Transcript OCULAR PHARMACOLOGY

OCULAR PHARMACOLOGY
for ASSISTANTS AND
TECHNICIANS
John W. Snead MD, MBA, FACS
Lynn Lawrence, CPOT, ABOC
ROLE of the
ASSISTANT AND TECHNICIAN
 Recording
 Patient
Education
 NEVER Work in Doubt!
PATIENT CASE HISTORY
 General
Health
 Medications
 Allergies
VITAMIN SUPPLEMENTS
CLASSIFICATIONS
 Solutions
 Suspensions
 Ointments
DIAGNOSTIC AGENTS
DPA’s treat symptoms, unknown disease
Topical Anesthestics
 Mydriatics
 Cycloplegics
 Dyes/Stains
 Fluress
 Gonioscopic Solutions
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Topical Anesthetics
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Proparacaine
Tetracaine
Cocaine
Alcaine
Mydriatics & Cycloplegics
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Tropicamide
Phenylephrine
Cyclogyl
Atropine
Homatropine
Scopalomine
Dilation Hazards
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Cross Contamination
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Narrow anterior
chamber angle
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Potential risk in
dilating … opt vs oph
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Plan for acute angle
glaucoma attack
Make sure you are far enough away not to
Touch the patient
Dyes & Stains
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Fluorescein
Rose Bengal
Lissamine Green
Fluress
Gonioscopy Solutions
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Goniosol
Gonioscopic
Celluvisc
CLINICAL
ADMINISTRATION
 Patient
History
 Clinical Procedures Which May
Be Influenced by Medications
 The ERx Option
Ophthalmic Drug Complications
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Giving people medications may seem routine,
but there are possible negative consequences.
Not all people are tolerant of all medications. If
given a drug they can’t tolerate, a patient may
have an allergic or toxic reaction. As an eye
technician administering drugs to people on a
daily basis, it’s important you understand and
recognize what is occurring if a patient does
have a reaction. You also need to understand
how drugs affect the body’s autonomic nervous
system (ANS), to include the sympathetic and
parasympathetic divisions.
THERAPEUTIC AGENTS
TPAs treat disease, known problem
Antibiotics
 Anti-virals
 Drugs that lower IOP
 Anti-inflammatory agents
 Non-Steroidal
 Combinations
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GLAUCOMA MANAGEMENT
 Pilocarpine
 Beta-Blockers
 Carbonic
Anhydrase
Inhibitors
 Adrenergic Agonists
OCULAR INFLAMMATION
 Corticosteroids
 Steroid-Antibiotic
Combinations
 Non-Steroidal Anti-inflammatory
Drugs (NSAIDS)
 Oral Analgesics
OCULAR INFECTIONS
 Topical
Antibiotics
 Oral Antibiotics
 Anti-Viral
 Analgesics
Antibiotic
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Biotic means relating
to, produced by, or
caused by living
organisms
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The prefix anti
"against" the referent
of the stem to which
the prefix is affixed
OCULAR SURFACE
 Artificial
Tears
 Lubricating Ointments
 Punctal Occlusion
OCULAR ALLERGIES
 Artificial
Tears
 Antihistamine-Decongestants
 Corticosteroids
Cap Color Code
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Tan- antibiotics
Pink- anti-inflammatory/steroids
Red- mydriatics/cycloplegics
Grey- NSAIDS
Green- miotics
Yellow or Blue- beta-blockers
Purple- adrenic agonists
Orange- carbonic anhydrase inhibitors
Turquoise- Prostaglandin analogues
IN-OFFICE PROCEDURES
Patient Instruction- Solutions
and Suspensions
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Wash hands thoroughly before administration
Tilt head backward or lie down and gaze upward
Gently grasp lower eyelid below eyelashes and pull
the eyelid away from the eye to form a pouch
Place dropper directly over the eye. Avoid contact of
the dropper with the eye, finger or any other surface
Release the lid slowly and close the eye
Occlude punta for 2-3 minutes
Wait 5 minutes before administering a second
medication or drop
Patient Instruction- Ointment
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Wash hands thoroughly
Tilt head backward or lie down and gaze upward
Gently pull down the lower lid to form a pouch
Place .25 to .50 inch of ointment with a sweeping
motion
Close the eye for 1-2 minutes
Temporary blurring of vision may occur.
