pharmacology opto Flashcards
Which of the following anti-histamines does NOT have FDA labeling as a non-sedating antihistamine?
Clarinex®
Zyrtec®
Claritin®
Allegra®
Zyrtec®
Of the above oral anti-histamines, only Zyrtec® is not considered non-sedating. Clinical trials show an incidence of sedation of 14% vs. 6% in the placebo arm. Trials with Claritin® showed an incidence of sedation of 8% with Claritin® vs. 6% in the placebo arm. Clarinex® showed a sedation incidence of 2%; Allegra’s® incidence of somnolence was less than 2% in most study populations, although one pediatric study showed an incidence of 2.8%.
Which of the following oral medications has the MOST potential to cause a serious interaction with Amiodarone?
Warfarin
Zoloft®
Lisinopril
Simvastatin
Warfarin
Which of the following ophthalmic drops acts as both a cycloplegic and a mydriatic?
2.5% Phenylephrine
Dapiprazole
Hydroxyamphetamine
Atropine
Atropine
Atropine causes both cycloplegia and mydriasis. Phenylephrine and hydroxyamphetamine result solely in mydriasis. Dapiprazole blocks alpha-1 receptors and is therefore classified as a mydriolytic, as its use leads to pupil miosis.
Which of the following medications should be prescribed to a patient suffering from shingles to help decrease the chances of postherpetic neuralgia?
Prednisolone
Zovirax® (acyclovir)
Viroptic® (trifluridine)
Natacyn® (natamycin)
Zovirax® (acyclovir)
- Postherpetic neuralgia is a painful condition that can last for months to years after the resolution of lesions that occur with shingles. Shingles is caused by the virus Varicella zoster, which causes chicken pox. Shingles are generally experienced by patients who have already had chicken pox and are elderly or immunocompromised. After resolution of chicken pox, the virus lays dormant in the root of the nerves and, for reasons that remain unclear at this time, becomes reactivated later on in life, causing shingles. Shingles presents as lesions on only one side of the body or is limited to a specific dermatome. Initially, one may only first experience a headache followed by tingling, itching, or sensitivity in the affected area. A rash will then develop in this area, followed by lesions that eventually blister over. Lesions do not always appear. Shingles cannot be contracted from one person to another; however, if a person has never been infected with chicken pox, it is possible to contract chicken pox from a person suffering from shingles. Oral antiviral agents like acyclovir, famciclovir or valacyclovir should be initiated within 72 hours of the onset of skin lesions to help minimize the chances of postherpetic neuralgia. Viroptic® is a topical antiviral frequently utilized for Herpes simplex. Natacyn® is an antifungal. Prednisolone, although useful for treating pain associated with shingles, does not help in preventing postherpetic neuralgia.
Which 4 of the following drugs are classified as opioid analgesics? (Select 4)
Acetylsalicylic acid
Acetaminophen
Morphine
Ibuprofen
Codeine
Hydrocodone
Oxycodone
Morphine Codeine Hydrocodone Oxycodone Acetaminophen (Tylenol®) is a non-opioid analgesic that inhibits prostaglandin synthesis. Ibuprofen (Advil®, Motrin®) is a non-steroidal anti-inflammatory drug commonly used for mild pain relief. Acetylsalicylic acid (aspirin) is classified as a salicylate drug that possesses anticoagulant and mild analgesic properties. Morphine, oxycodone, hydrocodone and codeine are opioid analgesics and are derived from the opium poppy or a derivative of it.
Which of the following pain relievers is MOST LIKELY to cause liver damage and therefore should not be given to a person who suffers from liver disease?
