CYCLOPLEGICS Flashcards
Catecholamines
Hormones including:
DOPAMINE
EPINEPHRINE
NORE-PINEPHRINE
COMT
Catechol-o-methyl Transferase
-an enzyme of catecholamine metabolism
MAO
An enzyme of catecholamine metabolism
CYCLOPLEGIA
Paralysis of the ciliary body musculature responsible for accommodation
What is ANAPHYLAXIS
- Acute, systemic allergic hypersensitivity reaction to a previously sensitized allergen
EPI-PEN
Serious anaphylactic reactions develop within minutes (up to 2 hours) and require immediate emergency treatment with epinephrine
what are the dosage of EPIPEN ?
EpiPen 0.3mg
EpiPen Jr 0.15mg
Pregnancy category C
what diseases should you be cautious wit EPI-PEN
Caution in patients with heart disease or high blood pressure, Parkinson’s disease, diabetes, or a thyroid disorder
FIGHT OR FLIGHT
Regulated by the SYMPATHETIC or ADRENERGIC branch of the autonomic nervous system
REST AND DIGEST
Regulated by the PARASYMPETHETIC or CHOLINERGIC branch of the autonomic nervous system
Nicotininc Receptors are located in the ANS HOW?
using postganglionic in the ANS and terminally located in the somatic nervous system
Muscarinic receptors are associated with?
Terminal organs of postganglionic nerves in the cholinergic system
Norepinephrine (NE) are used?
NT used in sympathetic adrenergic system and its target receptors are ALPHA AND BETA
Presynaptic FOUND IN THE SYMPATHETIC PHARMACOLOGY
+α2 inhibition of signal propagation
VASCULAR
+α1 vasoconstriction; +β2 vasodilation
RESPIRATORY
+β2 bronchodilation
CARDIAC
+β1 ↑ contractility & conduction
HEPATIC
+β2 glucogenolysis
PANCREATIC
+β2 ↑ insulin release;
+α2 ↓ insulin release
IRIS
+α1 mydriasis
Ciliary BODY
+β2 relaxation & ↑ aqueous production
-β2 or +α2 ↓ aqueous production
What is Relative receptor Activity?
Epinephrine Vs Norepinephrine
when it comes to Alpha 1
Norepeinephrine (NE) - Neurogenic
it is NE> E (epinephrine)
What it comes to alpha 2
Epinephrine (greater than equal) to NE
When it comes beta 1
Epinephrine (equals) to NE
when it comes to beta 2?
epinephrine
What are ocular adrenergic Effects on Mydriasis?
- Increase interpalpebral aperture (Müeller’s muscle)
- Modulate aqueous generation
- Receptors in lateral rectus modulate vascular tone
- Receptors in trabeculum & Schlemm’s canal suppress accommodation
What is the standard care for all new patients when it comes do dilation?
Last to be performed in exam sequence
Bilateral under most every circumstance
What should be used to estimate the ocular angle?
Gonioscopy > Van Herick > shadow test
Commonly large in myopes and aphakes
what are the factors that affect when it comes to reduced sensitivity?
Age-related miosis Unstable diabetes Post-op pupils Posterior synechiae Dark irides Pseudoexfoliation Syndrome
what is the factors that are affecting increased sensitivity?
Down syndrome
who are the poor dilation candidates?
Homocystinuria & Marfan’s syndrome: ectopia lentis risk
Pregnancy: use Tropicamide; consult OB/GYN
Pigmentary or exfoliative glaucoma; transient IOP elevation
What is the angle closure within ususally?
IATROGENIC ANGLE CLOSURE GENERALLY
OCCURS 4-8 HRS POST INSTILLATION
what are contraindictations when it comes to poor dilation candidates?
- Iris supported intraocular lens
- Subluxated lens or intraocular lens
- Extremely narrow angle*
- Angle closure history without peripheral iridotomy (PI)
When do you do CYCLOPLEGIA?
- Strabismus (especially esotropia)
- Pseudomyopia (accommodative spasm)
- Latent hyperopia
- Anisometropia
- Amblyopia, hysterical amblyopia
- Functional deficits
- Malingerers
- Unexplained refractive error
- Uncooperative, non-communicative, inconsistent patient
CYCLOPLEGIA also known as
otherwise known as a ‘WET REFRACTION’
what are the sympathetic Mydriatics?
Phenylephrine
Hydroxyamphetamine
what is the activity of PHENYLEPHRINE
α1 selectivity
Some indirect effects via norepinephrine release
what are the ACTIONS of Phenylephi?
- Mydriasis in 45-60 min
- Conjunctival blanching
- Mild accommodation suppression ~2D
- Lid retraction
- IOP reduction
what are the SPECIAL INDICATIONS OF PHENYL
Posterior synechiae breakage (10%)
Pre-LASIK vasoconstriction (10%)
Inhibition of iris cysts (caused by echothiophate*)
Horner’s evaluation (1%)
what are ADVERSE EFFECTS OF PHNYELEPI?
