Med classes Ocular- Quiz 1 Flashcards
Aminoglycosides (EYE ABX)
- If you can, you should something be”SIDES” this abx because its harsh
-Tobramycin and Gentamycin
-Effective against Gram - AND +
-ADE: Ocular tox +hypersnesitivty
Fluoroquinolones (EYE ABX)
ADE
Effective against
-This standa”LONE” abx class can make your tendon rupture
-Ex. Ciprofloxacin, Ofloxacin, Moxifloxacin, Levofloxacin
-Effective against Gram - AND +
-ADE: Crystal precipitate in eyes/ crusting/ foreign body feel/corneal stain
-Do NOT give with theophylline (INR)
Macrolides (EYE ABX)
-Ex. Erythromycin, Azithromycin
-Effective against Gram +
-EES Given within 1 hour of birth (doesn’t prevent chlamydia but DOES prevent opthalmia neonatorum/ gonorrhea)
Sulfonamides (EYE ABX)
Effective against
-Ex. Sulfacetamide
-Effective against Gram - AND +
-NOT compatible with zinc + silver (forms precipitate)
-Antagonized by the “caines”
Polypeptides ABX
(USUALLY COMBO EYE ABX)
-Ex. Polymyxin B, Bacitracin
-Often combined with other abx (ex polysporin, polytrim)
-Effective against Gram -
-NOTE* Straight polypeptide abx are only gram -, combo is often Gram - AND+*
Nucleoside Analogues (EYE ANTIVIRALS)
-“analogues” are too old to go viral
-WE DONT PRESCRIBE THESE
(critical care ophthalmologist does ;)
-Ex. Gancyclovir, Vidarabine,
Trifluridine
-Mainly treat: HSV, VZV, CMV
-Can cause burning/ irritation/ blurry
What do I actually need to know about ocular agents absorption?
-Abx/ antivirals penetrate only ocular fluid & tissues
-Limited systemic absorption so limited ADE EXCEPT Sulfacetamide (also dont use with ocular exudate, sulfa may be inactivated)
-Local irritation—usually transient
-Superinfection can occur with prolonged/repeated use
When should you not use ointments in the eyes and why?
-After trauma or surgery, ointments may decrease corneal healing
Which ocular med classes are Category C in pregnancy?
-Polypeptide (abx)
-Macrolides (abx)
-Nucleoside analogues (antivirals)
-Sulfonamides (abx)
-
Which ocular med classes should not be used in lactation?
-Sulfacetamide & Fluoroquinolones (harmful to infant)
-NOTE* EES and tobra safe in children*
Common Conjunctivitis per age
-Most common cause: H ifluenza or Strep Pneumoniae (Bacterial)
-Preschoolers: usually bacterial
-School aged: Viral w adenovirus
-Sexually active teens/adults—check
for Neisseria gonorrhea
-Adults—viral or bacterial
Ophthalmia Neonatorum- what to know
-Seen in infants <1 month of age
-Chlamydia most common pathogen
-GC is most serious—Ceftriaxone
-Cannot give Rocephin to those with elevated bilirubin—give Cefotaxime
-Prevention—proph abx to eye
within 1 hour of delivery (EES)
Neonatal Chlamydia
-Chlamydia—systemic ABX for 2-3 weeks OR Zithromax for 3 days
-Chlamydia conjunctivitis NOT prevented with EES at birth
-Any mucopurulent discharge in 1st few weeks of life—check for chlamydia
Bacterial Conjunctivitis Children V elderly common causes
-Children (3 mo to 8 years):
Staph, Strep or Haemophilis
- >7 years—H flu most common
-Elderly—Staph aureus and Pseudomonas (those >70 years)
-Usually self limiting but abx can speed up recovery
Bacterial Conjunctivitis Tx
-Uncomplicated disease can be treated with: Polypeptides, sulfonamides, aminoglycosides, macrolides, fluroquinolones
(sulfa stings and doesnt cover H flu)
Conjunctivitis-Otitis Syndrome
-Seen in those under 6
-Usually caused by H . Flu
-Treat with Augmentin PO
(No specific eye therapy)
Gonococcal conjunctivitis (GC)
-SEVERE infection by Neisseria gonorrhoeae.
