Chapter 74 - Glaucoma, Ophthalmics & Otics (23)

Front 1

GLAUCOMA - an eye disease caused by ...

Back 1

Intraocular pressure (IOP) → vision loss if untreated

Front 2

Glaucoma - drugs that ↑ IOP

Back 2

• Cough/cold/motion sickness meds (antihistamines, scopolamine)
• Anticholinergics (oxybutynin, tolterodine, benztropine, trihexyphenidyl, tricyclics)
• Chronic corticosteroids - especially eye drops such as prednisolone
• Topiramate (Topamax)

Front 3

Glaucoma - SX's

Back 3

• Asymptomatic or
• Pain
• HA
• Decreased vision
  

Front 4

Glaucoma - risk factors ...

Back 4

• FH
• AA ethnicity
• Nearsightedness (myopia)
• Eye surgery HX
  

Front 5

Glaucoma - two main forms ...

Back 5

• Angle-closure or closed-angle glaucoma (medical emergency)
• Open-angle glaucoma - most common type
  

Front 6

Open-angle glaucoma - treatment methods

Back 6

• Eye drops
• Surgery (sometimes)
  

Front 7

Eye drops - formulations used ...

Back 7

• Solutions
• Suspensions - shake well B4 use
• Ointments applied conjunctiva sac or over lid margins (not used with contact lenses)
• Gels - invert & shake once with cap on
  

Front 8

Persistently high IOP - two causes

Back 8

• Poor eye drop technique
• Poor adherence due to lack of SX's
  

Front 9

Open-angle glaucoma - eye drops used ...

Back 9

Beta-blockers (all non-selective except the last)

• Timolol 0.25% & 0.5% (Timolol GFS, Timoptic, Timoptic XE, Timoptic Ocudose, Istalol, Betimol)
• Levobunolol (Betagan)
• Carteolol (Ocupress)
• Metipranolol (OptiPranolol)
• Betaxolol (Betoptic, Betoptic S)

PG analogs

• Travoprost (Travatan Z)
• Bimatoprost [(Lumigan, Latisse for eyelash hypotrichosis (↑ eyelash growth)]
• Latanoprost (Xalatan)
• Unoprostone (Rescula)
• Tafluprost (Zioptan)

Cholinergics (Miotics)

• Carbachol (Isopto Carbachol, Miostat)
• Pilocarpine (Isopto Carpine, Pilopine HS)
  

Carbonic anhydrase inhibitors

• DorZOLAMIDE (Trusopt)
• AcetaZOLAMIDE (Diamox Sequels)
• BrinZOLAMIDE (Azopt)
• MethaZOLAMIDE (Simbrinza)

Adrenergic alpha-2 agonists

• Brimonidine (Alphagan P)
• Dipivefrin (Propine, Akpro)
• Apraclonidine (Lopidine)

Combination products

• Timalol + dorzolamide (Cosopt, Cosopt PF)
• Timalol + brimonidine (Combigan)
• BrinZOLAMIDE + brimonidine (Simbrinza)

Front 10

Open-angle glaucoma - selection of eye drops ...

Back 10

• PG's & BB's - commonly used initial agents
• PG's - safe, most effective in reducing IOP & dosed once a day
• BB's - used as initial agent when IOP high in one eye, thus the color of iris stay the same
• The rest of classes used as add-ons
  

Front 11

Open-angle glaucoma - BB eye drops used ...

Back 11

• Timolol 0.25% & 0.5% (Timolol GFS, Timoptic, Timoptic XE, Timoptic Ocudose, Istalol, Betimol)
• Levobunolol (Betagan)
• Carteolol (Ocupress)
• Metipranolol (OptiPranolol)
• Betaxolol (Betoptic, Betoptic S)

Front 12

BB eye drop - MOA

Back 12

Reduce aqueous humor production

Front 13

BB eye drops - SE's

Back 13

• Slight burning
• Stinging
  

Front 14

BB eye drops - time to wait B4 reinserting contact lenses after admin ..

