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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
Artificial Tears MOA
* Increase tear film stability | * Decrease ocular surface stress
26
Artificial Tears Treatment
Improves symptoms and vision ability | • Prevents ocular damage
27
Artificial Tears Consider
* Preservatives * Present in multi-dose products * Viscosity * ↑viscosity = ↓ evaporation / ↑ retention time * pH / Tonicity * Similar to physiological
28
Artificial Tears Adverse Effects
* Preservatives * Irritation * Ocular damage * Visual changes • Infection - Inappropriate use / storage
29
Preservatives Role
* Bactericidal | * Included in multi-dose containers
30
Preservatives
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
31
Ophthalmic Ointments: Non-medicated Products
* Petrolatum * Mineral oil * Lanolin
32
Ophthalmic Ointments: Severe disease
• ↑ viscosity = tear film stability / ↑ retention time
33
Ophthalmic Ointments: Adverse effects
• Blurry vision - apply at bedtime
34
Dry Eye Treatment Approach-Mild
* Low viscosity agent | * Drops 1-2 times per day
35
Dry Eye Treatment Approach- Moderate
* Low viscosity | * Drops 3-4 times per day
36
Dry Eye Treatment Approach-Severe
* Non-preservative low viscosity – applied every hour as needed * Ophthalmic ointment at bedtime
37
No relief in 72 hours?
Refer to provider
38
Dry Eye Additional Therapies
``` -Medications (RX) • Anti-inflammatory • Systemic omega-3 • Cyclosporine • Systemic agents ``` - Interventions • Punctal plugs • Corrective surgery • Corrective lenses
39
Allergic Conjunctivitis Chief Complaint
* Redness * Watery discharge * Pruritus * “Allergic shiners” * Visual changes = atypical * Seasonal allergic rhinitis
40
Allergic Conjunctivitis Pathophysiology- Allergen contact
IgE mediated immune reaction
41
Allergic Conjunctivitis Pathophysiology- • Mast cell degranulation
histamine release
42
Allergic Conjunctivitis Pathophysiology-Histamine
vasodilation and itching
43
Allergic Conjunctivitis Risk factors
* Spring / summer * Geographical location * Environmental factors * Seasonal allergic rhinitis * Topical preparations
44
Allergic Conjunctivitis : Exclusions to Self-care
``` 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
Allergic Conjunctivitis NON-Pharm treatments
* Cold compress 3-4 times / day * Environmental changes * Close doors/windows * Use air conditioning * Use air filters * Monitor pollen counts * Avoid rubbing
46
Allergic Conjunctivitis Pharm treatments
First line - artificial tears • Second line - topical antihistamines, mast cell stabilizers, decongestants
47
Antihistamines MOA
* Antagonize histamine at H1 / H2 receptors | * Primary mast cell mediator
48
Antihistamines Products
* Pheniramine, antazoline, olopatadine (Pataday®) - use 3-4 x day * Ketotifen (antihistamine / mast cell stabilizer) - use 2-3 x day
49
Antihistamines Adverse Effects
* Burning /stinging * Discomfort * Pupil dilation
50
Antihistamines Contraindications
Closed angle glaucoma
51
Mast Cell Stabilizers-Mechanism
Prevent mast cell degranulation | • Inhibit eosinophils (late reaction)
52
Mast Cell Stabilizers-Products
* Ketotifen (antihistamine / mast cell stabilizer) * Immediate relief * 12 hour duration * Safest and most effective
53
Decongestants MOA
α – agonist properties cause vasoconstriction | • Decreases red-eye, edema, congestion
54
Decongestants Products
ducts • Phenylephrine • Imidazolines = oxymetazoline / tetrahydrozoline / naphazoline • 1-2 drops q 4-6 hours
55
Decongestants caution
``` Rebound toxicity (>72 hours) • Hyperemia • Allergic conjunctivitis • Blepharitis • Congestion ``` CAD/hypertension, Diabetes, Hyperthyroidism
56
Decongestants Adverse Effects
* Rebound toxicity (>72 hours) * Hyperemia * Allergic conjunctivitis * Blepharitis * Congestion
