Pharm HEENT Exam 1 Flashcards
Eye steroids
Do not prescribe eye steroids
Refer
Viral treatment of eye
Eye lavage with saline BID 7-14 days
Vasoconstrictor - antihistamine drops may help
Warm to cool compresses reduce discomfort
ABX drops for secondary infection
Bacterial Treatment of eye
Hygiene
Hand washing
ABX drops More effective than ointment
Rare pathogens may need concurrent systemic ABX
Allergic treatment of eye
Cold compress
Artificial tears
Empiric ABX for Bacterial conjunctivitis
Erythromycin ointment
4 times a day x 5-7 days
Trimethoprim -polymyxin B drops
1-2 drops 4 times a day 5-7 days
Ofloxacin drops
1-2 drops x 5-7 days (contacts)
Cipro drops
1-2 drops 4 times a day x 5-7 days (contacts)
Viral conjunctivitis treatment
Antihistamine / decongestant drops OTC
1-2 drops 4 times a day for 3 weeks
Allergic conjunctivitis treatment
Antihistamine / decongestant drops OTC
1-2 drops 4 times a day for 4 weeks
Mast cell stabilizer drops
1-2 drops 3 times a day
Eye lubricant drops
Antihistamine / decongestant drops
Class and MOA
anti histamine
inverse agonism of histamine H1 receptors
Mast cell stabilizer drops
Class and MOA
mast cell stabilizer
prevention of mast cell degranulation
Vasoconstrictors
Class and MOA
Vasoconstrictors (decongestants)
Activation of Alpha adrenergic receptors
Leukotriene receptor antagonists
Class and MOA
Leukotriene receptor antagonist
Competitive binding to leukotriene receptors
NSAIDS
Class and MOA
NSAID
prevention of prostaglandin production
Corticosteroids
Class and MOA
Corticosteroids
Broad anti-inflammatory action through prevention of proinflammatory mediator synthesis
Single agent antihistamine - mast cell stabilizer
Class and MOA
Single agent antihistamine - mast cell stabilizer
Inverse histamine H1 receptor agonism plus prevention of mast cell degranulation
Corneal ulcer treatment
Refer
Lesion should be stained and cultured to identify cause and guide treatment
Avoid topical steroids for risk of further tissue loss and increase risk of perforation
Infectious keratitis
Risk increased with contacts
extended wear lenses
poor prep and disinfection
95% of bacterial keratitis is
contact lens infection
In referral based institutions
bacterial infections are typically
Gram negative like Pseudomonas
Followed by
gram positive like staph and strep
These are the normal ocular surface flora
Bacteria keratitis tx
4th gen fluoroquinolone
Moxifloxacin, gatifloxacin, besfloxacin
Close follow up in 24 hours
Do not use glucocorticoids
Do not patch
Acute dacrocystitis
most common organisms
Alpha hemolytic strep
Staph epidermis
Staph aureus
Acute dacrocystitis
Empiric Tx
Depends on age of child
severity of infection
presence and type of complications
Mild infections can be treated with oral clindamycin
Severe infections - IV Vanc with 3rd gen Cef
7-10 days
Blepharitis indications to refer
Severe eye redness Severe pain Severe light sensitivity impaired vision corneal abnormalities (scarring, ulcers) malignancy refractory symptoms
Blepharitis tx
Good lid hygiene
eliminate triggers
Allergens, smoking, contacts etc
goal is to minimize symptoms and limit exacerbations
Chronic condition
Can use ABX ointment is severe
(bacitracin, erythromycin)
Can use oral ABX if need further tx
(Doxy, tetra, azithro)
Hordeolum
Sty (acute infection of oil gland)
can be associated with blepharitis
warm compress
Chalazion
firm non tender eyelid bump
chronic sterile inflammation of oil gland
results in granulomatous inflammatory reaction
warm compress
if needed can be surgically excised
and intra-glucocorticoid injection
Nystagmus tx
Treatment is symptomatic
meds depend on type of nystagmus
4 types of therapy
medication
Botox injections
prism lenses and optical solutions
surgery
Nystagmus medications
Gabapentin
memantine
Optic neuritis treatment
IV methylprednisolone
for severe vision loss or two
or
more white matter lesions
Oral prednisone is not recommended
