Pediatric Ocular Pharmacology Flashcards
What are the topical antivirals used in children?
Trifluroidine 1% (Viroptic); Gancyclovir (Zirgan)
What ages can trifluoridine be used for?
6 and up
What are the oral antiviral agents that can be prescribed for children?
acyclovir, valacyclovir
At what age can oral antivirals be prescribed?
2 years old
What is the dosage frequency for trifluridine 1% (Viroptic)
Q2H, up to 9x/ day
What is the dosage frequency for Gancyclovir (Zirgan)
5x/ day until heals then TID x7 days
What is the dosage for oral acyclovir?
10-20mg/ kg 4x per day
What is the dosage for oral valacyclovir?
20mg/ kg 3x/ day for 5 days
What is a common cause of Viral Conjunctivitis?
Upper respiratory infections
What are non-prescription treatments for viral conjunctivitis?
cool compresses, artificial tears, hygiene
When do we consider antibiotics in viral conjunctivitis?
secondary infection
What steroids are prescribed for children?
loteprednol etabonate 0.2% (Alrex); 0.5% lotemax; fluoromethalone 0.1% (FML); 0.25% (FML forte); Prednisolone acetate 1% (pred forte); difluprednate 0.05% (Durezol)
What is the only steroid agent that is established and recommended for children?
Fluoromethalone
What formulations are available for fluoromethalone?
ung or soln
what ages is fluoromethalone prescribed?
2 years old and up
What are the steroid and antibiotic combination drops that are available for children?
- TobraDex (Dexamethasone 0.1% + Tobramycin 0.3%);
- Zylet (Loteprednol 0.5% + Tobramycin 0.3%);
- Maxitrol (Dexamathasone 0.1% + Neomycin 0.35% + Polymixin B);
- Blephamide (Sulfacetamide 10% + Prednisolone 0.2%);
- pred G (Gentamicin + prednisolone)
What is the dosage frequency for all steroid/ Ab combo drops except for pred G?
1 gtt q4-6 hours
What is the dosage for Pred G
1 gtt 2-4x/ day
15-67% of uveitis cases in children are secondary to what systemic condition?
JIA-U
Which type of uveitis is usually idiopathic in children?
intermediate uveitis
JIA-U commonly presents as chronic _____________ uveitis, which is often clinically ____________
anterior; silent
Enthesitis-related arthritis (ERA) category of JIA presents as what type of uveitis?
Acute anterior uveitis- symptomatic, unilateral and episodic
When is the highest risk of uveitis with JIA?
within 4 years of onset
What are risk factors of JIA-U
gender, JIA category, age of onset, ANA and HLA-B27 positivity
How does JIA cause uveitis?
T and B lymphocytes generate an immune response against native intraocular antigens
JIA patients that are ANA positive have a (higher/ lower) risk of chronic anterior uveitis
higher
Which subtype of JIA has the highest risk of uveitis?
Oligoarthritis or polyarthritis, ANA +, age of onset at 6 or under; 4 years or less duration of disease
What is the frequency of screening for a high risk JIA patient?
q3 months
What is the treatment for children with uveitis secondary to JIA?
pred forte qid (or more); cyclopentolate QD (prevent synechiae, pain relief); systemic steroids, NSAIDs, Methotrexate, TNFI (Biologics)
If a child with uveitis secondary to JIA is a steroid responder (IOP > 30 mmHg), what hypotensive should be used?
Timoptic 0.25%
What is the only approved NSAID for children?
Acular (Ketorolac tromethamine 0.5%) for children older than 2 years old
What are indications for systemic steroids in children?
Asthma, allergies, inflammation
Systemic side effects of steroids (systemic)
weight gain, stomach ulcers, sleep difficulties, increased blood pressure, increased blood sugar, decreased wound healing
What are steroid Allergy medications for children?
Flonase, veramyst, Nasonex, Rhinocort, omnaris
Which two systemic steroids used for allergies are used in children 6 years old or older?
Rhinocort (Budesonide) and Omnaris (Ciclesonide)
Which two systemic steroids used for allergies are used in children 2 years and older?
veramyst (Fluticasone) and Nasonex (Nometasone)
At what age is Flonase (fluticasone) used?
4 years old and up
What are ocular allergy medications used for acute allergies in children?
- Ketotifen 0.025% (zaditor, alway);
- Olopatadine 0.1% or 0.2% (Patanol/ Pataday);
- Alcaftadine 0.25% (lastacraft, pazeo) *others non-bold on slide
What are agents for chronic ocular allergies?
