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Ocular Pharm > Ocular Pharm: L7: Drugs for Treating Dry Eye > Flashcards

Ocular Pharm: L7: Drugs for Treating Dry Eye Flashcards

1
Q

Epidemiology of Dry Eye

  1. % 13 and over that have 1 or more symptoms of Dry Eye?
    a. % in Arizona
    b. % That experience Dry Eye Symptoms Frequently?
  2. % in US population that consist of Postmenopausal Women?
    a. Highest incidence of what?
  3. Less than 1/2 the peeps w/dry eye have been what?
A
  1. 40%
    a. 80% probably…
    b. 11%
  2. 6%
    a. of dry eye
  3. have been diagnosed w/dry eye
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2
Q

Nomenclature

  1. KCS?
    a. Refers to what?
  2. Xerophthalmia: Dry Eye associated w/what deficiency?
  3. Xerosis: Extreme what?
    a. Occurs in eyes with what?
  4. Sjogren’s Syndrome Keratoconjunctivitis Sicca?
A
  1. a. Any eye w/some degree of dryness, Non-Sjogren’s; Dry eye syndrome/ocular surface disease; Dysfunctional Tear Syndrome
  2. w/Vit A Deficiency
  3. ocular dryness w/keratinization
    a. w/Cicatricial Pemphigoid
  4. AI inflammatory disease associated w/dry eye
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3
Q

Dry Eye Symptoms

  1. 3 main things?
  2. Vision?
  3. Tearing?
  4. Can be exacerbated by what?
  5. May be exacerbated by prolonged use of the eye…like in what?
  6. When does it get worse?
  7. Uni/Bi? Acute/Chronic?
  8. Discomfort in/out of proportion to signs?
A
  1. Burning, Dryness, FBS
  2. Mild to moderate decrease in Vision
  3. Reflex tearing
  4. by Environmental Conditions (Wind, heat, smoke, low humidity)
  5. computer work
  6. Later in the day
  7. Bilateral; Chronic
  8. Out of proportion to signs
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4
Q

Dry Eye Signs

  1. Tear Film
    a. Tear meniscus reduced. Should be GREATER than or EQUAL to what?
    b. That test will be LESS than 10 seconds w/Dry eye?
    c. What 2 types of tear film?
  2. Meibomian Gland: What is going on?
  3. Conjunctiva: 2 things seen?
  4. Cornea: 3 things?
A
  1. a. 1 mm
    b. TBUT
    c. Foamy Tear film or Debris in Tear film
  2. MGD/Posterior Blepharitis
  3. Mild Injection and Mild Keratinization
  4. SPK, Filaments, Mucus Plaques
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5
Q

Causes of dry eye

  1. What is the MOST IMPORTANT CAUSE?
  2. There are so many. (10 more)
A
  1. Idiopathic
  2. a. Vit A Deficiency
    b. Drugs (oral contraceptives, antihistamines, Beta-blockers, atropine)
    c. Connective Tissue Disease (Sjogren’s, RA, SLE, Wegener’s)
    d. Conjunctival Scarring (burns, cicatricial pemphigoid, SJS, old trachoma)
    e. Post LASIK
    f. Lacrimal Tissue Dysfunction (Aging) or Destruction (inflammation or tumor)
    g. MGD
    h. Lagophthalmos or other mechanical lid issues
    i. CL Wear
    j. Environmental Factors (eg. AC??)
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6
Q

Tear Film: Classical View

  1. Mucin Layer
    a. Secreted by what?
    b. What does it do to the tear film?
  2. Aq. Layer
    a. Secreted by what glands?
  3. Lipid Layer
    a. Secreted by what glands?
    b. Prevents what?
A
  1. a. Goblet Cells (harder to damage: Vit A deficiency
    b. Adheres and distributes tear film over the eye
  2. a. Lacrimal Glands (glands of Krause and Wolfring)
  3. a. Meibomian Glands (glands of Zeiss and Moll)
    b. Prevents evaporation
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7
Q