due to no affect on vison loss and
due to possible increasing recurrent optic neuritis
Papilledema tx
Treat cause
Neuro-surg consultation
Reduce ICP = mannitol CSF withdrawal Sedative (Propofol, barbiturate) Control hyperventilation Decompressive craniotomy Remove mass or lesion Hypothermia Steroids
Orbital cellulitis vs pre-septal cellulitis
Orbital =
infection of soft tissue posterior to orbital septum
Pre-septal =
Infection of soft tissue anterior to the orbital septum
Orbital cellulitis tx
empiric ABX =
Vanc plus Cef
for
staph, strep, MRSA, gram neg bacilli
if concern for intracranial extension
add metronidazole
Should show improvement in 24-48 hours after proper therapy started
if not
imaging, surgery, biopsy, culture, histology
Age related macular degeneration
leading cause of legal adult blindness and severe visual impairment in industrialized countries
Dry macular degeneration
patients with:
extensive intermediate drusen
one large drusen
or non central geographic atrophy
be treated with
daily oral vitamin eye supplement
daily oral vitamin eye supplement
AREDS2
Vit C 500 Vit E 400 Lutein 10 zeaxanthine 2 zinc 80 copper 2
non smokers can use AREDS 1
which has beta carotene instead of lutein
OTC
Bevaciumab
Avastin
Vascular endothelial growth factor inhibitor (VGEFi)
Interactions
Increased risk of CHF and decline with LVEF with concomitant anthracycline based therapy
Retinal detachment Tx
Emergent consult
laser surgery or cryosurgery
Patient should remain supine with head turned to side of the retinal detachment
80-15-5% rule
Diabetic retinopathy tx
Initial therapy
For most patients with diabetic macular edema (DME) and impaired visual acuity,
we recommend intravitreal vascular endothelial growth factor inhibitors
Hypertensive retinopathy tx
Treat underlying condition
Blowout fracture
Emergent referral
keep calm, avoid sneezing, coughing etc
start nasal decongestants, ice packs and ABX right away
Patients with orbital fractures that involve the sinus get prophylactic ABX
(same ones as sinusitis)
Acute bacterial rhinosinusitis in children
Mild/Moderate
TX
Mild/Moderate
Preferred:
Augmentin PO 45mg/kg QD divided in 2 doses
Alternate
Amoxicillin PO 90mg/kg QD divided in 2 doses
Corneal abrasion tx
Refer
Lesion should be stained and cultured to identify cause and guide treatment
Avoid topical steroids for risk of further tissue loss and increase risk of perforation
CRVO
Central retinal vein occlusion
(eye DVT)
in patients with macular edema from BRVO or CRVO that cause visual loss, we recommend intravitreal anti-vascular endothelial growth factor inhibitor treatment as first line
Second line
Dexamethasone implant 0.7mg
or
intravitreal triamcinolone acetonide
Amaurosis Fugax
ESR and CRP should be checked in patients over 50 for giant cell arteritis
with transient monocular or binocular vision loss
Amblyopia
It may be caused by strabismus (most common)
uremia,
Toxins (etoh, TOB, lead or others)
Amblyopia tx
Glasses
Atropine drops
Patching
Patching atropine are equally effective in treating mild to moderate amblyopia
Pathing usually first line and preferred by patients/parents
atropine is reasonable first line when patching is expected to fail
Visual outcome for most children with patching/atropine under 7 is good
(most do not achieve normal vision)
Close angle Glaucoma acute attack
Emergency use of topical ophthalmic meds to reduce IOP
Beta blockers
alpha agonists
miosis producing agents
Systemic meds
Oral or IV acetazolamide
IV mannitol
Once attack is controlled
Laser peripheral iridotomy is definitive
(small drainage hole through the iris or cataract surgery)
Meds that cause
Angle closure glaucoma
Anticholinergics
Mydriatics eye drops:
Atropine, homatropine, cyclopentolate, tropicamide
Inhaled:
Ipratropium
Systemic:
Atropine, scopolamine, other meds with anticholinergic effects
Anti-histamines
H1 receptor antagonists
diphenhydramine, chlorpheniramine, loratadine
