1. OCULAR PHARMACOLOGY for ASSISTANTS AND TECHNICIANS
John W. Snead MD, MBA, FACS
Lynn Lawrence, CPOT, ABOC

2. ROLE of the ASSISTANT AND TECHNICIAN
Recording
Patient Education
NEVER Work in Doubt!

3. PATIENT CASE HISTORY
General Health
Medications
Allergies

4. VITAMIN SUPPLEMENTS

5. CLASSIFICATIONS
Solutions
Suspensions
Ointments

6. DIAGNOSTIC AGENTS Topical Anesthestics Mydriatics Cycloplegics
DPA’s treat symptoms, unknown disease
Topical Anesthestics
Mydriatics
Cycloplegics
Dyes/Stains
Fluress
Gonioscopic Solutions

7. Topical Anesthetics
Proparacaine
Tetracaine
Cocaine
Alcaine

8. Mydriatics & Cycloplegics
Tropicamide
Phenylephrine
Cyclogyl
Atropine
Homatropine
Scopalomine

9. Dilation Hazards Cross Contamination Narrow anterior chamber angle
Potential risk in dilating … opt vs oph
Plan for acute angle glaucoma attack
Make sure you are far enough away not to
Touch the patient

10. Dyes & Stains
Fluorescein
Rose Bengal
Lissamine Green
Fluress

11. Gonioscopy Solutions
Goniosol
Gonioscopic
Celluvisc

12. CLINICAL ADMINISTRATION
Patient History
Clinical Procedures Which May Be Influenced by Medications
The ERx Option

13. Ophthalmic Drug Complications
Giving people medications may seem routine, but there are possible negative consequences. Not all people are tolerant of all medications. If given a drug they can’t tolerate, a patient may have an allergic or toxic reaction. As an eye technician administering drugs to people on a daily basis, it’s important you understand and recognize what is occurring if a patient does have a reaction. You also need to understand how drugs affect the body’s autonomic nervous system (ANS), to include the sympathetic and parasympathetic divisions.

14. THERAPEUTIC AGENTS Antibiotics Anti-virals Drugs that lower IOP
TPAs treat disease, known problem
Antibiotics
Anti-virals
Drugs that lower IOP
Anti-inflammatory agents
Non-Steroidal
Combinations

15. GLAUCOMA MANAGEMENT
Pilocarpine
Beta-Blockers
Carbonic Anhydrase Inhibitors
Adrenergic Agonists

16. OCULAR INFLAMMATION Corticosteroids Steroid-Antibiotic Combinations
Non-Steroidal Anti-inflammatory Drugs (NSAIDS)
Oral Analgesics

17. OCULAR INFECTIONS Topical Antibiotics Oral Antibiotics Anti-Viral
Analgesics

18. Antibiotic
Biotic means relating to, produced by, or caused by living organisms
The prefix anti "against" the referent of the stem to which the prefix is affixed

19. OCULAR SURFACE Artificial Tears Lubricating Ointments
Punctal Occlusion

20. OCULAR ALLERGIES Artificial Tears Antihistamine-Decongestants
Corticosteroids

21. Cap Color Code Tan- antibiotics Pink- anti-inflammatory/steroids
Red- mydriatics/cycloplegics
Grey- NSAIDS
Green- miotics
Yellow or Blue- beta-blockers
Purple- adrenic agonists
Orange- carbonic anhydrase inhibitors
Turquoise- Prostaglandin analogues

22. IN-OFFICE PROCEDURES

23. Patient Instruction- Solutions and Suspensions
Wash hands thoroughly before administration
Tilt head backward or lie down and gaze upward
Gently grasp lower eyelid below eyelashes and pull the eyelid away from the eye to form a pouch
Place dropper directly over the eye. Avoid contact of the dropper with the eye, finger or any other surface
Release the lid slowly and close the eye
Occlude punta for 2-3 minutes
Wait 5 minutes before administering a second medication or drop

