Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Chapter 57 Ophthalmic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Structures of the Eye Eyebrows, eyelids, eyelashes Palpebral fissure Sclera Uvea Choroid Iris Ciliary body Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Structures of the Eye (cont’d) Conjunctiva Pupil Medial canthus Lacrimal caruncle Lacrimal glands Lateral canthus Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Eye Muscles Each eye is held in place and moved by six muscles Rectus (four total) Oblique (two total) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Interior of the Eyeball Anterior chamber Posterior chamber Canal of Schlemm Aqueous humor Vitreous humor Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Interior of the Eyeball (cont’d) Retina Rods Cones Optic nerve Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Lens Accommodation Cataracts Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Drugs That Affect the Eye Mydriatics (apraclonidine) Dilate the pupil Miotics (acetylcholine, pilocarpine) Constrict the pupil Cycloplegics (atropine, cyclopentolate) Paralyze the ciliary body Have mydriatic properties Cycloplegia: paralysis of accommodation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Ocular Drugs Antiglaucoma drugs Antimicrobial and antiinflammatory drugs Topical anesthetics Diagnostic drugs Antiallergic drugs Lubricants and moisturizers Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Types of Glaucoma Angle-closure glaucoma Open-angle glaucoma Also characterized by underlying cause Primary Secondary Congenital Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question When administering eyedrops for glaucoma, the nurse understands the desired drug effect causes: increased intraocular pressure. decreased intraocular pressure. reduced cycloplegia. decreased inflammation. Correct answer: B Rationale: The desired effect of ophthalmic drops for glaucoma is decreased intraocular pressure. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Drugs Used to Reduce IOP Direct-acting cholinergics Indirect-acting cholinergics Adrenergics Antiadrenergics Carbonic anhydrase inhibitors Osmotic diuretics Prostaglandin agonists Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Cholinergic Drugs Mimic the PSNS neurotransmitter ACh Also called miotics, cholinergics Direct-acting and indirect-acting drugs Cause pupillary constriction (miosis), which leads to reduced IOP caused by increased outflow of aqueous humor Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Cholinergic Drugs (cont’d) Direct-acting drugs acetylcholine (Miochol-E) carbachol (Carboptic) pilocarpine (Pilocar) (also ocular insert form) Indirect-acting drugs echothiophate (Phospholine Iodide) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Cholinergic Drugs: Indications Open-angle glaucoma Angle-closure glaucoma Ocular surgery Convergent strabismus (“cross-eye”) Ophthalmologic exams Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Cholinergic Drugs: 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Sympathomimetics Mimic the sympathetic neurotransmitters epinephrine and norepinephrine Stimulate the dilator muscle to contract Result is increased pupil size (mydriasis) Enhance aqueous humor outflow through the canal of Schlemm IOP is reduced Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Sympathomimetics (cont’d) apraclonidine (Iopidine) brimonidine (Alphagan P) epinephryl (Epinal) dipivefrin (Propine) Prodrug of epinephrine When applied topically Hydrolyzed to epinephrine Penetrates tissues better Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Sympathomimetics: Indications Chronic, open-angle glaucoma (to reduce IOP) Reduction of perioperative IOP Reduction of ocular hypertension Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Sympathomimetics: Adverse Effects Primarily limited to ocular effects Burning Eye pain Lacrimation Rare systemic effects Hypertension Tachycardia Extrasystoles Headache Faintness Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Beta-Adrenergic Blockers Selective beta1 blocker betaxolol (Betoptic) levobetaxolol (Betaxon) Nonselective beta1 and beta2 blockers carteolol (Ocupress) levobunolol (Betagan) metipranolol (OptiPranolol) timolol (Timoptic) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Beta-Adrenergic Blockers (cont’d) Reduce IOP by Reducing aqueous humor formation Increasing aqueous humor outflow Do not affect pupil size, accommodation, or night vision Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Beta-Adrenergic Blockers: Indications Reduction of elevated IOP Chronic