H2 receptor antagonists
cimetidine
IOP of
Close angle glaucoma
40 - 70 mmhg
Normal is 8 -21
Close angle glaucoma Tx
Timolol 0.5% one drop
wait one minute
Apraclonidine 1% one drop
wait one minute
pilocarpine 2% one drop
wait one minute
give acetazolamide 500mg IV (can be PO)
Scleritis
Up to 50% of patients with scleritis have an underlying systemic illness
Most often a rheumatic disease
Scleritis tx
Less severe
NSAIDS are intial treatment
for diffuse nodular forms of anterior scleritis
(this is the less severe form)
Indomethacin 25 - 75mg PO TID
Scleritis Tx
Prednisone 1 mg/kg QD
max of 80mg
Prednisone is usually tapered over a period of 6 months, often closure to 9-12 months
Strabismus tx
Eye exercises
Patch therapy
Surgery
If left untreated after 2 years of age, amblyopia will occur
Foreign Bodies
Small corneal abrasions
Small corneal abrasions
(less than or equal to one fourth of corneal surface area) (eg. circular abrasion 4mm in diameter)
Oral analgesia -
Ibuprofen, APAP/Oxy combo
With or without nonsteroidal anti inflammatory ophthalmic drops (ketorolac, diclofenac)
Foreign Bodies
Large corneal abrasions
Oral opioid analgesia
(APAP/Oxy combo)
cycloplegic drops
and in select patients with abrasions >50% of cornea,
eye patching
Corneal abrasion heal time
Most small corneal abrasion heal within 24-48 hours
Cycloplegics
These drugs cause mydriasis like mydriatics,
but they also cause cycloplegia
Paralysis of ciliary muscle
Used to dilate pupils to examine fundus
Prevent ciliary spasm and pain in iritis patients
this stops the patient from constantly accommodating when the Dr. is trying to refract the patient and determine the prescription
Ciliary Muscle
Ciliary muscle controls focusing of the light rays entering the eye by changing the shape of the crystalline lens
Cycloplegic / Mydriatic drugs
Atropine Homatropine scopolamine cyclopentolate Tropicamide
Drugs that can cause cycloplegia
Chloroquine Phenothiazine Anticholinergics Antihistamines Anti-anxiety Tricyclic anti-depressants
When to have daily follow ups for abrasions
Larger abrasions
Abrasions from contact lens
Abrasions associated with decreased vision
Abrasions in young children
Which of the below class of eye drops have the MOA of activation of alpha-adrenergic receptors?
Antihistamines
Mast cell stabilizers
Decongestants
Corticosteroids
Decongestants
What are the most common pathogens associated with bacterial keratitis?
Anaerobes
Spirochetes
Gram-negatives
Gram-positives
Gram-negatives
What is the most common antibiotic medication used to treat mild infections of dacryocystitis with children?
Azithromycin
Amoxicillin
Doxycycline
Clindamycin
Clindamycin
What is the best antibiotic therapy for the initial empiric treatment of orbital cellulitis?
Metronidazole plus amoxicillin
Vancomycin plus ceftriaxone
Doxycycline plus gentamycin
Ciprofloxacin plus metronidazole
Vancomycin plus ceftriaxone
Which of the following medications is not used for bacterial conjunctivitis empiric therapy?
Azithromycin drops
Erythromycin ointment
Ofloxacin drops
Trimethoprim-polymyxin drops
Azithromycin drops
Which of the below medications is best used for the treatment of mild otitis externa?
acetic acid-hydrocortisone
ciprofloxacin-hydrocortisone
azithromycin-hydrocortisone
clindamycin-hydrocortisone
acetic acid-hydrocortisone
What is the best therapy for patients with mild acute bacterial rhinosinusitis?
clarithromycin
azithromycin
trimethoprim-sulfamethoxazole
amoxicillin
amoxicillin
What is the best therapy for patients with mild otitis media in adults?
clarithromycin
azithromycin
trimethoprim-sulfamethoxazole
amoxicillin
amoxicillin
What is the best therapy for patients with GAS pharyngitis?
clarithromycin
azithromycin
trimethoprim-sulfamethoxazole
amoxicillin
amoxicillin
Which of the following pathogens is not one of the more common pathogens for a patient with a peritonsillar abscess?