Ibuprofen (Motrin®)
Naproxen (Naprosyn®)
Acetylsalicylic acid (Aspirin)
Acetaminophen (Tylenol®)
Acetaminophen
Tylenol® is an oral analgesic that works well for mild to moderate and acute or chronic pain without inhibiting platelet aggregation. Tylenol® is metabolized by the liver and excreted by the kidneys and therefore should not be recommended to people who suffer from liver impairment or chronic alcoholism. Aspirin is also a mild oral analgesic; however, unlike Tylenol®, it can prolong bleeding time as it interferes with platelet aggregation. Aspirin is contraindicated in people who suffer from upper gastrointestinal (GI) disease, asthma, nasal polyps, bleeding disorders or have chronic renal or hepatic disease. Motrin® and Naprosyn® are classified as nonsteroidal anti-inflammatory drugs (NSAIDS) and also work very well for mild to moderate pain relief. NSAIDS may cause GI irritation, mild inhibition of platelet aggregation, and kidney damage. Any of the above drugs can cause liver problems if used inappropriately; however, because it is primarily metabolized by the liver, Tylenol® does have a greater propensity to cause liver damage.
Which of the following preservatives is now rarely utilized in contact lens disinfectant solutions due to its high affinity for causing corneal toxicity/allergic reactions?
Thimerosal
Polyquad
Benzalkonium chloride (BAK)
Hydrogen peroxide
Thimerosal
Thimerosal was once utilized by many companies as a preservative in contact lens cleaning solutions. However, many patients were sensitive to this component and suffered allergic or toxic reactions to the solution. It is now rarely, if at all, utilized by manufacturers of contact lens solutions. BAK, polyquad, and hydrogen peroxide are all good disinfectants currently used in contact lens cleaning solutions. People who suffer from allergies or have sensitive eyes are encouraged to use a hydrogen peroxide-based cleaning solution as it does not contain any preservatives.
Increased intake of which of the following may result in nystagmus?
Alcohol
Benadryl® (diphenhydramine)
Lipitor® (atorvastatin)
Aspirin (acetylsalicylic acid)
Alcohol
Excessive amounts of alcohol intake can result in nystagmus. Law enforcement officers take advantage of this knowledge to test for sobriety. Alcohol is a central nervous system depressant, and excessive amounts can lead to cognitive and motor impairment. Alcohol is metabolized by the liver, which is capable of processing roughly 0.5 ounce of ethanol per hour (depending on height, weight, food intake etc.). The effects of alcohol on the brain are not uniform. The first area of the brain to be affected is the outer cerebral hemispheres, followed by the limbic system, and lastly, the brainstem (which is comprised of the midbrain, pons, and medulla). Areas of the brain are affected at different rates; this explains why systems that regulate some functions (i.e. emotions) become deficient before others (heart rate and blood pressure). Alcohol causes impairment of smooth pursuits and saccades. Lithium can cause linear waveform jerk nystagmus. Benadryl is sometimes used to treat vertigo, which can also be associated with nystagmus.
A 63-year old female is seen at your office with a chief concern of blurry vision in the morning that takes about an hour to resolve before she can see clearly again. Biomicroscopy reveals endothelial guttata. You correctly diagnose her with moderate Fuch’s dystrophy. Which ophthalmic drop would be of MOST benefit to her?
Vigamox® (moxifloxacin)
Tobrex® (tobramycin)
1% Pred-Forte® (prednisolone acetate)
Muro-128® (5% sodium chloride)
Muro-128® (5% sodium
Sodium chloride is a topical hyperosmotic agent used to relieve stromal edema caused by endothelial decompensation. Topical steroids work well to decrease swelling caused by inflammation. In the above case, the corneal edema is not mitigated by an inflammatory response. Tobramycin and Vigamox® would be of no benefit since there is no active infection, and prescribing either of these would only lead to corneal toxicity or increased pathogen resistance over time.
Which of the following medications should be used with extreme caution in a patient with sickle-cell anemia because it can lead to exacerbation of the condition?
Percocet®
Ketorolac
Acetazolamide
Hydroxyurea
Acetazolamide
Acetazolamide is a carbonic anhydrase inhibitor that can lead to increased metabolic acidosis, resulting in a further sickling of red blood cells in patients with sickle-cell disease.