- Pemirolast Potassium 0.1%,
- Nedocromil Sodium 2%,
- Lodoxamine Trimethamine 0.1%,
- Cromolyn Sodium 4%
What are off label therapeutic agents used for chronic ocular allergies?
pred forte, durezol, lotemax/ alrex
What is the indication and MOA for Verkazia 0.1% (cyclosporine ophthalmic solution)
VKC in children 4 and up; calcineurin inhibitor immunosuppressant
True or False: Pediatric glaucoma generally does not require surgical intervention?
False
What is the long-term prognosis for pediatric glaucoma?
poor
What are commonly prescribed therapeutic agents for pediatric glaucoma?
brimonidine 0.2%, dorzolamide, timolol 0.25%, 0.5%; cosopt, prostaglandin analogs
What is the most common cause of pediatric hyphema?
blunt trauma
What is commonly seen with a hyphema?
tears in anterior ciliary body and iris vessels; iridodialysis, cyclodialysis
How many RBC’s are found in the anterior chamber in a microscopic hyphema?
1-4+
How is a macroscopic hyphema graded?
by percentage of space they occupy; measure height in mm in anterior chamber
What are possible complications of hyphema?
corneal blood staining (~5%), secondary hemorrhages; Elevated IOPs, Optic atrophy, glaucoma, amblyopia
What two medications are used for Hyphema management?
Atropine (BID) and Pred Forte (Q1H or Q2H initially)
What medications are NOT used for hyphema?
aspirin and ibuprofen
How often should you see a patient with a hyphema?
daily
What is important to monitor when a pediatric patient has a hyphema?
IOP
What is a non-medication management technique for hyphema?
bed rest with head elevated 30 degrees
What is a masquerader of hyphema?
xanthogranuloma
What are the FDA subcategories of Pediatrics?
neonates: birth to 1 month; infants: 1 month to 2 years; Children: 2 to 12 years; Adolescent: 12-16 years
When do cytochrome P450 levels reach adult levels? What about other enzyme systems?
1-2 years old; 10 years old
How is GI absorption different in children?
increased bioavailability of acid labile drugs, decrease bioavailability weakly acidic drugs, gastric emptying time
How does the blood brain barrier differ between children and adults?
Children: less effective
What anesthetics are used for children?
0.5% proparacaine, 0.4% benoxinate
What are the precautions when using Phenylephrine HCl?
cardiovascular disease, premature infants and children in the first 6 months of life
What strength of Phenylephrine HCl is used in children?
2.5% max dose 2 gtts spaced 5 minutes apart
What is in the combo mydriatic spray?
0.5% tropic + 2.5% phenyl + 0.5% Cyclo
What concentration of atropine is used in light irides? dark irides?
0.5% atropine in light irides, 1.0% in dark irides
What is the duration of action for atropine?
2-3 weeks
What is the onset of action for atropine drops?
3-6 hours
What populations may be hypersensitive to cholinergic antagonists?
Down syndrome, spastic paralysis, brain damage and very light pigmentation
What is the antidote for atropine toxicity
physostigmine salicylate
What concentration of cyclopentolate is used in children under 1 year old?
0.5%
what concentration of cyclopentolate is used in children over 1 year old?
1.0%
What cycloplegic agent is used in premature or LBW babies?
cyclomydril
what is the maximum cycloplegia action for cyclopentolate?
40 minutes
Because of the risk of side effect, what % of cyclopentolate is NOT used in children?
2%
What are the benefits of tropicamide 1%?
less potent, very safe, less adverse effects
What are 3 common uses of antibiotics in children?
bacterial conjunctivitis, K ulcer, K abrasion
Fluroquinolones inhibit bacterial DNA gyrase and are approved in children (older/younger) than 1 year old?
older
Moxeza: >/= 4 months
What aminoglycosides are used in children?
Tobrex (infants 2 months and older); Neomycin (NE); Gentamicin (6 yo and older)
Which macrolides are indicated for use in children?
erythromycin (infants and newborns), azithromycin 1% (1 yo and up)
What are 3 antibiotics commonly used in children?
penicillins, cephalosporins, macrolides
What is the most common cause of orbital cellulitis?
paranasal sinuses
What are causes of preseptal cellulitis?
breaches in skin barrier: trauma, insect bites; adjacent infections: hordeolum, dacryocystitis
What are the two bacteria that cause preseptal or orbital cellulitis?
staphylococcus aureus and streptococcus bacteria
When is the maxillary sinus fully developed?
6 years of age
what are the most commonly prescribed antibiotics for preseptal cellulitis in kids?
augmentin (250-500 mg po TID or 875 mg po BID); Keflex (250-500 mg po TID)
When is hospitalization and IV indicated in preseptal cellulitis?
severe cases or children under 5 years old
