Ears And Eye

Question 1

Conjunctivitis

Answer 1

Newborns should be checked for ophthalmia neonatorum
Preschoolers have bacterial conjunctivitis
School aged have viral conjunctivitis with adenovirus
Adolescents/adult can have sexually active conjunctivitis, check for neisseria gonorrhea, can also be bacterial or viral
Chlamydia can also be seen in neonates

Question 2

Miotics

Answer 2

Class: Antiglaucoma agents, Cholinesterase inhibits
MOA- Indirect acting agents that inhibit cholinesterase
Cause intense miosos and muscle contraction intraocular pressure is decreased by decreased resistance to aqueous outflow
Two types- reversible, and irreversible
Reversible - physostigmine and Demecarium with cholinesterase
Irreversible -echothiophate iodide binds to cholinesterase into a covalent bond that does not hydrolyze, cholinesterase must be obtained from other parts of the body for eye action to normalize
Direct acting parasympathetic drugs with muscarinic effects peoples will constrict , ciliary muscles are stimulated, and there is increased, aqueous humor outflow, outflow resistance is decreased from contraction of the iris sphincter
Pharmacokinetics- duration 6-8 hrs, direct acting 4-8 hrs
Contraindications with eye inflammation or with no construction, not warranted, such as with iritis, uveitis, secondary glaucoma
Adverse effect -corneal clouding, headache, retinal detachment may have systemic anticolic effects like headache, hypertension, salivation, sweating, nausea, vomiting
Drug-drug- echothiophate can have additive effects with system anticholineserase (MG meds)

Question 3

Carbonic anhydrase inhibitors

Answer 3

Class- Anti glaucoma agent
MOA- Decrease aqueous humor, secretions by decreasing the formation of bicarbonate ions this decreases sodium and fluid transport leads to less aqueous humor production
Pharmacokinetics- Brinzolamide (azopt) absorbed systemically widely distributed, including in breastmilk, and can cross placenta, metabolize, and excreted in urine
Dorzolamide (trusopt) some systemic absorption primary excreted unchanged in urine
Methazolamide (nepatazane) oral agent, absorbed from G.I. tract distributed throughout extruded by the kidneys 25% unchanged in urine.
Dorzolamide and brinzolamide contain sulfa, and are absorbed in amounts great enough to cause hypersensitivity in those with allergy, pregnancy C category, contraindicated and lactation safety in children is not known. Methazolamide is contraindicated in those with low potassium, low sodium renal disease, liver disease, Supra renal gland disease, severe COPD, not recommended in children and pregnancy category C
Adverse effect - dysgeusia, can punctuate keratosis, oral agents like neptazane can cause melena, GI upset, glycosuria, urinary frequency, renal stones, or nephro toxicity
Drug-drug- concurrent use of other CAI and high dose salicylates may cause metabolic acidosis, and salicylate toxicity, Methazolamide and topamax can increase risk of renal stones

Question 4

Sympathomimetics

Answer 4

Class- Anti glaucoma agent
MOA-Cause phase of construction pupillary dilation and decrease the intraocular pressure these drugs, decrease intraocular pressure by reducing production of aqueous humor and by increasing aqueous humor outflow
Pharmacokinetics- Apraclonidine (lopidine) is contraindicated in those allergic to clonidine, pregnancy category C
Dipivefrin (akpro, propine) is contraindicated in those with narrow angle glaucoma, pregnancy category B, not recommended for children or nursing moms
Adverse effects-conjunctival or corneal pigmentation, systemic effects such as headache, hypertension, elevated heart rate, cardiac arrhythmias
Drug-drug- no known drug interactions but apraclonidine do not use MOAI because of potential hypertensive crisis

Question 5

Alpha adrenergic agents

Answer 5

Class-Anti glaucoma agents
MOA- Decrease intraocular pressure by reducing the production of aqueous humor by increasing uveoscleral outflow
Pharmacokinetics- Brimonidine (alphagan) peak levels in 1-4 hours metabolized in liver eliminates in urine
Brimonidine is contraindicated in those on MAOIs
do not instill with contact lenses in 15 minutes use before putting contacts in pregnancy category C
Adverse effect - feeling of foreign body and eye and pain can have systemic effects such as dry mouth, drowsiness, or headache
Drug-drug- do not use MAOIs, additive effect, if use with a central nervous system depressant, drugs, I can lower heart rate may have added effect of depressing heart rate rate and blood pressure if Brimonidine used with alpha adrenergic agonist

