Chapter 18: Eye and Ear Medications.

Interactions with CAIs are frequent because of increasing or decreasing excretion of other drugs and can include:

Decreased effects of lithium and oral antidiabetics Increased effects of quinidine, amphetamines, and other diuretics Hypokalemia with thiazides and corticosteroids Dorzolamide (Trusopt) is a CAI that is applied topically to treat open-angle glaucoma. It is used as an adjunct to beta-blockers and is available as a combination product with timolol (Cosopt).

Nonsteroidal anti-inflammatory drug (NSAIDs) such as flurbiprofen (Ocufen) and ketorolac (Acular) ophthalmic drops are used to treat:

postoperative inflammation following cataract surgery.

Side effects of local anesthetics

rare, except with prolonged use, but may include hypersensitivity (transient stinging) reactions such as anaphylaxis in those allergic to the "-caine" local anesthetics (ester type).

Local ophthalmic anesthetics

such as tetracaine (TetraVisc), are applied topically to the eye for minor surgical and diagnostic procedures, removal of foreign bodies, or painful injury.

Pilocarpine

-is also used after ophthalmic examinations in glaucoma patients to constrict the pupil and counteract the mydriatic (pupil-dilating) effects of other agents. -has cholinergic action and side effects.

Antiglaucoma drugs include:

1. Carbonic anhydrase inhibitors, for example: dorzolamide (Trusopt). Act by decreasing the formation of aqueous humor and have a diuretic effect. 2. Miotics, for example, pilocarpine. Act by increasing the aqueous humor outflow. 3. Beta-adrenergic blockers, for example: timolol. Act by decreasing the rate of aqueous humor production. 4. Alpha-agonists, for example: brimonidine (Alphagan-P). Decrease the production of aqueous humor and increase outflow. 5. Prostaglandin analogs, for example: latanoprost (Xalatan). Act by increasing aqueous outflow.

Topical ophthalmic antibiotic medications should not be used for more than ___________

10 days.

Precautions or contraindications with prostaglandin analogs apply to:

Active intraocular inflammation (may worsen condition) Contact lens wearers Hepatic and renal diseases Pregnancy, lactation, and use in children.

Precautions or contraindications with corticosteroids apply to:

Acute bacterial, viral, or fungal infections Primary open-angle glaucoma Pregnancy Prolonged use.

Patients being treated with mydriatics should be instructed regarding:

Administration by closing tear duct after instillation (see Figure 18-2) Aseptic technique to prevent contamination of the medicine Blurred vision and sensitivity to light to be expected (wear dark glasses or stay out of bright light).

Patients being treated with beta-adrenergic blockers should be instructed regarding:

Administration by closing tear duct after instillation to reduce systemic effects; do not exceed the recommended number of drops Caution in patients with cardiac or pulmonary disorders or who are taking oral beta-blockers Importance of regular eye examinations Continuous use of medications for glaucoma; do not discontinue abruptly When administering more than one ophthalmic medication, allowing a time interval (at least 5 min) between medications; ophthalmic solutions should always be used before gels and suspensions to optimize the absorption of each medication.

beta-adrenergic blocker

Agent that blocks the beta receptors such as those found in the heart, causing a decrease in the rate and force of cardiac contraction.

Precautions or contraindications for mydriatics apply to:

Angle-closure glaucoma Infants Phenylephrine is an alpha-sympathomimetic that produces mydriasis without cycloplegia. Side effects and precautions or contraindications are similar to those of epinephrine.

Precautions or contraindications with pilocarpine apply to:

Angle-closure glaucoma with acute inflammation History of retinal detachment or retinal degeneration Acute inflammatory processes Soft contact lenses in place Corneal abrasion.

Side effects of pilocarpine, usually dose related, can include:

Blurred vision and myopia Twitching, stinging, and burning Ocular pain and headache Photophobia and poor vision in dim light Aggravation of inflammatory processes of the anterior chamber of the eye Cataracts and retinal detachment (due to ciliary muscle spasm).

Side effects of prostaglandin analogs include:

Blurred vision, burning, macular edema, and stinging Slow, gradual change in the color of the iris (resultant color change may be permanent) Change in the length, thickness, and pigmentation of eyelashes (Latisse, a form of bimatoprost, is approved for the treatment of hypotrichosis, or inadequate eyelashes) Systemic effects rarely, including upper respiratory tract infection and muscle and joint pain.

Precautions or contraindications with beta-blockers apply to:

Bradycardia, heart failure, and heart block Patients receiving oral beta-blocker drugs Asthma and chronic obstructive pulmonary disease (COPD)—betaxolol (Betoptic-S) can be used with caution in patients with bronchospastic pulmonary disease because it does not affect the pulmonary receptors Pregnancy and lactation Children Diabetes and hyperthyroidism Closed-angle glaucoma.