Remove excess ointment with a tissue
Wait 10 minutes before applying the second
ointment
Continuous release delivery
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A medication device placed in the eye and
lasting for a week is quite a benefit to patients
who have
trouble keeping up with their drops. The most
common of these devices is the Pilocarpine
Ocusert®,
which permits continuous delivery of
medication 24 hours a day for seven days.
Retro-Bulbar Injection
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Subconjunctival injections
Injections may be administered under the
conjunctiva to deliver medications in large doses
and longer
durations (fig. 4–4). The subconjunctival medication
gains access to the eye by absorption into the
bloodstream through the episcleral and conjunctival
vessels. Subconjunctival injections are used
primarily in the treatment of intraocular infection or
acute uveitis cases.
ABBREVIATIONS
Examples
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ad lib- freely as needed
ac – before meals
bid- twice a day
gtt- Drops
hs- at bedtime
pc -after meals
po- by mouth
prn- as needed
Examples- con’t
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oint- ointment
q- every
qh- every hour
q4h- every four hours
qid- 4 times a day
sig- instructions
sol- solution
susp- suspension
Examples- con’t
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tab- tablet
tid- three times a day
top- topically
ung- ointment
ut dict- as directed
Abbreviation
Meaning
Abbreviatio
n
Meaning
Prescription
abbreviations
(ante cibum) before
meals
ac
q
(quaque) every
(ad libitum) as much as
wanted
qd
(quaque die) every day
aq
Water
qh
(quaque hora) every hour
bid
(bis in die) twice a day
qid
(quater in die) 4 times a
day
(gutta; guttae) drop;
drops
ql
ad lib
gt; gtt
(quaque quarta hora) every
four hours
h
hora) hour
hs
(hora somni) at bedtime
qs
quantity sufficient
mg
Milligram
Rx
(recipe) prescription
(non repetatur) do not
repeat
Sol
solution
pc
(post cibum) after meals
Tid
(ter in die) three times a
day
po
(per os) by mouth, orally
ung
(unguentum) ointment
prn
(pro re nata) as needed
non rep
qqh or q4h
(quantum libet) as much as
desired
Mydriatic
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Mydriasis is the dilation of the pupils, so, logically,
a mydriatic drug causes dilation. The main
reason the eyes is dilated is to allow the doctor to
perform a thorough exam of the posterior portion
of a patient’s eyes. A big pupil allows a wider field
of view and gives the examiner a chance to see
the vast majority of the retina, rather than the
very small amount seen in an undilated eye.
Mydriasis is also useful in allowing you to take
fundus photographs of the macula, optic nerve,
and any retinal anomalies present.
Cycloplegics
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These drugs cause mydriasis like mydriatics, but they also cause cycloplegia, which
is paralysis of the ciliary muscle. Remember, the ciliary muscle controls focusing of
the light rays entering the eye by changing the shape of the crystalline lens.
Cycloplegics are used in dilating the pupils to facilitate examination of the fundus,
prevent ciliary spasm and pain in iritis patients, and prevent a patient (usually a
suspected hyperope) from constantly accommodating while the doctor is trying to
refract the patient and figure out the prescription.
Cycloplegics are also used to perform entrance eye exams on flyers to find what their
true refractive error is. Again, this is accomplished by paralyzing the focusing
mechanism of the eyes (temporarily) while the doctor refracts the patient.
Cycloplegics almost always come in bottles with red caps.
Tropicamide (Mydriacyl®; Opticyl®)
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The information you need to know about tropicamide is:
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• Preparation: Solution, 0.5 – 2 percent (most common usage is 1 percent).
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• Dosage: Instill one drop in each eye. Repeat if the doctor requests it.
