Self-Care II Exam 4: Sharma

1. _____ → vascular, thin and transparent lining covering the sclera

2. _____ → inner side of eyelids

3. _____ → Space between bulbar and palpebral conjunctiva that accommodates most of the fluid volume after administering eye drops

Bulbar Conjunctiva, Palpebral Conjunctiva, Cul De Sac

Lipid Layer

• _____ (located inside _____)

• _____ (located at base of _____)

Meiboman Glands, eyelid, Gland of Zeis and Moll, each eyelash

Aqueous layer

• _____ (one each located _____)

• _____ (located _____)

Lacrimal gland, above each eyeball, Gland of Krause and Wolfring, under eyelids

Mucous layer

• _____ present in conjunctiva

• _____ epithelial cells form the _____ layer of cells present on cornea + conjunctiva

Goblet cell, corneal and conjunctival, outermost

Where does tear film go? Tears drained into the upper + lower _____ → into the _____ and into the _____

canaliculi, tear duct, nose

KNOW IMAGE

Tear film → consist of two layers

• _____ → prevents liquid from evaporating 

• _____ 

  • Function

    • Hydration of ocular surface

    • Lubrication for smooth eyelid movement 

    • O2 and nutrition to cornea

    • Removal of debris

    • Antimicrobial function smooth optical surface

Lipid Layer, Aqueous Mucous Layer

List the Sxs of dry eye (keratoconjunctivitis Sicca)

1. _____, _____, _____ sensation 

2. Foreign body sensation (sandy/gritty)

3. Excessive _____ in the initial stages

4. _____ around eyes

5. Difficulty wearing contact lenses

6. _____

itching, burning, scratching, tearing, stringy mucous, redness

Dry eye Non-modifiable RFs

• _____ - incidences incr with age (15% population > _____ y/o) having dry eye

• _____ sex: _____ (typically > _____ y/o) have significantly higher incidence

Age, 65, Female, post-menopausal women, 50

Dry eye Modifiable RFs

• _____ - _____ disorders (KNOW _____), RA, Lupus, rosacea, 

  • Endocrine disorders → DM, graves’ disease, MS

• Local eye conditions: _____ - _____ defects

• Environment: _____, _____

• Lifestyle: excessive use of _____ or other screens, _____, _____

Systemic Diseases, autoimmune, Sjogren’s Syndrome, Blepharitis, eyelid, dry, dusty, computer, smoking, alc

Drugs that can cause dry eye as SE (especially know said in video!!!!!)

• Inhibits aqueous secretion from lacrimal glands by blocking muscarinic receptors

  • Anticholinergics

  • AHs and decongestants (_____)

  • Anticholinergics (_____, _____)

  • Antipsychotics, Antidepressants (_____, _____ better alt)

  • Antiparkinsonians (_____)

• Interfere with neuronal inputs and inhibits aqueous secretion fromm lacrimal glands

  • _____

  • _____

  • Other _____-based pain relievers

Diphenhydramine, Atropine, Scopalamine, TCAs, SNRI, anticholinergic, BZDs, morphine, opiate

Drugs that can cause dry eye as SE (especially know said in video!!!)

• Affects meibomian gland and lipid layer

  • _____ (13-cis retinoic acid)

  • Aromatase inhibitors (_____, _____)

  • _____

• Reduce body fluids

  • _____

  • _____

• Interfere with corneal epithelial cell growth

  • Epidermal growth factor receptor inhibitors (Gefitinib, erotinib)

  • Fibroblast GFR inhibitors (eradafatinib, futibatinib, infratinib, pemigatinib)

Isotrentinoin, Anastrazole, Letrozole, Contraceptives, Diuretics, BBs

Dry Eye Exclusions 

• _____ eye with _____, _____ vision, acutely _____ eyelids 

• _____ onset of Sxs within the past few hrs/days

• Discharge and matty lids

• Ex of ophthalmic conditions for referral that can cause above mentioned s/sx

  • Angle-Closure Glaucoma (Emergency care = EC)

  • Keratitis → acute infection of cornea (EC - antibiotics immediately)

  • Uveitis → autoimmune condition of eye (urgent care - treat within a day)