57
Pediatric Toxicity
Ingestion of ophthalmic decongestants: • Hypotension and bradycardia • CNS depression • Respiratory depression
58
Allergic Conjunctivitis Treatment Strategy
1st line = non-pharmacological treatment 2nd line = artificial tears 3rd line = Antihistamine / mast cell stabilizer (alone or combo product) Alternatives = decongestant, oral antihistamine
59
Corneal Edema Pathophysiology
Corneal swelling leading to visual changes (starbursts, halo around light) *Diagnosis required from HCP before OTC treatment*
60
Corneal Edema Etiology
* Over-wearing contact lens * Surgical damage * Inherited corneal dystrophy
61
Corneal Edema treatment
* Draw fluid from cornea | * OTC agents = Sodium Chloride (NaCl) solutions / ointment
62
Corneal Edema Treatment Strategy
1: 2% NaCl solution 4 times daily 2: add 5% ointment at bedtime 3: Increase to 5% NaCl solution
63
Corneal Edema Adverse effects
5% NaCl = burning / stinging
64
Foreign Substance Treatment
* Irrigation * Use saline solution, irrigation fluid, water * DO NOT use eye cup * Ointment at bedtime
65
Foreign Substance Refer
* Visual changes * Pain * Persistent redness * Wood or metal in eye
66
Chemical Burn-Products
* Acids / alkalis * Detergents * Solvents
67
Chemical Burn-Emergent irrigation
* Saline solution / water | * Immediate transfer to ED
68
Cerumen Impaction Epidemiology
* More common in pediatric and geriatric patients * 10% peds * 30% nursing home patients
69
Cerumen Impaction Self-Treatment
• OTC options for external ear disorders
70
Cerumen Impaction- Clincial Presentation
* Fullness / pressure in ear * Reduced hearing ability * Dull pain * Tinnitus * Vertigo
71
Cerumen Impaction-Pathophysiology
* Excess cerumen * Damage EAC which is a pathogen risk * Causes * Narrow or misshapen EAC * Excess hair * Overactive ceruminous glands * Hearing aids, ear plugs
72
Cerumen Impaction exclusions to Self-care
* Infection * Pain with discharge * Bleeding, trauma * Ruptured tympanic membrane * Recent surgery (<6 weeks) * Tympanostomy tubes * <12 years old
73
Cerumen Impaction Non-Pharm treatment
* Wet washcloth * Only for outermost portion of EAC * Otic bulb to administer warm water * Cotton swabs * NOT recommended
74
Cerumen Impaction Pharm-Treatment
Carbamide Peroxide
75
Carbamide Peroxide MOA
* Exposure to O2 → effervescence + urea * Effervescence helps to loosen and soften cerumen * Urea aids in tissue debridement
76
Carbamide Peroxide Directions of Use
* Twice daily for 4 days, then refer | * Rinse with warm water with otic bulb after dose
77
Ear Anatomy-External ear
* Auricle * External auditory canal (EAC) * Tympanic membrane
78
Ear Anatomy-Cerumen
* Lubricates EAC, traps dust, prevents pathogens * Collects dead skin * Travels outward to end of EAC
79
Water-clogged Ears Causes
* Altered external auditory canal * Excess cerumen * Hot and humid environment (excess sweating) * Swimming / bathing * Poor hygiene
80
Water-clogged Ears External Otitis (Swimmer's ear)
• Not amenable to self-care
81
Water-clogged Ears Clincial Presentation
* Feeling of wetness / fullness | * Reduced hearing ability
82
Water-clogged Ears treatement goals
* Prevent maceration * Reduce itching, pain, infection risk * Dry with safe and effective agent
83
Water-clogged Ears Exclusions to Self-care
* Infection * Pain with discharge * Bleeding, trauma * Ruptured tympanic membrane * Recent surgery (<6 weeks) * Tympanostomy tubes * <12 years old
84
Water-clogged Ears Non-Pharmacologic treatment
* Head tilt + auricle manipulation * Hair dryer * Water absorbing ear plugs
85
Water-clogged Ears Pharmacologic Treatments
* Isopropyl alcohol / glycerin | * Half and half mixture = 50% vinegar / 50% isopropyl alcohol (95%)

PHRM 504 (22 decks)

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