Ophthalmic Disorders, Lens Care, & Otic Disorders

When administering more than 1 drop of artificial tears, a patient should wait ______ minutes before instilling the second drop.

5; this ensures that the first drop is not flushed away by the second and the second is not diluted by the first

natural defenses of eye:

eyelid

tear layer

Damage to the cornea of the eye alters what, and what can cause damage to the cornea

- drug absorption rates.

- trauma, routine contact lens wear, topical ocular anesthetics, thermal or UV light exposure

Self-treatable disorders of the eye occur primarily on the _________.

eyelids

Signs & symptoms of dry eye include

- white or mildly red eye

- sandy/gritty feeling

- the sensation that something is in the eye

- Initial presentation of this condition is excessive tearing

what is the initial presentation of dry eye

excessive tearing

Ocular lubricants such as _______ & _______ are the primary OTC products for treatment of dry eyes.

artificial tears, nonmedicated ophthalmic ointment

what are the treatment goals of dry eye

- alleviate dryness

- relieve irritation

- prevent tissue and corneal damage

what is the primary treatment for dry eye

ocular lubricants, like artificial tears or non medicated ophthalmic ointment

what are non-pharmacologic therapy for dry eyes

- humidifiers

- avoiding prolonged use of computer screens

- eye protection

- warm compress

- omega-3 oils or flax seed oil

T/F: Combination therapy of artificial tears & nonmedicated ointment is recommended for treatment of dry eyes.

T

Artificial tear solutions have varying

viscosities, preservatives, electrolytes, & water-soluble polymeric systems (vehicles).

what is the vehicle of artificial tears

water-soluble polymeric systems

what is the MOA of artificial tear solutions

help treat dry eye by stabilizing the tear film, increasing viscosity, & by acting as mucomimetics (povidone).

Dosing of artificial tears can vary from

1-2 times daily to hourly depending on the severity of the condition.

Adverse effects due to artificial tears are uncommon, but when they occur, most are caused by the _______ within the solution.

preservatives

When using both drops & an ointment to treat dry eyes, the ______ should be used first, & the patient should wait _____ minutes before applying the next product.

drop, 10

which types of eye drops should never be refrigerated

Suspension

first thing that should be done before instilling eye drops

wash hands

When instilling eye drops, the patient should pull down the _______ eyelid to create a pouch for the drops.

lower

nonmedicated ophthalmic solutions contain:

- white petrolatum (60%)- acts as lubricant/base

- mineral oil (40%)- helps the ointment melt at body temp

- lanolin- facilitates incorporation of water soluble meds and prevents evaporation

component of nonmedicated ophthalmic ointments (60%) that acts as the lubricant & ointment base

white petrolatum

component of nonmedicated ophthalmic ointments (40%) that helps the ointment melt at body temperature

mineral oil

component of nonmedicated ophthalmic ointments that facilitates the incorporation of water-soluble meds & prevents evaporation

lanolin

non-medicated ophthalmic ointments compared to drops

have an enhanced retention time & enhances the integrity of the tear film, but they also cause blurred vision.

MOA of nonmedicated ophthalmic ointments

enhanced retention time= enhance of the integrity of tear film

A ______ to ______ inch strip of ointment should be placed in the lower eyelid when using nonmedicated ophthalmic ointments.

1/4, 1/2

After applying nonmedicated ophthalmic ointment to the eye, the patient should close the eye gently for ______ minutes.