Back 14

15 minutes

Front 15

Timolol 0.25% & 0.5% - brands

Back 15

• Timolol GFS
• Timoptic
• Timoptic XE
• Timoptic Ocudose
• Istalol, Betimol

Front 16

Levobunolol - brand

Back 16

Betagan

Front 17

Carteolol - brand

Back 17

Ocupress

Front 18

Metipranolol - brand

Back 18

OptiPranolol

Front 19

Betaxolol (the only selective) - brand

Back 19

• Betoptic
• Betoptic S

Front 20

Open-angle glaucoma - PG's eye drops used

Back 20

• Travoprost (Travatan Z)
• Bimatoprost (Lumigan)
• Latanoprost (Xalatan)
• Unoprostone (Rescula)
• Tafluprost (Zioptan)

Front 21

PG's eye drops - MOA

Back 21

Increase aqueous outflow

Front 22

PG's eye drops - warnings

Back 22

• Darkening of the iris & eyelashes
• Increase in number & strength of eyelashes
  

Front 23

PG's eye drops - SE's

Back 23

• Blurred vision
• Increased pigmentation of the iris/eyelashes
• Eyelash growth & sickening
  

Front 24

Travoprost - brand

Back 24

Travatan Z

Front 25

Bimatoprost - brand

Back 25

• Lumigan
• Latisse for eyelash hypotrichosis (↑ eyelash growth)

Front 26

Latanoprost - brand

Back 26

Xalatan

Front 27

Unoprostone - brand

Back 27

Rescula

Front 28

Tafluprost - brand

Back 28

Zioptan

Front 29

Open-angle glaucoma - cholinergics (Miotics) eye drops used...

Back 29

• Carbachol (Isopto Carbachol, Miostat)
• Pilocarpine (Isopto Carpine, Pilopine HS)

Front 30

Cholinergics (Miotics) eye drops - MOA

Back 30

Work just like PG's

Front 31

Carbachol - brand

Back 31

• Isopto Carbachol
• Miostat

Front 32

Pilocarpine - brand

Back 32

• Isopto Carpine
• Pilopine HS

Front 33

Open-angle glaucoma - carbonic anhydrase inhibitors eye drops used...

Back 33

• DorZOLAMIDE (Trusopt)
• AcetaZOLAMIDE (Diamox Sequels)
• BrinZOLAMIDE (Azopt)
• MethaZOLAMIDE (Simbrinza)

Front 34

Carbonic anhydrase inhibitors eye drops - MOA

Back 34

Work Just like BB's

Front 35

Carbonic anhydrase inhibitors eye drops - warnings

Back 35

AcetaZOLAMIDE - sulfonamide allergy with eye drops or oral forms

Front 36

DorZOLAMIDE - brand

Back 36

Trusopt

Front 37

AcetaZOLAMIDE - brand

Back 37

Diamox Sequels

Front 38

BrinZOLAMIDE - brand

Back 38

Azopt

Front 39

MethaZOLAMIDE - brand

Back 39

Simbrinza

Front 40

Open-angle glaucoma - adrenergic alpha-2 agonists eye drops used

Back 40

• Brimonidine (Alphagan P)
• Dipivefrin (Propine, Akpro)
• Apraclonidine (Lopidine)

Front 41

Adrenergic alpha-2 agonists eye drops - MOA

Back 41

Have combination of MOA's of all eye drops mentioned so far

Front 42

Brimonidine - brand

Back 42

Alphagan P

Front 43

Dipivefrin - brand

Back 43

• Propine
• Akpro

Front 44

Apraclonidine - brand

Back 44

Lopidine

Front 45

All eye drops - select counseling points ...

