OCULAR PHARMACOLOGY for ASSISTANTS AND

TECHNICIANS

John W. Snead MD, MBA, FACS

Lynn Lawrence, CPOT, ABOC

ROLE of theASSISTANT AND TECHNICIAN

RecordingPatient EducationNEVER Work in Doubt!

PATIENT CASE HISTORY

General HealthMedicationsAllergies

VITAMIN SUPPLEMENTS

CLASSIFICATIONS

SolutionsSuspensionsOintments

DIAGNOSTIC AGENTS

Topical AnesthesticsMydriaticsCycloplegicsDyes/StainsFluressGonioscopic Solutions

DPA’s treat symptoms, unknown disease

Topical Anesthetics

Proparacaine Tetracaine Cocaine Alcaine

Mydriatics & Cycloplegics

Tropicamide Phenylephrine Cyclogyl Atropine Homatropine Scopalomine

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 toTouch the patient

Dyes & Stains

Fluorescein Rose Bengal Lissamine Green Fluress

Gonioscopy Solutions

Goniosol Gonioscopic Celluvisc

CLINICAL ADMINISTRATION

Patient HistoryClinical Procedures Which May

Be Influenced by MedicationsThe ERx Option

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.

THERAPEUTIC AGENTS

AntibioticsAnti-viralsDrugs that lower IOPAnti-inflammatory agentsNon-SteroidalCombinations

TPAs treat disease, known problem

GLAUCOMA MANAGEMENT

PilocarpineBeta-BlockersCarbonic Anhydrase

InhibitorsAdrenergic Agonists

OCULAR INFLAMMATION

CorticosteroidsSteroid-Antibiotic CombinationsNon-Steroidal Anti-inflammatory

Drugs (NSAIDS)Oral Analgesics

OCULAR INFECTIONS

Topical AntibioticsOral AntibioticsAnti-Viral Analgesics

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

OCULAR SURFACE

Artificial TearsLubricating OintmentsPunctal Occlusion

OCULAR ALLERGIES

Artificial TearsAntihistamine-DecongestantsCorticosteroids

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

IN-OFFICE PROCEDURES

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

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

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.

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.

ABBREVIATIONS

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

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

Examples- con’t

tab- tablet tid- three times a day top- topically ung- ointment ut dict- as directed

Prescription abbreviationsAbbreviation Meaning Abbreviatio

nMeaning

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

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.

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

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.

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.

Risk of ComplicationsThus, 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.

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

Topical Steroids

Durezol Pred Forte Prednisone Omnipred Econopred

Avoid using steroids on viral infections

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.

Topical NSAIDS

Bromday – Prolenza Nevanec

Used often for pre/post cataract surgery

CAP ColorsCap 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)

HOW TO WRITE AN Rx

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

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.

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

What else?

Make sure that it is legible!

Type in correctly

Verify

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

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****

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

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

Examples

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

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

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

THANK YOU!