Question 6

Prostaglandin agonists

Answer 6

Class- Anti glaucoma agents
Prototype- Lantanoprost (xalantan) MOA- selective agonist of a prostaglandin receptor FP, increases outflow of aqueous humor by acting on the receptors and thus decreasing intraocular pressure, absorbed through cornea, hydrolyzed to active form, not knowing if it crosses, placenta and animal studies there are adverse fetal effects metabolize in the urine
Bimatoprost (lumigan) is synthetic form, decreases intraocular pressure by increasing aqueous humor outflow
Unoprost (rescula) and travaprost (travatan) are also synthetic, F2 alpha analogues,
Pharmacokinetics- Bimatoprost- absorb and reach a steady state of plasma, metabolize by oxidation and exerted in urine and feces.
Travaprost- absorbed from cornea and peaks and plasma within 30 minutes hydrolyzed in cornea and rapidly cleared within 60 minutes
Unoprostone- rapidly absorbed from cornea and hydrolyzed into unoprostone free acid rapidly eliminated in urine
MOA is unknown- thought to decrease intraocular pressure by decreasing uveoscleral outflow
Bimatoprost is also marked as Latisse to treat lash hypotrichosis
Lantanoprost -do not instill with contacts in use caution in those with iritis, pregnancy category C
Brimatoprost pregnancy category C
Adverse effect - feeling a foreign body in eye, keratopathy, Iris discoloration, gradual, increase in amount of brown pigment from increase and number of melanosomes which is usually permanent, Bimatoprost can cause permanent brown iris, pigment, and hair growth outside of the treatment area must only be applied to upper lashes
Drug-drug- interacts with thimerosal, wait 5 between the two different drops

Question 7

Beta blockers

Answer 7

Class- Anti glaucoma agent
Pharmacokinetics- Little is known, duration is 12 to 24 hours , systemic absorption does occur in a can be seen on the lungs and heart
Contraindicated and deal with asthma, COPD or other pulmonary diseases
Decreases conduction through atrial ventricular node topical beta blockers are contraindicated in those with bradycardia or AV blocks or those with a cystic blood pressure less than 100 use in caution with those with poorly control diabetes, raynauds, peripheral artery, occlusive, disease or CVA, pregnancy C category, topical beta blocker excrete in breastmilk so contraindicated in breast-feeding
Adverse effects -headache, dizziness, systemic, like bradycardia, hypotension, broncos spasm
Drug-drug- use with systemic beta blockers can’t cause additive effects, timolol can cause bradycardia and asystole, also interact with beta blocker, pressers, calcium channel blockers, amiodarone, quinidine, beta agonist
betaxolol/caretolol/metipranol interacts with beta blockers other pressers calcium channel blockers did Jackson amiodarone and beta agonist, levobunolol-interacts with other beta blockers and beta agonist

Question 8

Adverse drug reactions for all antiglaucoma agents

Answer 8

All drugs may cause transient discomfort, or tearing blurred vision, photophobia, hyperemia may occur

Question 9

Bacitracin (eye)

Answer 9

Class- bacteriostatic
Inhibits incorporation of amino acid and nucleotides into the cell
Active against gram positive staph, steep, clostridia, corynebacterium, anaerobes
Active against gram negative gonococci, meningococci, fusobacteria
Can cause blurred vision but transient
No drug to drug interactions

Question 10

EES (eye)

Answer 10

Class- bacteriostatic
Marcolide that binds to 50S ribosomal subunits, inhibits bacterial protein synthesis
Active against gram positive staph aureus, strep pyogenes, strep pneumonia; strep viridians, corynebacterium diptheriae, chlamydia, trachomatis
Limited gram negative coverage
Safe in children
No drug drug interactions

Question 11

Sulfacetamide (eye)

Answer 11

Class- sulfonamide
Inhibits bacterial Dihydrofolate synthesis
Active against strep, staph, ecoli, klebiseilla, pseudomonas, pyocynea, neisserria gonorrhea, chlamydia
Drainage can inactive
Not for those less than 2 mths old
Can cause hypersensitivity reactions in those all allergic to oral sulfa , can also cause burning or stinging
Drug-drug- Incompatible with silver preparations if use with zinc preparation it precipitates, interacts with -Caine drugs, can antagonize sulfa

Question 12

Tobrmycin (eye)

