Chapter 38. Common Conditions of Eyes and Ears

Letters in RX Prescription

D is for right

S is for left

O is for Eye

A is for ear (auris)

What are the two main forms of Glaucoma?

1. Open-Angle Glaucoma: (most common)

   1. W/out symptoms and treated with eye drops or surgery

2. Closed-Angle Glaucoma

   1. sharp, sudden increase in IOP due to blockage

      1. Has sx of eye pain, hx, and low vision (MEDICAL EMERGENCY → treat surgically)

What drops can be used in ear, but never use in eyes?

Eye drops can be used in ear, but never ear drops for eyes (wrong pH, not isotonic, may not be sterile)

1 drop = ? mL

0.05 mL

Counseling for suspensions

shake well

Counseling for eye ointments

Can make vision blurry

Counseling for eye gels

invert and shake once

Glaucoma diagnosis

-Glaucoma: disease of eye; Damage to optic nerve and loss of visual field

Measured by:

• Visual field test

• IOP above normal range of 12-22 mmHg

• Goal of tx: reduce IOP

Drugs that can increase IOP

• Anticholinergics (antihistamines, oxybutynin, tolterodine, benztropine, scopolamine, trihexyphenidyl, TCAs)

• Decongestants (e.g. pseudoephedrine)

• Chronic steroids (esp. eye drops like prednisolone [Pred Forte])

• Topiramate (topamax)

Glaucoma Treatment goal is to decrease IOP - what are the strategies to do this?

Reduce Aqueous humor production (make less fluid)

• BB (i.e. timolol)

• Carbonic Anhydrase Inhibitors (i.e. dorzolamide)

(Cut Back)

Increase Aqueous Humor Outflow (move fluid out)

• PG analogs (i.e. latanoprost)

(Push out)

Do Both (often achieved w add-on tx)

• Alpha 2 agonists (i.e. brimonidine)

(All of the above) = Targeting Aqueous humor (fluid in eye)

Which drug class is the most effective at decreasing IOP?

Protasglandin (PG) analogs (~30%)

Naming Tip: -prost = prostaglandin analog

Bimatoprost brand

Lumigan

Latanoprost brand

Xalatan, Xelpros

Travoprost brand

Travatan Z

Which drug class for glaucoma is preferable if the IOP is high in one eye only?

BBs

What is the brand name of Bimatoprost for eyelash growth? (eyelash hypotrichosis)

Latisse - do not use w/ prostaglandin analogs for glaucoma

What is the dosing for Prostaglandin analogs?

1 drop QHS

• Includes Bimatoprost, Latanoprost, Travoprost

Warnings/Side effects associated with Prostaglandin Analogs

Warnings:

• Darkening of iris and eyelashes, increased pigmentation

• Eyelash length and number increases

Side effects:

• Blurred vision, stinging

• Increased pigmentation of iris/eyelashes, eyelash growth and thickening

Naming Tip: -prost = prostaglandin analog

How should Xalatan (Latanoprost) be stored?

Refrigerated before opening

• Store at room temp once opened

Timolol 0.25% and 0.5% brand names

Timoptic, Timoptic-XE, Istalol

+ dorzolamide = Cosopt or Cosopt PF

Dosing for BB Timolol

1 drop QD or BID

Dosing for Timoptic-XE, GFS (GELS)

Once daily

*shake once before use; wait 10 minutes after administering other eye drops before gel

Side effects of BBs for Glaucoma

SEs:

• burning, stinging

• bradycardia/fatigue

• bronchospasm

What kind of BBs are used for glaucoma?

Non-selective, except Betaxolol (less likely to cause pulmonary effects)

Which drugs cause pupil constriction and poor vision at night?

Cholinergics

• Carbachol (Miostat), Pilocarpine (Isopto Carpine)

Warnings associated with Carbonic Anhydrase Inhibitors

Caution with sulfonamide allergy

(tip: both have -amide, dorzolamide, sulfonamide)

Which CAI [carbonic anhydrase inhibitor] is not frequently used for glaucoma, but is used for acute mountain (altitude) sickness?

Acetazolamide

• Naming Tip: -zolamide = caution with sulfonamide allergy

Adrenergic Alpha-2 Agonists increase aqueous humor outflow, reduce aqueous humor production. What is a common example/drug option?