Back 45

• Hand wash
• Suspensions - shake few minutes
• Gels - shake once
• One finger to pull down lower eyelid
• ONE drop into space b/n eye & lower eyelid
• Close eye - then press finger b/s the eye & top of the nose for at least 1 full minute → less likely SE's
• If benzalkonian choloride preservative, remove contact lenses if you wear B4 admin & wait for 15 min after admin
• Wait for 5-10 min (10 min if gel) to put if you have to use another med...

Front 46

Timolol (Timoptic) eye drops - select counseling points

Back 46

• SE - see above
• Non-selective - best avoided in pts with asthma, COPD, chronic bronchitis, emphysema & advanced cardiac dz
• If dispensing in Ocudose, - unscrew the cap to arrow direction but no pulling the cap off (spoiling)
• Invert bottle & finger push area until ONE drop
  

Front 47

PG analog eye drops - select counseling points

Back 47

• Remove contact lenses (staining) & wait 15 min to reinsert
• ↑ Brown pigmentation of the iris & gradual color change in the eye ...
• Usually not for people with light eyes with glaucoma in one eye
• Eyelash growth/pigmentation ↑
• Well tolerated - report if excessive tears, pain or lid crusting
• Latanoprost (Xalatan) - unopened bottles refrigerated
• Tafluprost (Zioptan) - refrigerated but opened pouch of 10 good at RM for 4 wks
• Not use if using bimatoprost (Latisse) for eyelash growth (↓ effectiveness)
  
• If gel (Timoptic XE, Timoptic GFS) - shake once & used once/day, Other topical should be used at least 10 min B4 timalol gels.
  

Front 48

Alpha blockers →

Back 48

Iris syndrome (difficulty to perform cataract surgery)

Front 49

Amiodarone →

Back 49

• corneal deposits
• Optic neuropathy

Front 50

Bisphosphonates →

Back 50

Ocular inflammation

Front 51

Digoxin →

Back 51

• Yellow/green vision
• Blurriness
• Halos
  

Front 52

Chlorquine (Aralen) →

Back 52

• Retinopathy
• Possible permanent visual damage
  

Front 53

Hydroxychlorquine (Plaquenil) →

Back 53

Retinopathy

Front 54

Ethambutol (Myambutol) & Linezolid (Zyvox) →

Back 54

Optic neuropathy esp with chronic use

Front 55

Ezogabine (Potiga) →

Back 55

• Retinal changes
• Vision loss
  

Front 56

Isoniazid →

Back 56

Optic neuritis

Front 57

Isotretinoin →

Back 57

• Decrease in night vision (possible permanence)
  
• Dry eyes irritations

Front 58

Quinolones →

Back 58

Retinal detachment

Front 59

Sildenavil (Viagra) & other PDE-5I's for ED, PAH, BPH →

Back 59

• Greenish tinge around things
• Possible vision loss - one eye or both

Front 60

Tamoxifen (Soltamox) →

Back 60

• Corneal changes
• Decreased color perception
  

Front 61

Telithromycin (Ketek) →

Back 61

• Blurry vision
• Diplopia
  

Front 62

Voriconazole (Vfend) →

Back 62

• Abnormal vision
• Color vision change
• Photophobia
  

Front 63

CONJUNCTIVITIS (pink eye) - causes

Back 63

• Allergens
• Bacteria
• Virus
  

Front 64

Conjunctivitis (pink eye) - all types management

Back 64

• Most cases resolve by themselves
• Compresses to ↓ swelling & discomfort
• Artificial tears to lubricate and ↓ "gritty" feeling
• NSAIDs (if mild) or steroid eye drops to ↓inflammation of all types of conjunctivitis
  

Front 65

Conjunctivitis (pink eye) - drugs to treat...

Back 65

• Viral - nothing & takes its course (2-3 wks)
• Bacterial - antibiotic eye drops or ointments
• Allergic - mast cell stabilizer eye drops & antihistamine eye drops
• Inflammation - steroid & NSAID's eye drops
• Dryness - lubricants eye drop
  

Front 66

Bacterial conjunctivitis - select antibiotics eye drops or ointments...

