Ocular Lecture 1 Flashcards by Bryan Parrott

ocular drugs that inhibit nucleic acid or protein synthesis

antivirals

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Ocular viral infections more common in elderly

HSV

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Ocular viral infections more common in immunocompromised

CMV

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purine nucleoside analog 3% ointment intervenes with DNA synthesis, discontinued from market, treats HSV 1/2 and VZV

Vidarabine

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topical thymidine analog that inhibits DNA synthesis DOC for HSV Keratitis, Corneas with lesions only, used with lubricant due to severe dry eye SE

Trifluridine

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Topical antiviral, DNA synthesis inhibitor, Gel, herpetic keratitis, off label use for EKC, SE Blurred Vision (b/c gel)

Gancyclovir

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Antiviral 200 and 400 mg for HSV1/2 and 800mg for VZV. Prophylactic treatment in patients with history of HSV Stromal Disease and treat HZO, start tx within 72 hours of symptoms,after that, tx is not effective SE: Diarrhea, maculopapular rash, CI in elderly, immunocompromised with renal disease

Acyclovir

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Oral Antiviral, , hydrolyzed by esterase liver and GI tract for improved bioavailability, used for HSV keratitis and HZO

Valacyclovir

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DNA synthesis and replication inhibitor, Bioavilability of 65-77%, used to Decrease Twofold Duration of Post-Herpetic Neuralgia (pain) SE: MIGRAINES, Parathesia

Famciclovir

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Antiviral injection, acyclic nucleoside analog, used for CMV retinitis in HIV patients (severe manifestations)

Cidofovir

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IV antiviral that inhibits DNA and RNA polymerase, for CMV retinitis in immunocompromised patients, SE: retinal toxicity, azotemia, Anemia, CNS, GI

Foscarnet

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Fungal infection common in CLS patients

Aspergillus Umigatus

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4 Fungal ocular infections

Candida albicans, Aspergillus, Fusarium, Curvularia

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Predisposing factors for ocular fungal infections

CLS, Vegetative Trauma, Immunocompromised

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Limited treatment, requires laboratory evidence from spears, scrapping and cultures

Fungal Treatment

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Limitations of Fungal treatment

SE’s, Narrow spectrum, Poor penetration, Fungal resistance

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Type of antifungal that inhibits ergosterol synthesis

Azoles- Ketoconazole, Miconazole, Fluconazole, Voriconazole

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Type of antifungal that binds to ergosterol to interrupt it, binds less to human cells, less toxic

Polyene- Ampho B, Natamycin

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Polyene antifungal used to treat candida and histoplasmosis ulcers, orbital infections, and endophthalmitis, has good corneal penetration, SE tissue necrosis, yellow cornea (toxicity), monitor kidney function

Amphotericin B

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TOPICAL antifungal polyene, very aggressive tx, DOC for Anterior segment infections (keratitis/blepharitis/conjunctivitis), uses dropper that CANNOT touch cornea, well tolerated, SE allergic rxn, corneal opacity

Natamycin

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Oral antifungal azole, topical and oral, second line for corneal ulcurs after natamycin. Less toxic than ampho b, effective against candida albicans and aspergillums, careful with antacids SE papilledema, cross rxn with other meds

Ketaconazole

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Azole anti fungal suspension/ sonconj. depot/ oral, effective against aspergillus and fusarium, used clinicaly to treat corneal ulcers and endophthalmitis, Third Line after natamycin and ketaconazole

Miconazole

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Azole anti fungal, 90% bioavailability, DOC for Fungal Keratitis, fights against candida and cryptococcus, , SE drug interactions, resistance in HIV, potent teratogenic

Fluconazole

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2nd gen broad spectrum azole antifungal, first line against Keratitis by Aspergillus. SE blurred vision PHOTOPHOBIA, altered perception, CI in many systemic medications

Voriconazole

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Anti protazoal, Folic acid antagonist -requires supplement- combo with sulfonamide, treats Toxoplasmosis, SE folate deficiency, carcinogenic, skin rash- stop immediately, anorexia, CI in renal and hepatic disease, pregnant, children