Side effects of dorzolamide can include:

Burning or stinging and blurred vision Bitter taste.

Acute (angle-closure) glaucoma.

Characterized by a sudden onset of pain, blurred vision, and a dilated pupil, this condition is considered a medical emergency.

Precautions or contraindications with CAIs apply to:

Chronic obstructive pulmonary disease (COPD) Diabetes Electrolyte, hematological, hepatic, pulmonary, and renal disorders Sulfonamide hypersensitivity Pregnancy and lactation.

Side effects of alpha-agonists can include:

Conjunctival redness, itchiness, stinging Dizziness, drowsiness, dry mouth, and headache Alpha-agonists have the potential to enhance the CNS depressant effects of ethanol, opiate agonists, anxiolytics, sedatives, and hypnotics.

Anti-inflammatory ophthalmic agents

used to relieve inflammation of the eye or conjunctiva in allergic reactions, burns, irritation from foreign substances or postoperatively.

cycloplegic

Drug that paralyzes the muscles of accommodation for eye examinations.

Miotics

Drugs that cause the pupil to contract. => reduce IOP by increasing the aqueous humor outflow. They act by contracting the ciliary muscle; this mechanism also leads to blurred vision.

Mydriatics

Drugs that dilate the pupil.

Carbonic anhydrase inhibitors

Drugs that reduce the hydrogen and bicarbonate ions and have a diuretic effect (increasing the excretion of fluids from the body through the urine).

Patients being treated with miotics should be instructed regarding:

Following directions carefully regarding time and amount Administration by closing tear duct after instillation Reporting side effects to the physician for possible dosage adjustment Administration at bedtime to reduce side effects Not driving at night.

Side effects of mydriatics, more likely in older adult patients, may include:

Increased IOP Local irritation, tearing, and burning sensation (transient) Blurred vision (common) Flushing, dryness of skin, and fever Decreased salivation and sweating Confusion (caution in older adults).

Side effects of corticosteroids can include:

Increased intraocular pressure (IOP; depends on the drug, dose, frequency, and length of treatment; less likely with fluorometholone) Reduced resistance to bacteria, viruses, or fungi Delayed healing of corneal wounds, thinning of cornea, and corneal ulceration Stinging, burning, or ocular pain Increased risk of developing cataracts.

anti-infective

Medication used in the treatment of infections; includes antibiotics, antifungals, and antivirals.

Antiglaucoma

Medications used to lower intraocular pressure.

Ophthalmic medications that cause pupillary contraction are classified as:

Miotics.

Chronic (open-angle) glaucoma.

Much more common and often bilateral, this condition develops slowly over a period of years with few symptoms except a gradual loss of peripheral vision and possibly blurred vision. Halos around lights and central blindness are late manifestations.

Systemic effects with frequent or prolonged use or high doses of pilocarpine, especially in children, can include:

Nausea, vomiting, and diarrhea Increased lacrimation, salivation, and sweating Hypotension and bradycardia Bronchospasm.

Side effects of oral and IV CAIs, infrequent and usually dose related, can include:

Nausea, vomiting, diarrhea, and constipation Thirst, taste alteration; frequent urination Drowsiness, fatigue, confusion, and seizures Numbness, muscular weakness, and tingling, with high doses Blood dyscrasias; electrolyte imbalance Hepatic and renal disorders (can lead to kidney stones) Photosensitivity (avoid excessive sunlight exposure).

Patients given local ophthalmic anesthetics should be instructed regarding:

Necessity of wearing an eye patch after the use of tetracaine because of the loss of the blink reflex Avoidance of touching or rubbing the eye until the anesthesia has worn off.

Patients being treated with anti-inflammatory ophthalmic drugs should be instructed regarding:

Not rubbing their eyes, which can worsen the condition Following directions carefully regarding time and amount Lowered resistance to infection—do not use long term Administration (i.e., applying pressure on tear duct at inner corner to reduce systemic absorption); Not wearing contact lenses if eyes are red Removing lenses prior to using the product; contacts may be reinserted for most products if eyes are not red Not using leftover drug for new eye inflammation—discard the drug when no longer needed.

Atropine

used topically to dilate the pupil for ophthalmic examinations; also acts as a cycloplegic.

Side effects of beta-blockers are infrequent and transient but may include:

Ocular irritation, tearing, conjunctivitis, or diplopia Transient blurred vision with the gel formulation Aggravation of preexisting cardiovascular or pulmonary disorders, which may cause bradycardia, hypotension, dizziness, and bronchospasm.

Interactions of beta-blockers may occur with:

Other antiglaucoma drugs to help lower IOP Oral beta-blockers to increase chances of hypotension, bradycardia, and heart block.