Ketorolac is a non-steroidal anti-inflammatory drug that may be administered intravenously and serves to decrease inflammation by interfering with prostaglandin synthesis. The medication is occasionally used in the management of sickle-cell anemia.
Percocet® is a combination of oxycodone and acetaminophen and is used to manage pain. This medication is particularly useful for patient who cannot take aspirin.
Hydroxyurea is an antimetabolite that is frequently used in the management of sickle-cell disease. This medication helps to prevent and decrease sickling of red blood cells.
References:
http://emedicine.medscape.com/article/205926-treatment
Which of the following topical nonsteroidal anti-inflammatory drugs is also approved for seasonal allergic conjunctivitis?
Nepafenac (Nevanac®)
Flurbiprofen (Ocufen®)
Diclofenac (Voltaren®)
Ketorolac (Acular®)
Ketorolac (Acular®)
Acular® is used to decrease conjunctival and post-cataract inflammation, prevent and treat cystoid macular edema, and control discomfort associated with seasonal allergic conjunctivitis.
Tetracycline should not be prescribed to children because of which of the following potential adverse effects?
Depressed bone marrow formation
Thromboembolism
Depressed skeletal growth
Urinary tract infections
Depressed skeletal growth
Tetracycline, when administered to children, can lead to short stature due to the fact that tetracycline becomes incorporated into calcifying bone, leading to stunting of growth. Tetracycline also causes yellowing of teeth because it can be integrated into dentin and enamel in developing teeth; this is yet another reason not to prescribe tetracycline to children. Other common side effects of tetracycline include allergic response, photosensitization, and GI distress. Tetracycline has not been known to cause urinary tract infections (it would actually serve to treat them), bone marrow depression, or thromboembolisms.
Which of the following MOST closely resembles the typical amount of time that it takes for a topical ocular corticosteroid to cause an elevation in the intraocular pressure?
1 hour
1 month
1 day
6 months
3 months
1 month
Corticosteroid-induced glaucoma was first described in 1950 when a study of steroid use and subsequent IOP elevation showed that 18-36% of healthy individuals and 46-92% of patients with primary open-angle glaucoma “responded” with an elevation of IOP over a course of 2-4 weeks. Other studies have also agreed that the average time it takes for a corticosteroid to cause an increase in IOP is close to 4 weeks as well. However, if the corticosteroid being utilized is of high potency, or is used at a very frequent rate, the rise in IOP can present sooner. In some cases, the rise in IOP can also be delayed for years. Thus, patients undergoing any steroid treatment must be examined on a regular basis.
A dilated fundus exam reveals white crystalline deposits within the macular region of your patient. Which of the following medications is MOST likely responsible for causing these deposits?
Tamoxifen
Amiodarone
Ciprofloxacin
Plaquenil®
Tamoxifen
Tamoxifen; is frequently used in the treatment of breast cancer. Patients taking this medication may experience decreased visual acuity due to white crystalline retinal deposits; these are most densely concentrated around the paramacular region. Tamoxifen; may also cause corneal deposits, cystoid macular edema, grey lesions within the RPE, retinal hemorrhages, and optic disc edema.
Plaquenil® is an anti-malarial drug that is frequently prescribed to treat systemic lupus and rheumatoid arthritis. The medication binds to melanin and accumulates in the retina, leading to macular mottling and retinal pigment epithelial disruptions and often resulting in what is known as “bull’s eye maculopathy”.
Amiodarone is an anti-arrhythmic medication. Use of this drug commonly causes yellow/brown or white powdery corneal epithelial deposits located infero-centrally that appear to swirl outward while sparing the limbus (vortex keratopathy).
Fluoroquinolones are a powerful class of antibiotics that inhibit bacterial DNA gyrase but, when taken orally, pose a risk of tendon rupture and tendinitis. The risk of the aforementioned side effects increases in individuals over the age of 60 or those with renal failure or taking oral steroids or in people who have undergone an organ transplant. Fluoroquinolone use also may be associated with diplopia.