-Purulent bacterial conjunctivitis
usually responds to topicals
(except hyperpurulent in a newborn in which need gram stain)
-Adults: acquired through direct contact w infected genital secretions
-Neonates: Passed from an infected mother to the baby during childbirth (known as ophthalmia neonatorum).
-Treat with Rocephin IM and NS irrigations to clear exudate
Blepharitis
-Acute/ chronic inflammation of the lash follicles and Meibomian glands
-Treat with: warm compresses, scrub lashes with no-tear shampoo, EES ointment until symptoms resolve, THEN for another 7 days OR Zithromax solution for 4 weeks
-NOTE* No contacts during tx and discard all eye make up*
Hordeolum (Stye)
-Infection of sebaceous gland of lashes or lid
-Cause—Staph aureus
-Treatment—warm moist compress, Sulfacetamide Polytrim gtts or EES
ointment until sx are gone then for
another 3 days
-Stye will usually rupture on its own—if not—refer to ophthalmologist
Extra shit for eyes that’s good to know
-H. flu high on your list of causes (do not use Sulfacetamide d/t poor coverage—Polysporin or Polytrim have good coverage)
-In infants—EES is DOC
-NOTE* Zithromax/ Fluoroquinolones are 10x the cost of EES
Glaucoma
-Leading cause of blindness
-Therapies for glaucoma are aimed at decreasing production of aqueous humor and increasing outflow of this fluid from the angle structures
-Mandatory Ophthalmology consult
What are the 6 main categories of anti-glaucoma agents?
- Beta blockers
- Adrenergic agonists
- Miotics (Inhibit cholinesterase)
- Carbonic anhydrase inhibitors (CAI’s)
- Sympathomimetics
- Prostaglandin agonists
Beta Blockers for Glaucoma
MOA
ADE
Interactions
- MOA:—decrease IOP by
interfering with production of aqueous humor and IOP is decreased (Exact MOA unknown)
2.Pharmacokinetics: Little is known (Duration is 12-24 hours)
-Systemic absorption DOES occur and can be seen w lungs and heart - Precautions/ CI:
-Topical BB are contraindicated with
bradycardia/AV block or SBP <100
-Also contraindicated with Raynaud’s, PAOD or vascular disease
-Use with caution with poorly controlled DM (can prolong & enhance hypoglycemia
-Pregnancy category C
-Topical BB excreted in breast milk (contraindicated in breast feeding) - ADE: HA, dizziness and systemic BB effects, bradycardia, hypotension, bronchospasm
5: Drug/drug inter: Use w systemic BB- worry about bradycardia/ ASYSTOLE
-Interacts with: other BB, pressors, CCB, Digoxin, Amio, Beta agonists
Adrenergic Agonists for Glaucoma
1.MOA: Decreases IOP by reducing the production of aqueous humor by increasing uveoscleral outflow
2. Pharmacokinetics: peak levels in 1-4 hours; metabolized in liver/ eliminated in urine
3. Precautions/ CI: Brimonidine is CI in those on MAOIs
-Do not instill with contact lens in—wait 15” after use before contacts
-Pregnancy Category C
4. ADE: feel like they have a foreign body in the eye/ pain
-Systemic effects—dry mouth, drowsiness, HA
5. Drug-drug inter: Do not use with MAOIs
-Additive effects w CNS depressants
-Drugs that can lower HR may have additive effects of depressing HR/ BP
brimonidine (Alphagan P) and apraclonidine (Iopidine)
Miotics for Glaucoma
- MOA: Indirect agents that inhibitcholinesterase and Cause intense miosis & muscle contraction
–>IOP is decreased by a decreased resistance to aqueous outflow - Pharm: Little is known (Duration is 6-8 hours)