Patients being treated with prostaglandin analogs should be instructed regarding:

Possibility of iris color change (increase of the brown pigment). Contacting the physician immediately if ocular reactions develop. Prostaglandin analogs contain a preservative that may be absorbed by contact lenses. Remove lenses prior to administration of the drug and wait 15 min before reinserting.

intraocular pressure

Pressure within the eyeball.

Otitis Media

The most common type of otic infection, located in the middle region of the ear.

Patients being treated with anti-infective ophthalmic preparations should be instructed regarding:

Using only as directed and checking dosage and frequency Careful instillation into the lower conjunctival sac to avoid contamination of the tip of the dropper or ointment tube Possible hypersensitivity reactions in patients with allergies of any kind Discontinuance of the medication and reporting immediately to a physician any signs of sensitivity (e.g., burning and itching) Careful handwashing to prevent the spread of infection to the other eye or other persons Not using eye makeup or not wearing contact lenses while treating eye infections Replacing contact eye makeup and contacts due to possible contamination by the causative organism When using more than one ophthalmic product at the same time, space them at least 5 min apart (to ensure maximum absorption) and administer the more viscous preparation (i.e., ointment, suspension) last.

Glaucoma

a group of sight-threatening diseases of the eye in which there is increased intraocular pressure (IOP) due to obstruction of the outflow of aqueous humor. This causes deterioration of and damage to the optic nerve (which carries images on the retina to the brain), resulting in vision loss.

Timolol (Timoptic)

a nonselective beta-adrenergic blocker that is used topically to lower IOP in open-angle glaucoma by decreasing the rate of aqueous humor production.

Brimonidine (Alphagan-P)

a selective alpha2-agonist that decreases the formation and increases the outflow of aqueous humor. It does this without causing mydriasis and with minimal effects on cardiovascular or pulmonary hemodynamics. => an alternative for those for whom topical beta-blocker therapy is contraindicated.

A client has been prescribed a corticosteroid eye drop and is fearful of taking any medications that will be absorbed into her body. How does the health care practitioner respond? a. When administering eye drops, gently apply pressure to the inner canthus. b. When administering eye drops, gently apply pressure to the upper lid. c. This drug is not absorbed systemically. d. When administering eye drops, gently apply pressure to the lower lid.

a. When administering eye drops, gently apply pressure to the inner canthus. (When administering eye drops, gently apply pressure to the inner canthus. This will minimize absorption into the systemic circulation).

Debrox (carbamide peroxide)

an OTC medication used to soften, loosen, and remove excessive earwax.

Miotics (e.g., pilocarpine) are used in the treatment of:

open-angle glaucoma (considered third-line therapy due to side effects) or in the short-term treatment of angle-closure glaucoma before surgery.

A pediatric client is being treated for bacterial conjunctivitis. Bacitracin, an anti-infective ophthalmic antibiotic, is prescribed. The health care practitioner knows that the preferred form of this treatment for a pediatric client is which of the following? a. Eye drops b. Sublingual c. Oral d. Ointment

d. Ointment.

A client is to be started on Diamox, a carbonic anhydrase inhibitor. Which condition does the health care practitioner know would prevent the client from using this medication? a. Hypertension b. Burning and stinging of the eyes c. Increased intraocular pressure d. Sulfa allergy

d. Sulfa allergy.

Side effects of anti-infectives can include

hypersensitivity reactions such as conjunctivitis, irritation, local burning, stinging, blurred vision, rash, and urticaria in persons with a history of allergy.

Topical cyclosporine (Restasis)

increases tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation. It is an immunosuppressive agent for organ transplant rejection prophylaxis when administered systemically.

Patients being treated with alpha-agonists should be:

instructed regarding reporting side effects to the physician immediately. Because drugs in this class may cause fatigue or drowsiness in some patients, those who engage in hazardous activities should be cautioned of the potential for a decrease in mental alertness.

When a client is using more than one ophthalmic medication at a time, the more viscous preparation should be administered _________

last.

first-line agents for IOP

latanoprost (Xalatan), travoprost (Travatan Z), and others are prostaglandin analogs that cause the greatest reduction in IOP by increasing the outflow of aqueous humor. They may be used concomitantly with other topical ophthalmic drugs to lower IOP (administer the drugs at least 5 min apart).

Ophthalmic antibiotic preparations (singly and/or in combination) include:

macrolides, bacitracin, fluoroquinolones, sulfonamides, bacitracin-polymixin, and trimethoprim-polymyxin.

Side effects of topical cyclosporine

mild and transient, including ocular burning, itching, stinging, pain, and blurred vision.

Treatment of acute glaucoma consists of

miotics (e.g., pilocarpine), osmotic agents (e.g., mannitol), carbonic anhydrase inhibitors (e.g., acetazolamide), and surgery to open a pathway for the release of aqueous humor.

Treatment of chronic glaucoma consists of

miotics, carbonic anhydrase inhibitors, and a local beta-adrenergic blocker, such as timolol (Timoptic) eye drops.