ocular meds

how many drops are always recommended for ocular medicines

one drop - the max that can fit in eye

what is nasolacrimal occlusion NLO

pinch inside corners of eyes for 30-60 seconds --> decreased systemic absorption of drug and decreased systemic side effects --> greater local absorption in eye

what percentage of topical antimicrobial agents reach anterior segment of eye and what does this result in clinically

only 1-2%

many eye infx require topical agent and systemic agent

cornea is lipo or hydrophilic and most antimicrobials are lipo or hydrophilic

cornea - lipo

antimicrobials - hydro

in a 20 drops/ml solution that is 2.5 ml, how many days will this last a pt

20 x 2.5 ml = 50 drops in bottle/4 drops per day = 12.5 day supply

normal drops/ml for solutions (liquid) vs suspensions (gel)

sol = 20 drops/ml

susp = 12-15 drops/ml

do ocular fqs, macrolides, aminoglycosides have systemic absoprtion

very little

when is bacitracin 500 u/gm used and what is dosage

susceptible opthalmic infx - gram + (usually staph) no mrsa

1-3 drops daily

these are examples of?

4th gen:

moxifloxacin

levofloxacin

gatifloxacin

besifloxacin

non 4th gen: ciprofloxacin, ofloxacin

opthalmic fluoroquinolones

fluoroquinolones cover for

p aeruginosa

contraindications for opthalmic fqs

allergy or intolerance, detached retina

normal interactions and contraindications do not apply to eye

opthalmic macrolides and uses

azithromycin - bacterial conj by h influenza, staph aureus, strep pneumo

erythromycin - prophylaxis of aopthalmia neanatorum due to n gonorrheae, c trachomatis, and bacterial conj by h influenza, staph aureus, strep pneumo

opthalmic aminoglycosides and coverage

gentamicin

tobramicin

neomycin + polymyxin B sulfate

gram - infx, including p aeruginosa

opthalmic sulfa agent and what do we have to be careful of

sulfacetamide sodium 10% - watch for sulfa allergy!!!

viroptic (trifluridine) and zirgan (ganciclovir) are examples of

antiviral opthalmic rxs

why is viroptic used max 21 days

toxic to cornea after 21 days

what does a fortified antibiotic mean and when should they be used

enhanced/strengthened abx compounded by pharmacy

used for sight-threatening infx, keratitis and corneal ulcers

in a pt with over 72 hours of pain + severe corneal ulcer, should fortified or standard abx be used

fortified

in a pt with 4-5 days of pain + mild clinical apperance, should fortified or standard abx be used

standard FQ (zymar, vigamox)

polymer that becomes a gel on instillation, w lubricant propylene glycol as active ingredient, inactive ingredients of phospholipid DMPG and mineral oil to help deliver the active ingredient

HP Guar (hydroxypropyl guar)

tear replacement containing HP Guar

systane

why is systane complete better than systane balance eye drops

lipid nanodroplet tech that results in better coverage of ocular surface

does systane have benzalkonium chloride and why

no, its a preservative and irritating to cornea

what does enhanced concentration of hp guar in systane complete allow

greater cross-linking and persistence of protective elastic matrix --> better retention of propylene glycol lubricant and protection against tear evaporation

moa of cyclosporine emulsion (restasis)

dry eye med - increases ability to produce tears by autoimmune suppression

side effects of most topical eye meds

burning sensation (mc), eye redness, discharge, watery eyes, eye pain, FBS, itching stinging, blurred vision

how to use topical ocular agents with contacts

remove contact lens before use and wait 15 mins before putting them back in after applying med

dry eye med using nanomicellar formulation tech with micelles

cequa - cyclosporine opthalmic med

cequa moa

nanomicellular formulation of gelatinous aggregates of amphipathic (hydrophobic and philic) molecules --> easy entry into cornea to delivery cyclosporine A (csa) to reduce dry eye

xiidra or lifitegrast 5% is indicated for and what is its unique side effect

dry eye

dysgeusia - bad taste in mouth due to the med going into sinuses and mouth

xiidra or lifitegrast moa

lymphocyte function associated antigen-1 antagonist

meds that are sympathomimetic agents that act on adrenergic receptors in nasal mucosa producing vasoconstriction

decongestants

naphazoline (naphcon) and oxymetazoline (visine) are examples of

topical opthalmic decongestants

topical opthalmic decongestants - what do we have to be careful of and what is recommended use to avoid this

rebound congestion

cannot be used for more than 3 days

meds used for pain and inflammation post cataract surg, prevention/tx of cystoid macular edema, ocular inflammatory conditions, seasonal allergic conjunctivitis

topical nsaids

bromfenac (xibrom) is a

topical nsaid

diclofenac (voltaren) is a ?

topical nsaid

flurbiprofen (ocufen) is a

topical nsaid

ketorolac (acular) is a?

topical nsaid

nepafenac (nevanac) is a

topical nsaid

side effects of topical opthalmic corticosteroids

may increase IOP or cause cataracts

should topical corticosteroids be used for eye infx

no - suppress immune system and worsen infx

medrysone is an example of a

low potency topical corticosteroid

fluorometholone, loteprednol, prednisolone acetate 0.12% (pred mild)/sodium phosphate 0.125% and 1% (inflamase) are examples of

med potency corticosteroids

prednisolone acetate 1% (pred forte) is an example of

high potency topical corticosteroid

topical corticosteroids can be used for

post surgery pain, corneal ulcer pain

xalatan (latanaprost) and anything ending in -prost is an example of a? that is used for?