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• Action and uses: Produces mydriasis and cycloplegia. Onset of action is rapid (20 –
30
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minutes) and duration varies from one-half to four hours. Used primarily in
conjunction with phenylephrine when dilating patients for routine fundus exams. May
be used for unofficial
Beta-Blockers
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Beta-blockers are the current drugs of choice in lowering
IOP. Timoptic®, Betoptic®, and Betagan® are some of the
most popular drugs being used to lower IOP today.
Introduced in the late 1970s, they quickly became the initial
drug of choice for lowering IOP.
One reason beta-blockers are so popular is, on average,
they reduce IOP by 25 percent. Another reason is they can
be used once or twice daily, unlike most previous
medications that were used up to four times a day. Finally,
most of the previous drugs used to lower IOP caused miosis
(pupillary constriction), dim vision (due to constricted pupil
size), eyebrow ache, and stimulation of accommodation
(which can blur vision). Fortunately, beta-blockers work
without these side effects. However, this does not mean
they are perfect, as they also have some side effects.
Beta-Blocker Complications
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Beta-blockers block the beta–1 and beta–2 receptors from
doing their jobs in the body. This is good because one of
the jobs of the receptors involves maintaining normal
production of aqueous humor. By slowing down aqueous
production, the IOP can be lowered. The downside is some
of the other jobs beta–1 and beta–2 receptors include
proper heart rate and breathing.
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Basically, if a patient systemically absorbs a beta-blocking
medication, it slows the heart rate and makes breathing
difficult. Not a great thing to have happening when you
consider the age and general health of a lot of your
glaucoma patients.
Risk of Complications
Thus, patients with certain systemic diseases warrant special consideration by
a doctor trying to decide whether the person should use beta-blockers or
not. The following is a very general list of systemic conditions
contraindicating beta-blocking medication usage.
• Asthma.
• Heart or circulatory problems.
• Chronic obstructive pulmonary disease (COPD).
 In addition, patients already on systemic beta-blockers (e.g., Inderal® for
high blood pressure) should be considered high-risk candidates for use of
any of the beta-blocker medications. Patients may be better off using one of
the cholinergic medications, carbonic anhydrase inhibitors, or prostaglandin
inhibitors instead.
 Some of the common side effects of beta-blockers (especially the more
medication the patient systemically absorbs) are:
• Bradycardia—the slowing down of the heart rhythm (leading to low
blood pressure and dizziness).
• Induced asthma.
• Mood changes.
Cholinergic agents (direct-acting
miotics)
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These drugs are the traditional medications used to lower IOP. They
have fallen out of the widespread usage once enjoyed before the
beta-blockers and prostaglandins came along. However, they still
play a role in the management of IOP as there are times betablockers alone do not lower IOP enough or patients require specific
treatment working on the outflow of aqueous humor rather than just
slowing its production.
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These cholinergic drugs lower IOP by causing the longitudinal
muscle of the ciliary body to pull on the sclera near the base of the
iris and the trabecular meshwork. Pulling in the ciliary body causes
an opening or rearranging of the trabecular meshwork, allowing the
aqueous to drain from the eye faster.
Since these drugs work directly to cause contraction of the ciliary
muscle, they are considered to be direct-acting miotics and are
primarily used in the treatment of angle-closure glaucoma.
While the primary action desired from these miotic medications is to
increase aqueous humor
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Topical Steroids
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Durezol
Pred Forte
Prednisone
Omnipred
Econopred
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Avoid using steroids on viral infections
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Contraindications for Steroids
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Cataracts.
Increased IOP.
Fungal overgrowth.
Delayed wound healing.
Decreased wound healing.
Decreased resistance to infection.
Proliferation of herpes simplex virus
NOTE: Virtually all of these side effects are quite rare when the proper dosage of topical steroid is used in a short-term manner as prescribed by the doctor.