- Photophobia, blur, glare
- Allergic dermatoconjunctivitis
- Rebound miosis
- Anterior chamber pigment liberation
- Systemic hypertension → bradycardia
who should you avoid PHENYLPHRINE
- Avoid 10% in neonates/elderly
- History of CVD or MI, DM1, aneurysm, advanced arteriosclerosis, ideopathic orthostatic hypotension
- Atropine, TCAD, MAOI, reserpine, guanethidine, methyldopa
what is HYDROXY-AMPHETAMINE
Indirect acting: promotes norepinephrine release from nerve terminals
Negligible direct α & β receptor stimulation
what is the HYDROXY-AMPHETAMINE for 1%
No accommodation suppression
what makes up the PAREMYD?
1% HYDROXYAMPHETAMINE
+
0.25% TROPICAMIDE
What are the actions of PAREMYD?
- Mydriasis independent of age or pigmentation
- Faster recovery than phenylephrine/tropicamide combo thus better suited for a shallow angle
- No benefit from pre-anesthetizing cornea
- Differentiate pre/post-ganglionic dennervation
what are the adverse effects PAREMYD?
Similar to phenylephrine except, systemic hypertension –> tachycardia
what medications should you not use these PAREMYD on?
it is similar to phelephrine but
safer Similar to phenylephrine but safer in diabetes, ideopathic orthostatic hypotension, chemical sympathectomy agents
what are the parasympathetic pharmacology?
M1, M2 AND M3
which one VASCULAR binds to?
M3 salivary gland, vasodilation secretion
whhich one RESPIRATORY binds to
M2 = M3 bronchoconstriction, secretion
which one is CARDIAC binds to?
M2»_space; M3 ↓ contractility & conduction
which one is EMETIC binds to?
M3
which one PANCREATIC binds to?
M2 = M3 acini secretion
which one IRIS binds to?
M2 < M3 miosis
which one CILIARY BODY binds to?
M2 < M3 contraction & ↑ aqueous outflow
which one is CNS binds to?
M1 memory
M4 and M5 are also coming of interest for their role in CNS cognition
what is Acetylcholine is broken into?
Acetate and Choline using ACHe
what is AChE
= acetylcholinesterase is ubiquitously distributed throughout the body therefore metabolism is rapid
what are ANTICHOLINERGIC AGENTS?
Atropine Scopolamine Homatropme 2% and 5% Tropicamide Cyclopentolate 1% Cyclomydril
What is ATROPINE is selected for?
It is NON SELECTIVE Muscarinic and some are Nicotinic
Scopolamine
are non selective
Homatropme 2% and 5%
They are equivalent to 10% atropine potency
Tropicamide
are Moderately M4 selective
Cyclopentolate 1%
not given
Cyclomydril
Which is 0.2% cyclopentolate + 1% phenylephrine
What is ATROPINE used for?
Cycloplegia
Severe uveitis
amblyopia
Dianosis of Accommodative esotripia
What is Scopolamine used for?
Travel sickness
has produced CNS effects
What is Homatropine used for?
Modetrate uveitis
Corneal Abrasion
Mydriasis
What is CYCLOPENTOLATE used for?
Cycloplegia
Moderate Uveitis
Corneal abrasion
** have CNS effects including hyperactivity, halucinations and psychosis
What is TROPICCAMIDE used for?
Cycloplegia
Mydriasis
Mild uveitis
what are ANTICHOLINERGICS adverse effects on OCULAR?
increase in IOP
Angle closure risk
Allergy
What are ANTI-CHOLINERGICS systemic adverse effects?
ABCDS A = Anorexia B= Blur C = Constipation and Confusion D = Dryness and sedation S = Sedaton S = Stasis of urine == you get thirst, tachycardia, hypertension, decrease glandular secretions: SWEAT/BRONCHIAL/ SALIVA > heart, smooth muscle > GIT
What are the adverse effects on CNS using Anticholinergics
CNS (MEDULLA)
decrease in Parkinson Tremor
Decrease in HR
ATROPINE comes as
1.0% ointment or 0.5/1.0/2.0% solution
what is ATROPINE used in?
Anterior Uveities: ciliary body spasm, posterior synechiae, lens advancement, vessels permeability
- Myopic progression
- Amblyopia :penalization
WHAT IS TROPICAMIDE 0.5/ 1.0% solution used in?
Mydriasis
Dose dependent cycloplegia
Less pigment-sensitivity than cyclopentolate, homatropine and atropine
Best mydriasis as 0.25% with paremyd 1%
what is CYCLOPENTOLATE 0.5/1.0/2.0% solution used in?
Delayed/ sustained effects in darkly pigmented
Less flushing and dryness than atropine
** AVOID 2% IN KIDS
