Lecture 3 Stuff Flashcards
What is aqueous humor?
A watery substance that nourishes the lens and cornea. It is formed and secreted by the ciliary processes. On the ciliary body, carbonic anhydrase, alpha and beta adrenergic receptors, and sodium and potassium activated ATPases are present and appear to be involved in the pathway of aqueous humor. Aqueous humor is secreted into the posterior chamber of the eye creating pressure that then pushed the aqueous humor between the iris and lens and through the pupil into the anterior chamber of the eye.
Aqueous humor in the anterior chamber drains the eye via what routes?
- Filtration though the trabecular meshwork (conventional outflow)to the Schlemm canal (80 to 85%)
- Through the ciliary body and the suprachoroidal space (uveoscleral outflow or unconventional outflow).
What is glaucoma’s statistics?
It is the 2nd leading cause of blindness and is 6 times more likely in African Americans.
What are the risk factors for glaucoma?
IOP Older age Family history of glaucoma Genetic mutations African ancestry or Latino/ Hispanic ethnicity Low ocular perfusion pressures Type 2 DM Myopia thinner central cornea
What is the normal IOP?
21 mmHg
What are the two types of open angle glaucoma(60 to 70 percent of glaucoma)?
Primary:
Most common type of glaucoma
With or without increased IOP
Vision loss is typically the 1st sign
Secondary:
Known eye disorder altering normal fluid flow.
What are the two types of closed angle glaucoma?
Chronic:
less than 5 percent of all glaucoma’s
Mechanical blockage of trabecular meshwork by peripheral iris.
Acute:
Medical emergency
IOPs greater than 40 percent
What is the first sign of glaucoma?
visual field loss (IOP can be increased or normal)
vision loss is associated with increasing IOP
The increased IOP in all types of glaucoma results from?
decreased facility for aqueous humor outflow through the trabecular meshwork
What causes closed angle glaucoma?
The angle formed by the cornea and iris closes, preventing the aqueous humor from draining normally. Partial or complete blockage occurs intermittently resulting in fluctuations between symptoms and no symptoms.
What are the signs and symptoms closed angle glaucoma?
Can cause acute elevations in IOP greater than 40 mmHg. Cloudy, edematous cornea, ocular pain, or discomfort, nausea, vomiting, abdominal pain, and sudden onset of visual disturbance (often in low light)
What is the goal of therapy of open angle glaucoma?
A target IOP of 20 to 30 percent reduction from baseline is recommended. The main goals of therapy include reduction of IOP to preserve vision, prevent functional vision loss, and slow/stop the progression of optic nerve damage, while minimizing adverse effects associated with therapy.
What are the first line agents for glaucoma?
beta blockers or prostaglandin analogs
if contradiction then brimonidine
if contradiction again then topical CAI
What if there is no response to first line agents for glaucoma?
Switch to alternative first-line agent if no response.
Add second first-line agent if partial response.
What is the treatment for closed angle glaucoma?
1st line = Iridectomy
may use pharmacologic therapy as an adjunct or prior to surgery to reduce IOP
Treatment of an acute attack generally involves pilocarpine, hyerosmotic agents, and a secretory inhibitor (Beta blocker, alpha 2 agonist, prostaglandin analog, or topical or systemic CAI)
What are the glaucoma clinical pearls?
Instilling more than one drop at a time does not improve response.
Monocular use of medication is suggested for initial administration to assess efficacy and tolerance.
Initial IOP response does not predict long-term response.
Ideally, only one drop of a single medication should be instilled in the eye at any given time. If a patient is on more than one eye drop, they should be administered at least 5 to 10 minutes apart to allow for complete absorption of each eye drop.
If compliance is an issue, consider oral therapy.
It is important to teach patients proper eye drop instillation technique.
How much glaucoma medication passes through the nasolacrimal canal into systemic circulation?
about 80 percent
Why should you close eyelid and punctual occlusion and for how long?
Significantly decreases the systemic absorption and other things….
Recommended amount of time is 2 to 5 minutes.
What are the colors of the caps on the glaucoma agents?
