Ocular Pharm: L4: Drugs for Managing Ocular Inflammation (Anterior Segment and Adnexia)

Question 1

Type of Anti-Inflammatory Drugs

1. Steroids
2. NSAIDs
   a. Used in what inflammation type?
   b. Primarily used in what?
3. Immune System Suppressants
   a. What drug?
   b. What does it do?

Answer 1

2. a. Mild inflammation to avoid affects of steroids
   b. In Ocular Surgery
3. a. CYCLOSPORINE (Restasis)
   b. Interferes w/development and Activity of T Cells

Question 2

Mechanism of Steroids

1. Reduce existing what?
2. Prevent production of additional what?
3. Disrupt what?

Answer 2

1. Inflammatory Mediators
2. Inflammatory Mediators
3. Inflammatory Cascade

Question 3

1. Corticosteroids block what in the Inflammatory Cascade?

2. NSAIDs block what in the inflammatory cascade?

Answer 3

1. Tissue damage producing Phospholipase A2

2. the conversion of Arachidonic Acid to Cycloxygenase and thus no production of Prostaglandins from that route.

Question 4

Steroids

1. Do they TREAT the INFECTION?
2. GENERALLY used for what kind of DISORDERS (infectious/non-infectious)?
3. IF used when there is or may be an infection, what else should be given?

Answer 4

1. NO. They just reduce inflammation by TURNING the Cascade OFF!
2. STERILE (non-infectious disoders)
3. Anti-infective Meds

Question 5

Therapeutic Guidelines

1. Type and location of inflammation tells us whether to use what kind of drugs?
2. When do we treat?
   a. How high of a dosage?
3. When do we re-evaluate the dose?
4. how long do we treat for?
5. Long-term High Dosage therapy: How do we end it?
6. Short-term low dose therapy: Does it produce significant side effects?

Answer 5

1. Topical, Periocular, or Systemic Drugs
2. ASAP
   a. As high enough to suppress the inflammation
3. at Frequent Intervals
4. until we get the desired clinical response, then taper.
5. Taper the dose down. DONT ABRUPTLY STOP IT.
6. Shouldn’t create them.

Question 6

Strength of Steroids

1. Depends on derivative (3: highest strength to lowest)
2. Generally what formula tells you how well it will penetrate the corneal epithelium?
3. LOTEPREDNOL
   a. What is it?
   b. What causes loss of activity?
   c. Systemic exposure?
   d. Effective penetration of the globe?

Answer 6

1. Acetate > Alcohol > Phosphate
2. The Salt formula (and efficay once in the tissue)
3. a. Inactive Steroid Analog that’s Activated by DERIVATIVIZATION w/an ESTER GROUP
   b. De-Esterification in tissue causes loss of activity
   c. VERY LITTLE systemic exposure to active moiety
   d. Limited effective penetration of the globe

Question 7

Routes of Administration

1. Topical
   a. What areas of the eye?
   b. Many steroids are in what?
   c. What is an EMULSION?
2. Oral
   a. For what part of the eye?
   b. Can use what kind of dosing?
3. Systemic Injection
   a. For greater what?
   b. Can use what formulation?
4. Intravitreal administration
   a. To get what?
   b. Can use what?

Answer 7

1. a. Anterior Segment and Adnexia
   b. SUSPENSIONS (make sure pt mixes it well before using)
   c. DUREZOL: Doen’t need to be shaken before use
2. a. Posterior Segment
   b. Alternate Day Dosing (double dose every other day)
3. a. For greater anti-inflammatory effect than obtainable w/Topical or Oral Administration
   b. Depot Formulation
4. a. Sustained, High Intraocular Levels and minimizes Systemic Effects
   b. Injections or Inserts (Retrisert: Flucinolone Acetate)

Question 8

Side Effects

1. What are they?

Answer 8

1. Cataracts
2. Elevated IOP
   a. Steroid Responders
   b. Takes 4-8 wks to develop
   c. Higher incidence in pts w/POAG, or FHx of it
3. Immune System Suppression
   * Infection risk, don’t give alone in infectious condition
   * Never give w/Herpetic Corneal Defect
4. Retardation of Corneal Epithelial Healing
5. Corticosteroid-induced Uveitis
6. Mydriasis and Ptosis

Question 9

Commonly Used Topical Steroids

1. Difluprednate
2. Dexamethasone
3. PREDNISOLONE ACETATE
4. FLUOROMETHOLONE
5. Loteprednol

Answer 9

1. Durezol (EMULSION)
   * Rest are suspensions
2. Maxidex (Solution)
3. Pred Forte; Pred Mild
4. FML Forte (or Liquifilm or Ophthalmic ointment)
5. Lotemax