  • Conjuntivitis 

    • _____ → more mucopurulent discharge

    • _____ –< less mucopurulent discharge ; antibiotics

red, pain, blurred, inflamed, sudden, Viral, Bacterial

Goal for dry eye: to provide or preserve ocular surface hydration to relieve Sxs and prevent ocular surface injury and inflammation caused by increased tear osmolarity

KNOW

Non pharm for Dry Eye: Pt Education

• Water intake: 

  • Men → _____ L (15.5 cups) 

  • Woman → _____ liters (11.5 cups)

• Freq deliberate blinking while working on computer 

• Position computer screen below eye level so that upper eye lid minimizes evaporation 

• Consider wrap-around glasses

• Keep hairdryer and car air conditioner directed away from eye

• DO NOT sleep directly under fan

• Use humidifier during winter indoors

• Consider stopping smoking

• Stay away from dusty/smoky environment

3.7, 2.7

Non pharm for Dry Eye: nutritional supplements

• Oral intake of _____ dietary supplements is NOT currently supported by clinical evidence linking an omega-3-rich diet to dry eye is weak

• Basically good advice to take nutritional supplements on omega-3 fatty acid-rich supplements like _____ and _____

• BUT clinical trial conclusions are “kind of” not very supportive

• However a lot of ophthalmologist rec OTC supplements wich in omega-3s lek fish oil or general intake if nuts high in it

Omega-3 FA, fish, nuts

Name the active ingredient, inactive ingredients and preservatives present in artificial tears

1. Active ingredient → _____ → primarily water-soluble polymer applied topically to eye to protect and lubricate couscous membrane surfaces and relieve dryness and irritation

2. Universal (inactive) ingredient → NaCl, KCl, MgCl2, Phosphate.bicarbonate based buffer

3. Preservatives → pH typically neutral most tears are isotonic; few _____ (Thera tears)

Demulcent, hypotonic

Artificial tears: Active Ingredient

• Cellulose derivatives → use _____

• _____ → Propylene glycol, polyethylene, glycol, glycerine, polysorbate 80

• _____ → Polyvinyl alc, povidone

• _____

CMC or HPMC, Polyol, Alcohols, Dextran 70

Artificial tears: Inactive Ingredients

• _____

  • Ex. TREhalose, CARnitine, ERYthritol

• _____ → absorb and retain water

  • Ex. Sodium HYAluronate

• _____ mimetic action

  • Ex hydroxypropyl guar GUM

• Prevention of water evaporation

  • _____

Osmoprotectants, Humectants, Mucin, Oils

Artificial tears: Preservative Ingredients

• BEST to avoid eyedrops containing _____

• Vanishing preservatives

  • _____ → breaks down to O2 and H2O: oxychloro complex containing 99.5% chlorite, 0.5% chlorate upon instillation, light

  • Sodium Perborate (_____) → breaks down to low levels of H2O2

• Quaternary ammonium compounds

  • Polyquaternium-1 → high MW ammonium cmpd w/ microbicidal activity - _____ to corneal/conjunctival epithelial cells

  • Benzalkonium (BAK → high MW quaternary ammonium comp - _____ to corneal/conjunctival epithelial cells

BAK, Purite, Dequest, very low toxicity, very toxic

Artificial tears: Preservative-Free Ingredients

• Contain no preservative → Cap needs to be snapped open 

• Should be discarded after opening and single-use 

• Some ophthalmologist/optometrist rec that can be used multiple times in a single day but discard at end of day 

• Advise pt to keep in a cool place (refrigerated if possible) and do not touch the tip by and or any other object

KNOW

Artificial tears: Preservative-Containing Ingredients

• Instil 1 drop _____

4-6x/day

Artificial tears: Single Dose (Preservative-Free)

• Unit dose single use eye drops for > _____ uses/day 

• Chen after _____ then increase to _____x

6, 2 weeks, 10

KNOW IMAGE

Describe the process for selection of artificial tears for management of dry eye disease

• Educate pt that dry eye disease is chronic lifelong and pt should continue to use artificial teas as the symptoms improve → continue use to maintain improvement

