What is glaucoma caused by?
High intraocular pressure in the eye caused by aqueous humor behind the iris
What three parts of the eye are involved in vision?
1. cornea 2. inner lense 3. pupil
What is the difference between bacteriocidal vs. bacterostatic?
Bacteriocidal : bacteria killingBacteriostatic : bacteria inhibiting
An eye infection, allergy, inflammation, or irritation directly effects:
Conjunctiva or mucous membrane of the eyeball &/or eyelid
Name 5 Examples of Fluroquinolones.
"-floxacin"
1. ciprofloxacin 2. gatifloxacin 3. moxifloxacin 4. norfloxacin 5. levofloxacin
What are two examples of Macrolides?
1. Erythromycin 2. Azithromycin
What two things are mixed to make Polytrim?
polymyxin B + trimethoprim
What two things are mixed to make polysporin?
polymyxin B + bacitracin
Macrolides are : bacterio_____.
Macrolides are bacterstatic
True or False:
Use of Macrolides had decreased due to resistance by staph aureus.
True False
True.
Fluroquinolones are bacterio____.
Fluroquinolones are bacteriocidal.
Fluroquinolones work against gram____.
Gram positive & gram negative
*Fluroquinolones are broad spectrum!
Polymyxin is bacterio_____.
Polymyxin is bacteriocidal.
What two things are combined to make Polymyxin?
Polytrim + Polysporin *comes in combination
Polymyxin works against gram ____.
Gram negative
True or False:
Polymyxin penetrates tissues poorly.
True False
True.
-This is the reason use has diminished
What are examples of aminoglycosides?
1. Gentamycin 2.Tobramycin
Aminoglycosides are bacterio_____.
Aminoglycosides are bacteriocidal.
Aminoglycosides work primarily on gram___.
Aminoglycosides work primariily on gram negative bacteria
True or False:
Vigamox is moxifloxacin.
True False
True.
Only available as brand name drug [$$], cheaper alternative is a generic ciprofloxacin.
True or False:
Ophthalmic anti-infectives have little systemic absorption.
True False
True!
-Mostly just ocular penetration
What 4 bacteria are common causes of conjunctivitis in neonates?
1. Chlamydia trachomatis 2. Staph aureus 3. Haemophilus influenzae 4. Streptococcus pneumoniae
What 7 bacteria are common causes of conjunctivitis in children?
1. H influenzae 2. S pneumoniae 3. Moraxella sp. 4. Staphlococci sp. 5. Coagulase-neg staphloccocci sp. 6. Eschericia coli 7. Psuedomonas sp
*classroom conjunctivitis
What 5 bacteria are common causes of conjunctivitis in adults?
1. Staph aureus 2. coagulase-negative staphlococci sp 3. H influenzae 4. S pneumoniae 5. S epidermidis
What is the most potent ophthalmic antibacterial agent?
Fluoroquinolones
True or False
Over the past two decades, there has been an increased in bacterial resistance to antibiotics.
True False
True!
*Especially for erythromycin
True or False:
Fluoroquinolones are the most potent agents against bacterial pathogens.
True False
True
Pregnancy Category for Erythromycin, Azithromycin, and Tobramycin.
Pregnancy Category B
Pregnancy Category for Gentamicin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin, polymyxin B, and Sulfacetamide.
Pregnancy Category C
Which ophthalmic medications should be avoided during lactation?
Fluoroquinolones and Sulfacetamides
Which two ophthalmic antibiotics are safe and effective in children?
erythromycin and tobramycin
Which two medications has safety not been established for kids?
Fluoroquinolone and azithromycin
What are some adverse reactions to ophthalmic antibiotics?
-Local irritation (burning, irritation, inflammation) -Superinfection (with prolonged or repeated use) -Stevens Johnson syndrome (rare) (related to sulfa allergies/drugs)
What characteristics/symptoms indicate bacterial conjunctivitis?
-Mucousy appearance/drainage -HALLMARK : crusty eye on awaking & can't open eye-Redness, irritation
What is the most serious cause of opthalmia neonatorum? (AKA neonatal conjunctivitis)
What's recommended treatment?
-Gonococcal
-CDC recommends prophylactic erythromycin .5% 1/4-1/2 of an inch within 1 hour of delivery
What are the three most common pathogens for ages 3 months to 8 years?
-Staphlococcal -Haemophilus -Streptococcal
What is the preferred antibiotic delivery for bacterial conjunctivitis?
Topical!