Question 10

NSAIDs

1. Used for treating what?
2. Typical Use of Steroids?
3. Uses in Treating Pain…discussed later..

Answer 10

1. treats inflammation when condition is mild or corticosteroids are CI, and for pain
2. Ocular Rosacea, Pingueculitis, Scleritis, Treating/Preventing CME, Corneal Abrasions, Allergic Conjunctivitis, Dry Eye
3. before and after Betadine EKC Tx, Post foreign body removal, PKP, Adapting to punctal plugs, post cataract

Question 11

Commonly Used NSAIDs

1. DICLOFENAC
2. KETORALOC
3. Nepafenac
4. Bromfenac

Answer 11

1. QID
2. QID
3. QD
4. QD

Question 12

Immune System Suppressants

1. Cyclosporine
   a. consider use for what?
   b. MOST COMMON use if for what?

Answer 12

1. a. unusual or refractory inflammatory conditions

b. SEVERE DRY EYE

Question 13

Common Inflammatory Disorders

Answer 13

1. Subepithelial Infiltrates
2. Keratitis
3. Phlyctenulosis
4. Pingueculitis
5. Chalazion
6. Uveitis
7. Episcleritis/Scleritis
8. Dry Eye
9. Allergic Conjunctivitis (ocular allergy)
10. Contact Dermatitis

Question 14

Subepithelial Infiltrates

1. Sterile/Non-sterile?
2. Overlying epithelium may have what?
3. Usually where?
4. How many seen?
5. Conj injection?
6. Vision?

Answer 14

1. Sterile
2. Defect
3. Marginal and Separated from the Limbus
4. One or Several
5. Mild. w/little to no Chemosis or Ocular Irritation
6. Normal Vision

Question 15

Causes of Subepithelial Infiltrates

1. Blepharitis
2. EKC
3. CL Wear

Answer 15

1. Low grade response to bacterial toxins
2. Infiltrates may appear in 2nd wk of condition
3. solution allergies, VLK, CL-SLK, CLARE, CLPU

Question 16

Subepithelial Infiltrate Tx

1. Self resolving?
2. Tx? (FLP)
   d. How long do we use them for?

Answer 16

1. Usually
2. a. Fluorometholone (BID to QID)
   b. Loteprednol (QID)
   c. Prednisolone Acetate (BID to QID)
   d. during 1st 2 wks of EKC, up to a month for CL-or Blepharitis-Associated Infiltrate

Question 17

Keratitis

1. SPK
2. Dendrites, or Pseudodendrites
   a. Usually associated with what?
   b. Resolves after what?
   c. Can we use STEROIDS on HSV Epitheliopathy?
3. 3 more Keratitis we are discussing.

Answer 17

1. Treat w/Antibiotic Cover
2. a. Viral Infection
   b. after Anti-viral Tx
   c. NO!!!
3. Disciform Keratitis; Necrotizing Interstitial Keratitis, Thygeson’s SPK

Question 18

Disciform Keratitis

1. Causes: What viruses/disease?
2. Generally due to what reaction?
3. TREATMENT?
4. For SEQUELAE of HSV: Also treat with what?
5. Treat underlying what?

Answer 18

1. HSV, HZV, other Systemic Diseases (Kawasaki Disease, TB)
2. Hypersensitivity Reaction. Not an active infection
3. PREDNISOLONE ACETATE 1% Drops (PRED FORTE) q1-6h
4. Treat with Antiviral. DO NOT use steroid if there’s an Active Epithelial HSV Infection
5. underlying Systemic Disease

Question 19

Necrotizing Interstitial Keratitis

1. Sequelae of what?
2. Same treatment as what?
   a. explain..

Answer 19

1. of HSV
2. as for Disciform Keratitis
   a. Prednisolone Acetate 1% drops as needed; and ANTIVIRAL COVER (HSV!!)

Question 20

Thygeson’s SPK

1. What is it?
2. Cause?
   a. May be related to what infection?
3. TREATMENTS
   a. Mild Cases?
   b. What 2 mild Topical Steroids could be used?

c. What else that’s a little stronger than a steroid?

Answer 20

1. Mild inflammation of Corneal Epithelium w/Small Opacities and Mild Subepithelial Infiltrates
2. Unknown
   a. to Viral Infection
3. a. BCL for mild cases

b. Fluorometholone BID
or
Loteprednol QID

c. 3-5 times per day (up to 6 months)

Question 21

Phlyctenulosis

1. What 4 symptoms do the pt feel?
   a. usually occurs in whom?
2. What do we see?
3. Cause?

Answer 21

1. Tearing, Irritation, Pain, Photophobia
   a. Children and young adults
2. Small white nodule on Bulbar Conj, usually at the LIMBUS, in the Center of a HYPEREMIC AREA!
3. Hypersensitivity RxN to Bacterial Exotoxins (Blepharitis), TB (rarely), or other infectious Agent

Question 22

Marginal Keratitis (Adult version of Phlyctenulosis)

1. Cause?
2. Nodule pronounced?
3. Infiltrate/ulcer separated from LIMBUS by what?
4. Occurs in what pts?
5. Associated with what 3 things?