prostaglandin

antiglaucoma med

glaucoma is caused by

high IOP

newer anti glaucoma med that is the first prostaglandin analog with one of its metabolites being nitrous oxide (NO)

vyzulta (latanoprostene bunod)

vyzulta (latanoprostene bunod) moa

metabolizes into 2 moeities:

latanoprost acid to work within uveoscleral pathway to increase aqueous humor outflow

butanediol monitrate which releases NO to increase outflow through trabecular meshwork and schlemm's canal

prostaglandins side fx and are they reversible or irreversible

hyperemia (redness of eye) - reversible with cessation

increased iris coloration - irreversible

periorbitopathy: skin darkening - maybe reversible if stops early enough

hypertrichosis

dry eye

where are alpha 1 receptors in eye and what does stimulation cause

blood vessels of ciliary body --> vasoconstriction, reducing blood flow and aqueous production

where are beta 1 and 2 receptors in eye and what does stimulation and blocking cause

on ciliary body

stimulation increases aqueous production, blocking reduces aqueous production

what drugs stimulate alpha 1 receptors in eye

epinephrine like drugs

what drugs block beta 1 and 2 receptors in eye

beta blockers or sympatholytics

what category of drugs have these effects

miosis of iris

accomodation and trabecular meshwork opening in ciliary body

aqueous outflow increase of trabecular meshwork

aqueous outflow decrease of ciliary meshwork (uveal meshwork-uveoscleral pathway)

parasympathomimetics (miotics)

brimonidine and iopidine (apraclonidine) are examples of

sympathomimetics

brimonidine acts on what receptors on the eye in what way

alpha 2 agonist to decrease IOP

brimonidine moa

acts presynaptically to inhibit release of norepi and reduce adrenergic receptor stimulation --> reduced sympathetic activity in ciliary body (contraction of vessels) --> reduced aqueous production

alpha 2 agonist ex brimonidine side effects

drowsiness and fatigue, headache, dry mouth (mc)

- early and late onset alphagan allergy

- follicular conj, blurring, burning

beta blockers all end in

-olol

ocular beta blockers side fx

decreased HR and BP, conduction, defects, bronchospasm

what ocular med has highest risk of systemic side effect

beta blockers

when are ocular beta blockers contraindicated

bronchospastic pts - even small amounts of bb absorbed systemically can be dangerous

pilocarpine, carbachol, isopto carbachol are examples of

parasympathomimetics (miotics)

what drugs have these functions

induce ciliary body contraction

increase outflow of aqueous through trabecular meshwork (conventional pathway) and decrease outflow through uveoscleral pathway (unconventional pathway)

parasympathomimetics (miotics)

miotics side fx (know)

miosis --> visual reduction, esp w cataract

field constriction

accomodative spasm and myopic shift

brow ache from ciliary body contraction

globe and orbital pain

allergic rxn

retinal detachment due to cb contraction (not common)

are miotics first line and why

nooo lots of side fx

acetazolamide is an example of what

diuretic

oral/systemic carbonic anydrase inhibitor CAI

dorzolamide, brinzolamide

topical CAIs

can pts with sulfa allergies use CAIs

yes - sulfa non abx structures but should be safe

carbonic anhydrase inhibitor CAI moa

blocking carbonic anhydrase blocks bicarb formation in secretory neuroepithelial cells of ciliary body --> blocks normal osmosis into posterior chamber and thus excess aqueous formation

CAIs are used often in conjunction with

prostaglandin analogs

CAIs work especially well to lower IOP during what time of day

nighttime

when IOP reduction is needed in children what med works best

topical CAIs

what is a good option when traditional anti glaucoma meds have failed

rock-net inhibitor: netarsudil

netarsudil (rock-net inhibitor) moa

triple action

ROCK inhibition relaxes TM, increasing outflow

NET inhibition reduces fluid prodution

ROCK inhibition lowers episcleral venous pressure EVP

roclatan (rock-net inhibitor/latanoprost) moa

quadruple action

ROCK inhibition relaxes TM, increasing outflow

NET inhibition reduces fluid prodution

ROCK inhibition lowers episcleral venous pressure EVP

PGA receptor activation increases uveoscleral outflow

which is triple or quadruple action

roclatan (rocknet inhibitor/latanoprost) or netarsudil (rock-net inhibitor)

roclatan quadruple

netarsudil triple

conditions that are due to overproduction of protein called vascular endothelial growth factor VEGF

choroidal neovascularization (CNV)

ranibizumab (lucentis), bevacizumab (avastin), pegaptanib (macugen), and faricimab (vabysmo) are used to treat what condition and how are they administered

macular degeneration

intravitreal injection

injected meds for macular degeneration side fx

conj hemorrhage, eye pain, floaters, increased IOP, intraocular inflammation

most common cause of unilateral/bilateral exopthalmos aka infiltrative orbitopathy

thyroid eye disease

what causes exopthalmos in thyroid eye disease

increased volume of extra ocular muscles

tepezza (teprotumumab) moa

inhibitor of insulin-like growth factor (IGF-1) receptor

what is tepezza used for

thyroid eye disease

how is tepezza administered

IV infusion

tepezza side fx

hyperglycemia, infusion rxns, muscle spasm, alopecia, hearing impairment, dysgeusia

opthalmic solution indicated for tx of neurotrophic keratitis

oxervate (cenergermin)

oxercate (cenegermin) moa

mimics structure of endogenous nervce growth factor - tricks body into thinking there is nerve growth factor present

oxervate side fx

normal topical - eye irritation

well tolerated