Sulfacetamide 10% solution Dosing
1-2 drops every 2-3 every hour during the day
Erythromycin .5% ointment Dosing
1/2 to 1 inch ribbon 2-3 times daily
Polytrim solution Dosing
1 drop every 3 hours for 7-10 days
Polysporin Ointment Dosing
1/2 to 1 inch ribbon every 3-4 hours
True or False:
Antibiotic treatment is for all patients with eye complaints.
True False
FALSE!
-Only for patients with hallmark symptoms for an eye infection
What is blephartis?
Acute or Chronic Inflammation of the eyelash follicles
What is the treatment for blephartis?
1. Scrub the eyelashes with no tear shampoo 2. Erythromycin .5 ointment (1/4" BID until symptoms clear then for additional 7 days after that)
What are important teaching considerations for patients with blephartis?
1. Don't wear contacts 2. Don't wear make up 3. Throw away makeup that has come into contact with your eye!
(teaching point for all patients with eye infections)
What is Hordeolum?
-typically referred to as a stye
-infection of sebaceous gland of eyelash or eyelid caused by staph aureus
What is the treatment for Hordeolum?
1. moist, warm compresses four times a day for 15 minutes (allow for greater blood flow) 2. Sulfacetamide 10% eyedrops OR erythromycin 5% ointment four times daily until symptoms subside and for additional 2-3 days
How does Hordeolum typically clear?
-spontaneously ruptures and immune system gets rid of it naturally
What is viral conjunctivitis typically caused by?
-Adenovirus -HIV -Herpes Zoster
What is the course of treatment for viral conjunctivitis?
-RARELY treated with sulfacetamide 10% drops or ointment 4x daily to prevent secondary bacterial infection -course is usually 12-15 days and gets cleared out naturally by the immune system
What is a KEY clinical pearl for a patient with an eye infection?
Hands should be washed before and after instillation of medication.
Describe the best way to administer an eye medication.
1. WASH YOUR HANDS 2. Pull the eye down with one hand to create a pocket (so the med doesn't roll off the eye) 3. Keep tip of dropper/tube from touching eye, fingertips, other surfaces
True or False
Eye medications can be shared between family members.
True False
FALSE
True or False
It is important to tell patients with eye infections to through out eye makeup.
True False
True. (otherwise they'll just continue to spread the infection)
What are two examples of antiglaucoma Beta Blockers?
What is the mechanism of action of antiglaucoma Beta-blocker medications?
Decreases cAMP-induced production of aqueous humor
What is an example of an antiglaucoma cholinesterase inhibiting miotic?
Phospholine
What is the mechanism of action of antiglaucoma cholinesterase inhibiting miotics?
Decreases resistance to aqueous outflow
What is an example of an antiglaucoma direct acting miotic?
Pilocarpine
What is the mechanism of action of antiglaucoma direct acting miotics?
1. muscarinic effects for pupillary constriction 2. increased aqueous humor outflow
Name SEVEN categories of antiglaucoma medications
1. Beta Blocker 2. Alpha Adrenergic Agonist 3. Miotic (direct acting) 4. Miotic (cholinesterase inhibiting) 5. Sympathomimetic 6. Carbonic Anhydrase Inhibitors 7. Prostagladin Agonists
What are three examples of antiglaucoma carbonic anhydrase inhibitors?
1. Acetazolamide (Diamox) 2. Brinzolamide (Azopt) 3. Dorzolamide (Trusopt)
What is the mechanism of action for antiglaucoma carbonic anhydrase inhibitors?
Slow bicarbonate ion formation leading to decreased aqueous humor outflow
What is an example for antiglaucoma alpha-adrenergic agonists?
Brimonidine
What is the mechanism of action for antiglaucoma alpha-adrenergic agonists?
1. reduce aqueous humor production 2. increase aqueous humor outflow
What are two examples of antiglaucoma sympathomimetics?
*Not commonly used
1. Epinephrine 2. Diprevefren
What is the mechanism of action of antiglaucoma sympathomimetics?
Causes vasoconstriction and therefore reduces aqueous humor production
What are two examples of antiglaucoma prostaglandin agonists?
1. Latanoprost 2. Bimatoprost
Basically, all antiglaucomas reduce intra-ocular pressure by:
1. decreases production of aqueous outflow 2. decreases resistance to aqueous outflow (increases outflow) 3. BOTH
What is the mechanism of action for antiglaucoma prostaglandin agonists?
Increase aqueous humor outflow
What is a commercially marketed prostaglandin agonist?
