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PHRM 504 > Lecture 19: Ophthalmic & Otic Disorders > Flashcards

Lecture 19: Ophthalmic & Otic Disorders Flashcards

1
Q

Ophthalmic Disorders

A
  • Dry eye (keratoconjunctivitis sicca)
  • Allergic conjunctivitis
  • Corneal edema
  • Foreign substance
  • Chemical burn
  • Contact dermatitis
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2
Q

Epidemiology: •Dry Eye

A

Most common eye disorder
• Appropriate for self-care
• Exacerbated by environmental conditions and low humidity

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3
Q

Epidemiology: Allergic Conjunctivitis

A
  • Occurs in up to 40% of US population
  • Variable causes - geography, seasonal
  • Appropriate for self-care
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4
Q

Eye Anatomy

A
  • Protective barriers
  • Nasolacrimal system
  • Cornea
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5
Q

Protective barriers

A

Eyelid, eyelashes

• Non-stimulated tears (make up the tear layer)

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6
Q

Nasolacrimal system

A

• Drainage from punctum to the to nose

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7
Q

Cornea

A

Trilaminar barrier facilitates drug absorption
• Outer epithelial layer - lipophilic (fat soluble drugs)
• Middle stromal layer - hydrophilic (water soluble drugs)
• Inner epithelial layer

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8
Q 
What pharmacokinetic issue would you expect to most commonly
occur with ocular drug administration?
A) Drug dilution
B) Excessive ocular penetration
C) Retinal damage
D) Pupillary constriction
A

A) Drug dilution

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9
Q

Ophthalmic Pharmacokinetics Absorption

A
  • Increased by: increased time in cul-de-sac

* Decreased by: dilution and nasolacrimal drainage

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10
Q

Ophthalmic Pharmacokinetics Distribution

A

Typically local; may have systemic absorption via nasolacrimal
system

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11
Q

Ophthalmic Pharmacokinetics Metabolsim

A

Locally by enzymes and proteins

• Systemically by standard drug metabolism

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12
Q

Ophthalmic Pharmacokinetics Excretion

A

Nasolacrimal → systemic vasculature → standard elimination

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13
Q

Dry Eye Pathophysiology

A
  • Etiology
  • Decreased tear production
  • Increased tear evaporation (stability)
  • Mixed
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14
Q

Dry Eye -• Precipitating event

A
  • Stress to ocular surface → inflammatory process
  • Ocular damage
  • Decreased blink rate
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15
Q

Dry Eye -Chief Complaint

A
  • Redness
  • Burning, stinging
  • Foreign body sensation
  • Gritty, sandy
  • Pruritus
  • Photophobia
  • Visual changes
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16
Q

Dry Eye Disease: Risk is increased by

A
  • Older age
  • Female sex
  • Hormonal changes
  • Medications / comorbidities
  • Activities: computer / TV / reading
  • Ocular surgeries
  • Vitamin A deficiency
  • Environmental factors
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17
Q

Medications contributing to Dry Eye

A
  • Anticholinergic
  • Antihistamines (systemic)
  • Antipsychotics
  • Decongestants
  • Diuretics
  • Beta-blockers
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18
Q

Dry Eye Exclusions to Self-care

A
  • Symptoms
  • Eye pain (irritation is appropriate for self-care)
  • Blurry vision
  • Photophobia
  • > 72 hours symptoms
  • History
  • Contact lenses
  • Blunt trauma
  • Chemical / heat exposure
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19
Q

Approach to Treatment

A

1) Symptoms
2) Onset / Duration / Severity
3) Location / Time of day (diurnal)
4) Exacerbating / Mitigating
5) Previous treatments
6) Comorbidities / Medications
7) Allergies

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20
Q

Dry Eye Classification-Mild

A
  • Itching / irritation

* Intermittent visual changes (vision fatigue)

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21
Q

Dry Eye Classification-Moderate

A
  • More frequent symptoms

* Impacts activities of daily living (ADLs)

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22
Q

Dry Eye Classification-Severe

A
  • Constant symptoms

* Disabling

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23
Q

Dry Eye Non-pharmacologic: Avoidance

A
  • Cigarette smoke
  • Dry heating and air-conditioning
  • Computer / TV / reading
  • Environmental exposures / dust
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24
Q

Dry Eye Non-pharmacologic Treatments

A
  • Humidifier
  • Goggles/glasses
  • Eyelid hygiene
  • D/C or limit exacerbating medications
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25
Q

Artificial Tears MOA

A
  • Increase tear film stability

* Decrease ocular surface stress

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26
Q

Artificial Tears Treatment

A

Improves symptoms and vision ability

• Prevents ocular damage

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27
Q

Artificial Tears Consider

A
  • Preservatives
  • Present in multi-dose products
  • Viscosity
  • ↑viscosity = ↓ evaporation / ↑ retention time
  • pH / Tonicity
  • Similar to physiological
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28
Q

