Med Exam 2 - Ophthalmic Disorders, Otitis externa, Allergy

dry eye syndrome

compromised tear film, leading to irritation and potentially long term vision consequences

- aqueous (tear) deficiency

- evaporative

dry eye syndrome risk factors

female

increased age

smoking

cataracts

lasik

rheum. arthritis

lid trauma

tear film - layers

purpose is to protect and lubricate eyes

- mucin layer

- water layer

- oil layer

dry eye syndrome symptoms

redness

burning/irritation

itching

foreign body sensation

watery eyes

blurry vision

non-pharm interventions for dry eye syndrome

blink regularly

increase humidity

wear sunglasses outside

hydration

nutrition supplements

control allergies

pharm interventions for dry eye syndrome - first line

OTC lubricating gels and ointments

- carboxymethylcellulose

- hydroxymethylcellulose

pharm interventions for dry eye syndrome - second line

- cyclosporine drops

- lifitegrast drops

- secretagogues (oral tablets)

- corticosteroids drops (mostly post-op)

conjunctivitis first line therapy

empiric (covers gram +/-)

- erythromycin ointment

- polymyxin B with Bacitracin

bacterial conjunctivitis second line therapy

fluoroquinolones

- moxifloxacin

- besifloxacin

- gatifloxacin

polymyxin B and Trimethoprim

neomycin and polymyxin B

gentamicin

sulfacetamide

general dosing for bacterial conjunctivitis

start with high frequency q2-q4h

decrease frequency after 3-4 days

viral conjunctivitis treatment

Cold compresses and artificial tears

topical corticosteroids

oral antivirals

allergic conjunctivitis treatment

topical antihistamines (eye drops)

- olopatdine

- ketotifen

- azelastine

topical vasoconstrictors

- naphazoline

- phenylephrine

oral NSAIDS and antihistamines

blepharitis first line treatment

non-pharm!

improve ocular hygiene

warm compress

vertical eyelid massage

clean eyelids

blepharitis second line treatment

topical antibiotics

- erythromycin or bacitracin ointment

oral antibiotics If severe

- tetracycline or azithromycin

corticosteroid drops or ointment/suspension

acute closed-angle glaucoma treatment

iridectomy: hole in iris that permits aqueous flow

drug therapy

- miotic

- secretory inhibitor (beta-blocker)

- prostaglandin agonist

osmotic agents: decrease IOP

topical corticosteroids

open-angle glaucoma first line treatment

Beta blocker or prostaglandin analog

alternative: alpha-2 adrenergic agonist

open-angle glaucoma second line pharm

carbonic anhydrase inhibitor (CAI)

beta blocker MOA

antagonist at ciliary body

reduce aqueous humor production

prostaglandin analog MOA

increase aqueous outflow

alpha-2 adrenergic agonist MOA

agonist at ciliary body

decrease aqueous humor production

carbonic anhydrase inhibitor (CAI) MOA

decrease in aqueous humor production

cholinergic agonist MOA

increase in aqueous humor outflow by stimulating ciliary muscle contraction

Rho kinase inhibitors MOA

increase in aqueous humor outflow through the trabecular meshwok

glaucoma treatment - surgical options

- laser surgery

- conventional surgery

- drainage implants

otitis externa microbes

98% of cases are s. aureus or pseudomonas

otitis externa diagnosis criteria

symptoms of ear canal inflammation; otalgia, itching, or fullness

tenderness

erythematous ear canal with occasional otorrhea

otitis externa treatment

clear debris from canal

topical antibiotics (ear drops)

otitis externa first line treatment

fluroquinolone drops

* not recommended for children under 6 months

otitis externa second line treatment + when to avoid

neomycin-polymyxin B drops (usually contain steroid)

avoid in viral or fungal

otitis externa third line treatment + when to consider

antifungals (clotrimazole)

consider if infection extends beyond ear canal or obstruction is not relieving

mastoiditis treatment

antibiotics:

IV

oral

topical

surgery if chronic

allergic reactions

adverse drug reaction from stimulation of immune system by a medication

- drug may act as an antigen and elicits classic immune responses

- drug may directly interact with immune receptors and under certain circumstances, lead toactivation of specific immune cells

Type 1 drug reaction

immediate reaction

IgE mediated

immunoglobulin IgE attaches to mast cells and binds with antigen, inducing degranulation and release of histamines and other inflammation mediators

release of mast cells and basocells, as well as vasoactive substances

(histamines, prostaglandins, leukotrienes)

Type 1 drug reaction clinical features

anaphylaxis

angiodema

brnochopasm

urticaria (hives)

hypotension

type 1 drug reaction treatment

epinephrine SQ or IM

injectable antihistamine

nebulizer albuterol

systemic corticosteroids

type 2 drug reaction

antibody-dependent cytotoxicity

antigen/hapten that immediately binds to antibody leading to tissue injury

type 2 drug reaction clinical features

hemolytic anemia

thrombocytopenia

neutropenia

type 3 drug reaction

immune complex disease

damage is caused by formation of antigen-antibody complexes

recruitment of neutrophils

type 3 drug reaction clinical features

serum thickness

arthus reaction

type 4 drug reaction

cell mediated or delayed hypersensitivity

antigen exposure activates T cells, which mediates tissue injury

type 4 drug reaction clinical features

contact dermatitis

morbidilliform reactions

severe exolfiative dermatoses

AGEP

DRESS/DiHS

interstitial nephritis

drug induced hepatitis

intranasal corticosteroids

OTC:

- budesonide

- flucticasone

Rx:

- beclomethasone

- ciclesonide

- flunisolide

- mometasone

- triamcinolone

intranasal corticosteroids MOA

interfere with antigen-antibody

reduces mast cell degranulation

diminished secretion of cytokines = decreased inflammation

antihistamines 1st gen

diphenhydramine (Benadryl)

chlorpheniramine (ChlorTrimeton)

1st gen antihistamines MOA

non selective, competitive, antagonist of histamine H1 receptor

antihistamine 2nd gen

certizine (Zyrtec)

loratadine (Claritin)

levocetirizine (xyzal)

fexofenadine (allegra)

desloratidine (clarinex)

antihistamine 2nd gen MOA

selective

comppetitive antagonist of histamine H1 receptor

decongestants

psuedoephedrine

phenylephrine nasal spray or oral tablets

nasal oxymetolazine (farina)

psuedoephedrine MOA

direct alpha = vasoconstriction

beta agonist = bronchiole relaxation

phenylephrine nasal spray or oral tablets MOA

direct alpha agonist = vascoconstriction