1-2

how are nonmedicated ophthalmic ointments dosed

BID up to every few hours

what are the safety concerns of nonmedicated ophthalmic ointments

- viscosity (amount and time of administration)

- toxicity (preservative free formulas)

________ free ophthalmic products are for 1-time use only & should be discarded after use.

Preservative

what are examples of ophthalmic preservatives

for multidose products

- bactericidal surfactants: benzalkonium Cl (BAK) and benzethonium Cl

- chlorhexidine: not as toxic

- mercury and iodide metals

- chlorobutanol: antifungal and antibacterial

- p-hydroxybenzoic acid derivatives (methylparaben and propylparaben)

- EDTA chelating agents

- disappearing preservatives

Benzalkonium Cl (BAK) & benzethonium Cl are _______ that act as bactericidal agents & are used as ophthalmic preservatives. They are very effective.

surfactants

ophthalmic preservative that is not as toxic as benzalkonium Cl & benethonium Cl

chlorhexidine

what are the bactericidal surfactants/ophthalmic preservative

benzalkonium Cl and Benzethonium Cl

metals that can be used as ophthalmic preservatives, but they are rapidly being replaced.

mercury and iodide

ophthalmic preservative that acts as an antifungal & antibacterial; tends to disappear during prolonged storage

chlorobutanol

Sodium perborate (H2O2 > H2O + O) & Purite (H2O2 > H2O + NaCl) are "__________" ophthalmic preservatives.

disappearing

Disappearing & preservative free ophthalmic products are more

costly than other products.

ophthalmic excipients and what do they do

antioxidants- delay deterioration of products exposed to oxygen

wetting agents- reduce surface tension

buffers- help maintain pH of 6-8

tonicity adjusters- isotonic with the physiologic tear film

if there is no improvement of dry eyes with artificial tear products

refer

Signs & symptoms of allergic conjunctivitis include

itching, red eye, watery discharge, & no vision impairment.

what are the causes of allergic rhinitis

pollen, animal dander, topical eye preparations, seasonal allergic rhinitis

treatment goals of allergic rhinitis

- remove or avoid allergen

- limit/reduce the severity of the reaction

- provide symptomatic relief

- protect the ocular surface

what is the nonpharm therapy for allergic conjunctivitis

cold compress, remove or avoid the allergen

________ (Warm, Cold) compresses can be used as nonpharmacologic therapy for allergic conjunctivitis.

Cold

The first-line treatment of allergic conjunctivitis is _______, but if that is not helpful what can you do?

what do you do if symptoms dont resolve

- artificial tears

- decongestants, decongestant/antihistamine combinations, & antihistamine/mast cell stabilizer combinations can be used.

- medical referral

ophthalmic decongestants:

- phenylephrine- alpha-adrenergic agonists

- imidazoles

ophthalmic decongestant that is an alpha-adrenergic agonist

phenylephrine

nonrx concentration of ophthalmic phenylephrine

0.12% or lower

Alpha-adrenergic agonists cause what? what do they not diminish

decongestants: cause vasoconstriction to reduce redness, vascular congestion, and eyelid edema

do NOT diminish the allergic response

Ophthalmic decongestants examples of imidazoles

naphazoline, tetrahydroxoline, and oxymetazoline

Adverse effects of ophthalmic decongestants include

rebound conjunctival hyperemia (congestion), allergic conjunctivitis, epithelial xerosis, allergic blepharitis, & pupillary dilation

Ophthalmic decongestants should not be used for more than _______ hours to prevent rebound congestion from occurring.

72

Ophthalmic decongestants and ophthalmic antihistamines are contraindicated in patients with

angle-closure glaucoma

what are examples of ophthalmic antihistamines

pheniramine maleate, antazoline phosphate

can both be used in combination products with naphazoline

what are some adverse effects of ophthalmic antihistamines

burning, stinging, & discomfort upon instillation.

ophthalmic antihistamine/mast cell stabilizer that is a potent H1-receptor antagonist

ketotifen fumarate

what are 2 opthalmic antihistamines/mast cell stabilizers

ketotifen fumarate and olopatadine HCl

explain the MOA of ketoifen fumarate as a mast cell stabilizer. what is the safety of this medication

inhibits mast cell degranulation to prevent release of inflamm mediators and inhibits eosinophils

- very safe

when is relief felt with ophthalmic mast cell stabilizer (ketotifen fumarate) and how long does it last

relief within minutes and lasts up to 12 hours

If an ophthalmic antihistamine/mast cell stabilizer does not effectively treat allergic conjunctivitis, a ________ can be added.