S. pyogenes(group A streptococcus),
Streptococcus anginosus
Fusobacterium necrophorum
Staphylococcus aureus
Staphylococcus aureus
3 components of managing Otitis Externa
Cleaning the ear canal
Treating the inflammation and infection
Pain control
Otitis externa tx
Mild Disease
Mild Disease
non antibiotic topical preparation containing an acidifying agent and a glucocorticoid
(acetic acid - hydrocortisone)
Moderate disease
Otitis externa tx
Moderate disease
Moderate disease
Topical preparation that is acidic and contains an antibiotic, antiseptic an a glucocorticoid
Cipro HC, Cortisporin
Otitis externa tx
Severe disease
Severe disease
Topical preparation that is acidic and contains an antibiotic, antiseptic an a glucocorticoid
Cipro HC, Cortisporin
Otitis externa
Antibiotics
First line
Coverage of most common pathogens
Staph aureus and pseudomonas
Quinolones are good first line options with few side effects against both pathogens
(Cipro, Ofloxacin)
If infection is outside auditory canal or malignant OE, refer urgently
Combined systemic and topical antibiotics are also indicated in patients who are immunosuppressed
Ear pain
Oral NSAIDS
Otitis externa
Antibiotics
Second line
Aminoglycosides
Tobramycin, gentamycin
both are good against Staph aureus and pseudomonas
Beware ototoxicity with aminoglycosides
Tobramycin, gentamycin, neomycin
Cipro HC Otic
ABX + Steroid
Contra
Perforated tympanic membrane
Viral otic infections (herpes, varicella)
Cholesteatoma
Surgical determinants
The extent of disease
Size and pattern of mastoid pneumatization
Eustachian tube dysfunction
Otitis Media S/S
Pain Pressure Popping / Cracking Drainage Hearing Loss Tinnitus Feels like "water in ear" Feels like "Ear needs to pop"
Otitis Media S/S
by age
Neonates / infants
Change in behavior, irritability, ear tugging, decreased appetitive, vomiting
Children 2-4
Otalgia, fever, noise in ears, cant hear properly, changes in personality
Children over 4
Complains of ear pain, changes in personality
Acute otitis media bacteria
Most common are:
Strep pneumo
H Flu
Less common are:
Group A strep
Staph aureus
M Cat
Acute otitis media in adults
Drug must work against
Strep pneumo, H Flu, M Cat
Augmentin over amoxicillin
Better against beta lactamase
2nd/3rd gen cef are alternates for Pen allergy
next is doxy
Acute otitis media in adults
who don’t respond in 48-72 hours
Should be reexamined
Then give
high dose Augmentin (if not initial drug)
or
2nd/3rd gen cef (if not initial drug)
Acute otitis media in children
Pain tx
Ibuprofen or APAP for ear pain in AOM
Topical benzocaine, procaine, or lidocaine can be used as an alternate in children over 2
(not with TM perf)
Do not use decongestants or antihistamines
Acute otitis media in children
ABX tx
Children under 6 months should get ABX
Children 6mo - 2yrs should get ABX
Amoxicillin is first line in children
90mg/kg QD divided in to 2 doses (3g max)
Macrolides or clindamycin are alternatives
Penicillin reactions
Immediate hypersensitivity reactions anaphylaxis angioedema bronchospasm urticaria
Severe delayed reactions
SJS, TEN, Hemolytic anemia,
Acoustic neuroma
Surgery or radiation
Eustachian tube functions
Protection of the middle ear
pressure regulation
mucociliary clearance
Eustachian tube dysfunction
in the absence of an underlying cause of obstructive dysfunction
systemic decongestants such as pseudoephedrine or phenylephrine may be helpful for congestive symptoms (ear fullness, pressure)
Do not exceed 3 days of nasal decongestants to avoid mucosal dependency and rhinitis medicamentosa
Labrinthyitis
Vestibular stimulants and antiemetics to limit symptoms in 24-48 hours
Vertigo treatments
Treatments aimed at
Underlying vestibular disease
Symptoms of vertigo
Promoting recovery
Antihistamines
Dimenhydrinate
Diphenhydramine
Meclizine
Benzodiazepines
Alprazolam
Clonazepam
Diazepam
Lorazepam
Antiemetics
Metoclopramide
ondansetron
Prochlorperazine
promethazine
Drugs that can cause Vertigo
Anti-inflammatories
Ibuprofen, indomethacin
Antihypertensive
HCTZ, atenolol, propranolol, f=nifedipine, verapamil
prazosin, terazosin
Anxiolytics
Alprazolam, chlordiazepoxide, clonazepam, diazepam, lorazepam, oxazepam
Meclizine
Antivert (antihistamine)
Motion sickness prophylaxis
vertigo of vestibular origin
Warnings
Asthma, glaucoma, GI/GU obstruction, Hepatic/renal impairment, elderly, pregnancy, nursing
Interactions
Alcohol, tranquilizers
Adverse
Drowsiness, dry mouth, HA, fatigue
Antiemetics
receptor sites for vomiting reflex
M1 - Muscarinic
D2 - dopamine
H1 - Histamine
5 HT-3 (5-hydroxytryptamine) - Serotonin
Neurokinin-1 NK1 receptor - Substance P
Sudden sensorineural hearing loss (SSNHL)
with idiopathic SSNHL
Glucocorticoids within 2 weeks of onset
Can use systemic or intratympanic
this is preferred first line
Neurokinin 1 antagonists
Aprepitant
Antimuscarinincs
Atropine
Hyoscine
M1 receptors
Antihistamines
Hydroxyzine
H1 receptors
Prokinetics
Metoclopramide
Domperidone
Prochlorperazine
D2 Receptors
Serotonin antagonists
Ondansetron
Granisetron
Ramosetron
Palonosetron
5HT-3 receptors
Acute mastoiditis
Strep pneumo
Strep pyrogens
Staph aureus
Consider pseudomonas in children with recurrent AOM