Causes of Dry Eye by Tear Film Layer

  1. Lipid Layer (3 causes) (RIM) (Miebomian Glands)
  2. Mucin Layer (4 causes) (V CAT) (Goblet Cells)
  3. Aq. Layer: So many (Lacrimal gland, accessory glands of Krause and Wolfring)
A
  1. Rosacea, Inflammation, Meibomianitis
  2. Vit A Deficiency, CLs, Atopic Disease, Topical Meds
  3. Age, AI deficiency, Stevens-Johnson, Surgery, Hormonal, Vit A Deficiency, Inflammation, Collagen Vascular Disease, Ocular Pemphigoid, Medicamentosa
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8
Q

Classification of Dry Eye

  1. Aqueous Deficient
    a. Sjogren’s
    b. Non-Sjogren’s
  2. Evaporative
    a. Intrinsic?
    b. Extrinsic
A
  1. a. Primary or Secondary
    b. Lacrimal Deficiency; Lacrimal Duct Obstruction, Reflex Block, Systemic Drugs
  2. a. Meibomian Oil Deficiency, Disorders of Lid Aperture, Low Blink Rate, Drug Action Accutane
    b. Vit A Deficiency, Topical Drugs Preservatives, CL Wear, Ocular Surface Disease (Allergy)
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9
Q

Dry Eye Workup

  1. Contributing Factors (4)
A
  1. Systemic Disease
  2. LASIK, Eye injury, mechanical lid problem
  3. CL wear
  4. Environmental
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10
Q

Dry Eye Workup

  1. Aq. Dificency (3)
  2. Evaporative (2)
  3. Mucin Deficient (1)
  4. Conjunctival and Corneal Signs (2)
A
  1. Schirmer’s Test, Phenol Read Thread Test, Measurement of Tear Meniscus
  2. a. TBUT
    b. Meibomian Gland Evaluation
  3. Tear Osmolarity
  4. a. Injection
    b. SPK location and Severity (use Fluorescein Strips, NOT FLURESS!!)
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11
Q

Treatment of Dry Eye

  1. Level 1
  2. Level 2
  3. Level 3
  4. Level 4
A
  1. None, Preserved Tears, Manage Environment, Allergy Drops, Water intake, Avoid drugs contributing to dry eye, Psychological support, use of hypoallergenic products
  2. Unpreserved tears, Gels, Ointments, Nutritional Support (fatty acids), Secretagogues, Topical Steroids, Topical Cyclosporine A
  3. Tetracyclines, Punctal Plugs
  4. surgery, systemic Anti-inflammatory therapy, Oral cyclosporine, moisture goggles, Punctal Cautery, Acetylcysteine, Contact Lenses
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12
Q

AT Preservatives

  1. Conventional (old, or cheaper ones)
    a. What 3 preservatives.
    b. THESE should NOT BE USED more than how many times a day?
  2. Mild
    a. Breakdown to what?
    b. GenAqua
    c. Purite
    d. Can be used more often than what?
  3. Non preserved: Any limitation on use?
A
  1. BAK; PHMB, Polyquad
    b. No more than QID or irritation may occur.
  2. a. to Inert ingredients upon contact w/eye
    b. Sodium Perborate
    c. Sodium Chlorite
    d. than QID
  3. none…except financial.
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13
Q

Artificial Tear Active Ingredients

  1. Carboxymethyl Cullulose
  2. Polyethylene Glycol
  3. Hydroxypropyl Methylcullulose (HPMC)
  4. Glycerine
    a. Mostly preserved with what?
    b. 2 of them?
  5. PVA
    a. Mostly preserved with what?
    b. 2 of them
A
  1. Optive, Refresh Tears, Thera Tears (non preserved)
  2. Systanes, Blink Tears
  3. Genteal, Tears brand, Visine Tears (BAK)
  4. a. BAK
    b. Moisture Eyes, Soothe Lubricating Eye Drops
  5. a. BAK
    b. Tears Again (non preserved), and FreshKote
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14
Q