24. Patient Instruction- Ointment
Wash hands thoroughly
Tilt head backward or lie down and gaze upward
Gently pull down the lower lid to form a pouch
Place .25 to .50 inch of ointment with a sweeping motion
Close the eye for 1-2 minutes
Temporary blurring of vision may occur.
Remove excess ointment with a tissue
Wait 10 minutes before applying the second ointment

25. Continuous release delivery
A medication device placed in the eye and lasting for a week is quite a benefit to patients who have
trouble keeping up with their drops. The most common of these devices is the Pilocarpine Ocusert®,
which permits continuous delivery of medication 24 hours a day for seven days.

26. Retro-Bulbar Injection
Subconjunctival injections
Injections may be administered under the conjunctiva to deliver medications in large doses and longer
durations (fig. 4–4). The subconjunctival medication gains access to the eye by absorption into the
bloodstream through the episcleral and conjunctival vessels. Subconjunctival injections are used
primarily in the treatment of intraocular infection or acute uveitis cases.

27. ABBREVIATIONS

28. Examples ad lib- freely as needed ac – before meals bid- twice a day
gtt- Drops
hs- at bedtime
pc -after meals
po- by mouth
prn- as needed

29. Examples- con’t oint- ointment q- every qh- every hour
q4h- every four hours
qid- 4 times a day
sig- instructions
sol- solution
susp- suspension

30. Examples- con’t tab- tablet tid- three times a day top- topically
ung- ointment
ut dict- as directed

31. Prescription abbreviations
Meaning ac
(ante cibum) before meals q
(quaque) every
ad lib
(ad libitum) as much as wanted qd
(quaque die) every day aq
Water qh
(quaque hora) every hour
bid
(bis in die) twice a day
qid
(quater in die) 4 times a day
gt; gtt
(gutta; guttae) drop; drops ql
(quantum libet) as much as desired h
hora) hour
qqh or q4h
(quaque quarta hora) every four hours hs
(hora somni) at bedtime qs
quantity sufficient mg
Milligram Rx
(recipe) prescription
non rep
(non repetatur) do not repeat
Sol
solution pc
(post cibum) after meals
Tid
(ter in die) three times a day po
(per os) by mouth, orally
ung
(unguentum) ointment
prn
(pro re nata) as needed
Prescription abbreviations

32. Mydriatic
Mydriasis is the dilation of the pupils, so, logically, a mydriatic drug causes dilation. The main reason the eyes is dilated is to allow the doctor to perform a thorough exam of the posterior portion of a patient’s eyes. A big pupil allows a wider field of view and gives the examiner a chance to see the vast majority of the retina, rather than the very small amount seen in an undilated eye. Mydriasis is also useful in allowing you to take fundus photographs of the macula, optic nerve, and any retinal anomalies present.

33. Cycloplegics
These drugs cause mydriasis like mydriatics, but they also cause cycloplegia, which is paralysis of the ciliary muscle. Remember, the ciliary muscle controls focusing of the light rays entering the eye by changing the shape of the crystalline lens.
Cycloplegics are used in dilating the pupils to facilitate examination of the fundus, prevent ciliary spasm and pain in iritis patients, and prevent a patient (usually a suspected hyperope) from constantly accommodating while the doctor is trying to refract the patient and figure out the prescription.
Cycloplegics are also used to perform entrance eye exams on flyers to find what their true refractive error is. Again, this is accomplished by paralyzing the focusing mechanism of the eyes (temporarily) while the doctor refracts the patient. Cycloplegics almost always come in bottles with red caps.
Tropicamide (Mydriacyl®; Opticyl®)
The information you need to know about tropicamide is:
• Preparation: Solution, 0.5 – 2 percent (most common usage is 1 percent).
• Dosage: Instill one drop in each eye. Repeat if the doctor requests it.
• Action and uses: Produces mydriasis and cycloplegia. Onset of action is rapid (20 – 30
minutes) and duration varies from one-half to four hours. Used primarily in conjunction with phenylephrine when dilating patients for routine fundus exams. May be used for unofficial