Topical NSAIDS
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Bromday – Prolenza
Nevanec
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Used often for pre/post cataract surgery
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Cap Color
Drug Class
Antibiotics, Antivirals, Antifungals
CAP
Colors
Pink
Anti-inflammatory/Steroids treats allergic reactions, swelling,
Tan
redness (slows healing can cause cataracts and glaucoma). Do not
use on fungal infections
Red
Mydriatics/Cycloplegics (dilate pupil)
Grey
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) control
inflammation caused by ocular allergies without steroidal sideeffects
Green
Miotics (stimulates sphincter and causes pupil constriction)
Yellow or Blue
Beta-Blockers traditionally used to treat glaucoma, reduce IOP by
decreasing aqueous humor
Purple
Adrenic Agonists (reduce IOP)
Orange
Carbonic Anhydrase Inhibitors (reduce IOP)
Turquoise
Prostaglandin Analogues (reduce IOP by increasing aqueous
outflow)
HOW TO WRITE AN Rx
Medication Administration
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Read the doctors
orders
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Check the medication
twice
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Name
Dosage
Amount
Expiration date
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Wait 5 min between gtts
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Punctal Occlusion
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Put ung in last
Preparation
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1. Wash your hands.
2. Triple check the medication you are going to instill to ensure it is what the
doctor ordered.
3. Advise the patient of what you are going to do.
4. Recline the patient or gently tilt the patient’s head back. Always ask the
patient about neck or back problems before tilting his or her head. Do not tilt a
Down’s syndrome patient’s neck due to the high risk of cervical fracture.
5. With one hand, hold the upper lid and, with a finger of the other hand (the one
holding the little bottle of medication), pull down gently on the lower lid (fig. 4–1).
6. Have the patient look down.
7. Keep the bottle about ½″ above the eye. This should be high enough to avoid
contamination by the patient’s eyelashes in the event the patient inadvertently
blinks, while still allowing good control of where the drop goes. Now, squeeze
the bottle to dispense a drop in the eye. Ideally, the drop hits just above the
upper limbus, causing minimal reaction by the patient (since the very sensitive
cornea isn’t hit directly), but allowing a good percentage of medication to flow
across the cornea before it gets diluted by tears.
CAUTION: Keep the eye dropper tip well away from the eye so, even if the
patient blinks, the lashes do not touch it. If the dropper tip comes into contact
with the patient’s eyes, lids, or lashes, the bottle is considered contaminated
and must be thrown away after you finish with the patient. Do not attempt to use
it on another patient.
Make sure that you include:
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Full name of patient
Address can be optional
Date of Rx
Inscription: name of drug; concentration
Subscription: amount to be dispensed
Instructions: route of administration; number
of drops or tablets; frequency of use; refill
What else?
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Make sure that it is legible!
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Type in correctly
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Verify
Questions
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What type of drug is used to lower IOP?
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A. Mydriactic
B. Antibiotic
C. Beta Blocker
How often is the following medications taken?
Maxitrol ophthalmic ung apply BID OU for 14
days:
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A. Once a day B. Twice a Day C. Three times a Day
Questions
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What drug is used to stain the cornea?
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A. Mydriacyl
B. Carbachol
C. Flourescein
How often is the following medications taken?
Pred Forte ophthalmic 1gtt qid q 6h OD 7 days
then 1gtt bid q 12h for 7 more :
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****No help****
Questions
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What drug is used to destroy bacteria?
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A. Bromday
B. Antibiotic
C. Beta Blocker
What drug is used increase aqueous outflow?
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A. Vigamox
B. Pilocarpine
C. Mydriacyl
Questions
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What drug is used to dilate the pupil?
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A. Miotic
B. Mydriacyl
C. Beta Blocker
What drug is used as an anti-inflammatory?
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A. Durezol
B. Vigamox
C. Besivance
Examples
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ad lib- ________
ac – ________
bid- _________
gtt- _________
hs- _________
pc -__________
po- __________
prn- __________
Examples
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ad lib- freely as needed
ac – before meals
bid- twice a day
gtt- drops
hs- at bedtime
pc -after meals
po- by mouth
prn- as needed
References and resources
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Ophthalmic Drug Facts 2002
Ophthalmic Medications and Pharmacology
Review of Optometry: 2002 Clinical Guide to
Ophthalmic Drugs (Melton and Thomas) May
issue
THANK YOU!