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37 Cards in this Set

  • Front
  • Back
What nerves innervate the eye?
What action do they cause?
Which drugs block them and what is the result?
parasymp - constrict - parasympatholytics (antichol) = dilation

symp = dilation - sympatholytics (cholinergics) = constriction
glaucoma def
involves changes to the...
loss of ... and ...
increased ...
Ocular disorder involving optic neuropathy with changes in the optic disk and loss of visual sensitivity and field; may or may not involve increased intraocular pressure (IOP
Acute Angle Closure Glaucoma
definition
cause
sxs
drug thpy
Rare
caused by increased pressure due to blockage of trabecular mesh = decr aqueous outflow
Causes abrupt rise in IOP (intra-ocular pressure)
Narrow angle between cornea and iris

Tight contact between the iris and lens (pupillary block)
*
SXS
Cloudy, edematous cornea
Ocular pain or discomfort
Nausea, vomiting, abdominal pain, and diaphoresis
IOP = 40-90

Rx Thpy:
1ST = SURGICAL / LASER
-Pilocarpine 2-4% 1 drop every 5 minutes for 4-6 administrations

-Hyperosmotic agents

-Secretory inhibitor
b-blocker, a2agonist, prostaglandin analog or topical CAI
Primary Open Angle Glaucoma (POAG)
common
chronic visual loss
Retinal ganglion cells perish
elevated OR normal IOP
what is the correct predominant route of creation and flow of aqueous humor through the eye?
ciliary body, posterior chamber, anterior chamber, trabecular meshwork, Schlem's canal, vein
Usual outflow through:
Unconventional path:
trabec meshwork -> schlems canal -> vein

ciliary body -> suprachoroidal space
Pharmacotherapy classes and drug MOAs
1.
2.
3.
Decrease aqueous production (constrict)

BB
2-Adrenergic Agonists
Carbonic anhydrase inhibitors (CAI)

Increased aqueous outflow (dilate)
PG analogs
Parasympathomimetics
Sympathomimetics
POAG Drug Therapy Choices
First line
Adunctive or Second line agents

Last Line

Rarely
1st line
Beta blockers
PG analogs
Brimonidine

Adjunctive or Second line
Topical CAIs carbonic anhydrasei nh

Last Line
Pilocarpine (gtts)
Apraclonidine

Systemic CAIs
Echothiophate

Rarely
Diprivefrinor epinephrine
First line are dosed ____ and are well tolerated
1-2x daily
Nonspecific BBs:
relatively specific:
Nonspecific with ISA:
Timolol, levobunolol, metipranolol

betaxolol

carteolol
BB's Use with caution in patients with....

Tachyphylaxis =

a)

The ____ is usually checked before and after initiating therapy
asthma/COPD, heart block, congestive heart failure, on oral beta-blockers

tolerance to bbs

pulse
Selective 2-receptor agonists

MoA
ADR
Counsel pts
Reduce IOP 18-27% at peak, less at nadir (10%)

Dont give concurrent with MAOI

ADR: allergy, dry mouth, dry eye, lethargy, mydriasis, and hypotension

Recommend Nasal lacrimalocclusion
Prostaglandin agonists
MoA
ADR
Counsel pts
Latanaprost

Works primarily onincreasing unconventional outflow path

Usually dosed at NIGHTIME

NO PREGNANCY USE

ADR:
altered iris pigmentation
become more brown in blended eye colors like hazel

stinging sensation

increase in eyelash length and deepening of color
Topical carbonic anhydrase inhibitors (CAI)�

Example
ADR
Counsel pts
ADR: side effects include burning, BITTER TASTE, and topical allergy

Same potential side effects as systemic CAI, except that more worrisome adverse effects like metabolic acidosis, hypokalemia, gastrointestinal symptoms, weight loss, and paresthesias are usually not seen

dorzolamiden
Systemic CAIs

Example
ADR
Counsel pts
USED IN EYE EMERGENCY to quickly drop IOP

SULFA ALLERGY
SE: fatigue, N, confusion, taste, parethesias
MONITOR K+ if other diuretics or digitalis
POAG Goal of Treatment
reducing pretreatment IOP by at least 25%

Reduce IOP by 20% lower than baseline as initial target

Usual ultimate goal for IOP < 21 mmHg
Therapeutic Monitoring, how often?
initial 4-6wks
chronic 3-4 mos
Time to Response
BBs?
PG analogs?
CAI?
a2 agonist?
3-6 weeks for beta-blockers, prostaglandin analogs

anytime after 3 days for topical carbonic anhydrase inhibitors, alpha-agonists, and miotics
Glaucoma Patient Counseling

Dont instill more than ____ at a time

If on combination therapy, separate drops by at least ___ min and ideally ____ min)

Order of drugs does/doesn't matter
1 drop
5, 10
doesn't
Preservative Used Most FrequentlymHg
Benzalkonium chloride (BAK)sts(
Options to Reduce Ocular Exposure to Benzalkonium Chloride
Single dose unit

Timoptic gel 1%

Cosopt (unit dose not yet in US)