- Precautions/CI: Contraindicated with eye inflammation or when no constriction wanted—iritis, uveitis, secondary glaucoma
- ADE: Corneal clouding, HA, RETINAL DETACHMENT
-Systemic effects—HA, HTN, salivation, sweating, n/v - Drug-Drug: can have additive effect w systemic anticholinesterases
Pilocarpine, Physostigmine, and Isoflurophate
Carbonic Anhydrase Inhibitors for Glaucoma (CAI’s)
- MOA: work by inhibiting the enzyme carbonic anhydrase, which reduces the production of bicarb and thus lowers the formation of aqueous humor–> resulting in decreased IOP
- Pharm: Differ greatly, generally well- absorbed systemically and distributed, primarily renal excretion
- Precautions/CI: absorbed in amounts great enough to cause hypersensitivity in those w Sulfa Ax
-Pregnancy Category C
-CI in lactation; safety in kids NOT known
-NOTE* There are A LOT of variations here I went generic don’t use this damn drug if possible* - ADE: taste alterations, keratosis
- Drug-drug:Concurrent use of CAI and high dose salicylates may cause
metabolic acidosis & salicylate toxicity
dorzolamide (Trusopt) and brinzolamide (Azopt)
acetazolamide (Diamox, AK-Zol) and methazolamide (Neptazane, GlaucTabs)
Sympathomimetics for Glaucoma
- MOA: stimulate adrenergic receptors leading to vasoconstriction and lowered IOP.
- Pharm: Unknown
- Precautions/CI: CI in those allergic to Clonidine in those with narrow angle glaucoma
-Pregnancy Category C +
Not recommended for children or nursing moms
-NOTE* again a lot of variability here* - ADE: Conjunctival and/or corneal pigmentation
-Systemic effects—HA, HTN, elevated HR, cardiac arrhythmias - Drug-drug:No known drug interactions (Except Apraclonidine dont use w MAOIs pot HTN crisis)
Brimonidine, Apraclonidine, Dipivefrin
Prostaglandin agonists for glaucoma
1.MOA: primarily increase aqueous humor outflow through uveoscleral pathway, which helps reduce IOP.
2. Pharm: absorbed through cornea—hydrolyzed to active form; not known if it crosses placenta; metabolized in the urine.
3. Precautions/CI: Latanoprost—do not instill with contacts in; use with caution in those with iritis
-Pregnancy Category C; not for use in
children or lactating moms
4. ADE: foreign body sensations, iris discoloration (usually permanent)
5: Drug-Drug: Interacts with Thimerosal; wait 5 minutes between gtts if one contains Thimerosal
Prostaglandin Agonist Prototype Drug
-Lantanoprost (Xalantan)
-FDA: Glaucoma
MOA: Exact unknown but thought to increase outflow of aqueous humor by acting on this receptor and thus decreases IOP
-ADE: eye redness/ irritation iris pigmentation, periorbital skin darkening
-CDR: HA/Dizziness/congestion
-No black box warning
-Category C/ dont use if lactating
Prostaglandin Agonist Drugs
-All have “PROST” in name
-Lantanoprost, Bimatoprost (Latisse), Unoprostone, Travaprost
What monitoring do anti- glaucoma agents require?
-BP and CV status
What are the ocular anti-allergics?
- Anti-histamines
- Mast cell stabilizers
Anti-histamines
-All have “INE” as in histamINE
-Levocabastine
-Antazoline
-Azelastine
-Bepotastine
-Epinastine
-Emedastine
-Ketotifen
-Olopatadine
-Pheniramine
- Emedastine
Mast Cell stabilizers
-Iodoxamide
-Nedocromil
- Cromolyn Na+
What are the ocular anti-inflammatory meds?
- NSAIDS
- Corticosteroids
NSAIDS
-All have “OFEN or AC”
-Fluriprofen
-Suprofen
-Diclofenac
-Nepafenac
-Ketorolac
Corticosteroids
-Potent antiinflammatories
[many different names] should be
prescribed by
ophthalmologists!!
