1. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 58 Ophthalmic Drugs

2. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Structures of the Eye  Eyebrows, eyelids, eyelashes  Palpebral fissure  Sclera  Uvea  Choroid  Iris  Ciliary body

3. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Structures of the Eye (cont’d)  Conjunctiva  Pupil  Medial canthus  Lacrimal caruncle  Lacrimal glands  Lateral canthus

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5. Layers of the Eye All protected by the eyelid  Protective external layer  Cornea and sclera  Middle layer  Choroid, iris, ciliary body  Internal layer  Light-sensitive retina

6. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Eye Muscles  Each eye is held in place and moved by six muscles  Rectus (four total)  Oblique (two total)

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8. Interior of the Eyeball  Anterior chamber  Posterior chamber  Canal of Schlemm  Aqueous humor  Vitreous humor

9. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Interior of the Eyeball (cont’d)  Retina  Rods  Cones  Optic nerve

10. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Lens  Accommodation  Cataracts

11. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

13. Drugs That Affect the Eye  Mydriatics  Dilate the pupil  Miotics  Constrict the pupil  Cycloplegics  Paralyze the ciliary body, and have mydriatic properties  Cycloplegia: paralysis of accommodation

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15. Ocular Drugs  Antiglaucoma drugs  Antimicrobial and antiinflammatory drugs  Topical anesthetics  Diagnostic  Antiallergic  Lubricants and moisturizers

16. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Glaucoma  Inhibition of the normal flow and drainage of aqueous humor  Results in increased intraocular pressure (IOP)  Pressure against the retina destroys neurons, leading to impaired vision and eventual blindness

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19. Types of Glaucoma  Angle-closure glaucoma  Open-angle glaucoma  Also characterized by underlying cause  Primary  Secondary  Congenital

20. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Drugs Used to Reduce IOP  β-blockers (antiadrenergic)  Osmotic diuretics  Carbonic anhydrase inhibitors  Direct-acting and indirect-acting parasympathomimetics (cholinergic)  Prostaglandin agonists  Sympathomimetics (adrenergic)

21. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Parasympathomimetics  Mimic the PSNS neurotransmitter ACh  Also called miotics, cholinergics  Direct acting and indirect acting  Cause pupillary constriction (miosis), which leads to reduced IOP due to increased outflow of aqueous humor

22. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

25. Parasympathomimetics (cont’d)  Direct-acting drugs  acetylcholine (Miochol-E)  carbachol  pilocarpine (Pilocar) (also ocular insert form)  Indirect-acting drugs  demecarium (Humorsol)  echothiophate (Phospholine Iodide)

26. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Parasympathomimetics: Indications  Open-angle glaucoma  Angle-closure glaucoma  Ocular surgery  Convergent strabismus (“cross-eye”)  Ophthalmologic exams

27. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Parasympathomimetics: Adverse Effects  Most limited to local effects  If sufficient amounts enter the bloodstream, systemic effect may occur (most likely with indirect-acting)  Hypotension, bradycardia or tachycardia  Headache, nausea, vomiting, diarrhea, abdominal cramps, asthma attacks  Others

28. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Sympathomimetics  Mimic the sympathetic neurotransmitters epinephrine and norepinephrine  Stimulate the dilator muscle to contract  Result is increased pupil size (mydriasis)  IOP is reduced

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31. Sympathomimetics (cont’d)  brimonidine (Alphagan)  apraclonidine (Iopidine)  epinephryl (Epifrin, Glaucon)  dipivefrin (Propine)  Prodrug of epinephrine  When applied topically, hydrolyzed to epinephrine, penetrates tissues better

32. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Sympathomimetics: Indications  Chronic, open-angle glaucoma (to reduce IOP)  Reduction of perioperative IOP  Reduction of ocular hypertension

33. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Sympathomimetics: Adverse Effects  Primarily limited to ocular effects  Burning, eye pain, lacrimation  Systemic effects rare  Hypertension, tachycardia, headache, faintness

34. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Adrenergic Blockers  Selective β 1 -blocker  betaxolol (Betoptic)  Nonselective β 1 - and β 2 -blockers  carteolol (Ocupress)  levobunolol (Betagan Liquifilm)  metipranolol (Optipranolol)  timolol (Timoptic, Betimol)

35. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Adrenergic Blockers (cont’d)  Reduce IOP by:  Reducing aqueous humor formation  Increasing aqueous humor outflow  Do not affect pupil size, accommodation, or night vision

36. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Adrenergic Blockers: Indications  Reduction of elevated IOP  Chronic open-angle glaucoma  Ocular hypertension  Treatment of some forms of angle-closure glaucoma

37. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Adrenergic Blockers: Adverse Effects  Primarily ocular effects  Transient burning and discomfort  Blurred vision, pain, photophobia, others  Limited systemic effects  Headache, dizziness, cardiac irregularities, bronchospasm

38. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. β-Adrenergic Blockers: Interactions  Administration of systemic β-blockers with high doses of ophthalmic β-blockers may result in additive effects

39. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Carbonic Anhydrase Inhibitors  Available in oral forms for treatment of glaucoma  Inhibit the enzyme carbonic anhydrase, which reduces aqueous humor formation in the eye  Result: decreased IOP

40. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

41. Carbonic Anhydrase Inhibitors (cont’d)  Topical ophthalmic preparations  brinzolamide (Azopt)  dorzolamide (Trusopt)  Oral forms  acetazolamide (Diamox)  dichlorphenamide (Daranide)  methazolamide (Neptazane)

42. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Carbonic Anhydrase Inhibitors: Indications  Treatment of glaucoma  Open angle  Angle closure

43. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Carbonic Anhydrase Inhibitors: Adverse Effects  Oral forms can produce systemic effects  Drowsiness, confusion  Transient myopia, tinnitus  Anorexia, vomiting, diarrhea  Several others  Patients with sulfa allergies may develop cross-sensitivities

44. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Osmotic Diuretics  Create ocular hypotension by producing an osmotic gradient  Water is forced from the aqueous and vitreous humors into the bloodstream  Result is reduced volume of intraocular fluid, thus reduced IOP

45. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Osmotic Diuretics (cont’d)  Administered IV, PO, or topically  Glycerin usually tried first  Mannitol used if glycerin is unsuccessful  Isosorbide and urea may also be used

46. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Osmotic Diuretics (cont’d)  Indications  Acute glaucoma episodes  Before and after ocular surgery to reduce IOP  Adverse effects  Nausea, vomiting, headache  May cause fluid and electrolyte imbalance

47. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Prostaglandin Agonists  New class of drugs for glaucoma  Three drugs  latanoprost (Xalatan)*  travoprost (Travatan)  bimatoprost (Lumigan) *Most popular

48. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Prostaglandin Agonists (cont’d)  Reduce IOP by increasing the outflow of aqueous fluid  Increases uveoscleral outflow of fluid  Used in the treatment of glaucoma  Most drugs allow for single daily dosing due to effects lasting for 20 to 24 hours

49. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Prostaglandin Agonists (cont’d)  Effects on eye color  In some persons with hazel, green, or bluish brown eyes, eye color will change permanently to brown  Color change occurs even if medication stopped  Iris color change does not affect IOP readings

50. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antimicrobial Drugs  Topical and systemic administration  Antibacterial  Antiviral  Antifungal

51. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antimicrobial Drugs (cont’d)  Topical application may cause transient and local inflammation, burning, and stinging  Use of ophthalmic antibiotics with corticosteroids may make it more difficult to rid the eye of infection

52. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antibacterial Drugs  Aminoglycosides  Antibacterial  gentamicin, neomycin, tobramycin

53. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antibacterial Drugs (cont’d)  Macrolides  Antibacterial  erythromycin, azithromycin, others  Erythromycin also is used for prevention of Neisseria gonorrhoeae eye infections in newborns

54. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antibacterial Drugs (cont’d)  Polypeptides  Antibacterial  bacitracin, polymyxin B

55. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antibacterial Drugs (cont’d)  Quinolones  ciprofloxacin (Ciloxan)  Sulfonamides  sulfacetamide (Bleph-10, others)

56. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antifungal Drugs  Natamycin  blepharitis, conjunctivitis, keratitis

57. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antiviral Drugs  ganciclovir (Vitrasert)  Treatment of ocular cytomegalovirus (CMV)  Given by surgical implant in the posterior of the eye  fomivirsen (Vitravene)  Treatment of ocular CMV  Given by intravitreal injection

58. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ocular Antiviral Drugs (cont’d)  trifluridine (Viroptic)  Used in the treatment of types 1 and 2 herpes simplex virus (HSV)  Applied topically as drops or ointment

59. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antiinflammatory Ocular Drugs  NSAIDs  ketorolac (Acular)  flurbiprofen (Ocufen)  Corticosteroids  dexamethasone (Decadron, AK-Dex)

60. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antiinflammatory Ocular Drugs (cont’d)  Act on various parts of the arachidonic acid metabolic pathway  Reduce the production of various inflammatory mediators  As a result, pain, erythema, and other inflammatory processes are reduced

61. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

62. Antiinflammatory Ocular Drugs (cont’d)  Applied topically  Used to treat various ophthalmic inflammatory conditions  Should not be used for minor abrasions or wounds—may suppress the eye’s ability to resist infections

63. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Antiinflammatory Ocular Drugs (cont’d)  Used prophylactically after surgery to prevent inflammation and scarring  NSAIDs used for symptomatic treatment of seasonal allergic conjunctivitis

64. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Topical Ophthalmic Anesthetics  Used to prevent eye pain during:  Surgery  Ophthalmic examinations  Removal of foreign bodies or sutures  Diagnostic testing and procedures  Short-term use only  Not for self-administration

65. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Topical Ophthalmic Anesthetics (cont’d)  tetracaine (Pontocaine)  proparacaine

66. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmic Diagnostic Drugs  atropine sulfate  Causes mydriasis and cycloplegia  Used for ophthalmic examinations  Also used for uveitis (which benefits from pupillary dilation)

67. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmic Diagnostic Drugs (cont’d)  cyclopentolate  Causes mydriasis and cycloplegia  Used for diagnostic examinations  Not used for uveitis

68. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmic Diagnostic Drugs (cont’d) Mydriatic-reversal drug  dapiprazole (RevEyes)  α-adrenergic blocker  Used to reverse the effects of mydriatic drugs and restore normal pupillary function when sustained mydriasis is not desired

69. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmic Diagnostic Drugs (cont’d) fluorescein (AK-Fluor)  Ophthalmic diagnostic dye  Used to identify corneal defects and to locate foreign bodies in the eye

70. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmic Antiallergic Drugs  Ophthalmic antihistamines  Used to treat symptoms of allergic conjunctivitis (“hay fever”)  azelastine (Optivar, 0.05%)

71. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Ophthalmic Antiallergic Drugs (cont’d) Used for seasonal allergy symptoms  Mast cell stabilizers  cromolyn sodium (Crolom)  pemirolast (Alamast), others  Decongestants  tetrahydrozoline  phenylephrine, others

72. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Lubricants and Moisturizers  Artificial tears  OTC products  Provide lubrication or moisture for dry or irritated eyes  Drops or ointment  Brand names include: Murine, Nu-Tears, Moisture Drops, Tears Plus

73. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Lubricants and Moisturizers  Restasis  Ophthalmic form of cyclosporine  Immunosuppressant drug  Used to treat “dry eyes”

74. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications  Assess the patient’s history, including medication history  Assess the patient’s baseline vital signs, visual acuity, and physical assessment of the eye and surrounding structures  Assess for contraindications to specific drugs

75. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Follow specific guidelines for administration of ophthalmic drugs  Avoid touching the eye with the tip of the dropper or container  Apply ointments as a thin layer in the conjunctival sac

76. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  When applying eyedrops, have the patient look up to the ceiling, and place the drop in the conjunctival sac  Pressure may be applied to the inner canthus for at least 1 minute to reduce systemic absorption of the drug

77. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  If more than one eye medication is ordered, clarify the correct order and intervals for administration  If the patient wears contact lenses, check to see if they should be removed during therapy with eye medications

78. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d) Provide patient/family education on correct procedures for administration of eye medications

79. Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Implications (cont’d)  Monitor for therapeutic response to therapy  Monitor for adverse effects