Latisse! (originally a antiglaucoma medication with a side effect of browning the eyelashes)
What are some general side effects for antiglaucoma medications?
blurred vision, photophobia
What are some adverse reactions to Beta Blockers? (antiglaucoma)
headache, dizziness
What are some adverse effects of miotics? (antiglaucoma)
corneal clouding, induced myopoia
*Anticholinergic symptoms: salivation, sweating, N&V
What are some adverse reactions to sympathomimetics?
(antiglaucoma)
Corneal pigmentation
What are some adverse reactions to prostaglandin agonists?
(antiglaucoma)
brown pigmentation in the iris
What is myopia?
Narrow focused vision
What are some contraindications/precautions for Beta Blockers? (antiglaucoma)
Contraindications: COPD, pulmonary disease, asthma, hypotension (BP<100mmHG)
Precautions: Diabetes
What are some contraindications/precautions for Miotics? (antiglaucoma)
Contraindicated for patients with active inflammation
What are some contraindications/precautions for Carbonic Anhydrase Inhibitors? (antiglaucoma)
Contraindicated : methazolamide contraindicated in patients with hyponatremia, hypkalemia, renal disease, and liver diseasePrecaution : Patients with sulfa allergiesDorzolamide contain sulfamide which can cause a hypersensitivity reaction
What are some contraindications/precautions for Alpha adrenergic agonists? (antiglaucoma)
Contraindicated: with MAOI's
Precaution: Patients with cardiac, renal, or liver disease
When using Romitidine and Latanoprost, it's important to teach the patient not to:
Wear contacts
What is the pregnancy category of Beta-Blockers? (antiglaucoma)
Category C
What is the pregnancy category of Miotics? (antiglaucoma)
Category C
*except for Humorsol!: Cat. X
What is the pregnancy category of Carbonic anhydrase inhibitors? (antiglaucoma)
Category C
What is the pregnancy category of Bromonidine? (antiglaucoma) (alpha adrenergic agonist)
Category B
What is the pregnancy category of Latanoprost? (antiglaucoma) (Prostaglandin agonist)
Category C
What is the mechanism of action of anti-allergy ophthalmic medications?
1. mast cell stabilizers limit hypersensitivity reactions 2. inhibit release of histamine
What are examples of anti-allergy ophthalmic medications?
Cromolyn sodium (Crolom) Ketotifen (Zaditor) Pheniramine (Naphcon-A) Azelastine (Optivar) Olopatadine (Patanol, Pataday)
What is the NSAID/anti-inflammatory mechanism of action for ophthalmic medications?
inhibit prostaglandin synthesis
What are examples of NSAID/anti-inflammatory ophthalmic medications?
diclofenac (Voltaren) Nepafenac (Nevanac) Ketoralac (Acular)
*Voltaren and Ketoralac are sold as oral NSAIDs as well
What are the general adverse reactions for anti-allergy and anti-inflammation ophthalmic medications?
*little systemic absorption, so side effects are mild
blurry vision, photophobia, transient discomfort, tearing
With an aspirin sensitivity, caution using any:
NSAIDs; due to possible cross sensitivity
What are some adverse reactions to histamine blocking ophthalmic medications?
rhinitis
What are some adverse reactions to NSAID ophthalmic medications?
ocular irritation
True or False:
Over the counter products that combine an antihistamine and decongestant (Ex. Naphcon A) are for temporary relief of minor eye symptoms only.
True False
True.
Decongestant causes vasoconstriction, could lead to eye problems with prolonged use
Pregnancy Category of Cromolyn Sodium (ophthalmic anti-allergy medication)
Pregnancy Category B
Pregnancy Category of Ketotifen, Nepafenac, and NSAID (ophthalmic medications)
Pregnancy Cateogry C
Ophthalmic histamine blockers are safe for children over:
3 years old
Naphazoline/Antazoline pediatric Dosing
1-3 drops every 3-4 hours
Azelastine Pediatric Dosing
1 drop twice a day
Ketotifen Pediatric Dosing
1-2 drops two to three times a day
Naphazoline/Pheniramine Pediatric Dosing
1-2 drops every 3-4 hours
*only use 1-2 days; DECONGESTANT!
Olapatadine Pediatric Dosing
1-2 drops twice a day
What is an example of an ocular lubricant?
Artificial Tears
What are trade name examples of artificial tears?
Murine, Tears Naturale, Dry Eyes, Moisture Drops *available generically
What are ocular lubricants used for?
eye irritation and dryness
What for things are lubricants made of?
1. Balance of salts to maintain ocular tonicity 2. buffers to adjust pH 3. viscosity to prolong eye contact time 4. preservatives
What type of eye medication is NOT recommended for use in children? (of any age)
Ophthalmic vasoconstrictors
What is the mechanism of action of ophthalmic vasoconstrictors?
sympathomimetic agents that constrict the conjunctival blood vessels
What are three examples of ophthalmic vasoconstrictors?