Answer 12

Class- aminoglycoside
Active against staph, strep, corynebacterium, klebsiella, morakella, proteus, beta hemolytic strep, HI
Not active against Neisseria or chlamydia
Safe in children
Can cause local ocular, toxicity or hypersensitivity
No drug to drug interactions

Question 13

Gentamycin (eye)

Answer 13

Class- aminoglycoside
Active against gram positive and negative pathogens
MOA unknown
Covers staph, strep pneumonia, beta hemolytic strep, ecoli, HI, n.gonorrhea, enterobacteria
Can cause local ocular, toxicity or hypersensitivity
Pregnancy category C
No drug to drug interactions

Question 14

Azithromax (eye)

Answer 14

Gets 88% of gram positive and 92% of gram negative bacteria in RCT including 93% of HI
Age less that one safety not established
No drug to drug interactions

Question 15

Fluoroquinolones (eye)

Answer 15

Bacterial cidal via inhibition of DNA gyrase
Active against staph, strep, HI, klebsiella, proteus, enterobacter, p.aeruginosa
Pregnancy category C
In those less than one year safety is not established
Moxifloxacin is ok for children for 4 moths and older
Can cause a white crystal precipitate in the cornea lid crusting crystal scales and sense of foreign body in the eye altered taste can also cause photophobia nausea decrease vision , conjunctival hyperemia, corneal straining
Drug-drug- increases theophyline and INR levels

Question 16

Polytrim (eye)

Answer 16

Combination of polymyxin B and trimethiprim
Polymyxin B binds to cell membranes with increased specifically with phospholipids in the cell wall increase cell wall permeability
Active against gram negative ecoli, pseudomonas, HI
Trimethoprim inhibits bacterial dihydrofolate reductase
Covers gram positive and negative bacteria active against staph, strep, strep pyogenes
No drug to drug interactions

Question 17

Polysporin

Answer 17

Polymyxin B and bacitracin
Active against gram positive and negative bacteria
Not for those less than 2 months

Question 18

Antiviral for eye

Answer 18

Should be prescribed by an ophthalmologist
Gancyclovir (Zirgan), ridarabine (vira A), trifluridine (viroptic)
Zirgan- inhibits relocation of Y HSV by inhibiting synthesis of viral DNA
Vira A- MOA unknown, active against HSV 1-2, VZV, CMV
viroptic-MOA unknown, active against HSV1-2, adenovirus, vaccinia
Can cause burning or irritation when instilling, gancyclovir can cause blurred vision, punctuate keratitis, conjunctival hyperemia, Vira A can cause photophobia itching erythema, ocular pain tears, punctuate keratitis exposed to UV light sunglasses needed,
Viroptic can cause reactions similar to Vira A, increase intraocular pressure

Question 19

Precautions/adverse effects on eye antibiotics

Answer 19

Ointment may decrease corneal healing after surgery or trauma
Local irritation usually transit
Super infection can occur with prolonged or repeated use

Question 20

Ophthalmia neonatorum

Answer 20

Seen an infants less than one month of age
Chlamydia most common
GC is most serious than patients need I M ceftriaxone 50 mg per kilogram is the max dose, 125 mg X1
If Extraocular s/s- 7 day course of IM or IV is needed, cannot give Rocephin to those with elevated bilirubin give cefatoxine 50-100 mg/kg/day BID for 7 days
Prevention -prophylactic antibiotics to one hour post delivery erthyromycin ointment 0.5 %, 0.25-0.5 inch ribbon to each eye
Chlamydia- systemic EES, 30-50 mg/kg/day for 2-3 weeks or Zithromax 20 mg/kg/day X 3 days
Chlamydia conjunctivitis is not prevented with EES at birch any mucopurulent drainage in 1st few weeks of life check for chlamydia

Question 21

Bacterial conjunctivitis

Answer 21

Children-3 months to eight years, staph, strep, HI. non typable HI in warm climates, May through October. Strep pneumonia in colder climates. In children greater than 7 years HI most common
Elderly- s aureus and pseudomonas in 70 years or older
Self limited infection, antibodies can speed recovery and may be required for most schools before returning
Uncomplicated can be treated with sulfa 10% solution or ointment, EES ointment, polytrim or polysporin, sofa does not cover HI, and it stings, better choice would be tobramycin, Gentamycin, azith, fluoroquinolone
If caused by dacrostenosis, s pneumonia, HI, uses EES, tobra, fluoroquinolone

Question 22

Conjunctivitis otitis syndrome

Answer 22

Conjunctivitis with otitis media in those less than six years of age
82% of the time it’s HI
Treatment is oral antibiotics active against HI such as Augmentin 80-90 mg/kg/day is DOC
No eye treatment needed if orals given