Answer 22

1. Hypersensitivity RxN to Bacterial Exotoxins
2. No
3. a Clear Zone
4. Middle Aged Patients
5. Dry Eye, RA, other Collagen Vascular Diseases

Question 23

Tx of Marginal Keratitis and Phlyctenulosis

1. What would you use to Get rid of the Bacteria or Treat an Overlying Ulcer?
   a. What ones?
   b. What else could be given for Recurrent Disease?
   c. What should be AVOIDED in CHILDREN?!
2. What should be given if it’s NOT associated with Blepharitis and there is NO EPITHELIAL DEFECT?
   a. What one if it’s mild?
   b. If it’s severe?
3. What other combination could be given?
   * Treat Blepharitis as Necessary

Answer 23

1. Topical Antibiotic
   a. Tobramycin or Fluoroquinolone QID
   b. Oral Tetracyclines
   c. TETRACYCLINES!
2. Topical Steroid
   a. Loteprednol QID
   b. Prednisolone QID (1%)
3. Antibiotic/Steroid Combo

Question 24

Combination Steroid and Antibacterial

1. Used in Inflammatory Infections when the CAUSE is what?
   a. Or if what is needed?
   b. What are some examples?
2. Common Antibiotic-Steroid Combo Drugs! (4: and dosages)

Answer 24

1. Bacterial
   a. or if Bacterial Cover is NEEDED!

b. Bacterial Conj. w/a LOT of CHEMOSIS; Phlyctenulosis, Marginal Keratitis, Subepithelial Infiltrates w/Epithelial Defect, Use AFTER EYE SURGERY!

2. a. TOBRADEX (1-2 gtt TID to QID)
   * Tobramycin, Dexamethasone

b. ZYLET (good insurance): 1-2 gtt (TID to QID)
* Tobramycin, Lotoprednol

c. MAXITROL (1 to 2 gtt: TID to QID)
* Neomycin, Polymyxin B, Dexamethasone

d. FML-S Liquifilm (1 gtt QID)
* Sulfacetamide, Fluorometholone

Question 25

Pingueculitis (See A LOT in ARIZONA) 1. What is it? 2. Caused by what? 3. Treatment a. What reduces Irritation b. What 2 Mild Topical Steroids Could be used? c. What NSAID? * If they have it Nasally on left eye, and bump on right eye, then it probably means they have an inflamed pinguecula.

Answer 25

1. Irritation, Redness, Decreased Vision 2. Inflamed Pingueculum 3. a. AT's 4-8 times a day b. Fluorometholone QID; or Loteprednol (QID) c. KETOROLAC BID to QID

Question 26

Chalazion 1. What is it? 2. Treatment a. First thing? b. If it fails to resolve in 3-4 weeks?

Answer 26

1. Painless, Focal inflammation w/in Tarsus of Eyelid caused by OBSTRUCTION of a MEIBOMIAN GLAND 2. a. Warm Compresses and Massage b. Surgical removal; Treat with Steroid Injection: * 0.2 to 1.0 ml TRIAMCINOLONE 40mg/dl (1:1 mix w/2% lidocaine and epinephrine)...may lead to Skin de-pigmentation at Injection site

Question 27

Anterior Uveitis 1. What is it? 2. What do we see? 3. Causes?

Answer 27

1. Pain, redness, photophobia (consensual), tearing, Decreased Vision 2. Cell and Flare in AC, Ciliary Flush, Keratic Precipitates 3. IDIOPATHIC, Traumatic, IOL-induced, HLA-B27 linked, Systemic diseases (Behcet, Lyme, Sarcoidosis, Syphilis, TB)

Question 28

Anterior Uveitis Tx 1. Topical Steroid a. DO NOT SUBSTITUTE out what? b. Consider adding what other Steroid for AT NIGHT TIME? c. What do you do for Non-responsive CASES? 2. Cycloplegic a. For Mild to moderate? b. For Severe?

Answer 28

1. a. PREDNISOLONE ACETATE (Pred Forte): q1-2 h at first, then q1-6h b. Fluorometholone ung 0.5'' ribbon at night. c. Difluprednate Emulsion: can be used as first-line therapy (off label) or Periocular steroid (triamcinolone, 20-40 mg, subtenon injection) * Treat Secondary Glaucoma as needed 2. a. Scopolamine 0.25% drop, BID b. Atropine 1% BID

Question 29

Intermediate and Posterior Uveitis 1. Intermediate a. Main problem? b. What do we see? 2. Posterior a. What does patient feel? b. What do we see?