oral antihistamine

Overwearing of contact lenses, surgical damage to the cornea, & inherited corneal dystrophies can cause ________.

corneal edema

corneal edema; signs and symptoms

swelling of the cornea

halos or starbursts around light

must be diagnosed by an eye care provider

what are the S/S of corneal edema

halos or starbursts around light

The hallmark sign of ______ is halos or starbursts around light.

corneal edema

corneal edema must be

diagnosed by an eye care provider before SC

treatment goals of corneal edema

draw fluid from the cornea and relieve associated symptoms

Hyperosmotics such as NaCl (2% & 5%) treat _______ by promoting the movement of fluid from the cornea to the more osmotic tear film.

corneal edema

what do hyperosmotics do

promote the movement of fluid from the cornea to more osmotic tear film to treat corneal edema

dosing for hyper osmotic solutions used to treat corneal edema:

1-2 drop q3-4 hrs

Hyperosmotic ointments used for treatment of corneal edema should be applied at _______.

bedtime

what are the adverse effects of hyperosmotics, and when do they occur

burning, stinging when using a product with more than 5%

Hyperosmotic products are contraindicated in patients with __________.

traumatized epithelium

first-line treatment for corneal edema

2% NaCl solution QID

If 2% NaCl solution is not useful in treating corneal edema, ________ should then be used.

5% NaCl hyperosmotic ointment

If 5% NaCl ointment is not successful in treating corneal edema, what should be used

5% NaCl solution and continue the HS ointment

corneal edema treatment guide

1. first line: 2% NaCl sol QID

2. if symp. persist, add 5% hyperosmotic ointment

3. if symp. persist, change the 2% to 5% NaCL and continue the 5% ointment

4. if symp. persist, refer

signs & symptoms of loose foreign substances in the eye include

immediate watering/tearing.

Presence of loose foreign substances in the eye should only be treated with self care if

it is only causing minor irritation & there is no abrasion to the eye surface.

what is the goal of loose foreign substances

to remove the irritant by irrigation

what two loose foreign substances should the patient be reffered

wood or metal fragments

If the foreign substances in the eye are ______ or ______, the patient should e referred.

wood, metal

Loose foreign substances in the eye should be treated with _______ or ________.

sterile saline, irrigants

Ocular irrigants are contraindicated in patients with

open wounds in or near the eyes.

ocular ingredients have

physiologically balanced pH and osmolarity

what are precautions for use of ocular irrigants

- continuous eye pain

- changes in vision

- continued redness or irritation

- condition persists or worsens

- discard eyecup due to contamination

In addition to artificial tears & nonmedicated ointments, _______, which is a mild astringent, can be used to treat minor eye irritation.

Zinc sulfate

zinc sulfate dosing:

1-2 drops up to QID

Patients who experience _______ of the eye should be referred to the doctor immediately. In the meantime, the patient should use continuous irrigation to treat the issue.

chemical burns

leading cause of blindness in the U.S.

macular degeneration

condition that results from damage to the central part of the retina

macular degeneration; leading cause of blindness in the US with no definitive cure

OTC product used to help macular degeneration; does not reverse condition

Preservision AREDS2

swelling, scaling, itching, or redness of the eyelids; must determine if the problem is caused by allergen or irritant

contact dermatitis

what must you determine when given a case of contact dermatitis of the eye

is it allergen or irritant

S/S of contact dermatitis

swelling, scaling, redness of the eyelid. profuse itching

If both eyelids are swelling with contact dermatitis, this suggests the cause is an _________.

allergen

used to treat contact dermatitis

oral antihistamine & cold compress TID-QID

chronic inflammation of eyelid margins & accumulation of debris; can be caused by staph epidermis

blepharitis

S/S of blepharitis

- red, scaly, thickened eyelids

- loss of eyelashes

- mild foreign body sensation

- itching, burning