Purite

Brimonidine purite 0.15% (Alphagan P)

SofZia

Travaprost 0.004% (Travatan Z)ow):
When to Recommend Non-BAK Drops
Patients experiencing significant irritation or local adverse effects

To reduce cumulative exposure to BAK when using more than 1 type of drops-
Drug Induced Glaucomat
POAG

Incr IOP most likely with: ____ & ____

______ may incr IOP, amt is dose related
Patients with untreated or uncontrolled POAG

Can be at risk for further increases in IOP

Topical (optical) anticholinergics

Increase in IOP most likely with atropine or homatropine

Corticosteroids(inhaled, nasal, topical or oral)

May increase IOP in pts with POAG and those without POAG

Amount increase in IOP is dose related,
Drug Induced Glaucomat
Most likely agents

Topical anticholinergics (optical)

Topical sympathomimetics (optical)2
Match the glaucoma medication to the its corresponding drug class.

Beta blocker - nonselective
Carbonic anhydrase inhibitor - topical

Prostaglandin analog

Beta blocker -B1 selective
Dorzolamide
Timolol
Latanoprost
Betaxolol
Brimonidine reduces intraocular pressure in patients with glaucoma by:
Both decreasing production and increasing outflow of aqueous humor
Match the glaucoma medication with its corresponding adverse reaction or warning.

timolol
latanoprost
dorzolamide`
use caution in patients with severe bradycardia

may cause iris PIGMENTATION

use caution in patients with sulfa allergy
TJ is a 60 yo Caucasian female with recently diagnosed primary open angle glaucoma.
Remarkable findings in her routine annual ophthalmic screening by her eye care professional last month:

IOP readings were 30 (OD) and 25 (OS). She was found to have minor peripheral vision loss in both eyes. Optic nerve was observed to have neurodegenerative changes signified by cupping.
Other pertinent history:

Controlled hypercholesterolemia (on simvastatin)
Controlled blood pressure (on enalapril/hydrochlorothiazide combination)
Allergies: Sulfa (nausea)
Which of the following agents would be an appropriate initial monotherapy choice for her glaucoma? Select three correct answers. No partial credit.

A. Apraclonidine (Iopidine)
B. Brinzolamide (Azopt)
C. Pilocarpine (Pilocar)
D. Travaprost (Travotan)
E. Timolol (Timpotic)
F. Brimonidine (Alphagan P)
G. Dipivefrin (Propine)
H. Acetazolamide (Diamox Sequels)
TRAVAPROST
TIMILOL
BRIMONIDINE
*Continuation of case above*
6 months later TJ's IOP has decreased some but is still >20 in both eyes. She is now prescribed two eye drops from different classes. She asks the pharmacist if she can administer the drops right after each other.

What is the best response?
No, she should wait at least five minutes between drops since it takes that long for the drug to penetrate the eye.
Refer/Treat

Red right eye, pupil is larger than the left, new since this AM
Refer
Refer/Treat

A contact lens wearer cannot open her eye spontaneously and keep it open
Refer
Refer/Treat

A small piece of metal is stuck in the patient's eye
Refer
Refer/Treat

Left red eye accompanied by headache and nausea
Refer
Refer/Treat

Pink eyes x 1 day, clear discharge every 8 hours, current upper respiratory infection
TREAT - URI = VIRAL
Over the last 2 days, he’s developed symptoms of bilateral ocular congestion, itchiness, and watery discharge. Matthew believes that symptoms started shortly after he began his new volunteer work at the animal shelter.

PMH: CAD s/p CABG 2001, erectile dysfunction, peripheral vascular disease, hypertension.

Allergies: Lisinopril, simvastatin, lovastatin, ASA

Meds: metoprolol 100 mg BID, sildenafil 100 mg PRN, clopidogrel 75 mg QD, losartan 25 mg QD, atorvastatin 80 mg QD

Last labs 11/25/10: BP 144/66 HR 60 Na+ 137 K+ 4.4 SCr 1.0 LDL 82 HDL 39

Why are topical decongestants NOT an optimal treatment choice for Matthew?
Decongestants should be avoided in people with cardiovascular diseases
Which of the following symptoms is an important indicator that Matthew likely has allergic conjunctivitis (as opposed to infectious conjunctivitis)?
Ocular itching
Anna is a 29 year-old female who presents to your pharmacy counter for some eye relief. Since last night, she’s developed ocular pain, redness, a thick green discharge, and woke up this morning with her eye “glued shut.” She also noticed this morning that she’s not seeing as sharp in her right eye (the sticky eye). She has no other complaints currently but notes that this is her 3rd bout of conjunctivitis in the last month. She also pulls you aside to ask about what female products you could recommend for her “infection down low”.
PMH: menstrual migraine, asthma

Allergies: Morphine, Ibuprofen

Meds: Yasmin, propranolol LA 80 mg, Proair PRN exercise

Last BP 4/2010: 110/78

Based on her presentation and history, what is the most likely diagnosis and cause of Anna’s symptoms?
Hyperacute conjunctivitis caused by N. gonorrhoea