Artificial Tears Adverse Effects

A
  • Preservatives
  • Irritation
  • Ocular damage
  • Visual changes

• Infection
- Inappropriate use / storage

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29
Q

Preservatives Role

A
  • Bactericidal

* Included in multi-dose containers

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30
Q

Preservatives

A

May have a toxic effect on the tear film and cornea
• Long term use can lead to ocular damage
• Many preservatives are available
• Chlorhexidine is preferred to benzalkonium chloride (BAK) → less toxic
• Preservative-free/disappearing preservative options
• Single use
• More expensive

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31
Q

Ophthalmic Ointments: Non-medicated Products

A
  • Petrolatum
  • Mineral oil
  • Lanolin
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32
Q

Ophthalmic Ointments: Severe disease

A

• ↑ viscosity = tear film stability / ↑ retention time

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33
Q

Ophthalmic Ointments: Adverse effects

A

• Blurry vision - apply at bedtime

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34
Q

Dry Eye Treatment Approach-Mild

A
  • Low viscosity agent

* Drops 1-2 times per day

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35
Q

Dry Eye Treatment Approach- Moderate

A
  • Low viscosity

* Drops 3-4 times per day

36
Q

Dry Eye Treatment Approach-Severe

A
  • Non-preservative low viscosity – applied every hour as needed
  • Ophthalmic ointment at bedtime
37
Q

No relief in 72 hours?

A

Refer to provider

38
Q

Dry Eye Additional Therapies

A 
-Medications (RX)
• Anti-inflammatory
• Systemic omega-3
• Cyclosporine
• Systemic agents
  • Interventions
    • Punctal plugs
    • Corrective surgery
    • Corrective lenses
39
Q

Allergic Conjunctivitis Chief Complaint

A
  • Redness
  • Watery discharge
  • Pruritus
  • “Allergic shiners”
  • Visual changes = atypical
  • Seasonal allergic rhinitis
40
Q

Allergic Conjunctivitis Pathophysiology- Allergen contact

A

IgE mediated immune reaction

41
Q

Allergic Conjunctivitis Pathophysiology- • Mast cell degranulation

A

histamine release

42
Q

Allergic Conjunctivitis Pathophysiology-Histamine

A

vasodilation and itching

43
Q

Allergic Conjunctivitis Risk factors

A
  • Spring / summer
  • Geographical location
  • Environmental factors
  • Seasonal allergic rhinitis
  • Topical preparations
44
Q

Allergic Conjunctivitis : Exclusions to Self-care

A 
Symptoms
• Eye pain (vs. irritation)
• Blurry vision
• Photophobia
• >72 hours
• Mucus discharge
•History
• Contact lenses – don’t use contacts until AC is resolved
• Blunt trauma
• Chemical / heat exposure
45
Q

Allergic Conjunctivitis NON-Pharm treatments

A
  • Cold compress 3-4 times / day
  • Environmental changes
  • Close doors/windows
  • Use air conditioning
  • Use air filters
  • Monitor pollen counts
  • Avoid rubbing
46
Q

Allergic Conjunctivitis Pharm treatments

A

First line - artificial tears
• Second line - topical antihistamines, mast cell stabilizers,
decongestants

47
Q

Antihistamines MOA

A
  • Antagonize histamine at H1 / H2 receptors

* Primary mast cell mediator

48
Q

Antihistamines Products

A
  • Pheniramine, antazoline, olopatadine (Pataday®) - use 3-4 x day
  • Ketotifen (antihistamine / mast cell stabilizer) - use 2-3 x day
49
Q

Antihistamines Adverse Effects

A
  • Burning /stinging
  • Discomfort
  • Pupil dilation
50
Q

Antihistamines Contraindications

A

Closed angle glaucoma

51
Q

Mast Cell Stabilizers-Mechanism

A

Prevent mast cell degranulation

• Inhibit eosinophils (late reaction)

52
Q

Mast Cell Stabilizers-Products

A
  • Ketotifen (antihistamine / mast cell stabilizer)
  • Immediate relief
  • 12 hour duration
  • Safest and most effective
53
Q

Decongestants MOA

A

α – agonist properties cause vasoconstriction

• Decreases red-eye, edema, congestion

54
Q

Decongestants Products

A

ducts
• Phenylephrine
• Imidazolines = oxymetazoline / tetrahydrozoline / naphazoline
• 1-2 drops q 4-6 hours

55
Q

Decongestants caution

A 
Rebound toxicity (>72 hours)
• Hyperemia
• Allergic conjunctivitis
• Blepharitis
• Congestion

CAD/hypertension, Diabetes, Hyperthyroidism

56
Q

Decongestants Adverse Effects

A
  • Rebound toxicity (>72 hours)
  • Hyperemia
  • Allergic conjunctivitis
  • Blepharitis
  • Congestion
57
Q

