Diagnostic Ophthalmic Agents: Drops Flashcards
What chemical class group is proparacaine in? What is another name for proparacaine?
Meta-aminobenzoic acid esters
AKA Proxymetacaine
What percent of ophthalmic solution is proparacaine?
0.5%
How long does proparacaine last?
10-20 minutes
Mechanism of action for proparacaine (3)
1) Selectively blocks conductivity of sodium ion permeability
2) Inhibits action potential
3) Changes in phospholipid bilayer of cell membrane and blocks nerve signals
Proparacaine effects on ocular surface
1) Anesthetizes the surface which decreases blink reflex and removes touch sensation.
2) Opens intracellular spaces of corneal epithelium
When do you use proparacaine?
For any procedures when we have to touch the eye or before using dilating drops.
Side effects of proparacaine
-May delay wound healing
-Prolonged use can cause corneal opacification
- may cause cytotoxicity and diffuse epithelial keratitis.
-may cause conjunctival redness
What is fluress made of?
Componen74s.
0.25% sodium flourescein
0.4% benoxinate hydrochloride (oxybuprocaine (anesthetic))
What is the shelf life of fluress?
18 months
What chemical class group is fluress in?
Para-aminobenzoic acid ester
Ocular side effects for fluress
burning, stinging,redness, blur (rare)
What color light filter do you use when using the fluress dye?
blue
What do you see on a positive stain when using fluress? What things could potentially give a positive stain?
You see hyperfluorescent areas.
Could be due to superficial punctate keratitis (SPK), corneal ulcers, or corneal abrasions.
If you use fluress and see hyperfluorescent dots, what are you looking at? How is it documented?
Dots = superficial punctate keratitis
Documentation: graded trace to 4+, and then note the location of the dots.
If you use fluress and see hyperfluorescent round stains, what are you looking at? How is it documented?
Round stains = corneal ulcers
Documentation: Note location, measure to track progression over time
If you use fluress and see hyperfluorescent scratches, what are you looking at? How is it documented?
Scratch = corneal abrasion
Documentation: Note location
What do you see on a negative stain when using fluress? What things could potentially give a negative stain?
You would see hypoflourescent areas.
Could be due to raised lesions or epithelial basement membrane dystrophy (EBMD).
If you use fluress and see a hypoflourescent raised lesion, what could you be looking at?
scarring or neoplastic lesion
If you use fluress and see hypoflourescent shapes (maps, dots, fingerprints), what could you be looking at?
Various shapes (dots maps, fingerprints) = EBMD (epithelial basememnt bembrane dystrophy.) AKA map dot dystrophy
What are the 5 ophthalmic dyes?
1) Flourescein
2) Lissamine Green
3) Rode Bengal
4)Tryptan Blue
5) Indocyanine Green
How much dye is in fluorescein strip?
0.6-1 mg of dye
What is fluorescein made of?
Fluress ophthalmic solution with benoxinate (anesthetic)
How can fluorescein be administered for fluorescein angiography?
Oral or IV injection
What are some properties of fluorescein?
Orange, water soluble dye
Absorbs blue light at 490nm and emits yellow-green at 530nm
What color light filter do you use with fluorescein?
Blue filter
What would you use fluorescein for?
-Ocular surface diseases/ dry eye
-Identifying corneal epithelial defects/abrasions/ulcers
-Applanation tonometry
-Perforating injury or surgery
-Nasolacrimal duct patency
-Rigid contact lens fitting
-Intravenous fluorescein angiography
What concentrations does lissamine green come in?
1%, 2%, 3%
How many mg of lissamine green are on strips?
1.5 mg
What color light does lissamine green absorb?
Absorbs red light (630 nm)
When an area is stained with lissamine green and a red-free filter is applied, what does the stained area look like?
Stained area is black.
What does lissamine green stain?
Dead and degeneerated cells including mucous strands
When would you use lissamine green?
-Diagnosis of dry eye
-In Sjogren’s syndrome, suspects to rule out keratoconjunctivitis sicca
-to access contact lens-induced conjunctival staining
-Assess lid margins for lid wiper epitheliopathy
How much dye is on Rose bengal strips?
1.3 mg dye
What does rose bengal stain?
dead and devitalized cells, including mucous strands
What should you warn your patients about before administering rose bengal?
Make patients eye red due to ocular toxicity
What would you use rose bengal for?
-Corneal staining for herpetic corneal epithelial dendrites
-Diagnosis of dry eye disease
-dysplastic or squamous metaplastic cells of conjunctival squamous neoplasm
What 5 things would you use tryptan blue for?
1)Anterior capsular staining
2)Descemets stripping endothelial keratoplasty
3)Deep anterior lamellar keratoplasty
4)Posterior segment surgeries
5)Enucleation surgery for Tenon’s capsule
What purpose does tryptan blue have for enucleation surgeries for tenons capsule?