Question 23

Gonococcal conjunctivitis

Answer 23

Purulent bacterial conjunctivitis usually respond to topicals unless hyperpurulent in a newborn with a sexually promiscuous parent, do a Gram stain and culture
Treatment is Rocephin 1 gram IM X1, normal irrigation to clear drainage

Question 24

Blepharitis

Answer 24

Acute or chronic inflammation of the lash follicles and meibomian gland of the lashes
Treatment is warm compress 5 to 10 minutes twice a day or four times a day, scrub lashes with gentle tears shampoo , EES ointment 0.24 inch ribbon to both eyes twice a day until symptoms resolve then for seven more days, ointment is preferred or Zithromax 1% solution twice a day times four weeks
No eye contacts during therapy sterilize before reinserting and discard all eye makeup

Question 25

Hordeolum

Answer 25

Also known as a stye and infected sebaceous gland of the lash or lid usually caused staph aureus
Treatment is a warm moist compress, four times a day for 15 minutes or a sulfa 10% or polytrim drops or EES ointment 0.5% QID until symptoms are gone then three more days
Usually ruptures on its own, if not needs a referral to ophthalmologist

Question 26

Viral conjunctivitis

Answer 26

Usually adenovirus, HSV, VZV
Adeno- treatment with 10% sulfa solution ointment, four times a day or tobrmycin to prevent bacteria superinfection for 12 to 15 days until conjunctivitis runs its course
HSV-heroes keratitis can be complication referred to a ophthalmologist
Can also be given antivirals

Question 27

Mast cell stabilizers

Answer 27

Anti-inflammatory or anti-allergic for the eye
Includes iodoxamide (alomide), nedrocromil (alocril), cromolyn Na(Cromolom)
MOA- decrease sensitivity reactions by inhibiting the granulation of sensitive mass cells, also inhibit, histamine, and slow reacting substance of anaphylaxis, selective for H1 receptor, block, histamine, receptor, and inhibit, histamine and stimulated vascular permeability in the conjunctiva, decrease ocular itching
Avoid wearing staff contact lenses when using drops
Lodoamide safe in 2 years or older, cromolyn safe in those 4 tales or older
Can cause transient discomfort or tearing, dry eyes, foreign bodies sensation itching of the eyes and crystalline deposits,
Adverse effects- naphazoline can precipitate narrow angle glaucoma, mydriasis, increased IOP, dermatitis
Can be continued for 90 days

Question 28

Antihistamines

Answer 28

Anti-inflammatory or anti-allergic for the eye
Includes levocabastine (livostin), antazoline (vascon-A), azelastine (optivar), bepotastine (bepreve), epinastine (elastat), emedastine (emadine), ketotifen (zabitor), olopatadine (pantanol, pataday), emedastine (emadine)
Avoid wearing soft contacts when using drops
Pregnancy category C
Headaches, conjunctival, injections, and rhinitis
Ketotifen- Used for conjunctivitis and tearing, 1 grr to each every every 8-12 hrs, levocabastine 1 gtt to affected eye QID

Question 29

NSAIDs

Answer 29

Anti-inflammatory or anti-allergic for the eye
Includes fluriprofen (ocufen), Suprofen (profenal), diclofenac (voltaren), nepafenac (nevanac), ketorolac (acular)
Have analgesic antipyretic and anti-inflammatory activity , decrease prostaglandin E2 in aqueous humor by inhibiting prostaglandin biosynthesis
If patients are allergic to acetylsalicyclic acid use caution when prescribing
Pregnancy category C
AE-may cause minor ocular irritation contribute to superficial ocular infection, superficial keratitis, superficial inflammation corneal edema

Question 30

Corticosteroids

Answer 30

Anti-inflammatory or anti-allergic for the eye
Potent anti inflammatory many different names should be prescribed by ophthalmologist
Topical steroids anti-inflammatory MOA is not known to include phosoholipase A2 inhibitory proteins, these can increase intraocular pressure mechanism not known
Pregnancy category C
AE- severe glaucoma, optical nerve damage, field defects and decrease vision, cataract formation, secondary infection and perforated globe