Prostaglandins are Turquoise
Beta-blockers are yellow or blue(low dose)
adrenergic agonists are purple
carbonic anhydrase inhibitors are orange
parasympathomimetic agents - Miotics are green
What are the prostaglandin analogs MOA?
increased aqueous humor uveoscleral outflow and to a lesser extent trabecular outflow.
What are the side effects of prostaglandin analogs?
Conjunctival hyperemia Eyelash growth Ocular pruritus iris color change (3-12 months) Periocular hyperpigmentation (panda eyes, reversible)
What are the contraindications to prostaglandin analogs?
Macular edema
History of herpetic keratits (herpes simplex virus 1 or 2) - it can make the virus spread
Which prostaglandin is preservative-free solution?
tafluprost (Zioptan)
How often are prostaglandins dosed?
1 drop every night
What is the strength of the latisse and lumigan?
latisse 0.03 percent
Lumigan 0.01 percent
What are the prostaglandin agents, strengths included?
latanoprost (Xalatan) - 0.005 percent
bimatoprost (Lumigan) - 0.01 percent
travoprost (Travatan Z) - 0.004 percent
tafluprost (Zioptan) - 0.0015 percent
What are the side effects of beta-blockers?
Stinging/burning bronchospasm (nonselective) bradycardia depression impotence decrease in blood pressure
What are the contraindications to beta blockers?
COPD (nonselective) Asthma (nonselective) bradycardia hypotension greater than first degree heart block
What beta blocker glaucoma drops come in a suspension?
betaxolol comes in a generic solution and brand suspension
What beta blocker glaucoma drops come in a gelling solution?
timolol
What are the doses of the beta blockers?
1 drop twice a day
timolol except XE is 1 drop 1 to 2 times a day
What are the side effects of alpha 2 adrenergic agonists?
allergic reactions dizziness fatigue somnolence headache dry mouth possible a slight reduction in blood pressure and pulse
What formulation does alpha 2 adrenergic agonists come in and what is the dose?
solution
1 drop 2 to 3 times a day
What are the nonselective adrenergic agonists side effects?
headache burning/stinging blurred vision ocular pain mydriasis brow ache
What are the contraindications to the non-specific adrenergic agonists?
Hypersensitivity
Angle-closure glaucoma
Aphakia
What are the contraindications to alpha 2 adrenergic agonists?
Monoamine oxidase inhibitor therapy
What is the usual dose of a non-specific adrenergic agonist?
1 drop twice a day
What are the contraindications of anhydrase inhibitors?
Sulfonamide allergy
Kidney stones
aplastic anemia
thrombocytopenia
What are the side effects of CAI?
Topical: Burning/stinging ocular discomfort transient blurred vision tearing
Oral:
Malaise, anorexia, depression, fatigue, nausea
Serum electrolyte imbalance
renal calculi
blood dyscrasias (aplastic anemia, thrombocytopenia)
Metallic taste
What is the usual dose of CAI’s?
Topical
Azopt (suspension more blurry)- 1 drop 2 to 3 times a day
Trusopt (solution) 1 drop 2 to 3 times a day
Systemic
tablet 125mg,250mg 2 to 4 times a day
injection 250-500mg
capsule 500 mg twice a day
What are the parasympathomimetic agents side effects?
miosis decreased vision eye or brow ache/pain eyelid twitching conjunctival irritation cataract precipitate angle closure glaucoma
What are the contraindications of parasympathomimetic agents?
hypersensitivity
angle-closure glaucoma
active uveal inflammation
What are the formulations of parasympathomimetic agents (Miotics)?
Solutions
Pilocarpine comes in a gel too
What is the usual dose of parasympathomimetic agents?
1 drop two to three times a day.
Which parasympathomimetic agents is the last option because of SE?
Echothiophate (Phospholine Iodide)
What is the overall benefits of prostaglandins vs beta blockers?
Prostaglandins - Excellent efficacy and side effect profile, better IOP reduction, once-daily dosing, good tolerance, availability of lower-cost generics.