Which of the following properties may increase the efficacy of a topical ophthalmic medication?
Prescribing the medication in suspension form
Possessing a pH that is close to the physiological pH of the eye
Decreased viscosity
Increased concentration of preservatives
Possessing a pH that is close to the physiological pH of the eye
An ophthalmic medication that possesses a pH that is as close to the natural pH of the tear film will generally cause less stinging and ocular irritation with instillation. A drop that results in stinging produces reflex tearing, which dilutes the topical medication, thereby decreasing its efficacy. A drug that results in ocular discomfort, for some patients, may also result in poor compliance with the dosing schedule.
Generally, medications that are in suspension form are not as beneficial as those in emulsion form due to poor patient compliance with shaking of the bottle prior to use to properly distribute the medication; this lack of compliance causes inadvertent non-uniform dosing. Increased viscosity of the medication, although possibly leading to varying degrees of vision blurring, offers better ocular retention and better performance. Although there is some debate regarding toxic effects on the cornea by preservatives, the majority of clinicians agree that if a drop is used with increased frequency, a preservative-free formulation is beneficial to the patient.
The following classes of drugs are all considered the first line of treatment for systemic hypertension. Which class is associated with transient myopia?
Angiotensin-converting enzyme inhibitors (ACE)
Angiotensin receptor blockers (ARB)
Diuretics
Calcium channel blockers
Diuretics
The choice of initial treatment of hypertension is complex and depends on co-morbidities. ACE and ARBs are the current preference. ACE inhibitors are available generically and thus are cheaper, but increasingly ARBs (notably Cozaar® (losartan)) are being made available generically. Calcium channel blockers are popular but less so than ACE and ARB, which work on the Renin system. The finding of transient myopia, while not common, is not altogether rare and should always be considered in patients on thiazide diuretics.
Which 3 of the following glaucoma medications are classified as beta blockers? (Select 3)
Bimatoprost (Lumigan®)
Unoprostone isopropyl (Rescula®)
Brimonidine (Alphagan-P®)
Timoptic Hemihydrate (Betimol®)
Carteolol HCL (Ocupress®)
Levobunolol HCL (Betagan®)
Timoptic Hemihydrate (Betimol®) Carteolol HCL (Ocupress®) Levobunolol HCL (Betagan®)
Alphagan-P® is an adrenergic alpha-2 agonist. Rescula® and Lumigan® are prostaglandins analogs. Betagan®, Ocupress® and Betimol® are all categorized as beta blockers. Beta-blockers serve to decrease intraocular pressure (IOP) by blocking respective beta receptors located in the ciliary body, thereby decreasing production of aqueous. Beta blockers also decrease the damaging effects of glaucoma by increasing outflow facility, resulting in a lowering of IOP. Note: beta blockers generally end in “olol”.
Drugs that act non-selectively on all adrenergic receptors (such as epinephrine) are likely to cause all of the following except for which side effect?
Increased heart rate
Miosis
Vasoconstriction of the skin, mucosa, kidneys, and veins
A reduction in IOP
Increased cardiac contractile force
Miosis
Drugs that stimulate adrenergic receptors, also known as sympathomimetic drugs, actually cause mydriasis of the pupil as it stimulates the radial muscle of the iris, causing dilation. The parasympathetic system regulates constriction of the pupil through contraction of the circular muscle of the iris. One can achieve dilation of the pupil either through stimulation of the sympathetic system (i.e., eye drops that contain phenylephrine) or via blockage of the parasympathetic pathway (i.e., eye drops that contain tropicamide, which is parasympatholytic).
Which of the following glaucoma medications is considered an adrenergic alpha-2 agonist?