open-angle glaucoma Ocular hypertension Treatment of some forms of angle-closure glaucoma Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Beta-Adrenergic Blockers: Adverse Effects Primarily ocular effects Transient burning and discomfort Blurred vision Pain Photophobia Others Limited systemic effects Headache Dizziness Cardiac irregularities Bronchospasm Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Beta-Adrenergic Blockers: Interactions Administration of systemic beta blockers with high doses of ophthalmic beta blockers may result in additive effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Carbonic Anhydrase Inhibitors brinzolamide (Azopt) dorzolamide (Trusopt) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Carbonic Anhydrase Inhibitors (cont’d) Inhibit the enzyme carbonic anhydrase, which reduces aqueous humor formation in the eye Result is decreased IOP Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Carbonic Anhydrase Inhibitors: Indications Treatment of glaucoma Open angle Angle closure Preoperatively to reduce intraocular pressure Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Osmotic Diuretics (cont’d) Administered IV, PO, or topically Glycerin usually tried first Can cause hyperglycemia Mannitol used if glycerin is unsuccessful Isosorbide and urea may also be used Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Prostaglandin Agonists Newest class of drugs for glaucoma Three drugs latanoprost (Xalatan) travoprost (Travatan-Z) bimatoprost (Lumigan) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Prostaglandin Agonists (cont’d) Reduce IOP by increasing the outflow of aqueous fluid Increase uveoscleral outflow of fluid Used in the treatment of glaucoma Most drugs allow for single daily dosing because of effects lasting for 20 to 24 hours Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Prostaglandin Agonists (cont’d) Effects on eye color In some persons with hazel, green, or blue/brown eyes, eye color will change permanently to brown Color change occurs even if medication stopped Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question Which antiglaucoma drug works by increasing the outflow of aqueous humor between the uvea and sclera as well as via the usual exit through the trabecular meshwork? Prostaglandins Osmotic diuretics Carbonic anhydrase inhibitors Ophthalmic beta blockers Correct answer: A Rationale: Prostaglandins reduce intraocular pressure by increasing the outflow of aqueous humor between the uvea and sclera as well as via the usual exit through the trabecular meshwork. Osmotic diuretics reduce ocular hypertension by causing the blood to become hypertonic in relation to both intraocular and spinal fluids. This creates an osmotic gradient that draws water from the aqueous and vitreous humors into the bloodstream, which causes a reduction in the volume of intraocular fluid; the result is a decrease in intraocular pressure. Carbonic anhydrase inhibitors work by inhibiting the enzyme carbonic anhydrase, which results in decreased intraocular pressure by reduction of aqueous humor formation. The ophthalmic beta blockers reduce both elevated and normal intraocular pressure. They reduce intraocular pressure by reducing aqueous humor formation. In addition, timolol may produce a minimal increase in aqueous outflow. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Ocular Antimicrobial Drugs Topical and systemic administration Antibacterial Antiviral Antifungal Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antibacterial Drugs Aminoglycosides Antibacterial gentamicin (Garamycin) , tobramycin (Tobrex) Copyright © 2014 by Mosby, an imprint 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 Treatment of neonatal conjunctivitis caused by Chlamydia trachomatis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antibacterial Drugs (cont’d) Polypeptides Antibacterial bacitracin (AK-Tracin), polymyxin B Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antibacterial Drugs (cont’d) Quinolones ciprofloxacin (Ciloxan) gatifloxacin (Zymar) moxifloxacin (Vigamox) levofloxacin (Quixin) ofloxacin (Ocuflox) Sulfonamides sulfacetamide (Bleph-10) sulfisoxazole (Gantrisin) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antifungal Drugs natamycin (Natacyn) Used topically to treat Blepharitis Conjunctivitis Keratitis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antiviral Drugs ganciclovir (Vitrasert) Treatment of ocular cytomegalovirus (CMV) Administered by surgical implant in the eye fomivirsen (Vitravene) Treatment of ocular CMV Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antiviral Drugs (cont’d) trifluridine (Viroptic,1% ophthalmic drops) Used for ocular infections (keratitis and keratoconjunctivitis) caused by types 1 and 2 of the herpes simplex virus Applied topically as drops Significant adverse effects include secondary glaucoma, corneal punctate defects, uveitis, and stromal edema (edema in the tough, fibrous, transparent portion of the cornea known as the stroma) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antiinflammatory Drugs NSAIDs ketorolac (Acular) flurbiprofen (Ocufen) bromfenac (Xibrom) diclofenac (Voltaren) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antiinflammatory Drugs Corticosteroids dexamethasone (Decadron, AK-Dex) fluocinonide (Retisert) fluorometholone (Fluor-Op) loteprednol (Lotemax) medrysone (HMS) prednisolone (Pred Forte) rimexolone (Vexol) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question Which statement about use of corticosteroids for ocular inflammation does the nurse identify as being true? They are used during the acute phase of the injury process to prevent fibrosis and scarring, which result in visual impairment. Corticosteroids produce a lesser immunosuppressant effect than the NSAIDs. They are used for the treatment of minor abrasions and wounds of the eye. Use of corticosteroids for ocular inflammation results in discoloration of the iris. Correct answer: A Rationale: Corticosteroids are used during the acute phase of the injury process to prevent fibrosis and scarring, which result in visual impairment. Corticosteroids produce a greater immunosuppressant effect than NSAIDs, and they are not used for the treatment of minor abrasions and wounds of the eye because of the greater risk for infection. They do not change the color of the iris. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Ocular Antiinflammatory 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ocular Antiinflammatory Drugs (cont’d) Used prophylactically after surgery to prevent inflammation and scarring NSAIDs used for symptomatic treatment of seasonal allergic conjunctivitis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Ophthalmic Anesthetics tetracaine proparacaine (Alcaine) 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Diagnostic Drugs Cycloplegic mydratics atropine sulfate (Isopto Atropine) Results in Mydriasis Cycloplegia Used for Ophthalmic examinations Uveitis (which benefits from pupillary dilation) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Diagnostic Drugs (cont’d) Cycloplegic mydratics (cont’d) cyclopentolate (Cyclogyl) Causes mydriasis and cycloplegia Used for diagnostic examinations Not used for uveitis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Diagnostic Drugs (cont’d) Other cycloplegic mydriatics scopolamine (Isopto Hyoscine) homatropine (Isopto Homatropine) tropicamide (Mydriacyl) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Diagnostic Drugs (cont’d) Ophthalmic dye fluorescein (AK-Fluor) Diagnostic dye used to identify corneal defects and to locate foreign objects in the eye Used in fitting hard contact lenses Various defects are highlighted in either bright green or yellow-orange, and foreign objects have a green halo around them Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Antiallergic Drugs Ophthalmic antihistamines Used to treat symptoms of allergic conjunctivitis (“hay fever”) azelastine (Optivar) olopatadine (Patanol) emedastine (Emadine) ketotifen (Zaditor) epinastine (Elestat) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Antiallergic Drugs (cont’d) Used for seasonal allergy symptoms Mast cell stabilizers cromolyn sodium (Crolom) pemirolast (Alamast) nedocromil (Alocril) lodoxamide (Alomide) Decongestants phenylephrine (Neo-Synephrine) oxymetazoline (Visine LR) naphazoline (Clear Eyes) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient receiving tetrahydrozoline asks how the drug works. The best response by the nurse will include that the drug works by pulling fluid from the eye tissue to the blood stream. decreasing the amount of fluid produced by the eye. promoting vasoconstriction of blood vessels in and around the eye. causing the pupil to constrict. Correct answer: C Rationale: Tetrahydrozoline is an ocular decongestant. It works by promoting vasoconstriction of blood vessels in and around the eye. This reduces the edema associated with allergic and inflammatory processes. It is specifically indicated to control redness, burning, and other minor irritations. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Ophthalmic Lubricants and Moisturizers Artificial tears Over-the-counter products Provide lubrication or moisture for dry or irritated eyes Available in drops or ointment Brand names include: Murine, Nu-Tears, Moisture Drops, Tears Plus, Akwa Tears Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Lubricants and Moisturizers (cont’d) Restasis Ophthalmic form of cyclosporine Immunosuppressant drug Used to treat keratoconjunctivitis sicca (dry eyes) It can be used together with artificial tears, if the drugs are given 15 minutes apart Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Nursing Implications Assess the patient’s history, including medication history Assess patient’s baseline vital signs and visual acuity, and perform a physical assessment of the eye and surrounding structures Assess for contraindications to specific drugs Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question When administering eyedrops to a patient, the nurse places the drop directly onto the cornea. in the inner canthus. into the lower conjunctival sac. onto the sclera. Correct answer: C Rationale: Eyedrops should be placed into the lower conjunctival sac. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint 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 Copyright © 2014 by Mosby, an imprint 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Provide patient/family education on correct procedures for administration of eye medications Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Monitor for adverse effects Monitor for therapeutic response to therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study A 60-year-old male with a history of benign prostatic hypertrophy and hypertension is seen in the Emergency Department because he was trimming his shrubs and got something in his right eye. He complains of a pain rating of 8 on a scale of 1 to 10 in the right eye. Which medication does the nurse anticipate administering via eyedrop to help control the patient’s pain? tetracaine atropine morphine lidocaine Correct answer: A Rationale: Tetracaine is a local anesthetic of the ester type. It is applied as an eyedrop to numb the eye for various ophthalmic procedures. Tetracaine begins to work in about 25 seconds and lasts for about 15 to 20 minutes. Additional drops are applied as needed. It is currently available only in solution form. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) After administering an ophthalmic anesthetic drug, which adverse effects does the nurse anticipate as possibly developing in the patient? (Select all that apply.) Stinging Burning Redness Lacrimation Blurred vision Correct answer: A, B, C, D, E Rationale: Adverse effects are rare with ophthalmic anesthetic drugs and are limited to local effects such as stinging, burning, redness, lacrimation, and blurred vision. Systemic toxicity is rare but can theoretically lead to central nervous system (CNS) stimulation and/or CNS or cardiovascular depression.   Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) The ophthamologist tells the patient that she is going to place a dye onto the patient’s eye to help identify the location of the foreign object. Which drug does the nurse anticipate the ophthamologist will use? olopatadine (Patanol) cromolyn sodium (Crolom) tetrahydrozoline fluorescein (AK-Fluor) Correct answer: D Rationale: Fluorescein (AK-Fluor) is an ophthalmic diagnostic dye used to identify corneal defects and to locate foreign objects in the eye. Olopatadine (Patanol) is an ocular antihistamine used to treat symptoms of allergic conjunctivitis (hay fever). Cromolyn sodium (Crolom) is an antiallergic drug that inhibits the release of inflammation-producing mediators from sensitized inflammatory cells called mast cells. Tetrahydrozoline is an ocular decongestant. It works by promoting vasoconstriction of blood vessels in and around the eye.   Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) A foreign particle is removed from the patient’s eye. He tells the nurse that he previously forgot to mention that he takes eyedrops for glaucoma. He can’t remember the name of the drug, but he knows the eyedrop bottle has a purple lid. The nurse identifies a purple lid as most likely containing which type of antiglaucoma drug? Direct-acting cholinergic Sympathomimetics Prostaglandin agonist Carbonic anhydrase inhibitor Correct answer: B Rationale: Sympathomimetics are usually in a bottle that has a purple lid. Direct-acting cholinergics are usually in a bottle that has a green lid. Prostaglandin agonists are usually in a bottle which has a teal or clear lid, and carbonic anhydrase inhibitors are usually in a bottle with an orange lid.   Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.