-DONT PRESCRIBE THESE
Mast cell stabilizers for ocular anti-allergic meds
MOA
CI
ADE
- MOA: decrease sensitivity reactions by inhibiting degranulation of sensitized mast cells that have been
exposed to antigens, also inhibit histamine & slow reacting
substance of anaphylaxis - Pharm: Limited systemic absorption; metabolism/ excretion not known
- Precaution/CI: Avoid wearing soft contacts when using gtts with benzalkonium chloride
- ADE: Transient tearing/ discomfort
- Safety: Are safe in adults,
children and pregnant women
Ocular antihistamines
MOA
CI
ADE
- MOA: selective for H1 receptor; block histamine receptor & inhibit histamine stimulated vascular
permeability in the conjunctiva;
decrease ocular itching - Pharm: Limited systemic absorption; metabolism/ excretion not known
- Precaution/CI: Avoid wearing soft contacts when using gtts with benzalkonium chloride
- ADE: Transient tearing/ discomfort/ HA/ conjun infection/ rhinitis
5: Safety: Are safe and can be
used in children as young as 2
NSAIDs ocular anti-inflammatory
MOA
CI
ADE
- MOA: decrease prostaglandin E2 in
aqueous humor by inhibiting
prostaglandin biosynthesis - Pharm: Limited systemic absorption; metabolism/ excretion not known
- Precaution/CI: If patient is allergic to acetylsalicylic acid—use caution when prescribing NSAIDs
-Pregnancy Category C - ADE: Transient tearing/ discomfort/ may cause minor irritation and can contribute to superficial ocular infection, keratitis, inflammation, corneal edema, iritis
5: Safety: Are safe in adults and used
for vernal conjunctivitis
Corticosteroids ocular anti-inflammatory
- MOA: Unknown; thought to induce
phospholipase A2 inhibitory proteins - Pharm: Limited systemic absorption; metabolism/ excretion not known
- Precaution/CI: those that need steroids should be referred for
slit-lamp to rule out HSV keratitis (steroids can cause blindness if this is present)
-Pregnancy Category C - ADE: Transient tearing/ discomfort/ glaucoma, optic nerve damage, field
defects/ decreased vision, cataract formation, secondary infection and PERFORATED GLOBE
What should be monitored with ocular agents?
-IOP
-ONLY BY OPTHOMALOGIST
Ocular Lubricants
-AKA “Artificial tears”
- Cyclosporine (Restasis)
MOA: Immune modulator/ anti-inflammatory
2. Pharm: Contain balanced
solution of salts to maintain ocular
tonicity, buffers to adjust pH, viscosity to prolong eye
contact time and preservatives; not absorbed
3. Precautions/CI: None (Other than Products that contain benzalkonium
chloride dont use with soft contacts)
4. Used mainly for dry eye syndrome
5. ADE’s: Transient Mild stinging and blurred vision
Ophthalmic Vasoconstrictors
- Use: Used for temporary relief of red eye from minor irritants and allergic conjunctivitis, and are used by ophthalmologic specialists to dilate pupils
- Pharm: Weak sympathomimetic agents that constrict the
conjunctival vessels - Duration: 1-6 hours
- Precautions/CI: if patient is sensitive to product or if patient has narrow angle glaucoma
-Category C
-NOT recommended for kids - ADE’s: Transient stinging/burning with instillation/ increased tearing
-Most serious—increased IOP
(Rebound congestion can develop with extended use) - Drug-drug: TCAs and Maprotiline
increases pressor effect;
No MAOIs within 21 days of use
Diagnostics for eyes
- Topical Fluorescein Na—used to
detect corneal defects/abrasions - Pharm: Is a yellow water soluble
dibasic acid xanthine dye that
produces intense green color in
alkaline [pH of 5.0] solution
(Corneal defect will uptake dye and
will appear bright green under UV or
Wood’s lamp) - Pharmacokinetic: not absorbed
- Precautions/ CI: Do not use with soft contacts in—they get stained; can re-insert after eyes are flushed with saline and patient waits 1 hour
-Pregnancy Category C
5: ADE: Drug-drug: None