Apraclonidine HCL (Iopidine®)
Latanoprost (Xalatan®)
Isopto-Carbachol (Carbachol®)
Dorzolamide (Trusopt®)
Apraclonidine HCL (Iopidine®)
Iopidine® is an alpha-2 agonist. This category of glaucoma medications serves to decrease intraocular pressure by both increasing uveoscleral outflow and decreasing production of aqueous by reducing blood flow to the ciliary body. Note: Adrenergic alpha-2 agonists generally end in “nidine”.
Which of the following medications can be used to treat lid myokymia (uncontrollable, intermittent lid twitching)?
Pred Forte® (prednisolone acetate)
Zyrtec® (cetirizine)
Lumigan® (bimatoprost)
Voltaren® (diclofenac)
Zyrtec® (cetirizine)
Oral H-1 antihistamines have several ocular indications. Common H-1 oral antihistamines include Claritin® (loratidine), Zyrtec® (cetirizine), Allegra® (fexofenadine), Clarinex® (desloratadine), and Benadryl® (diphenhydramine). The oral antihistamines serve to alleviate symptoms associated with a Type I allergic response which can include itching, lid edema, chemosis, and excessive tearing. Oral antihistamines can also be recommended for lid myokymia which, although irritating, is not sight-threatening. It is important to distinguish between first generation and second generation oral antihistamines because first generation oral antihistamines (Benadryl®) cause central nervous system (CNS) depression and drowsiness. The second generation oral antihistamines (Claritin®, Zyrtec®, Allegra®, and Clarinex®) are non-sedating as they do not penetrate the CNS. Voltaren® is an NSAID and will not alter the duration of lid myokymia; neither will prednisolone or bimatoprost (Lumigan®).
Topical application of a drug in solution form causes loss of medication retention in the eye. When the drop is introduced into the conjunctival cul-de-sac, what 2 locations does the MAJORITY of drug loss initially occur? (Select 2)
Spillover onto the cheek and face
Mixed and diluted in reflexive tears caused by drop instillation
Absorbed into the cornea and then diluted in the aqueous humor of the anterior chamber
Absorbed into conjunctival vessels and lost to systemic absorption
Drained through the nasolacrimal sac
Absorbed into the conjunctival fornixes and then lost to trabecular outflow
Spillover onto the cheek and face
Drained through the nasolacrimal sac
When an ophthalmic medication is first instilled into the conjunctival sac, particularly suspensions and solutions, much of the drug is lost to spillover and drainage through the nasolacrimal duct, both of which are exacerbated by an increase in blinking. Research also reveals that some of the medication is lost to absorption into the conjunctival, anterior uveal, and episcleral vessels. A small portion of the medication is eliminated via trabecular and uveoscleral outflow once it becomes absorbed into the anterior chamber. Lastly, a minor amount is lost to absorption through limbal vessels and the tear film.
A measure of drug activity that is expressed in terms of the amount of a drug that is required in order to produce a desired response is referred to as which of the following?
The potency of the drug
The efficacy of the drug
The affinity of the drug
The reliability of the drug
The potency of the drug
The potency of a drug refers to the amount of a drug that is required to achieve a desired biological effect. A drug that requires a lower dose is considered more potent than a drug that requires a higher dosage to achieve the same effect.
The affinity of a drug for a receptor is a measure of how tightly and how able the drug in question binds to the receptor. Affinity is typically determined by the chemical structure of the drug.
The efficacy of a drug is a measure of the drug’s ability to produce a biological effect or initiate a biological change once it is bound to the receptor. Efficacy is used to characterize the level of maximal response by a drug.
Oral steroid therapy can retard skeletal maturation and inhibit growth when utilized in children. How can this side effect be MOST EFFECTIVELY minimized without compromising the necessary therapeutic results?