Stains tenon’s capsule
What purpose does tryptan blue have for posterior segment surgeries?
To stain the ERM
What purpose does tryptan blue have for deep anterior lamellar keratoplasty?
Strips corneal endothelium from donor
What purpose does tryptan blue have for descemets stripping endothelial keratoplasty?
To stain and strip Descemet’s membrane
What purpose does tryptan blue have for anterior capsule staining?
Useful in eyes with a decreased red reflex, or weak zonules, as the dye can immediately allow the surgeon to detect a radial shift of the capsular bag
What is indocyanin green used for?
Staining the anterior capsule during cataract surgery
In chromovitrectomy, what does indocyanine green do?
Helps visualize the ILM
What do cycloplegias do?
Paralyse the ciliary muscle
Reduce accomodation
Dilation of the pupil
Mydriasis
What anatomical structures do cycloplegics and mydriatics effect?
Iris dilator muscle
Iris sphincter muscle
Ciliary Body
What are two cycloplegics and mydriatics used in this class?
Phenylephrine
Tropicamide
What drop contracts the radial dilator muscle of the iris causing a dilation of the pupil?
Phenylephrine
Is phenylephrine direct-acting sympathomimetic or indirect-acting?
Direct acting
What 3 effects does phenylephrine have?
1)Contraction of the radial dilator muscle of the iris = dilation of pupil
2)Vasoconstriction of blood vessels = conjunctival blanching
3) Widening of the palpebral aperture
How long does phenylephrine last?
up to 6 hours
If a bottle of phenylephrine had a concentration of 0.12%, what would it be used for? How many times do you take it a day? How many drops? How many days?
Used for ocular decongestant
Treats ocular allergies/redness
1 drop 0.12% solution every 3 to 4 hours for 1-2 days.
If a bottle of phenylephrine had a concentration of 2.5%, what would it be used for?
It functions as a mydriatic.
Used in routine pupil examination or Pre/Post operative ocular surgery.
For a routine eye exam, what drop of phenyl do you use to dilate the pupil? How long does it take for the effect?
1 drop of 2.5% phenylephrine solution
Achieves effect in 15-20 minutes
For a pre/post-operative exam on an adult, what drop do you use to dilate the pupil? How early before surgery would you apply the drop?
1 drop 2.5% or 10% of phenylephrine
Apply 30-60 minutes before surgery.
For a pre/post-operative exam on a child, what drop do you use to dilate the pupil? How early before surgery would you apply the drop?
1 drop 2.5% solution of phenylephrine
Apply 30-60 minutes before surgery
A bottle of phenylephrine has a concentration of 10%, what is it used for?
Used to break posterior synechia
Common side effects for phenylephrine (5)
Burning
Tearing
Photophobia
Brow ache
headache
What are 6 rare systemic side effects of phenylephrine 10%?
1) Tachycardia
2) High Blood Pressure
3) Sweating
4) Trembling
5) Dizziness
6) Paleness
In what patients would you caution the use of phenylephrine? (5)
1) Severe cardiac disease
2) Systemic hyper or hypotension
3) Insulin-dependent diabetes
4) Aneurysms
5) Advanced arteriosclerosis
What concentrations does phenylephrine come in?
0.12%, 2.5% , 10%
True or false:
Tropicamide is a muscurinic receptor antagonist.
True
How does tropicamide work? What does it cause?
Blocks the muscarinic receptors in the iris sphincter muscle. Causes strong mydriasis but weak cycloplegia.
What concentrations does tropicamide come in?
0.5% and 1%
How long does tropicamide last?
6 hours
For routine eye exams, what drop of tropicamide would you use? How long does it take to achieve the effect?
Either 0.5% or 1%.
Takes 15-20 minutes to achieve effect
For routine eye exams, what drop of tropicamide would you use? How long does it take to achieve the effect?
Either 0.5% or 1%.
Takes 15-20 minutes to achieve the effect
For weak cycloplegic refraction, what drop of tropicamide would you use for adults and kids?
Adults: 1 drop of 1% solution followed by 1 drop in 5 minutes
Children: 1 drop of 0.5% solution followed by 1 drop in 5 minutes
For pre/post-op surgery, what drop of tropicamide would you use? Is it before or after the dilation drop (phenyl)
1 drop of 1% tropic amide before the dilation drops of phenylephrine.
Ocular side effects of tropicamide
Blurry vision at near and distance
When performing a routine exam on new patients, dark irides, pre-existing retinal disease, risk of peripheral posterior segment disease, or history of ocular surgery, what drops would I use to dilate the patient?
Tropicamide(1%) followed by Phenylephrine(2.5%)
What are different combinations of tropicamide and phenyl that you can use in a routine eye exam?
Tropicamide(1%)
Phenylephrine(2.5%)
Tropicamide(0.5%) + Phenyl (2.5%)
Tropicamide (1%) + Phenyl (2.5%)
What might cause you to add more drops or use punctal occlusion when dilating?