Question 31

Ocular lubricants

Answer 31

Artificial tears
Immune modulator anti-inflammatory - cyclosporine (restasis) used to treat dry and usually prescribe by eye doctors
These products contain balance solutions of salt to maintain ocular tonicity buffers to adjust pH viscosity to prolong and preservatives. They are not absorbed.
No true contra indications product that contain benzalkonium chloride do not use with soft contacts
Used for Dry eye syndrome -wanted to drop in each eye, four times as needed
AE-mild stinging and blurred vision transient

Question 32

Ophthalmic vasoconstrictors

Answer 32

Use for temporary relief of redeye for minor irritants. These agents are used by optic specialist to dilate pupils
Sympathetic agents that construct the conjunct vessel sympathomimetic drugs
No data available on the Pharmacokinetics
Duration -oxymetazoline is 4-6 hrs, tetrahydrozoline is 1-4 hrs
Contraindicated in patients sensitive to the product or patient has narrow angle glaucoma
Pregnancy category C
AE- transient, stinging Burning with installation, mydriasis, increased tearing, irritation and discomfort, most serious side effect is increased intraocular pressure, rebound congestion
Drug-drug- TCAs and maprotiline (ludiomil) increases pressor effects, no MOAIs with 21 days of ophthalmologic sympathomimetics
Dosing- tetrahydrozoline 1-2 gtt QID, oxymetazoline 1-2 gtt QID, naphazoline 1-2 gtt QID, phenylephrine 1-2 gtt QID

Question 33

Diagnostic eye products

Answer 33

Topical fluorescein sodium used to detect corneal epithelial defects/abrasions
Fluorescein is a yellow water soluble dibasic acid xanthine due
Green color
Corneal Defect will uptake dye and will appear bright green under UV or lamp
Not absorbed pharmacokinetically
Do not use the soft contacts and they will get stained can reinsert After Iser flush with saline and patient weights one hour hour
Pregnancy category C
AE- none
Staining a cornea will resolve with a few hours

Question 34

Otic anti invectives

Answer 34

Otitis externa is an acute painful inflammation of the external auditory canal also called swimmers ear, when there’s a breakdown and protective mechanisms,
Medication used to involve cortisporin (hydrocortisone + neomycin), pediotic (hydrocortisone + polymixin B), ciprodex (dexamthasone + cipro), cipro HC( hydrocortisone +cipro)
Antibiotics alone include Gentamycin and ofloxacin, acid or alcohol drops-otic domeboro, burow’s otic, voSol, voSol HC
MOA-hydrocortisone decreases inflammation exact MOA is unknown, neomycin is an active against staph aureus, proteus, enterobacter, polymyxin B active against gram negative, Gentamycin active pseudomonas, staph, strep pneumonia, beta hemolytic strep, enterobacter, cipro/ofloxin- active against staph, strep pneumonia, proteus, enterobacter, and pseudomonas, acid solutions- otic doneboro and burow’s otic solution contain 2% acetic acid, decrease inflammation and are antibacterial and anti fungal
Cipro is contraindicated if eardrum is perforated
Cortiosporin otic solution ok if eardrum is perforated
Prolong use a topical antibiotic to superinfection and overgrowth of nonsensical organisms and fungi
AE- ofloxacin- taste, alterations, dizziness vertigo paresthesia, pediotic and cortisporin-ototoxicity may occur with long use
TX- If TM intact cleanse with warm NS or 3 % h202, topical antibiotics are DOC, 4 gtt QID for 7-10 days-cortisporin, pediotic, coly-mucin S otic, Ciloxin HC, Gentamycin or ofloxin, topical acid or alcohol solution 4 gtt QID if TM intact, if canal is too swollen for gtt, wick 0.25 gauze or cotton in EC for 24-3) hrs meds cha be dropped in wick
Chronic OE- 2-3 gtt of baby or mineral oil, steroid lotion and creams, shampoo
Malignant OE- rare but potentially deadly caused by pseudomonas, older patients with DM, can cause osteomyelitis and meningitis, treat with IV antibiotics aminoglycosides and carbenicillin for 4-6 weeks plus debridement

Question 35

Ceruminolytics

Answer 35

Excess wax can cause conductive hearing loss of wax impactation, and environment for OE to develop
Treat with mineral oil or carbamide peroxide (debrox) softens, and emulsifies wax, 1-5 gtt BID for 4 days
Once wax a soft irrigate year with warm water sailing if canal is extorted apply in antibiotics or steroid drops for 7 to 10 days to prevent the development of OE

Question 36

Ear drops

Answer 36

If TM ruptured so not give solutions most are CI, ciprodex suspension, ofloxin solution, cortisporin solution, pediotic solution are ok