Prescribe the therapeutic dose in one sitting every other day
Prescribe the therapeutic dose once a week
Divide the therapeutic dose in half and take twice a day
Substitution of different steroids (i.e. dexamethasone for prednisolone) every two weeks (same dosage)
Prescribe the therapeutic dose in one sitting every other day
Alternate day therapy is a good option that allows for minimization or elimination of growth suppression. Alternate day therapy is achieved by prescribing the entire therapeutic dose to the patient every other morning. This prescribing pattern allows for metabolic recovery of the system. However, this type of therapy is ONLY effective for short-acting steroids like prednisone. Triamcinolone and dexamethasone are both long-acting steroids and therefore are not applicable for alternate day therapy. Substitution of different steroids and daily therapy would still result in delayed skeletal maturation because systemic steroid levels would remain high due to continual ingestion.
hich 3 of the following are side effects of prolonged topical steroid use? (Select 3)
Development of keratoconus
Development of a ptosis
Delayed corneal epithelial healing time
Development of retinitis pigmentosa
Keratoconjunctivitis sicca
Reduced resistance to fungal and viral infections
Development of a ptosis
Delayed corneal epithelial healing time
Reduced resistance to fungal and viral infections
Ocular complications of prolonged steroid use include posterior subcapsular cataract development, elevation of intraocular pressure, reduced resistance to fungal, viral, and bacterial infections, delayed wound healing, mydriasis, and varying degrees of ptosis development. Steroids are frequently used in the treatment of dry eye, especially in conjunction with cyclosporine (i.e. Restasis®) to help alleviate the signs and symptoms of ocular desiccation at a much faster rate than with Restasis® alone.
Topamax® can lead to glaucoma via which of the following mechanisms?
Iris mydriasis, leading to angle-closure
Release of vascular endothelial growth factor, leading to neovascular glaucoma
Increased choroidal effusion
Decreased pore size of the corneoscleral meshwork
Increased choroidal effusion
Topamax® is a drug that is commonly used as an anti-seizure medication but may also be used in the management of migraines, depression, and bipolar disorder as well as to promote weight loss. Use of this drug can cause uveal effusions, leading to swelling of the ciliary body and narrowing of the angle (forward displacement of the lens-iris diaphragm) and leading to myopia and angle-closure glaucoma. Patients who report blurred vision with the use of Topamax® should immediately discontinue the medication due to the increased risk of developing angle-closure glaucoma. Signs and symptoms typically occur 3-14 days after the initiation of treatment.
Which of the following agents can be used for INTRAOCULAR surgical procedures?
Saline
Balanced salt solution (BSS)
Thimerosal
Benzalkonium chloride (BAK)
Balanced salt solution (BSS)
himerosal and BAK are microbial agents and can be used in small doses as preservatives on extraocular surfaces; however, if used intraocularly they will result in iritis, cataract formation, and death of corneal endothelial cells. Saline is not an acceptable intraocular irrigating solution because it does not contain the electrolytes needed to maintain proper isotonicity of the corneal endothelium (such as calcium, magnesium, glucose, sodium, potassium, etc.); this will result in swelling and lysis of the endothelial cells. BSS is frequently used for short-term intraocular surgeries as it is isotonic to ocular tissue and contains electrolytes that are needed for normal cell functions.
Riboflavin refers to which of the following vitamins?
Vitamin C
Vitamin E
Vitamin A
Vitamin B2
Vitamin B2
Vitamin B2 is also known as riboflavin. Riboflavin is important for the metabolism of nutrients. Because it is yellow or yellow/orange in color, riboflavin is frequency used to color foods. A deficiency (although quite rare) of vitamin B2 can lead to several ocular complications such as photophobia, corneal neovascularization and keratoconjunctivitis sicca. Dry, cracked lips, ulcers of the mouth, and sore throat may also be experienced. Some studies have reported that vitamin B2 supplementation may decrease the risk of cataracts.
Which of the following penicillin preparations is resistant to beta-lactamase?
