1. Gtts, Ungs, Tabs Mindy J Dickinson, OD Midwest Eye Care, PC
Comprehensive Review of Drops, Ointments, and Pills that Your Docs Rx for the Eyes
Mindy J Dickinson, OD
Midwest Eye Care, PC

2. Learning Objectives Abbreviation Review
Color Coded Caps Associated with each Class of Drops
Basic Dosage and Side Effects of the Drug Classes
Topical and Oral Agents
Become Familiar with Which Products Belong to Which Class of Drugs
Antibiotics
Anti-Inflammatories
Combination Drops
Antivirals
Anti-Allergy Agents
Eye Pressure Lowering Agents (Anti-Glaucoma)
Dilation/Cycloplegic Drops
Other

3. Abbreviation Review Gtt (gutta) Ung (unguentum) Tab OD (oculus dexter)
OS (oculus sinister)
OU (oculus uterique)
PO (per os)

4. Dosing Schedules QD
BID
TID
QID
QHS
QOD
Q15 min, Q1h, Q2h,…
PRN

5. Things that must be on a Rx
Drug Name (brand name or drug name)
Recommended Dosage
Dispense Quantity
Number of Refills
Generic allowed or not
Dr’s Signature
Date
Dr’s Contact Information

6. Cap Color-Coding
Most drug classes have a special color of cap to signify what it does
Antibiotics: tan
Steroids: pink
NSAIDS: grey
Dilation drops: red
Glaucoma: turquoise, yellow, orange, purple, blue
Helpful for patient education
Helpful when taking patient history to understand what drops they are using and how often
** Not all generic drops will follow this rule of thumb

7. Antibiotic Drops Purpose: kill bugs Cap Color: tan Dosage: variable
Used for corneal ulcers, bacterial conjunctivitis, blepharitis, prevent infection in setting of recent eye surgery, corneal abrasions, foreign bodies, etc
Cap Color: tan
Dosage: variable
May be as low as BID
Don’t usually dose any lower due to increased chance of bug resistance
Most frequently is QID
May be as much as Q15 min x 4 doses (a loading dose) or Q1h

8. Before Rxing any Antibiotics…
Always confirm if patient has any known allergies !!
Common: penicillin, sulfa
**Role of technician: must have this documented in every chart that you reviewed allergies with patient

9. Antibiotics ZYMAXID, VIGAMOX (TID), MOXEZA (BID) , BESIVANCE (TID)
Newest, “strongest”, brand name only, most $$$
No ung possible
Usually save for more serious infections, corneal ulcers
CILOXAN (ciprofloxacin), OCUFLOX
Older, still broad spectrum, generic, less $
CILOXAN ung – but no generic, very $
TOBREX (tobramycin)
Less $, Ung available as well
POLYTRIM (polymixin B sulfate and trimethoprim)
Great for conjunctivitis, safe in small children, cheap
AZASITE
Azithromycin drop, very $$, mostly used for blepharitis, conjunctivitis (BID x 2 d, QD x 5 d)
GENTAK (gentamycin)
Irritating to ocular surface, often from PCP or ER docs
Ung available as well
Can have fortified antibiotic drops compounded as well
Specialty pharmacy makes extra strength sterile drops
Usually in stetting for serious infection – corneal ulcer, endophthalmitis

10. Antibiotic Ungs Benefits: Cons: Common ungs:
Adhere longer to ocular surface
Offer increased comfort since greases up ocular surface so less friction between eyelid and cornea
May be dosed less often since sits on eye longer
Cons:
Blur vision
May be more difficult to instill
** may be helpful role as the technician to offer tips to patients/parents on how to instill ointment
Common ungs:
Polysporin (polymixin B/bacitracin)
CILOXAN
TOBREX (tobramycin)
GENTAK (gentamycin)

11. Oral Antibiotics
Used for ocular/peri-ocular infections where drops not going to be effective
Need to make sure not allergic to
Pre-septal cellulitis, hordeolum (stye)
Eyelid disease (chronic blepharitis, meibomitis)
Peri-ocular abcesses
Chlamydial conjunctivitis
In fractured orbit to prevent spread of sinus germs
? Sinus infection causing peri-orbital pain

