Case Analysis III MT 2

Dr. Lee (Impact of Meds), Dr. Wahl (Ant Seg)

FDA approved HCQ for the treatment of

• malaria

• rheumatoid arthritis

• lupus erythematosus

• others

• NOT: COVID-19

if a pt is taking HCQ or CQ, what important components do you look at in your exam of the pt?

• slit lamp: cornea

  • corneal verticillata

• DFE: macula

  • chloroquine retinopathy

what causes corneal verticillata?

CHAIR-T

• chloroquine

• hydrozychloroquine

• amiodarone

• indomethacin

• rho-kinase inhibitors

• tamoxifen

*either born with it or it’s systemic (meds)

on slit lamp, corneal verticillata presents as

punctate spots to whorl-like

• no symptoms

• resolves with d/c of meds

chloroquine retinopathy presents as

• starts off paracentrally → moves centrally (macula affected later)

• bull’s eye maculopathy in late stages

what additional tests should you pay extra attention to if the pt is taking chloroquine?

• VA/PH

  • cataracts, PHNI

  • reduced VA at dist/near

• amps reduced

  • reduced near VA

• slit lamp: lens

  • posterior subcapsular cataracts (the reason for drop in vision)

• slit lamp: cornea

• DFE: macula

typical dose of HCQ for RA and lupus

• dosage is the major risk factor

400 mg/day

• overdose is >5mg/kg

• 5 mg/kg x 80 kg = 400 mg/kg

  • 80kg =176 lb

  • if the pt weighs <176 lb they’re at risk of toxicity

besides dosage, what are other major risk factors for HCQ?

• duration > 5 years

• renal disease

  • drug builds up if kidneys aren’t working well

• tamoxifen use (increases risk by 5x)

what 3 things MUST be done in the annual exam if a pt is taking plaquenil?

• DFE: look for pigmentary changes parafoveal

• photos: retinal, macular

• VF: HFA 10-2 (charge the pt)

• OCT: look for parafoveal thinning (Dr. Lee would)

• schedule mERG: reduced amplitude parafoveal

• optos FAF:

  • early stages: hyperautofluorescence (build up of lipofuscin)

  • later stages: hypo (due to atrophy)

asian pts on plaquenil tend to present with

extramacular damage (unknown reasons)

• run 10-2 and 30-2 or 24-2

  • want to know if there’s functional damage

the biggest side effect of latanoprost is

it promotes inflammation

• latanoprost = first line drug for POAG

if a pt presents with glaucoma and a sulfa drug allergy, what class of drugs cannot be rx?

carbonic anhydrase inhibitors (CAI)

• trusopt, azopt

according to the DEA, for a rx to be valid it needs to have:

• doctor’s name, address

• pt’s full name and address

• rx: drug name, strength, dosage form, quantity prescribed

• sig: directions for use

• number of refills if authorized

• signature of doctor

• DEA number if applicable (ODs use license number or NPI)

what instruction should specified for any drug to treat anterior chamber issues (ex: anterior uveitis)?

”no substitutions”

before rx a steroid for a pt, you should check:

stain the eye and check the epithelium is intact

_____ work best on lids

ophthalmic ointments work best on lids vs. eye drops

• esp on external hordeola

• orals work better on internal hordeola (can rx. ointments too)

preferred and backup antibiotic (ophthalmic)

preferred: Vigamox ($109)

backup: ciprofloxicin generic ($13)

preferred and backup antibiotic steroid combo

preferred: Tobradex ST ($172)

backup Maxitrol ($14)

preferred and backup allergy med

preferred: pataday ($16)

backup: Zaditor ($14)

preferred and backup steroid meds

preferred: Pred Forte ($214)

backup: Prednisolone acetate generic ($24)

preferred and backup antiviral med

preferred: Zirgan ($465)

backup: acyclovir ($15)

preferred and backup antibiotic ointment

preferred: erythromycin ($12)

backup: neo-poly-bac generic ($11)

preferred and backup antibiotic (oral med)

preferred: Keflex ($14)

backup: erythromycin ($14)

preferred and backup glaucoma meds

preferred: latanoprost ($19)

backup: brimonidine ($10)

preferred and backup artificial tears

preferred: Systane Ultra ($11)

backup: Refresh Optive ($11)

according to dr. wahl, what are the more common problems (horses)?

• dry eye

• ocular allergy

• eye infection

• CL related complications

• hordeolum/chalazion

• subconj heme

• cataract

• pinguieculitis/inflamed pterygium

reduced vision can be caused by:

• unstable tear film (fluctuating blur)

• media opacity (constant blur)

• irregular astigmatism (constant blur)

• shift in RE

ALWAYS dilate ____ cases to check for vitritis

ALWAYS dilate ___ cases to check for penetration

always dilate uveitis cases to check for vitritis

always dilate metallic FB cases to check for penetration

what is an appropriate rx (topical sln) for bacterial conjunctivitis ?

rx: vigamox oph solution 3ml

sig: 1 gtt OU QID x 10 days

*alt: ciprofloxacin

what is an appropriate rx for allergic conjunctivitis ?

rx: pataday 0.2% oph solution 2.5ml

sig: 1 gtt ou QD x 7 days then prn

*alt: zaditor, alaway

what is an appropriate rx for external hordeolum?

Rx: erythromycin oph ung 3.5 gm

Sig: apply ¼” ribbon on UL and LL QID x 10 days

*alt: neo-poly-bac generic

what is an appropriate rx for preseptal cellulitis?

Rx: Keflex tab 500 mg #28

Sig: 1 tab PO BID x 14 days

*alt: Augmentin tab 500 mg #30

Sig: 1 tab PO tid x 10 days

what is an appropriate rx (antibiotic-steroid combo) for bacterial conjunctivitis ?

Rx: Tobradex ST oph susp 5 ml

Sig: 1 gtt OU QID x 10 days

*alt: maxitrol

what is an appropriate rx for anterior uveitis?

Rx: Pred Forte oph susp 5 ml

Sig: 1 gtt q1h x 10 days

• no substitutions

*alt: Prednisolone acetate 1% generic

what is an appropriate rx for HSV?

Rx: Zirgan oph gel 5 gm

Sig: 1 gtt q3h x 10 days

*alt: Acyclovir 400 mg tablets

Sig: 1 tab PO q3h x 10 days

what is an appropriate rx for glaucoma?

Rx: latanoprost oph sol 2.5 ml

Sig: 1 gtt OU QHS

*alt: Brimonidine

Sig: 1 gtt OU TID