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Ocular Pharmacology > Mydriatics and Cycloplegics > Flashcards

Mydriatics and Cycloplegics Flashcards

1
Q

What are catecholamines?

A

hormones including dopamine, epinephrine, and norepinephrine = produced from tyrosine in post-ganglionic fibers in ANS and adrenal medulla

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2
Q

What are the 2 enzymes for catecholamine metabolism?

A

COMT and MAO

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3
Q

What is cycloplegia?

A

paralysis of ciliary body musculature responsible for accommodation

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4
Q

What is anaphylaxis?

A

an acute, systemic allergic hypersensitivity reaction to a previously sensitized allergen

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5
Q

What causes histamine release, bronchoconstriction, vasodilation, and swelling during anaphylaxis?

A

IgE in bloodstream reacting with the antigen

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6
Q

What are the treatments for anaphylaxis?

A

O2, IV steriods, airway management (intubation) and EpiPen

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7
Q

Why is an Epipen effective for anaphylaxis reactions?

A

Epinephrine will counteract the anaphylaxis symptoms and restore normal BP and prevent shock

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8
Q

What conditions should you use caution in when administering an EpiPen?

A

heart disease, high BP, Parkinson’s disease, diabetes, and thyroid disorders

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9
Q

What regulates the fight or flight response?

A

sympathetic or adrenergic branch of ANS

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10
Q

What regulates the rest and digest response?

A

parasympathetic or cholinergic branch of ANS

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11
Q

What are the neurotransmitters in the sympathetic system?

A

epinephrine and norepinephrine

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12
Q

what is the neurotransmitter of the parasympathetic system?

A

acetylcholine

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13
Q

What is the receptor type for ganglia within the sympathetic system? (post-ganglionic neurons)

A

nicotinic receptors

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14
Q

What is the receptor type(s) for sympathetic adrenergic system?

A

alpha and beta

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15
Q

what is the receptor type for the sympathetic cholinergic system at the terminal organs?

A

muscarinic receptors

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16
Q

what is the receptor type for parasympathetic cholinergic system at the terminal organ?

A

muscarinic receptors

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17
Q

where are alpha 2 receptors primarily located?

A

pre-synaptic and stimulation causes inhibition of signal propagation

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18
Q

What are 2 things that occur with stimulation of alpha 2?

A

decreased insulin release and decreased aqueous production

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19
Q

What are 2 things that occur with stimulation of alpha 1?

A

vasoconstriction, mydriasis

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20
Q

what are 5 things that occur with stimulation of beta 2?

A

vasodilation, bronchodilation, glucogenolysis, increased insulin release, and relaxation of ciliary body with increased aqueous production

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21
Q

what occurs with beta 1 stimulation?

A

increased cardiac contractility and conduction

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22
Q

what is alpha 1 selective for?

A

NE>E

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23
Q

what is alpha 2 selective for?

A

E greater than or equal to NE

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24
Q

what is beta 1 selective for?

A

E=NE

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25
Q

what is beta 2 selective for?

A

E

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26
Q

What is the backbone of catecholamines?

A

tyrosine

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27
Q

what is tyrosine converted to once inside a pre-synaptic nerve terminal in sympathetic system?

A

converted to dopamine

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28
Q

what happens to dopamine after being converted from tyrosine?

A

placed in vesicles (stable and remains stored until needed) –> converts to NE when needed

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29
Q

What are the steps following a nerve impulse in the sympathetic system?

A

Ca++ uptake is facilitated and enters terminal –> with elevated Ca levels = degranulation of vesicles into synaptic cleft

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30
Q

what happens if NE acts as bio-feedback and stimulates an alpha 2 receptor?

A

interferes with Ca++ ability to cause degranulation and stops NE release

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31
Q

Where are MAO and COMT located to help metabolize NE?

A

MAO is in pre-synaptic terminal and COMT is in post-synaptic terminal

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32
Q

what happens to NE with cocaine and amphetamines?

A

blocks NE in synaptic cleft

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33
Q

what are the 5 ocular adrenergic effects (fight or flight)?

A

mydriasis, increased IP aperature, modulate aqueous production, modulate vascular tone, receptors in trabeculum and schlemms canal suppress accommodation

34
Q

what are some examples of cases with reduced sensitivity for dilation?

A

age-related miosis, unstable diabetes, post-op pupils, posterior synechiae, dark iris, pseudoexfoliation syndrome

35
Q

what is an example of a case with increased sensitivity to dilation?

A

down syndrome

36
Q

what are some cases you need to use caution before dilation?

A

homocystinuria and marfan’s syndrome, pregnancy, pigmentary or exfoliative glaucoma

37
Q

what are some examples of contraindications for dilating?

A

iris supported IOL, subluxated lens or IOL, extremely narrow angle, angle closure history w/o PI

38
Q

how soon will a patient have an iatrogenic angle closure after dilation?

A

4-8 hours post instillation

39
Q

what occurs to the ciliary body with cycloplegia?

A

prevents the ciliary body from contracting = disables accommodative function

40
Q

what are some examples of times you would want to use cycloplegia?

A

strabismus (esotropia), pseudomyopia/accommodative spasm, latent hyperopia, anisometropia, amblyopia, malingerers, unexplained refractive error or un-responsive patients

41
Q

what are 2 sympathetic mydriatics?

A

phenylephrine and hydroxyamphetamine (PAREMYD)

42
Q

what is the activity of phenylephrine?

A

alpha 1 selectivity and some indirect effects via NE release

43
Q

What are some actions of phenylephrine?

