Drugs for Ear & Eye Disorders

what are some examples of topical anti-infectives w/ or w/o corticosteroids for otitis externa?

- Neo + poly +hydrocortisone (Cortisporin Otic)

- Ciprofloxacin hydrocortisone (Cipro HC otic)

- Ofloxacin (Floxin)

- Neomycin (Myciguent)

- tobramycin (Tobradex)

- gentamicin (Garamycin)

which of the topical anti-infectives w/ or w/o corticosteroids for otitis externa are ophthalmic drops?

- tobramycin (Tobradex)

- gentamicin (Garamycin)

when would we use oral antibiotics for otitis externa?

if recurrent infections or infection is outside EOC (culture is recurrent)

what are the likely pathogens of otitis externa?

- P. aerginosa

- S. aureus

what is the usual treatment duration for otitis extera?

7 days (symptoms should resolve by this time)

is there a risk of systemic absorption with topical anti-infectives w/ or w/o corticosteroids for otitis externa?

minimal to no systemic absorption

what are topical anti-infectives w/ or w/o corticosteroids for otitis externa contraindicated with?

perforated TM

which of the topical anti-infectives w/ or w/o corticosteroids for otitis externa have a risk of ototoxicity?

- neomycin

- gentamicin

- tobramycin

what is preferred, the solution or the suspension of Corticosporin Otic?

suspension is preferred as the solution can burn

what are some acid-alcohol solutions to treat otitis externa?

- Acetic acid/aluminum acetate (Domeboro Otic)

- Isopropyl alcohol/ glycerine (Swim Ear)

- acetic acid/propylene glycol + HC (VoSol HC)

what is the action of acid-alcohol solutions for otitis externa?

decrease pH of the ear to prevent growth of organisms (defense mechanism of the ear)

what is the indication for acid-alcohol solutions for otitis externa?

superficial infections of the external auditory canal

what is the MOA of acid-alcohol solutions for otitis externa?

- Topical, antibacterial, and antifungal effect

- Inhibit CHO metabolism (starves bacteria)

- Induce drying of cellular infective agents

what can be used to manage pain of otitis externa?

oral NSAIDs and APAP

what are the most common pathogens that cause acute otitos media?

- VIRAL

- S. pneumoniae

- H. influenza

when are antibiotic beneficial to treat AOM?

- kids < 2

- if < 6 months, alway give

- high fevers, pain >48 hrs

when can "watchful waiting" be used for AOM?

if between 6-24 months and not ill-appearing, no or mild pain or fevers (

when is watchful waiting not advised?

if you don't think the parents will return of the child's symptoms worsen or don't improve

what are some complications of AOM?

- mastoiditis

- TM perforation

what adjunctive treatments can help with AOM?

- analgesics (NSAIDs, APAP)

- decongestants

*no Tylenol < 6 months*

what is the oral antibiotic first line treatment for AOM in pediatrics?

Amoxicillin 90mg/kg/d in 2 doses

what is the oral antibiotic first line alternative treatment for AOM in pediatrics?

- Amox/clav

- Cephalsporins

what is the oral antibiotic second line alternative treatment for AOM in pediatrics?

- Azithromycin

- Clarithromycin

- Levofloxacin

how long is the treatment for AOM?

5-10 days

how does treatment length differ between kids > 2 years and kids < 2 years for AOM?

- kids > 2 years: 5-7 days

- kids < 2 years: 7-10 days

what is the treatment length with systemic antibiotics for adults with AOM?

5-7 days

what is the first line treatment of antibiotics for adults with AOM?

Amoxicillin

what is second line treatment of antibiotics for adults with AOM?

- Cefdinir

- cefuroxime

- moxifloxacin

- levofloxacin

what PO antibiotic should NOT be used?

Cipro (does NOT cover Strep)

what antibiotic is reserved for recurrent infections or immunocompromised hosts?

Augmentin (amoxicillin/clavulanate)

what medications can be used for vertigo, Meniere's, labyrinthitis?

- Meclizine (Antivert)

- Scopolamine (Transderm Scop, Scopace)

what is Meclizine and what does it do?

Antihistamine that suppresses vasodepressor response

how often can Meclizine be given?