Back 66

• Azithromycin (Azasite) - refrigerated, 14 days at RT
• Moxifloxacin (Vigamox)
• Besifloxacin (Besivance)
• Topramycin/Dexamethasone (TobraDex, TobraDex ST)
• Ciprofloxacin (Ciloxan)
• Ofloxacin (Ocuflox)
• Gentamicin (Garamycin)
• Tobramycin (Tobrex)
• Sulfacetamide (Bleph-10)
• Trimethoprim/polymyxin B (Polytrim)
• Neomycin/bacitracin/polymyxin B (Neosporin)
• Erythromycin

Front 67

Allergic conjunctivitis - select mast cell stabilizers eye drops ...

Back 67

• Cromolyn
• Lodoxamide (Alomide)
• Nedocromil (Alocril)
• Pemirolast (Alamast)
  

Front 68

Allergic conjunctivitis - select antihistamine eye drops ...

Back 68

• Azalastine (Optivar)
• Epinastine (Elastat)
• Olopatadine (Patanol)

Front 69

Conjunctivitis inflammation - select steroid eye drops

Back 69

• Dexamethasone (Maxidex, Ozurdex)
• Loteprednol (Alrex, Lotemax susp., oint.)
• Flourometholone (Flarex, FML Forte, FML Liquifilm susp. oint.)
• Prednisolone ecetate (Pred Forte)
  

Front 70

Conjunctivitis dryness - select lubricants eye drop...

Back 70

• Common eye lubricants - miniral oil, glycerin, propylene glycol, dextran, hypromellose
• Examples - Systane, Refresh, Clear Eyes, Liquiflim ...
  

Front 71

BELPHARITIS ...

Back 71

Eyelid inflammation - chronic (hard to treat) or acute

Front 72

Belpharitis - SX's

Back 72

Inflamed, irritated, itchy eyelids

Front 73

Belpharitis - preferred treatment ...

Back 73

• Gentle wash & compresses to loosen crusty deposits
• Debris (after wash) wiped out with warm moist (H2O + a few baby shampoo drops)
  

Front 74

OTICS - common conditions include

Back 74

• Otitis pain such as from infection (antibiotic TX)
• Inflammation from swimmer's ear (otitis externa)
• Tinnitus - toxicity due to salicylates, noice exposure, or idiopathy
• Earwax (cerumen)

Front 75

Otitis externa (swimmer's ear) - treated preferentially with ...

Back 75

Systemic analgesics - ibuprofen, APAP

Front 76

Tinnitus - treatment

Back 76

No effective treatment but eye drops can be used as ear drops (NEVER THE OTHER WAY AROUND)

Front 77

Ear drops with antibiotics for outer ear infection include ...

Back 77

• Ciprofloxacin + hydrocortisone (Cipro HC)
• Ciprofloxacin + dexamethasone (CipraDex)
• Neomycin + colistin + hydrocortisone + thonzonium (Cortisporin-TC)
  

Front 78

Earwax (cerumen) - removal ...

Back 78

Hard to wash away - removal in doctor's office

Front 79

Earwax (cerumen) - removal agents used to prevent if chronic

Back 79

• Carbamide peroxide (Debrox)
• Triethanolamine (Cerumenex)
  

Front 80

Otic med application ...

Back 80

• Cold - hold bottle 1-2 min to warm
• Earlobe - pull back & up for adults (back & down for kids)
  

Front 81

Notes from the test..

Back 81

• Bimatoprost (Latisse) is indicated for eyelash hypotrichosis (to increase eyelash growth); it should not be used with same class for glaucoma without a physician's knowledge and approval (using PAs more frequently decreases effectiveness).
  
• Latisse is not applied to the lower lid or in the eye and excess solution around the eye during application should be blotted with a tissue.
• The carbonic anhydrase inhibitors often cause bitter taste, and possible eye burning and stinging.