Beta blockers - Twice daily dosing, less IOP reduction, tachyphylaxis, potential systemic side effects, monitor of DDI and other comorbidities, lower-cost generics.
What type of otic disorder are self treatable?
External disorders involving the auricle (also called the pinna) and external auditory canal (EAC), including excessive cerumen and water clogged ears.
How do childrens EAC differ from adults?
Childrens are shorter, straighter, and flatter
What is the clinical presentation of impacted cerumen?
Fullness or pressure Sometimes a dull pain is present Chronic cough Gradual hearing loss Vertigo and/or tinnitus can also be present Mild pain
What is the treatment for excess/impacted cerumen?
The first step is to use a cerumen softening agent, and then gently irrigating the ear with an otic bulb and warm water, if cerumen remains in the ear canal. Cotton-tipped swabs or other foreign objects should not be used to remove cerumen.
What are the exclusions for self-treatment for impacted cerumen and water-clogged ears?
Severe pain Signs of infection Pain associated with ear discharge Bleeding or signs of trauma Presence of ruptured tympanic membrane (abrupt hearing loss and sharp pain) Ear surgery within prior 6 weeks Tympanostomy tube present Incapable of following proper instructions Hypersensitivity to recommend agents less than 12 years of age
What is the nonpharmacologic therapy for impacted cerumen?
remove cerumen when it has migrated to the outermost portion of the EAC by using a wet, wrung-out washcloth draped over a finger. This method is not effective when cerumen is already impacted; however, it can help prevent impaction when used as a part of a daily routine.
What is the pharmacologic therapy for impacted cerumen?
Carbamide peroxide 6.5 percent in anyhydrous glycerin in the only FDA approved OTC product available at this time for cerumen softening. Mineral oil, olive oil, glycerin, docusate sodium, and dilute hydrogen peroxide have all been used by primary care providers, but there is no data to support these remedies as being more effective than caramide peroxide, thus they should not be recommended.
How often should carbamide peroxide be used?
twice daily, but should not be used for more than 4 consecutive days. Adverse effects include pain, irritation, redness, discharge, and dizziness. Referral should be made if no improvement is seen within 4 days of treatment or if worsening occurs.
What is the difference between water clogged ears and otitis externa?
Otitis externa, also called swimmer’s ear, is an infection of the outer ear. There is the thought that treating water=clogged ears to remove moisture will prevent the tissue maceration that causes otitis externa. Otitis externa requires treatment with antibiotics.
What is the clinical presentation of water-clogged ears?
Feeling of wetness or fullness
Gradual hearing loss
Can cause tissue maceration that can cause itching, pain, inflammation, or infection.
What is the nonpharmacologic treatment for water clogged ears?
Gentle manipulation of the auricle while tilting the affected ear downward can help to remove excessive water. Using the low setting of a blow dryer around the ear immediately after swimming or bathing can help dry the ear canal. ClearEars are single use ear plugs that help remove water from the ear in patients 17 years and older, though they will not prevent water from entering during bathing or swimming.
What is the pharmacologic treatment for water clogged ears?
Only the use of isopropyl alcohol 95 percent in anhydrous glycerin 5 percent is approved by the FDA as an “ear-drying aid”. If symptoms persist after several days of simultaneous use of ear-drying aids, patients should be referred to a physician.
Acetic acid 5 percent in a 50:50 mixture of isopropyl alcohol 95 percent has bactericidal and antifungal properties and has also been used. It is well tolerated, but may sting or burn slightly. This would need to be compounded. Repeated use can cause over drying of the ear canal.
A primary care provider should be consulted if symptoms have not improved or worsen within 4 days of treatment.
What are the guidelines for administering eardrops?
Wash hands thoroughly.
Warm eardrops by holding them in the palm of the hands. Do not warm in hot water as it may injure the ear.
Shake if indicated.
Tilt your head or lie with the affected ear up.
Position the dropper directly over, but not in the ear canal.
Adults: pull the ear back and up to open the ear.
Children less than 3: Pull the ear back and down.
Insert the number of drops indicated.