Given q6h for vertigo

what is Scopolamine and what does it do?

Topical patch or tablets that block cholinergic transmission from the vestibular nucleus

what are examples of cerumenolytics?

- Carbamide peroxide (Debrox)

- Triethanolamine polypeptide oleate (Cerumenex)

what do cerumenolytics aim to do?

softening and removing ear wax from the external

what alternative agents are there to soften and remove wax?

- Docusate (colace)

- sodium bicarbonate drops

when are cerumenolytics contraindicated?

perforated eardrum

how do you properly install ear drops in adults?

gently pull the earlobe up and back

how do you properly install ear drops in children?

gently pull the earlobe down and back

what are some tips when using ear drops?

- Keep the ear facing up for several minutes

- Use a cotton plug in the ear to maintain the medicine within the canal

- warm drops prior to use

what is important to do before use of suspension ear drops?

shake well

what is important to note with ear drops and ophthalmic drops?

you can use eye drops for ear infections but NOT ear drops for eye infections

what are examples of medications that can cause ototoxicity?

- Aminoglycosides (gentamicin, tobramycin, amikacin)

- Neomycin

- Vancomycin

- Loop diuretics (furosemide, bumetanide, ethacrynic acid)

- Chemotherapy (cisplatin, mechlorethamine)

- NSAIDs (aspirin, NSAIDs)

the eye is subject to....

- Infection

- Inflammation

- Allergies

- Hypersensitivities

- Pain

what are some examples of Ophthalmic Anesthetics?

- Tetracaine (Pontocaine) & Proparacaine (Ophthaine, Ophthetic)

- Lidocaine

what are the 2 classes of Ophthalmic Anesthetics?

amino esters and amino amides

which of the Ophthalmic Anesthetics are amides vs esters?

- esters = tetracaine, proparacaine

- amide = lidocaine

what are the clinical use of Ophthalmic Anesthetics?

produce local anesthesia for ophthalmic procedures

what is the MOA of Ophthalmic Anesthetics?

locally block initiation & conduction of nerve impulses

describe the onset and duration of Ophthalmic Anesthetics

- Within 20-30 seconds

- Tetracaine = longest duration

- procaine = shortest

What is the dosing of ophthalmic anesthetics?

1-2 drops in affected eye

what are some adverse reactions of ophthalmic anesthetics?

- Burning, stinging

- Deep corneal infiltrates, ulceration, and perforation

what is burning, stinging more common with?

tetracaine

what is deep corneal infiltrates, ulceration, and perforation more common with?

proparacaine, also due to improper use

what are some point for proper installation?

- Wash hands with soap and water

- Instill/apply medication in sac behind lower lid

- Do NOT touch the eye with applicator

- Drops BEFORE ointment (wait 5 minutes in between)

- Close eye for about 1 minute to allow maximum benefit

why can putting drops in the fridge be helpful for elderly people?

allows them to feel the drop hitting their eye and ensure proper application

what is conjunctivitis?

Inflammation of conjunctiva

what is the conjuntiva?

covers whites of the eyes and inner surface of the eye lids

what are the types of conjunctivitis?

viral, bacterial, allergic

what type of conjunctivitis is most common?

viral (pink eye)

what are the symptoms of allergic conjunctivitis?

itchy, worse with rubbing

what is the treatment of allergic conjunctivitis?

- avoid allergens

- irrigate with saline

- cold compress

- artificial tears

- topical vasoconstrictors

- antihistamines

- mast cell stabilizer

what are the symptoms of viral conjunctivitis?

- thin, mucousy discharge

- vesicles

- severe pain

what is the most common viral cause of conjunctivitis?

Adenovirus

how long is viral conjunctivitis contagious for?

~1 week

what is the treatment for viral conjunctivitis?

self-limited, warm compress

why might antibiotics be prescribed for viral conjunctivitis?

prophylactically for possible cornea infection due to scratching

what are the symptoms of bacterial conjunctivitis?

purulent, yellow/green discharge and crusty eyes

what are the common bacteria that cause bacterial conjunctivitis in adults?

- S. epidermidis

- S. aureus

what are the common bacteria that cause bacterial conjunctivitis in children?