Brimonidine (Alphagan P) + Timolol = Combigan

Viral and Bacterial Conjunctivitis occurs mostly in _______ and are highly ______. To prevent spread of infx, any patient should be instructed to:

Young Children , Contagious

• Avoid touching their eyes, use proper hand hygiene and wash hands thoroughly/frequently, change towels/washcloths daily (do not share towels), discard eye cosmetics (esp. masacara)

What is the most common viral cause of conjunctivitis? Alt Name?

Adenovirus

*NO topical tx (allow infx to run its course)

• Alt Name: “Pink Eye”

What are causes of bacterial conjunctivitis?

• S. Aureus

• more severe = N. gonorrhoeae or chlamydia

• More severe requires systemic tx

Tx for bacterial conjunctivitis

Topical abx eye drops/ointments:

• Moxifloxacin (Vigamox)

• Neomycin/Polymyxin B/Dexamethasone (Maxitrol)

• Ofloxacin (Ocuflox)

• Trimethoprim/Polymixin B (Polytrim*)

How should AzaSite (Azithromycin eye drop) be stored?

Store in refrigerator; stable for 14 days at room temp

*for bacterial conjunctivitis

Why are steroid eye drops not used long term? (i.e. for allergic conjunctivitis)

risk of increased IOP

• Options: prednisolone/steroid eye drops ACUTELY

Treatments for allergic conjunctivitis

Mast Cell Stabilizers (i.e. cromolyn)

Antihistamines

• Azelastine

• Olopatadine (Pataday) - OTC

Antihistamine/Mast Cell Stabilizer

• Ketotifen (Alaway, Zaditor)

What is Blepharitis?

Eyelid inflammation

• this is an acute, short-term condition

*Tx with warm, moist washcloth (to loosen crusty deposits)

How is inflammation of the eye treated?

Inflammation of eye can be reduced with:

• Cold compress

• NSAID eye drop (if mild)

• Steroid eye drop (if severe)

What is the most common preservative added to eye drops?

Benzalkonium chloride (BAK)

• Added to prevent growth of microorganisms

• PF = Preservative-Free

How long should you wait before placing contact lenses back in eye after a drop?

15 minutes

*especially important with BAK because these can damage the eyes w contacts

Inflammation of Eye treatments

Steroids (short term use only d/t risk of increased IOP)

• Prednisolone (PredForte, Pred Mild)

NSAIDs

• Ketorolac (Acular)

Dryness of eye treatments

• Refresh

• Systane

*often referred to as Artificial Tears

Chronic Dry Eye Disease Tx

Cyclosporine Emulsion Eye Drops (Restasis)

• Reserved for keratoconjunctivitis sicca (severe chronic dry eye)

Redness of Eye treatment

• Naphazoline (Clear Eyes Redness Relief)

• Naphazoline/Pheniramine (Naphcon A, Visine A)

• Tetrahydrozoline (Visine)

Common Drugs Known To Cause Vision Changes/Damage

Retinal Changes/Retinopathy

• Chloroquine

• Hydroxychloroquine

Optic Neuropathy

• Amiodarone (+Corneal deposits)

• Ethambutol

• Linezolid

Intraoperative floppy iris syndrome (IFIS) causes difficulty in cataract surgery

• Alpha-blockers (e.g. Tamsulosin)

Color discrimination

• Digoxin (with toxicity) - yellow/green vision

• PDE-5 inhibitors (e.g. sildenafil) - greenish tinge around objects

• Voriconazole - color vision changes

Vision loss/abnormal vision

• Digoxin (with toxicity) - blurriness, halos

• PDE-5 inhibitors - vision loss (one or both eyes; can be permanent)

• Isotretinoin - decreased night vision (can be permanent), dryness, irritation

• Topiramate - visual field defects

• Vigabatrin - permanent vision loss (high risk)

• Voriconazole - abnormal vision, photophobia

Tinnitus sx and tx?

Sx: ringing, roaring, buzzing noise → caused by drug toxicity (salicylates)

Tx: none available

What is an example of a cerumenolytic to remove ear wax build-up?

Carbamide Peroxide (Debrox)

• Cerumen = Ear wax

• Use for 3-5 days max

What can mild cases of otitis externa (swimmers ear) be treated with?

acetic acid and a glucocorticoid (VoSol HC)

What is a common topical otic abx to treat swimmers ear (otitis externa)?

Ciprofloxacin and Dexamethasone (Ciprodex)

Timing of Eye Drops

• 5 minutes between 2 drops of same medication

• 5-10 minutes betwen 2 drops of different medication

• Apply gels last. Wait 10 minutes after last eye drop before use

• Remove contacts prior and wait 15 minutes to re-insert