34. Beta-Blockers
Beta-blockers are the current drugs of choice in lowering IOP. Timoptic®, Betoptic®, and Betagan® are some of the most popular drugs being used to lower IOP today. Introduced in the late 1970s, they quickly became the initial drug of choice for lowering IOP.
One reason beta-blockers are so popular is, on average, they reduce IOP by 25 percent. Another reason is they can be used once or twice daily, unlike most previous medications that were used up to four times a day. Finally, most of the previous drugs used to lower IOP caused miosis (pupillary constriction), dim vision (due to constricted pupil size), eyebrow ache, and stimulation of accommodation (which can blur vision). Fortunately, beta-blockers work without these side effects. However, this does not mean they are perfect, as they also have some side effects.

35. Beta-Blocker Complications
Beta-blockers block the beta–1 and beta–2 receptors from doing their jobs in the body. This is good because one of the jobs of the receptors involves maintaining normal production of aqueous humor. By slowing down aqueous production, the IOP can be lowered. The downside is some of the other jobs beta–1 and beta–2 receptors include proper heart rate and breathing.
Basically, if a patient systemically absorbs a beta-blocking medication, it slows the heart rate and makes breathing difficult. Not a great thing to have happening when you consider the age and general health of a lot of your glaucoma patients.

36. Risk of Complications
Thus, patients with certain systemic diseases warrant special consideration by a doctor trying to decide whether the person should use beta-blockers or not. The following is a very general list of systemic conditions contraindicating beta-blocking medication usage.
• Asthma.
• Heart or circulatory problems.
• Chronic obstructive pulmonary disease (COPD).
In addition, patients already on systemic beta-blockers (e.g., Inderal® for high blood pressure) should be considered high-risk candidates for use of any of the beta-blocker medications. Patients may be better off using one of the cholinergic medications, carbonic anhydrase inhibitors, or prostaglandin inhibitors instead.
Some of the common side effects of beta-blockers (especially the more medication the patient systemically absorbs) are:
• Bradycardia—the slowing down of the heart rhythm (leading to low blood pressure and dizziness).
• Induced asthma.
• Mood changes.

37. Cholinergic agents (direct-acting miotics)
These drugs are the traditional medications used to lower IOP. They have fallen out of the widespread usage once enjoyed before the beta-blockers and prostaglandins came along. However, they still play a role in the management of IOP as there are times beta-blockers alone do not lower IOP enough or patients require specific treatment working on the outflow of aqueous humor rather than just slowing its production.
These cholinergic drugs lower IOP by causing the longitudinal muscle of the ciliary body to pull on the sclera near the base of the iris and the trabecular meshwork. Pulling in the ciliary body causes an opening or rearranging of the trabecular meshwork, allowing the aqueous to drain from the eye faster.
Since these drugs work directly to cause contraction of the ciliary muscle, they are considered to be direct-acting miotics and are primarily used in the treatment of angle-closure glaucoma.
While the primary action desired from these miotic medications is to increase aqueous humor

38. Topical Steroids Durezol Pred Forte Prednisone Omnipred Econopred
Avoid using steroids on viral infections

39. Contraindications for Steroids
Cataracts.
Increased IOP.
Fungal overgrowth.
Delayed wound healing.
Decreased wound healing.
Decreased resistance to infection.
Proliferation of herpes simplex virus
NOTE: Virtually all of these side effects are quite rare when the proper dosage of topical steroid is used in a short-term manner as prescribed by the doctor.