- H. influenzae

- S. pneumoniae

- M. catarrhalis

what are the common bacteria that cause bacterial conjunctivitis in infants?

- N. gonorrhoeae

- C. trachomatis

what are examples of ophthalmic anti-infectives?

- Erythromycin (Ilotycin)

- Polymixin B/TMP

- Polymixin B/ bacitracin

- Ciprofloxacin (Ciloxan)

- Moxifloxacin (Vigamox)

- Gentamicin (Garamycin)

- Tobramycin (Tobrex)

- Azithromycin (AzaSite)

what bacteria is it important to cover in contact lens wearers?

Pseudomonas

what is the preparation and spectrum of Erythromycin (Ilotycin)?

ointment, Gram + (some staph resistance)

what is the preparation and spectrum of Polymixin B/TMP?

Solution, Gram - /gram + and -

what is the preparation and spectrum of Polymixin B/ bacitracin?

ointment, Gram - /gram + and -

what is the preparation and spectrum of Sulfacetamide (Sulamyd, Bleph-10)?

Solution, ointment, Gram + (some staph resistance)

what is the preparation and spectrum of Ciprofloxacin (Ciloxan)?

Solution, ointment, Gram + and - (covers pseudomonas)

what is the preparation and spectrum of Moxifloxacin (Vigamox)?

Solution, Gram + and -

what is the preparation and spectrum of Gentamicin (Garamycin)?

Solution, ointment, Gram - (covers pseudomonas)

what is the preparation and spectrum of Tobramycin (Tobrex)?

Gram - only (covers pseudomonas)

what is the preparation and spectrum of Azithromycin (AzaSite)?

Solution, Gram + and -

what is important to denote when prescribing ophthalmic anti-infectives?

remember to always include ophthalmic and specify solution/ suspension/ ointment

adverse effects of ophthalmic anti-infectives are primarily....

localized

what is the usual treatment of ophthalmic anti-infectives?

5-7 days

what ophthalmic anti-infectives might people have allergies to?

polymyxin, bacitracin, sulfa

what should patients do with contact during use of ophthalmic anti-infectives?

remove contact lenses during treatment course (contacts like an occlusive dressing)

what are some examples of ophthalmic antihistamines and mast cell stabilizers?

- Azelastine 0.05% (Optivar)

- Epinastine 0.05% (Elestat)

- Nedcromil 2% solution (Alocril)

- Cromolyn 4% solution (Crolom)

- Lodoxamide 0.1% solution(Alomide)

- Ketotifen 0.025% (Zaditor) OTC (combo mast cell + antihistamine)

- Olopatadine 0.1% (Patanol), 0.2% (Pataday) (combo mast cell +

antihistamine)

what are the indications for ophthalmic antihistamines and mast cell stabilizers?

temporary relief of the itching associated with seasonal and typical allergic conjunctivitis

what is MOA of ophthalmic antihistamines?

Block the effects of histamine released during allergic reactions and

blunt its symptoms (gives immediate relief)

what is MOA of ophthalmic mast cell stabilizers?

Inhibit degranulation of mast cells after exposure to antigen (prevents further issues)

what is PK of ophthalmic antihistamines and mast cell stabilizers?

no absorption = no PK

when can contact lenses be re-inserted after using ophthalmic antihistamines and mast cell stabilizers?

15 minutes

what are examples of ophthalmic vasoconstrictors (most are OTC)?

- Oxymetazoline 0.025% (Visine L.R)

- Naphazoline 0.012%-0.1% (Naphcon, AK-Con)

- Tetrahydrozine 0.05% (Visine)

- brimonidine (Lumify) 0.025%

up to how many days can ophthalmic vasoconstrictors be used for?

4x/day

how many days should ophthalmic vasoconstrictors be limited to?

3-4 days (avoid rebound)

which ophthalmic vasoconstrictors can be used if need to use for more than 3-4 days?

Lumify

what are the indications of ophthalmic vasoconstrictors?

temporary relief of eye redness caused by minor irritants or allergic conjunctivitis

what is the MOA of ophthalmic vasoconstrictors?

Weak sympathomimetic agents that constrict the blood vessels in the conjunctiva