema, conjunctivitis

General-body:
* Dose related – Children
* CNS effects
* Dry mouth
* Flushing
* Tachycardia
* Urinary symptoms
* GI symptoms

31
Q

Cyclopentolate - additional uses

A
  • Adaptation to spectacles
  • Children almost always adapt well
    to hyperopic prescriptions
  • Use 1% cyclopentolate daily for 2/52
    – Accommodation abolished
    – Clear vision only obtained via
    spectacle wear
    – Child usually then accepts spectacle wear = as clear vision only obtained when wearing them
  • For anterior & posterior uveitis and
    posterior synechiae breakdown: 1 - 2 drops (1%) are instilled every 6- 8 hours.
  • For alleviation of ciliary spasm: 1 drop (1%) 2-3 times per day
32
Q

Duration of mydriasis

A

24 hours

33
Q

Homatropine Hydrobromide

A

POM
–Additional supply or independent prescriber
–1% multi-dose containers (non- proprietary)
–Store below 25°C, protect from light
– Used for dilating pupil in anterior uveitis
– Alleviation of ciliary spasm following corneal abrasion
- Mydriasis~30-40mins
- Recovery24-48hrs

34
Q

Tropicamide Hydrochloride - what does degree of cycloplegia depend on and what is the recovery and mydriasis time

A

Degree of cycloplegia dependent upon:
- Age
– Only indicated for cycloplegic refraction in older patients in late teens or older)
– 1% strength only suitable *Iris pigmentation
- Degree of cycloplegia dependent upon pigmentation - in blue eyes its more

Effects after instillation of 2 drops of 1% solution:
– Mydriasis after ~15 minutes * Recovery ~8-9 hours
– Cycloplegia maximal 30 mins * Recovery ~6 hours

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