A

mydriasis (45-60min), conjunctival blanching (vasoconstriction), mild accommodation suppression (2D), lid retraction, IOP reduction **fight or flight actions

44
Q

What are 4 special indications that Phenylephrine can be used for (other than mydriasis)?

A

posterior synechiae breakage, pre-Lasik vasoconstriction, inhibition of iris cysts (caused by echothiophate), horner’s evaluation

45
Q

How can phenylephrine help diagnose Horner’s syndrome?

A

use 1% - it will dilate the pupil with post-ganglionic sympathetic denervation and cause no/minimal dilation in the normal eye

46
Q

What are some adverse effects of phenylephrine?

A

photophobia/glare, allergic dermatoconjunctivitis, rebound miosis, anterior chamber pigment liberation, hypertension/bradycardia

47
Q

What is rebound myosis?

A

patient responds to agent with mydriasis but when effect wears off the miotic response is bigger (pupil is smaller than normal)

48
Q

What are some contraindications for phenylephrine?

A

avoid 10% in neonates/elderly, history of CVD/MI, DM1, aneurysm, arteriosclerosis, hypotension, drugs: atropine, TCAD, MAOI, reserpine, guanethidine, methyldopa

49
Q

What is hydroxyamphetamine used for?

A

mydriasis without suppressing accommodation - can be used to differentiate between pre-ganglionic and post-ganglionic sympathetic denervations (PAREYMD can too)

50
Q

What does hydroxyamphetamine act on?

A

indirect acting - promotes NE release from nerve terminals (blocks uptake of NE and keeps it in synaptic cleft)

51
Q

What is PAREMYD?

A

1% hydroxyamphetamine and 0.25% Tropicamide

52
Q

What are 3 benefits of PAREMYD?

A

mydriasis independent of age or pigmentation, faster recovery then phenylephrine/tropicamide (better for shallow angles), no benefit to anesthetic before use

53
Q

What is different about the adverse effects of PAREMYD vs. Phenylephrine?

A

leads to tachycardia instead of bradycardia

54
Q

Which types of patients is PAREMYD safer in vs. phenylephrine?

A

diabetics, hypotension, chemical sympathectomy agents

55
Q

Are the parasympathetic receptors inhibitory or stimulatory?

A

all are stimulatory (sympathetic receptors are both)

56
Q

What is the M1 receptor associated with?

A

memory

57
Q

Which parasympathetic receptor is better at miosis and ciliary body contraction/increased aqueous production?

A

M3

58
Q

Which parasympathetic receptor is responsible for salivary glands and vasodilation?

A

M3

59
Q

Which parasympathetic receptor is better at cardiac contractility and conduction?

A

M2

60
Q

Which parasympathetic receptor is responsible for emesis?

A

M3

61
Q

Which parasympathetic receptor is responsible for bronchoconstriction and secretion?

A

M2 = M3

62
Q

What 2 things does Acetylcholine break down into? (2 esters)

A

acetate and choline (broken down by esterases = AChE)

63
Q

What happens when choline enters a nerve terminal?

A

choline adds with acetyl-CoA to make ACh and placed into vesicles

64
Q

What happens in the parasympathetic system when Ca++ enters a nerve terminal?

A

triggers degranulation and the ACh vesicles are released into the synaptic cleft where AChE breaks it down into acetate + choline

65
Q

Name 6 anticholinergic agents?

A

atropine, scopolamine, homatropine, tropicamide, cyclopentolate and cyclomydril

66
Q

Which parasympathetic receptors does Atropine use?

A

non-selective M receptors

67
Q

which anticholinergic agent is selective for M4 only?

A

Tropicamide

68
Q

what is cyclomydril made of?

A

0.2% cyclopentolate + 1% phenylephrine

69
Q

What is atropine used for?

A

cycloplegia, severe uveitis, amblyopia, ciliary body spasm, synechiae, lens advancement, vessel permeability, myopic progression

70
Q

what is scopolamine used for?

A

travel sickness (emesis) - pronounced CNS effects

71
Q

what is homatropine used for?

A

moderate uveitis, corneal abrasions, mydriasis

72
Q

what is cyclopentolate used for?

A

cycloplegia, moderate uveitis, corneal abrasions

delayed/sustained effects in dark pigment iris (less flushing and dryness than atropine)

73
Q

what is tropicamide used for?

A

cycloplegia, mydriasis, mild uveitis

74
Q

What are 3 ocular adverse effects for anticholinergics?

A

increased IOP, angle closure risk and allergy

75
Q

What are the ABCDs (systemic) adverse effects of anticholinergics?

A

Anorexia, blue, constipation/confusion, dryness, sedation/stasis of urine

76
Q

What are 2 adverse effects for anticholinergics in the CNS (medulla)?

A

decreased Parkinson tremor and decreased heart rate

77
Q

what are some contraindications for anticholinergics?

A

classic antihistamines, TCADs, anti-psychotics, Down syndrome, albinism, cerebral palsy, narrow angle, iris supported IOL, spastic paralysis, OAG, ACG

78
Q

What combination of drugs gives the best mydriasis outcome?

A

0.25% tropicamide + 1% PAREMYD

79
Q

what is the safest dilation drop to use?

A

tropicamide (only lasts about 6 hours = shortest duration)

80
Q

which drop do you administer 1 drop initially then another 15-25 min later?

A

cyclopentolate

81
Q

which cycloplegic drop lasts the longest?

A

Atropine (7-12 days)

Ocular Pharmacology (10 decks)

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