1. Naphazoline 2. Oxymetazoline 3. Tetrahydrozoline
What are ophthalmic vasoconstrictors used for?
Temporary relief of eye redness due to irritation or allergies
Ophthalmic vasoconstrictor Dosing
1-2 drops four times a day
Contraindications for Ophthalmic Vasoconstrictors
Patients with narrow angle glaucoma
What are some adverse reactions of ophthalmic vasoconstrictors?
-transient stinging -temporary blurring of vision -increased lacrimation, irritation, discomfort -rebound congestion or redness with frequent use
What is lacrimation?
Tearing of the eye
-specifically related to ophthalmic vasoconstrictors: because of discomfort the eye is experiencing
Ophthalmic Vasoconstrictor Pregnancy Category
Category C
What lines the external ear canal?
Cerumen -acts as a protective bacteriostatic layer that protects epithelium against hyperhydration
Factors that can effect cerumen protective ability
1. abrasions in the ear 2. water in the ear canal
What is otitis externa?
acute, painful inflammatory condition of the external auditory canal
What is the most common cause of doctors visits for ear pain?
Otitis externa
What are common causitive organisms of otitis externa?
1. psuedomonas 2. enterobacter 3. proteus
What two things can help reduce inflammation in otitis media?
1. corticosteroids 2. acid-alcohol solutions*also are antibacterial
What corticosteroid/antibiotic treatments are available for otic infections?
Cortisporin Ciprodex Ciloxan HC
What antibiotic only treatments are available for otic infections?
Garamycin (gentamicin) Floxin (ofloxacin)
Whata acid-alcohol treatments are available for otic infections?
VoSol Otic VoSol HC Otic (hydrocortisone added)
What is an important teaching point when prescribing Ofloxacin?
SHAKE WELL!
Gentamicin Ophthalmic Pediatric Dosing
4 drops four times a day for 7-10 days
Ofloxacin Otic Pediatric Dosing
6mo-12 years: 5 drops once a day x10days
>12 years: 10 drops once a day x10days
Ciprofloxacin:hydrocortisone Otic Pediatric Dosing
>1 year: 3 drops twice a day x7days
Ciprofloxacin:Dexamethasone Otic Pediatric Dosing
>6 months: 4 drops BID x7days
Hydrocortisone:neomycin:polymyxin B Otic Pediatric Dosing
Children: 3 drops BID x7days
Cortisporin Otic Solution and Ciprofloxacin are contraindicated in:
tympanic membrane perforation
Which otic medication is okay to use with a perforated tympanic membrane?
Cortisporin Otic
Prolonged use of Otic Anti-infectives may lead to:
Superinfection
Otic Anti-infective adverse reactions:
taste alterations, dizziness, vertigo
*ear involved in balance: directly related to the # of drops instilling into the ear
To acclimate an otic medication to patient body temp:
warm bottle in hand for a few minutes!
Correct Administration of Ear Drops:
Pull ear back to straighten the ear canal
What can be done if ear canal is too swollen for drops to be instilled?
A wick can be inserted into the ear or medication can be put through it
How can you prevent Swimmers Ear?
Isopropyl ear drops (Swim-ear; Ear-sol) or rubbing alcohol
Instill 2-3 drops into ear canal after swimming to dry up water
What is a common otic analgesic?
Auralgan (antipyrine:benzocaine)
What are otic analgesics used for?
provide pain relief until antibiotic takes effect
To instill otic analgesics, the tympanic membrane must be:
INTACT
Pregnancy Category of Otic Analgesic
Pregnancy Category C
Otic Analgesic Administration Dosing
Instill 1-5 drops (enough to fill ear canal) every 1-2 hours PRN
Excessive accumulation of cerumen can lead to:
hearing loss, impaction, environment for otitis externa
Why can Qtips do more harm than good?
Can push wax farther into ear canal
What is a ceruminolytic?
Medication that softens and emulsifies ear wax
What is an example of a ceruminolytic?
Carbanide Peroxide (Debrox, Murine Ear Wax Removal)
Carbamide Peroxide Administration/Dosing Instructions
1. Instill 1-4 drops (enough to fill ear canal) twice a day for up to 4 days
2. Once cerumen is softened, can irrigate ear with warm water or saline
Pregnancy Category of Carbamide Peroxide (Ceruminolytic)
Pregnancy Category C
True or False:
Patient needs a prescription to get a ceruminolytic.
True False