When the patient has:
-narcotic drug use
-iris pathology/damage
-prior ocular surgery
-dark irides.
Why do darker irides take longer to dilate?
Melanin competes with receptor sites for the active ingredients in the eye drop. It can reduce the overall effect of the drops
Why would you caution use of cycloplegics/mydriatics in patients with chromosomal that have intellectual defects?
Condition can be aggravated by the instillation of drops
Why would you caution use of cycloplegics/mydriatics in patients with low birth weight and/or premature infants with respiratory distress syndrome?
Can cause risk of vomiting, bradycardia, hypotonia, and aspiration
What may happen when using cycloplegics/mydriatics in patients who are diabetic?
Can cause a denervated pupil and result in poor dilation. May need to add more drops.
What may occur in a geriatric patient when using cycloplegics/ mydriatics?
Senile myosis. May need to add more drops
(Usually isn’t a concern)
Is there a concern of using cycloplegics/mydriatics on pediatric patients?
No
What is Paremyd a combination of? What effect does it provide? What may it not work as well on?
Tropicamide(0.25%), Hydroxyamphetamine(1%)
Good dilation with minimal effect on accomodation.
Expensive.
May not work well against patients with dark irides, diabetics, or older patients
What is Cyclopentate a combination of? What concentrations does it come in?
Parasympatholytic / Antimuscarinic
0.5%, 1%, 2%
What would you use Cyclopentate for?
1) Cycloplegic refraction (wet)
2) Pupil dilation
3) Uveitis treatment
For a cycloplegic refraction, what combo drop may you use? (Adults/children, infants) How long does it take to get effect?
Adults/Children: 2 drops of cyclopentate(1%) 5 minutes apart. Effect in 30-45 minutes.
Infants: 1 drop(0.5%)
For pupil dilation using cyclopentate, what is the dosing?
Adults/Children: 2 drops of cyclopentate(1%) 5 minutes apart. Effect in 30-45 minutes.
Infants: 1 drop(0.5%)
For uveitis treatment using cyclopentate, what is the effect? What is the dosing?
-Prevent anterior/posterior synechiae
-Reduce pain – immobilize iris.
1 drop of 1% or 2% 2-3 times per day
Ocular side effects for cyclopentate.
Blurred vision, photophobia, stinging
Systemic effects of cyclopentate in adults.
Clumsiness/unsteadiness
confusion
constipation
full feeling
passing gas
stomach cramps
tachycardia
hallucinations
skin rash
slurred speech
disorientation
increased thirst
dry mouth
Systemic effects of cyclopentate in infants/children.
swollen stomach
restlessness
hyperactivity
drowsiness
weakness
What is the length of dilation for cyclopentate?
6-24 hours
MOA of tropicamide and cyclopentate
Compete with acetylcholine at affected receptor site of iris sphincter and ciliary muscle.
Tropicamide vs. Cyclopentate:
Which is better with mydriasis of the pupil?
Tropicamide
Tropicamide vs. Cyclopentate:
Which is better at paralyzing accommodation?
Cyclopentolate
What are the 3 dilation combo drops?
Paremyd
Cyclopentate
Atropine
What could you use atropine for?
Uveitis treatment
Dialted eye exams
When treating Uveitis with Atropine, what is the dosing for adults and children?
Adults: 1 drop of 1% atropine 1-2 times a day.
Children: 1 drop of 1% atropine 1-3 times a day
When using atropine for dilated eye exams, what is the dosing for adults and children?
Adults: varies
Children: 1 drop of 1% atropine 1-3 days PRIOR to examination
How long does the mydriasis effects of atropine last for?
Up to 15 days
How long does the cycloplegia effects of atropine last for?
up to 120 minutes (2 hours)
What is the onset of action for atropine?
30-40 minutes
True or false:
Atropine also comes in an ointment form.
True
Systemic side effects of atropine for adults
Clumsiness/unsteadiness
confusion
constipation
full feeling
passing gas
stomach cramps
tachycardia
hallucinations
skin rash
slurred speech
disorientation
increased thirst
dry mouth
Systemic side effects of atropine for children
swollen stomach
restlessness
hyperactivity
drowsiness
weakness
What are you warned against using atropine?
When patient has:
History of brain damage
Down’s Syndrome
Angle Closure Glaucoma
Spastic Paralysis
For Atropine 1%, what is the onset and duration of effects?
Onset: 40 minutes
Duration: 7-14 days
For Cyclopentate (0.5% or 1%), what is the onset and duration of effects?
Onset: 20-45 minutes
Duration: 6-24 hours; up to several days
For Tropicamide (0.5% or 1%), what is the onset and duration of effects?
Onset: 15-30 minutes
Duration: Up to 3-8 hours; up to 1 day