Oils, Gels, Ointments

  1. Oil-Containing Drops
  2. Ointments and Gels
A
  1. Refresh Endura (Castor Oil), SootheXP (Light Mineral Oil)
  2. Refresh PM (Petrolatum, mineral oil)

Liposic Gel (Phospholipid Liposomes, non-preserved)

*Didn’t mention: Tear Naturale PM ointment or Genteal Gel

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15
Q

Inserts and Sprays

  1. Inserts:
  2. Tear Again Advanced Liposomal Spray
A
  1. Lacriserts

2. Has Liposomes and Vitamins ACE; Good for lipid defiicent Dry Eye; good in pts who have TROUBLE WITH DROPS!

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16
Q

Which ATs to Use

  1. What preservatives are LESS LIKELY to Irritate the Eye themselves?
    a. For frequent application, use what?
  2. Time on eye (period of relief) Depends on what?
  3. What solutions will Help Correct Hyperosmolarity?
  4. What are good for Cases with MGD?
A
  1. Milder Preservatives
    a. Non-preserved
  2. on Viscosity and Certain Ingredients like GUAR
  3. Hypotonic solutions
  4. Oils and Lipid/Liposomal Formulations
17
Q

Antibiotics

  1. SYSTEMIC what Improve QUALITY of MEIBOMIAN GLAND SECRETIONS?
    a. What is the DOC? Dosage?
    b. Lower dose (how much?) may be effective.
  2. What other drug may be EQUALLY EFFECTIVE?
  3. BLEPHARITIS can be treated with what?
A
  1. Systemic TETRACYCLINES!
    a. Oral Doxycycline: 100 mg qd 1-2 wks
    b. 20 mg BID
  2. Topical Azithromycin: BID x2d, or QD x 5 days
  3. BACITRACIN ung applied to affected lids.
18
Q

Anti-Inflammatory Agents

  1. Inflammation can interfere with functioning of what 2 types of Glands?
  2. Mild Steroids
    a. What 2?
    c. They can be used to assess whether what drug would be effective?
  3. Topical Cyclosporin A (Restasis)
    a. Takes how long to get an Effect?
  4. What oral med?
  5. Lifitigrast
    a. What is it?
    b. Just completed what trial phase?
A
  1. Meibomian and Lacrimal Glands
  2. a. Fluorometholone Alcohol 1% QID 1-2 w
    b. Loteprednol QID 1-2w
    c. Cyclosporin A
  3. a. Weeks to Months
  4. ORAL Cyclosporin A
  5. a. Integrin Antagonist
    b. Phase 3 Clinical Trials
19
Q

Secretagogues

  1. What do they do?
  2. What is one that is currently in Clinical Trials?
  3. What else could increase Tear Production (recent study suggests this)…
A
  1. Increase Tear Secretion
  2. DIQUAFOSOL (P2Y purinergic Receptor Agonist)
  3. Caffeine (wouldn’t recommend Pt actually using this)
20
Q

Drugs for Sjogren’s Syndrome

  1. Used as what for Non-Sjogren’s Dry eye?
  2. Cevimeline
    a. What is it?
  3. Pilocarpine
    a. What is it?
  4. CI’s and Cautions (5)
A
  1. “Off-Label)
  2. a. Cholinergic Agonist
  3. a. Cholinergic Agonist
  4. a. Asthma
    b. Angle-Closure Glaucoma
    c. History of Heart Disease
    d. Chronic Bronchitis or COPD
    e. History of Kidney or Gallbladder Stones
21
Q

Nutraceuticals

  1. Advertised to PROMOTE what?
  2. Generally Contain what?
  3. Used continuously to TREAT/PREVENT what?
  4. Many brands
A
  1. Eye Health”
  2. Omega-3 Fatty Acids
  3. Dry Eye
  4. MaxiTears (dry eye formula) or Vision Science Dry Eye Formula
    * Lot of money in it. Don’t need FDA Approval. *Need to be very critical of them. Peeps are making a ton of money off of them.
22
Q