Pyrimethamine

Antihelminthic drug, 200 mcg per kg body weight, that targets GABA receptors, treats onchovcerca volvulus, used clinically to treat River Blindness, SE anorexia, constipation, dizzy, peripheral and facial edema

Ivermectin

Anti inflammatory drugs that targets phospholipase A2 to prevent prostaglandin formation, will reduce immune system with long term use

Steroids

Anti inflammatory drugs that target cyclo-oxygenase to prevent prostaglandin formation

NSAIDs

Form of Corticosteroids with best penetration

Acetate

Which type of treatment of corticosteroids crosses the BBB and can cause ovular hypertension and psuedoendopthalmitis?

Intravitreal

Category of treatment that causes adrenal insufficiency, CUSHINGS syndrome, peptic ulcers, osteoporosis, hypertension, muscle weakness or atrophy, stunted growth, DIABETES (causes hyperglycemia), mood changes, delayed wound healing

Corticosteroids

Prednisolone, fluorometholone, dexamethasone, rimexolone, diflruoprednisolone- type of corticosteroids

Ketones - corticosteroids

Loteprednol- type of corticosteroid

Ester - corticosteroids- less SE

2. Ocular anti inflammatory, oral cortisol analog, acetate, often combined with sulfacetamide antibiotic, more frequent tx = more effective, but more likely SE's

Prednisolone

1. Stronger than prednisolone, cortisol analog, usually in combo with tobramycin, neomycin, or as implant 0.7%,

Dexamethasone

3. progesterone analog, Not as strong but comparable anti inflammatory to prednisolone but is good at reducing inflammation

Fluoremetholone

Ester corticosteroid "soft drug", 0.2% for allergic conjunctivitis and 0.5% for general inflammation, combo with tobramycin, little to no IOP elevation

Loteprednol

Similar to Loteprednol, but only used for reducing inflammation after cataract sx, no effect on IOP

Rimexolone

Newest corticosteroid derived from prednisolone that effects IOPS after 10 days, also used for inflammation after surgery AND Anterior Uveitis, only needed 2x per day.

Difluprednate

SE of Corticosteroids- most common, seen in both eyes, more common with oral tx, common in SLE and RA pts due to extended use, 80% occurrence in doses above 15mg

Cataracts- posterior subcapsular

SE of Corticosteroids- due to ouflow resistance, mostly prednisolone or dexamethasone 2 to 8 weeks after therapy, History is important: POAG, fam hx, age, myopia 5D or more, Krukenberg's spindles

Ocular hypertension or Glaucoma, AVG 4.6 - 6.6 mmHG increase

SE of Corticosteroids- reason to avoid use in bacterial infections with no scarring, not used alone in active infection, usually in combo also

Increased susceptibility to infections

SE of Corticosteroids- more common in black patients with discontinuation of prolonged therapy

Corticosteroid Uveitis

SE of Corticosteroids- Involving Pupil size and Eyelids

mydriasis and ptosis

CAUTION for what category of drugs? DM, infection, renal failure, CHF, HTN, potentiates Barbiturates and reduces anticoagulants

CAUTION with Corticosteroids

CONTRAINDICATIONS for what category of drugs? Peptic ulcer, osteoporosis, psychosis, GLAUCOMA

Contraindications with Corticosteroids

Drug category used for mild to moderate inflammation, but mostly for PAIN, do NOT increase IOP and are not toxic, better tolerance, mostly used to reduce pain after surgery

NSAIDs

Drug for pain reduction after REFRACTIVE surgery, off label post op CME, seasonal allergic conjunctivitis, and inflamed pterygium, 0.4% solution, used with phenylephrine for post cataract sx

Keterolac

First opthalmic NSAID in US, clinical DILATION after cataract surgery

Flurbifrofen

Pos op PAIN MANAGEMENT in post op cataract surgery, refractive surgery, and strabismus, also filamentary keratitis

Diclofenac sodium

NSAID with LESS side effects than most NSAIDs, used for post op INFLAMMATION and pain reduction after cataract surgery

Bromfenac

SUSPENSION for Post op inflammation and pain reduction after cataract surgery

Nepafenac

are NSAID's used for corneal abrasions, allergic conjunctiitis- mild, FB removal, adapting hard contact lens, adapting punctal plugs?