Answer 29

1. a. Painless, Floaters, Decreased Vision, Min. Photophobia or external Inflammation b. Vitreous cells, Snow Banking and Snow Balls 2. a. Pain, Redness, Floaters, Blurred vision, Minimal Photophobia b. Vitreous Haze and Cells, Retinal or Choroidal Inflammatory Lesions, Vasculitis

Question 30

Intermediate and Posterior Uveitis Tx 1. Intermediate a. Start with What Topical Steroid and how much? b. If that doesn't work, Do a Subtenon injection of what? How much? c. If that doesn't work, use ORAL what? * Determine Cause and treat as appropriate for that cause.

Answer 30

1. a. Topical Prednisolone Acetate 1% drops q1-2 h w/taper at end of Tx. b. Subtenon Injection with Triamcinolone 40 mg 1ml. Repeat every 6-8 wks c. Oral Prednisolone 40-60 mg QD 4-6 wks w/taper, if no improvement w/Triamcinolone

Question 31

Episcleritis 1. What do they feel? 2. What do we see? 3. May have systemic Association

Answer 31

1. Acute onset of mild-to-moderate discomfort (may see area of painless injection) 2. Photphobia and watery Discharge. Can be flat or nodular (freely movable nodule) 3. RA, SLE, Polyarteritis Nodosa, Seronegative Spondyloarthropathies

Question 32

Tx of Episcleritis 1. Topical (2) 2. Oral a. If no response to first drug, use what?

Answer 32

1. Prednisolone Acetate as needed, or Dexamethasone as needed. 2. Flurbiprofen (100 mg TID) a. use Indomethacin 100 mg QD then decrease to 75 mg when there is a response

Question 33

Scleritis 1. What is it? 2. same associations as Episcleritis

Answer 33

1. Pain, Severe, Penetrating, Radiating. Decreased VA Redness: Bluish red tinge, localized or whole sclera. * Discoloration doesn't blanche after 2.5% Phenylephrine * Can be Diffuse, Nodular or Necrotizing.

Question 34

Tx of Diffuse or Nodular Scleritis 1. Oral what? 2. If those don't work, use Oral what? a. Remission can be maintained with what? 3. Immunosuppressive Drugs added if previous mentioned drugs (2.) aren't effective a. What three? 4. If therapy fails, use what?

Answer 34

1. Oral NSAID or 2 different NSAIDs in succession 2. Oral Corticosteroids if NSAIDs aren't effective a. with Continued NSAIDs * can use Periorbital and Subconjunctival Steroid injections as Adjunct 3. Immunosuppressive drugs are added if Corticosteroids are not effective a. METHOTREXATE, Cyclosporine, or Cyclophosphamide 4. Other immunomodulatory drugs (like INFLIXIMAB (TNFa-Inhibitor)

Question 35

Tx for Necrotizing Scleritis 1. What should be given? 2. What should be given to pts w/underlying Systemic Vasculitis like Wegener Granulomatosis or Polyarteritis Nodosa 3. If therapy fails, use what? 4. WHAT should NOT BE USED? 5. What may be needed for URGENT CASES?

Answer 35

1. Oral Immunosuppressive Drugs supplemented w/Corticosteroids 2. Cyclophosphamide 3. other Immunomodulatory Drugs 4. Periocular Steroid Injections 5. Pulse Intravenous Cyclophosphamide w/or w/o Pulse Intravenous Corticosteroids

Question 36

Dry Eye 1. Tx a. Mild b. Moderate c. Moderate or Severe

Answer 36

1. a. ATs b. Ats, Punctal Plugs c. Cyclosporine BID * can take 1-3 months for clinical effect. * maybe do a 1 month pretreatment w/mild steroid: Fluorometholone to determine whether anti-inflammatory will be effective

Question 37

Allergic Conjunctivitis 1. Mild 2. Moderate 3. Severe

Answer 37

1. Cool Compresses 2. Antihistamines/Mast Cell Stabilizers 3. Add a Mild steroid to above treatments * Loteprednol QID, 1-2 wks (0.2%) or Fluorometholone 0.1% QID, 1-2 wks

Question 38

Contact Dermatitis 1. Tx a. Avoid what? b. What else can be used?

Answer 38

1. a. allergen b. ATs, Topical antihistamine, Mild Steroid Cream (Fluorometholone BID to TID for 5-15 days)...around eyes..AVOID getting into eyes.