Non-Drug Treatments

  1. What are they?
A
  1. Warm Compresses
  2. Lid Scrubs
  3. Boston Scleral Lens Prosthetic Device
  4. Humidifying Goggles and other devices
  5. Environmental Changes (like moving away from AC Vents)
  6. Pre-packaged Txs.
    a. Lid Scrubs
23
Q

Aldox Convenience Kit

  1. Low dose of what?
  2. What scrub pads/foam come with it?
  3. what Moist heat therapy.
    a. Goggles and Reusable Heat packs relief
  4. Supply cost?
A
  1. of Doxycycline (20 mg BID)
  2. OCuSOFT premoistened lid scrub pads and lid scrub foam
  3. Tranquileyes
  4. $110 for one month supply
24
Q

Nutridox Convenience Kit *Maybe something I should try…Expensive tho.

  1. What is in it?
A
  1. NutriDox (Doxycycline Monohydrate: 75 mg)

TheraTears Nutrition (Omega-3)

iHeat Warm Compress

25
Q

Treating Dry Eye: Severity

  1. Level 1
  2. Level 2
  3. Level 3
  4. Level 4
A
  1. No treatment; Preserved Tears
  2. a. Unpreserved Tears
    b. Gels
    c. Ointments
    d. Nutritional Support
    e. Secretagogues
    f. Topical Steroids
    g. Topical Cyclosporine A
  3. Tetracyclines (combine with unpreserved Tears)
  4. a. Systemic Anti-inflammatory Therapy
    b. Acetylcysteine
    c. Oral Cyclosporine
26
Q

Treating Dry Eye Severity

  1. Level 1
  2. Level 2
  3. Level 3
  4. Level 4
A
  1. Mild, No Visual symptoms, or MILD FATIGUE, MGD present variably. TBUT and Schirmer are Variable
  2. Moderate, episodic, chronic discomfort, Visual: Annoying and/or activity-limiting, Variable Corneal Staining, Mild debris TBUT and Schirmer less than or equal to 10
  3. TBUT and Schirmer Less than or equal to 5. Severe frequent or constant discomfort. Moderate conj. staining.
  4. SEvere and or disabling and constant discomfort.
27
Q

Treatment Based on Etiology

  1. Aq. Deficient
  2. Mucin Deficient
  3. MGD
  4. Other
A
  1. Conventional ATs
  2. Tears w/better Corneal Adhesion
    a. Systane, Systane Ultra (Guar)
    b. Blink Tears (hyaluronic Acid)
  3. Lipid Containing Tears
    a. Tears Again Advanced Liposomal*
    b. Liposic Gel
    c. Systane Balance
    d. FreshKote
  • Level 2/3: give antibiotic w/ MGD
  • Aq. Deficient and a Lot of corneal staining: go with non-preserved tears, and gel or ointment
    4. Osmolarity: Thera Tears (Hypotonic)
28
Q

Treatment Based on Success: Learn the list

  1. 6 of them (He would use this on MILD, maybe moderate cases. BUT NOT SEVERE CASES!)
A
  1. QID Conventional ATs
  2. Increased Frequency: Mild preservative or non-preserved (if 1. didn’t help)
  3. Increased duration of tear on Eye: (Guar, Gel, Oil, Ointment)
  4. Etiology-based Tx
  5. Supplementation (Lid Scrubs)
  6. Alternative Treatment (Punctal Plugs)
29
Q

General Approach to Tx

  1. Start with what?
  2. If satisfactory relief not achieved…
  3. If still not relieved?
  4. If dry eye persists?
A
  1. Environmental changes, ATs, Warm Compresses (if indicateD), increased intake of Omega vitamins, address medication or medical issues that can cause dry eye.
  2. try Non-preserved ATs at higher frequency or more viscous AT, add gel or ointment at night, Add topical Anti-inflammatory or Immune Suppressant
  3. Add Antibiotic if indicated; Consider Punctal Plugs
  4. systemic anti-inflammatory or immune suppressant, prosthetics, devices, surgical interventions

Ocular Pharm (13 decks)

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