1. Mild cases → start with single active ingredient tears typically _____ or _____-bases (+ rec lifestyle modifications)

2. Incr the freq

   1. Preservative - max _____ 

   2. Preserve-free - _____ 

3. Recommend tears with multiple active ingredients → especially with lipic component

   1. _____ + (tregalose, hyaluronic acids, oil, glycerin, polysorbate) OR

   2. Switch to _____ containing tears (guar gum, mineral oil)

4. Consider addition of gel-based tears

5. Supplement with nighttime ointments 

   1. For steps 4 + 5 may consider referral to an optometrist or ophthalmologist fo detailed evaluation if symptoms do not improve or worsen 

CMC, HPMC, 4-6x/day, >6, CMC, Polyols

Artificial tear inserts → _____ (Rx only)

• Water-soluble cylindrical rose 1.25 mm wide 3.5 mm long

• _____ mg hydroxypropylcellulose (hypromellose)

• Swells up and dissolves over _____ 

• Limitation 

  • Expulsion, vision blurring + does not work in pt with LOW tear secretion

Lacrisert, 5, 6-8 hours

What is NOT recommended

• _____ (tetrahydrozoline, nephazoline, phenylephrine) containing eye drops → DO not use in pt with dry eye 

  • Eg _____, _____ 

• WHY ?? bc it causes

  • Rebound incr in redness

  • Tolerance and pt ends up using more freq

  • Ocular surface damage due to preservatives

  • Vascular fragility

Vasoconstrictor, Visine, Clear Eye

Dry eye pharm manage ment 

• Tear supplement → _____

• Tear conservation → _____

• Tear-film stabilizer → perfluorohexyl octane (_____)

• Inhibit ocular surface inflammation → _____ or lifitegrast (_____) 

artificial tears, ointments or punctual plugs, Meibo, Cyclosporine, Xiidra

Tear conservation

• _____ - nighttime use only bc it interferes with vision

  • All = _____ + _____

  • take off contact lenses and close eyes for 2 mins

• _____ 

  • Limitations → spontaneous extrusion

  • Replacement has higher rate of expulsion

  • _____ and _____

  • Prevent the tear outflow → retaining the tear film

  • Inserted under topical anesthesia using jeweler's forceps!!!

Ointments, Mineral, white Petrolatum, Punctual Plugs, silicone, collagen

Tear-film stabilizer

• Perflurohexyl octane (_____)

  • _____, _____ vial

  • 1 drop _____ Remove contact lens, reinsert AFTER _____

Meibo, non-aqueous, non-perservative multidose, QID, 30 mins

Inhibit ocular surface inflammation

• _____

  • _____ 0.05% → single or multidose

  • _____: 0.09% → nonosphere solution in single dose

  • _____: 0.1→ semi-fluorinated alkane solvent in multidose vial - non-aqueous preservative free

• Counsel:

  • Invert bottle a few times before application

  • Allowing a minimum of _____ interval between instillation of cyclosporine and artificial tears or other eyedrops 

  • Not to use while wearing contacts: remove prior to application and can be reinstalled 15 mins later

• SE: _____ (most common), conjunctival hyperemia, discharge, eyepain, foreign body sensations, pruritus, stinging, blurring

Cyclosporine, Restasis, Cequa, Vevye, 15-min, burning sensation

Inhibit ocular surface inflammation

• Lifitegrast (_____)

  • 5% ophthalmic solution in single unit vial

  • Store at _____

  • Instill 1 drop _____ in affected eye

• Counseling:

  • Allow a minimum of _____ interval between installation of Liftegrast and artificial tears or other eye drops 

  • Not to use while wearing contacts: remove prior to application and can be reinstalled 15 mins later

• SE: _____, conjunctival hyperemia, eye irritation, headache, incr lacrimation, eye discomfort, eye pruritus

Xiidra, room temp, BID, 15-min, blurred vision

Tear/mucous secretion stimulation - drugs causing stimulation of tear

• _____ (Tryptyr)

  • Ophthalmic solu 0.003% single unit preservative free

  • Store in _____

  • 1 drop _____

  • Remove contacts before use

• _____ (Trvaya)

  • Nasal spray 0.03 mg

  • Store at _____

  • Prime pimp by _____ in the air

  • Reprime by one spray if the bottle has not been used > _____

  • Wipe the nasal applicator with clean tissue

  • DO NOT _____

Acoltremon, fridge, BID, Varencicline, room temp, 7 sprays, 5 days, shake or freeze