Other "beneficial" uses for NSAIDs, but not necessary or best

NSAID with SE of delayed wound healing

Ketorolac

NSAID with SE of corneal melting

Diclofenac

NSAIDs are CI in patients hypersensitive to this drug

Aspirin

Anti inflammatory Immunomodulator- inhibits T-cell activation, used to treat KERATOCONJUNCTIVITIS SICCA (severe DES), refractivs surgery DES, Behcet's disease, Uveitis, contra in children/pregnant, NO IMMEDIATE RELIEF so need paired with something else, expensive so use as last resort

Cyclosporin A

Immediate or anaphylactic hypersensitivity, takes 15 to 30 min, mediated by IgE, lots and lots of Itching,

Type 1 Hypersensitivity

Delayed hypersensitivity, involves T lymphocytes and granular monocytes or macrophages: CKC, GPC, contact dermatitis

Type 4 Hypersensitivity

Clinical Use and Time Constraint for Decongestants

Histamine induced erythema, used no more than 48 to 72 hours after symptoms

Decongestants are CI in what kind of patients?

Narrow angle, risk of angle closure

First gen Anti Histamines, OTC and combo with decongestants

Pheniramine maleate and Antazoline phosphate

OTC Anti allergic TRIPLE ACTION drug, for allergic conjunctivitis, mild CKC and GPC

Ketotifen fumarate

Anti allergic drug, treats seasonal allergic conjunctivitis, mild VKC and GPC, same as ketotifen

Olapatadine HCL

Dual Action H1 inhibitor and Mast Cell stabilizer, aproved for allergic conjunctivitis, >2 years old

Bepotastine

Dual action anti allergic for ITCHING PREVENTION in allergic conjunctivitis

Epinastine HCL

Dual action anti allergic for allergic conjunctivitis, like bepotastine, epinastine, and olapatidine SE: HEADACHES

Emedastine Difumarate

anti allergic TRIPLE ACTION with RAPID ONSET used for allergic conjunctivitis

Azelastine HCL

PEDIATRIC anti allergic triple action for allergic conjunctivitis, Bepotastine also works for children over 2

Alcaftadine

Which causes burning stinging, first or second gen antihistamines? Which can occlude the angle?

FIRST, also FIRST

First Gen antihistamines- cross BBB, sedation

brompheniramine, chlorphenirmine, clemastine, diphenhydraine, promethazine

Second Gen antihistamines- selective for H1

loratadine, desloratadine,

drug category used to treat moderate to severe lid edema and chemosis, subconjunctival and nasal itching, watery and red eyes.

Oral Antihistamines

2 mast cell stabilizers approved for VKC

Cromolyn sodium and lodoxamide

Pemirolast, nedocroil, lodoxamide, cromalyn sodium

Mast cell stabilizers

mast cell stabilizers are used instead of antihistamines when?

prophylactic tx, for prevention of allergic reaction

Corticosteroid used for allergic reactions

loteprednol etabonate

NSAID used for chemosis in allergic reaction

Keterolac tromethamine

3 main pain mediator substances

PG- from damaged tissue Bradykinins- enter damaged tissue from circulation Substance P- from highly myelinated nerve endings

Non-opioid analgesic used for mild to moderate ocular pain

Aspirin

Most commonly prescribed analgesic, used when aspirin and NSAIDS are CI, caution in chronic alcoholism

Acetaminophen

Side Effect of Decongestants-Pupils

Pupil Dilation then Rebound Miosis

Antihistamines that cause Verticillate-type Keratopathy (2)

Naphazoline and Antazoline