Post on 23-Dec-2015
OCULAR PHARMACOLOGY for ASSISTANTS AND
TECHNICIANS
John W. Snead MD, MBA, FACS
Lynn Lawrence, CPOT, ABOC
ROLE of theASSISTANT AND TECHNICIAN
RecordingPatient EducationNEVER Work in Doubt!
PATIENT CASE HISTORY
General HealthMedicationsAllergies
VITAMIN SUPPLEMENTS
CLASSIFICATIONS
SolutionsSuspensionsOintments
DIAGNOSTIC AGENTS
Topical AnesthesticsMydriaticsCycloplegicsDyes/StainsFluressGonioscopic Solutions
DPA’s treat symptoms, unknown disease
Topical Anesthetics
Proparacaine Tetracaine Cocaine Alcaine
Mydriatics & Cycloplegics
Tropicamide Phenylephrine Cyclogyl Atropine Homatropine Scopalomine
Dilation Hazards Cross Contamination
Narrow anterior chamber angle
Potential risk in dilating … opt vs oph
Plan for acute angle glaucoma attack
Make sure you are far enough away not toTouch the patient
Dyes & Stains
Fluorescein Rose Bengal Lissamine Green Fluress
Gonioscopy Solutions
Goniosol Gonioscopic Celluvisc
CLINICAL ADMINISTRATION
Patient HistoryClinical Procedures Which May
Be Influenced by MedicationsThe ERx Option
Ophthalmic Drug Complications 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
AntibioticsAnti-viralsDrugs that lower IOPAnti-inflammatory agentsNon-SteroidalCombinations
TPAs treat disease, known problem
GLAUCOMA MANAGEMENT
PilocarpineBeta-BlockersCarbonic Anhydrase
InhibitorsAdrenergic Agonists
OCULAR INFLAMMATION
CorticosteroidsSteroid-Antibiotic CombinationsNon-Steroidal Anti-inflammatory
Drugs (NSAIDS)Oral Analgesics
OCULAR INFECTIONS
Topical AntibioticsOral AntibioticsAnti-Viral Analgesics
Antibiotic
Biotic means relating to, produced by, or caused by living organisms
The prefix anti "against" the referent of the stem to which the prefix is affixed
OCULAR SURFACE
Artificial TearsLubricating OintmentsPunctal Occlusion
OCULAR ALLERGIES
Artificial TearsAntihistamine-DecongestantsCorticosteroids
Cap Color Code
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
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
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
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
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
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
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
tab- tablet tid- three times a day top- topically ung- ointment ut dict- as directed
Prescription abbreviationsAbbreviation Meaning Abbreviatio
nMeaning
ac (ante cibum) before meals q (quaque) every
ad lib (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
gt; gtt (gutta; guttae) drop; drops
ql (quantum libet) as much as desired
h hora) hour qqh or q4h (quaque quarta hora) every four hours
hs (hora somni) at bedtime qs quantity sufficient
mg Milligram Rx (recipe) prescription
non rep (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
Mydriatic 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 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®) The information you need to know about tropicamide is: • Preparation: Solution, 0.5 – 2 percent (most common usage is 1 percent). • Dosage: Instill one drop in each eye. Repeat if the doctor requests it. • Action and uses: Produces mydriasis and cycloplegia. Onset of action is rapid (20 –
30 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 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 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.
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 ComplicationsThus, 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)
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 beta-blockers alone do not lower IOP enough or patients require specific treatment working on the outflow of aqueous humor rather than just slowing its production.
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
Topical Steroids
Durezol Pred Forte Prednisone Omnipred Econopred
Avoid using steroids on viral infections
Contraindications for Steroids
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
Bromday – Prolenza Nevanec
Used often for pre/post cataract surgery
CAP ColorsCap Color Drug Class
Tan Antibiotics, Antivirals, Antifungals
Pink Anti-inflammatory/Steroids treats allergic reactions, swelling, 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 side-effects
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 Read the doctors orders
Check the medication twice Name Dosage Amount Expiration date
Wait 5 min between gtts
Punctal Occlusion
Put ung in last
Preparation
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:
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?
Make sure that it is legible!
Type in correctly
Verify
Questions
What type of drug is used to lower IOP? A. Mydriactic B. Antibiotic C. Beta Blocker
How often is the following medications taken?
Maxitrol ophthalmic ung apply BID OU for 14 days:
A. Once a day B. Twice a Day C. Three times a Day
Questions
What drug is used to stain the cornea? 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 :
****No help****
Questions
What drug is used to destroy bacteria? A. Bromday B. Antibiotic C. Beta Blocker
What drug is used increase aqueous outflow? A. Vigamox B. Pilocarpine C. Mydriacyl
Questions
What drug is used to dilate the pupil? A. Miotic B. Mydriacyl C. Beta Blocker
What drug is used as an anti-inflammatory? A. Durezol B. Vigamox C. Besivance
Examples
ad lib- ________ ac – ________ bid- _________ gtt- _________ hs- _________ pc -__________ po- __________ prn- __________
Examples
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
Ophthalmic Drug Facts 2002 Ophthalmic Medications and Pharmacology Review of Optometry: 2002 Clinical Guide to
Ophthalmic Drugs (Melton and Thomas) May issue
THANK YOU!