DPA Part 2 Flashcards
1 cause for malpractice in optometry
Failure to properly diagnose intraocular disease-majority involved OD’s who failed to use diagnostic drops. Not approved in all states until 1980s-90s
BEFORE dilating the pt, always do the following:
Check visual acuities (distance)
Check pupils
Check IOP
Check angles- Van Herick/Shadow test
If gonio shows ___ or less of the trabecular meshwork visible in all 4 quadrants, pt is at risk of angle closure
Half or less!
Less than grade __ van heroic angle= risk of angle closure. Do gonio. If you only see ____ of the trabecular meshwork, pt is at risk of an angle closure
Grade II
Half or less of the trabecular meshwork in all 4 quadrants.
5 Signs and symptoms of a closed angle attack
- Does pt see halos around light?
- Intermittent eye pain especially going from dim to bright illumination
- Intermittent blur
- Intermittent ocular redness due to inflammation
- Nausea- affects vagus nerve
If your patient is at risk for angle closure and you choose to dilate, what should you do?
Check IOP following dilation. If IOP increases more than 5mmHg, it should be monitored and/or treated until the IOP is normal. Use drops to bring pressure down- don’t let them leave until pressure decreases.
What you should ask your patients before dilating?
Have you dilated safely before?
Have you been told you are at risk for angle closure?
Any complications from previous dilations?
How do you know what drops to use? 2 goals
Agent producing least possible adverse affects
Lowest concentration that will allow you to attain sufficient pupil mydriasis
What to tell pt before instilling drops?
They will sting
How long they will last
Light sensitivity, near blur
Answer any questions pt has
Cycloplegia
Paralysis of the ciliary muscle- Reduction of accommodation
Mydriasis
Dilation of the pupil. Contract dilator muscle.
Function of pharmaceutical agents on iris dilator, sphincter, and ciliary body
Iris dilator muscle contracts
Iris sphincter muscle paralyzed
Ciliary body- partial or total paralysis
Phenylephrine hydrochloride is what type of pharmacological agent and how does it work
Direct acting sympathomimetic. Alpha 1 Agonist. Causes dilation.
Works by contraction of the radial dilator muscle of the iris.
Pupil will constrict when you shine light in it!
Phenylephrine dosages
- 12% OTC vasoconstrictor for allergies. Gets red out by shrinking conj blood vessels.
- 5% Routine pupil dilation. Mydriasis only, no cycloplegia. Widening of palpebral aperture
10% Break synechia. Serious side effects, but rare.
Does phenylephrine have any cycloplegia
No. No affect on accommodation. Only mydriasis.
10% phenylephrine systemic side effects
Be caution in pts with conditions such as:
Serious, but rare.
Sympathetic side effect: Dizzy, achy, increased sweating, increased BP, pale.
Use with caution in pts with: Cardiac, HTN, diabetes, aneurysms and arteriosclerosis.
More common side effects of phenylephrine
More common: burning, stinging, brow ache, HA, increased tears, photophobia.
Tropicamde Hydrochloride. How does it work?
Muscarinic antag/cholinergic antag.
Blocks muscarinic receptor in iris sphincter muscle
How does tropicamide work?
Causes mydriasis- strong
and cycloplegia- weak
Affects receptors on the iris sphincter and ciliary body muscles. Eye will not constrict when you shine light into it!
Tropicamide side effects for uncorrected hyperope
Blurry distance vision.
When should you be cautious about eye drops and pregnancy
Earlier in pregnancy- when baby is developing the most.
iris color and eye drops
Darker irides have more pigment
Melanin competes with receptor sites for active ingredient in eye drop. Takes longer to dilate and undulate.
Reduces the overall affect of some drops.
Dilating drops in pts with senile meiosis
May need more drops since their pupils are much smaller to begin with. Especially if they have dark iris.
Systemic conditions that may mess with dilation drops
Diabetic pts may need more drops due to denervated pupil.
Low birth weight/premature. Benefits outweigh risk because need to make sure they don’t have detachments.
Down syndrome could be aggravated by drops.
Paremyd
- Combo of what?
- Benefits
- Down sides
- May not work as well on:
Combo of 0.25% tropicamide and 1% hydroxyamphetamine. (sympathomimetic)
Works on both muscles in iris. Provides good dilation with minimal affect on accommodation!
more expensive.
may not work well on pts with:
- Dark brown iris
- Older pts
- Diabetic pts
Tropicamide and cyclo MOA
Compete with each at the affected receptor sites of the iris sphincter and ciliary muscle
Paralyzes iris sphincter and ciliary body muscle.
Doses of cyclo
0.5%, 1%, 2%
Why is cyclo good for uveitis tx
Prevents posterior synechiae- iris attached to anterior lens.
Immobilizes iris and reduces pain.
Systemic side effects of cyclo
*Anti-cholinergic= anti parasympathetic= sympathetic side effects
adults: Clumsiness, confusion, constipatieon, full feeling, passing gas, stomach cramps, achy, skin rash, hallucination, thirst, dry mouth.
Kids: Swollen stomach, restlessness, drowsy, weak
What eye drop could be used for myopia progression?
Atropine
Why would you use atropine?
Myopia progression, uveitis
Atropine 1% ointment when to use:
Uveitis
Adults- 1 to 2 times
Children- 1 to 3 times
Dilated eye exams
Atropine action duration of
Mydriasis
Cyclo
Mydriasis: weeks
Cyclo: 120 mins
Cyclo action duration of
Mydriasis
Cyclo
Mydriasis: 1 day
Cyclo: 20-45 mins
Phenylephrine action duration of
Mydriasis
Mydriasis only 4-6 hours
Tropicamide action duration of
Mydriasis
Cyclo
Mydriasis 4-5 hours
Cyclo 15 mins
What happens if you close your patients anterior chamber angle?
Patient symptoms
Pain Blurred vision Colored halos around lights Frontal HA Nausea/vomitting
Critical signs of anterior chamber angle closure
Acute increase in IOP Corneal edema Shallow anterior chamber between iris and cornea Conj injection due to inflam Fixed, mid-dilated pupil. **********
How to tx a closed angle
Topical glaucoma meds- faster acting. BB, CAI’s, adrenergic agonist (Sympathetic)
IV/oral glaucoma meds if urgent- can only see hand movement
Topical steroids
Topical miotics- pilocarpine. Constricts pupil, but IOP must be lower than 40.
If pt has closed angle attack, when you you use topical miotics
if their IOP is less than 40
Miotics have what color cap
Dark green
Beta blocker combo has what color cap
Dark blue
Red caps
Mydriatics and cyclo
Pink caps
Steroids and anti inflam
Dark blue
BB combo
Dark green cap
Miotics
Duresta implant
Implant that lasts 12 weeks and then lowers IOP by 30%
Inserted into anterior chamber