Press the tragus gently over the ear canal opening to force out bubbles and push the drops into the ear canal.
Stay in the same position for the amount of time indicated. If a child will not stay still you may place a piece of clean cotton gently into the ear that is large enough to remove easily. Do not leave in longer than 1 hour.
What is tooth hypersensitivity?
Short, sharp pain in response to a stimulus (thermal, chemical, or physical) that cannot be attributed to any other dental issue. The pain is caused by exposed dentin, which is the mineralized tissue of the teeth.
What is the difference between toothache and hypersensitivity?
Hypersensitivity:
Exposed or open dentin tubules
Quick, fleeting, sharp, or stabbing pain on stimulation.
Stops after stimuli are no longer present.
Toothache:
Bacterial invasion to the pulp.
Intermittent, short, and sharp pain on stimulation may indicate reversible damage.
Continuous, dull, and throbbing pain without stimulation usually indicates irreversible damage.
What are exclusions for self-care for a dental?
Toothache
Mouth soreness associated with poor-fitting dentures
Presence of fever or swelling
Loose teeth
Bleeding gums in the absence of trauma
Broken or knocked-out teeth
Severe tooth pain triggered or worsened by hot, cold, or chewing.
Trauma to the mouth with bleeding, swelling, and soreness
What is the nonpharmacologic therapy for tooth hypersensitivity?
Eliminate predisposing factors
Soft bristle toothbrush
Brush less vigorously
Fluoride containing toothpaste
What is the pharmacologic therapy for tooth hypersensitivity?
Toothpaste containing a potassium salt decreases the nerve excitability.
Potassium nitrate with sodium fluoride
potassium nitrate and dimethyl isosorbide
Not recommended in children less than 12 years.
Do not brush 30 minutes after eating acidic foods.
How do you apply dentrifices?
Use a strip of at least 1 inch twice daily with a soft bristled toothbrush for at least 1 minute. It may take 2-4 weeks to relieve the symptoms.
When does teething occur?
Over an 8 day period with each tooth and usually starts at 6 months of age.
What is the pharmacological treatment for teething?
Benzocaine is available for the treatment of oral pain in strengths of 5 percent. 20 percent should not be used in children!! FDA says benzocaine should not be used. Acetaminophen may be used.
What are canker sores?
Recurrent Aphthous stomatitis (RAS) are precipitated by stress and local trauma. The sores are localized on nonkeratinized mucosa, such as the tongue, floor of the mouth, soft palate, and inside lining of the lips and cheeks.
What is the nonpharmacologic treatment of RAS?
Increased Nutrient consumption
Avoid food allergies, spicy and acidic food
Ice can be applied in increments of 10 minutes but not longer than 20 minutes in an hour.
Stress reduction
What is the nonpharmacologic treatment of RAS?
Oral debriding and wound cleansing agents.
Carabamide peroxide (10-15 percent)
Hydrogen peroxide (1.5%)
Use up to 4 times daily after meals for no more than 7 days
Don’t use sodium laurel sulfate.
Saline rinses - 1 to 3 teaspoons of salt in 4 to 8 ounces of warm water.
Paste of baking soda and water.
What are the triggers for Herpes Simplex Labials?
stress, fatigue, cold, windburn, UV radiations, and injury
What are exclusions for treatment for HSV-1?
Lesions present more than 14 days Increased frequency of outbreaks Compromised immunity Symptoms of systemic infection no previous diagnosis of cold sore
What are the exclusions for self-treatment of dry mouth?
Tooth erosion, decalcification and decay
Candidiasis, gingivitis and periodontitis
Reduced denture-wearing time
Mouth soreness associated with poor fitting dentures
Presence of fever or swelling
Loose teeth
Bleeding gums in the absence of trauma
Broken or knocked-out teeth
Severe tooth pain triggered or worsened by hot, cold or chewing.
Trauma to the mouth with bleeding, swelling, and soreness
What are common anticholinergics?
Diphenhydramine Chlorpheniramine Amitriptyline Cyclobenzaprine Prmethazine Oxybutynin Tolterodine