Augmentin®
Penicillin V
Ampicillin
Amoxicillin
Augmentin®
Augmentin® is resistant to beta-lactamase because it is comprised of amoxicillin and clavulanic acid, a compound that inhibits the enzyme beta-lactamase. Clavulanic acid deactivates the enzyme, thereby preserving the beta-lactam ring of the penicillin and allowing it to maintain its effectiveness in destroying the targeted bacteria.
Which of the following glaucoma medications causes lengthening and thickening of eyelashes as a side effect?
Bimatoprost (Lumigan®)
Brimonidine (Alphagan-P®)
Pilocarpine
Dorzolamide (Trusopt®)
Bimatoprost (Lumigan®)
lumigan® is classified as a prostaglandin. This category of glaucoma medications can cause growth of eyelashes as a side effect along with pseudodendrites, photophobia, irritation, superficial punctate keratitis, cystoid macular edema, hyperemia and changes to iris color. By taking advantage of this desired cosmetic side effect, Latisse®, patented by Allergan, was created specifically for the purpose of promoting eyelash length and thickness.
Which of the following steroids, when applied topically, is MOST likely to cause in INCREASE in intraocular pressure (IOP)?
Rimexolone
Fluorometholone
Loteprednol
Dexamethasone
Dexamethasone
Prolonged use of steroids both systemically and topically have been linked to an increase in intraocular pressure (IOP). The mechanism by which this occurs is most likely due to a decrease in the facility of aqueous outflow. Of the steroids mentioned, dexamethasone has the greatest tendency to result in increased IOP. Loteprednol is a steroid that minimally affects IOP and therefore should be used in cases where one is concerned about a potentially damaging rise in IOP.
Atropine is used to treat which 3 of the below conditions? (Select 3)
Presbyopia
Glaucoma
Amblyopia
Anterior uveitis
Posterior synechiae
Keratoconus
Anterior uveitis
Amblyopia
Posterior synechiae
Atropine is a parasympatholytic drug. Administration of atropine may result in glaucoma in narrow-angle patients because it causes pupil dilation that leads to blockage of the trabecular meshwork, causing a spike in intraocular pressure. Because atropine causes cycloplegia, it can be used in the management of amblyopia, as it forces the child to utilize their weaker eye, hopefully serving to strengthen and increase the visual acuity of that eye. Due to the fact that atropine results in pupil dilation, it is often used in the treatment of anterior uveitis to help prevent formation or promote breakdown of synechiae. It also aids in pain management by controlling pupil size and avoiding unnecessary movement of the iris muscles, which can be very painful in this inflammatory condition.
A 26-year old male presents in your office with an intraocular pressure of 28 mmHg in the right eye and 20 mmHg in the left eye. His cup-to-disc measurement is 0.5 vertically by 0.3 horizontally, with a superior notch in the right eye and 0.3 round in the left eye. You correctly diagnose him with primary open angle glaucoma. His ocular history is significant for a previous retinal detachment in the right eye six years prior that was repaired via laser photocoagulation. Which of the following glaucoma medications is strongly contraindicated unless there is a definite decision that the risk-benefit ratio makes using this medication acceptable?
Pilocarpine
Lumigan® (bimatoprost)
Xalatan® (latanoprost)
Alphagan-P® (brimonidine tartrate)
Timoptic® (timolol maleate)
Pilocarpine
Pilocarpine should not be prescribed to this patient for several reasons. First, he is young and pilocarpine should not be prescribed to patients less than 40 years old as it can increase the risk of early cataract formation. Secondly, he has a history of a retinal detachment; pilocarpine use increases the likelihood of retinal detachment. All of the other choices would be suitable; however, it is best to start with a prostaglandin as this class of anti-glaucoma medication generally results in good compliance since it needs to be administered once daily; it also leads to excellent intraocular pressure stability.
Other reasons not to prescribe pilocarpine as a primary glaucoma treatment include the fact that it can create a brow ache, cause an increase in myopia and it constricts the pupil thereby reducing acuity under low light levels.