40. Topical NSAIDS Bromday – Prolenza Nevanec
Used often for pre/post cataract surgery

41. CAP Colors Cap Color Drug Class Tan
Antibiotics, Antivirals, Antifungals
Pink
Anti-inflammatory/Steroids treats allergic reactions, swelling, redness (slows healing can cause cataracts and glaucoma). Do not use on fungal infections
Red
Mydriatics/Cycloplegics (dilate pupil)
Grey
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) control inflammation caused by ocular allergies without steroidal side-effects
Green
Miotics (stimulates sphincter and causes pupil constriction)
Yellow or Blue
Beta-Blockers traditionally used to treat glaucoma, reduce IOP by decreasing aqueous humor
Purple
Adrenic Agonists (reduce IOP)
Orange
Carbonic Anhydrase Inhibitors (reduce IOP)
Turquoise
Prostaglandin Analogues (reduce IOP by increasing aqueous outflow)

42. HOW TO WRITE AN Rx

43. Medication Administration
Read the doctors orders
Check the medication twice
Name
Dosage
Amount
Expiration date
Wait 5 min between gtts
Punctal Occlusion
Put ung in last

44. Preparation 1. Wash your hands.
2. Triple check the medication you are going to instill to ensure it is what the doctor ordered.
3. Advise the patient of what you are going to do.
4. Recline the patient or gently tilt the patient’s head back. Always ask the patient about neck or back problems before tilting his or her head. Do not tilt a Down’s syndrome patient’s neck due to the high risk of cervical fracture.
5. With one hand, hold the upper lid and, with a finger of the other hand (the one holding the little bottle of medication), pull down gently on the lower lid (fig. 4–1).
6. Have the patient look down.
7. Keep the bottle about ½″ above the eye. This should be high enough to avoid contamination by the patient’s eyelashes in the event the patient inadvertently blinks, while still allowing good control of where the drop goes. Now, squeeze the bottle to dispense a drop in the eye. Ideally, the drop hits just above the upper limbus, causing minimal reaction by the patient (since the very sensitive cornea isn’t hit directly), but allowing a good percentage of medication to flow across the cornea before it gets diluted by tears.
CAUTION: Keep the eye dropper tip well away from the eye so, even if the patient blinks, the lashes do not touch it. If the dropper tip comes into contact with the patient’s eyes, lids, or lashes, the bottle is considered contaminated and must be thrown away after you finish with the patient. Do not attempt to use it on another patient.

45. Make sure that you include:
Full name of patient
Address can be optional
Date of Rx
Inscription: name of drug; concentration
Subscription: amount to be dispensed
Instructions: route of administration; number of drops or tablets; frequency of use; refill

46. What else?
Make sure that it is legible!
Type in correctly
Verify

47. Questions What type of drug is used to lower IOP?
A. Mydriactic
B. Antibiotic
C. Beta Blocker
How often is the following medications taken?
Maxitrol ophthalmic ung apply BID OU for 14 days:
A. Once a day B. Twice a Day C. Three times a Day

48. Questions What drug is used to stain the cornea?
A. Mydriacyl
B. Carbachol
C. Flourescein
How often is the following medications taken?
Pred Forte ophthalmic 1gtt qid q 6h OD 7 days then 1gtt bid q 12h for 7 more :
****No help****

49. Questions What drug is used to destroy bacteria?
A. Bromday
B. Antibiotic
C. Beta Blocker
What drug is used increase aqueous outflow?
A. Vigamox
B. Pilocarpine
C. Mydriacyl

50. Questions What drug is used to dilate the pupil?
A. Miotic
B. Mydriacyl
C. Beta Blocker
What drug is used as an anti-inflammatory?
A. Durezol
B. Vigamox
C. Besivance

51. Examples ad lib- ________ ac – ________ bid- _________ gtt- _________
hs- _________
pc -__________
po- __________
prn- __________

52. Examples ad lib- freely as needed ac – before meals bid- twice a day
gtt- drops
hs- at bedtime
pc -after meals
po- by mouth
prn- as needed

53. References and resources
Ophthalmic Drug Facts 2002
Ophthalmic Medications and Pharmacology
Review of Optometry: 2002 Clinical Guide to
Ophthalmic Drugs (Melton and Thomas) May issue

54. THANK YOU!