Pediatric Toxicity

A

Ingestion of ophthalmic decongestants:
• Hypotension and bradycardia
• CNS depression
• Respiratory depression

58
Q

Allergic Conjunctivitis Treatment Strategy

A

1st line = non-pharmacological treatment
2nd line = artificial tears
3rd line = Antihistamine / mast cell stabilizer (alone or combo product)
Alternatives = decongestant, oral antihistamine

59
Q

Corneal Edema Pathophysiology

A

Corneal swelling leading to visual changes (starbursts, halo around light)

Diagnosis required from HCP before OTC treatment

60
Q

Corneal Edema Etiology

A
  • Over-wearing contact lens
  • Surgical damage
  • Inherited corneal dystrophy
61
Q

Corneal Edema treatment

A
  • Draw fluid from cornea

* OTC agents = Sodium Chloride (NaCl) solutions / ointment

62
Q

Corneal Edema Treatment Strategy

A

1: 2% NaCl solution 4 times daily
2: add 5% ointment at bedtime
3: Increase to 5% NaCl solution

63
Q

Corneal Edema Adverse effects

A

5% NaCl = burning / stinging

64
Q

Foreign Substance Treatment

A
  • Irrigation
  • Use saline solution, irrigation fluid, water
  • DO NOT use eye cup
  • Ointment at bedtime
65
Q

Foreign Substance Refer

A
  • Visual changes
  • Pain
  • Persistent redness
  • Wood or metal in eye
66
Q

Chemical Burn-Products

A
  • Acids / alkalis
  • Detergents
  • Solvents
67
Q

Chemical Burn-Emergent irrigation

A
  • Saline solution / water

* Immediate transfer to ED

68
Q

Cerumen Impaction Epidemiology

A
  • More common in pediatric and geriatric patients
  • 10% peds
  • 30% nursing home patients
69
Q

Cerumen Impaction Self-Treatment

A

• OTC options for external ear disorders

70
Q

Cerumen Impaction- Clincial Presentation

A
  • Fullness / pressure in ear
  • Reduced hearing ability
  • Dull pain
  • Tinnitus
  • Vertigo
71
Q

Cerumen Impaction-Pathophysiology

A
  • Excess cerumen
  • Damage EAC which is a pathogen risk
  • Causes
  • Narrow or misshapen EAC
  • Excess hair
  • Overactive ceruminous glands
  • Hearing aids, ear plugs
72
Q

Cerumen Impaction exclusions to Self-care

A
  • Infection
  • Pain with discharge
  • Bleeding, trauma
  • Ruptured tympanic membrane
  • Recent surgery (<6 weeks)
  • Tympanostomy tubes
  • <12 years old
73
Q

Cerumen Impaction Non-Pharm treatment

A
  • Wet washcloth
  • Only for outermost portion of EAC
  • Otic bulb to administer warm water
  • Cotton swabs
  • NOT recommended
74
Q

Cerumen Impaction Pharm-Treatment

A

Carbamide Peroxide

75
Q

Carbamide Peroxide MOA

A
  • Exposure to O2 → effervescence + urea
  • Effervescence helps to loosen and soften cerumen
  • Urea aids in tissue debridement
76
Q

Carbamide Peroxide Directions of Use

A
  • Twice daily for 4 days, then refer

* Rinse with warm water with otic bulb after dose

77
Q

Ear Anatomy-External ear

A
  • Auricle
  • External auditory canal (EAC)
  • Tympanic membrane
78
Q

Ear Anatomy-Cerumen

A
  • Lubricates EAC, traps dust, prevents pathogens
  • Collects dead skin
  • Travels outward to end of EAC
79
Q

Water-clogged Ears Causes

A
  • Altered external auditory canal
  • Excess cerumen
  • Hot and humid environment (excess sweating)
  • Swimming / bathing
  • Poor hygiene
80
Q

Water-clogged Ears External Otitis (Swimmer’s ear)

A

• Not amenable to self-care

81
Q

Water-clogged Ears Clincial Presentation

A
  • Feeling of wetness / fullness

* Reduced hearing ability

82
Q

Water-clogged Ears treatement goals

A
  • Prevent maceration
  • Reduce itching, pain, infection risk
  • Dry with safe and effective agent
83
Q

Water-clogged Ears Exclusions to Self-care

A
  • Infection
  • Pain with discharge
  • Bleeding, trauma
  • Ruptured tympanic membrane
  • Recent surgery (<6 weeks)
  • Tympanostomy tubes
  • <12 years old
84
Q

Water-clogged Ears Non-Pharmacologic treatment

A
  • Head tilt + auricle manipulation
  • Hair dryer
  • Water absorbing ear plugs
85
Q

Water-clogged Ears Pharmacologic Treatments

A
  • Isopropyl alcohol / glycerin

* Half and half mixture = 50% vinegar / 50% isopropyl alcohol (95%)

PHRM 504 (22 decks)

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