12. Oral Antibiotics Doxycycline Minocycline
Used for blepharitis/meibomitis, recurrent styes
Has an enzyme in it that cleans the glands out from the inside and reduces inflammation in the eyelid glands as well
Dosage:
20, 40 , 50, 100 mg tablets
1 tab po QD x 30 days or 1 tab po BID x 2 weeks, then QD x 2 weeks
May dose for several months at a time so may need refills
May get as a convenience pack ($$) that also includes eyelid scrubs, heated goggles
ALODOX, OCUDOX
Cannot give if pregnant or if a child (permanently discolors teeth)
Side effects:
GI upset
More likely to sunburn
Females: ? Increased risk for yeast infection, reduced efficacy of BCP
Minocycline
50 or 100 mg – good alternative if doxycycline not available

13. Oral Antibiotics Azithromycin Augmentin (amoxicillin + clavulanate)
Chlamydial conjunctivitis – 1 gram tab po x 1 dose
ZPAK – 1 day, 3 days or 5 days
Cannot give if heart beat issues
Augmentin (amoxicillin + clavulanate)
Cannot give in PCN allergy
500 mg PO BID or TID or 875 mg PO BID
Amoxicillin
Cannot give if PCN allergy
mg PO TID or PO BID
Keflex
250 mg QID or 500 mg BID
Cipro
fluoroquinolone
Bactrim DS (trimethoprim sulfamethoxazole)
Cannot give in sulfa allergy
1 tab po BID

14. Antiviral Drops Purpose: kill viruses on ocular surface
Used for Herpes Simplex dendritic keratitis, possibly viral conjunctivitis
Cap color: white
2 options:
VIROPTIC (trifluridine) –
Older, not as expensive (still >$100), more toxic/irritating to eye
Dosage: variable - Q2hr while awake, QID, sometimes tapered
ZIRGAN
Newer, $$$$, comes in tube, more gel-like, not all pharmacies carry, much less toxic/irritating to eye
Dosage: 5x per day until ulcer healed, then reduce to TID x 1 more week

15. Oral Anti-Virals Purpose: Options:
Used to reduce recurrences of Herpes Simplex (Cold Sore) flare-ups
Used upon first evidence of a Herpes Zoster (Shingles) outbreak
Options:
ZOVIRAX (acyclovir)
400 mg BID long term for HSV
800 mg 5x/day x 1 wk for active Shingles
can get made into suspension for a child
VALTREX (valacyclovir)
500 mg QD long term for HSV
1000 mg TID x 1 wk for active Shingles
FAMVIR
500 mg TID x 1 week for active Shingles

16. Anti-Inflammatory Drops - Steroids
Purpose: reduce inflammation
Used for conjunctival/corneal/anterior chamber inflammation – perhaps related to allergies, chemical exposure, recent infection, trauma, contact lenses or surgery; iritis/uveitis; as both prevention and treatment of post-operative swelling in front of eye and/or in macula; reduce chance of rejecting transplanted corneal tissue
Cap Color: pink
Dosage: variable
QD all the way up to Q1hr
Often start more aggressive and then slowly taper

17. Steroids Facts Most are suspensions – separate in bottle
MUST SHAKE before each use
particularly generics
Cloudy in color, “milk”
Usually important to taper, not stop suddenly
Potential Side Effects:
Increase in eye pressure
Early cataract formation
Increased risk of infection
Bad taste in back of mouth after instilling

18. Steroid Eye Drops (+) Stongest Weakest DUREZOL
Emulsion – only one you don’t have to shake
More expensive, but more potent
PRED FORTE, OMNIPRED (prednisolone acetate 1%)
Suspension – MUST SHAKE
Brand name thought to penetrate into eye better
LOTEMAX
Suspension – must shake
Not as potent, but less potential side effects
Can get in gel or in ung ($)
Often used more in more chronic situation
Preventing an iritis flare up, anti-rejection, dry eye syndrome
ALREX, FLAREX, VEXOL, FML (fluometholone 0.1%)
Weakest, but least side effects
Often in less inflamed, more chronic conditions
Indicated for allergic conjunctivitis, dry eye syndrome
Weakest

19. Oral Steroids
Used in severe allergic and inflammatory conditions where drops not effective enough
Immune-mediated corneal melts/ulcers, Scleritis/Severe Episcleritis, Severe Uveitis (both in front or back of eye), Inflammatory Orbital Pseudotumor , Giant Cell Arteritis (optic nerve swelling)
Optometrists cannot Rx oral steroids in all states
Side Effects a big deal
Increase blood sugars (concern in diabetics)
Change in mood, sleeping habits, appetite
Weight gain, acne, outbreaks of other problems (cold sores, shingles, genital herpes)
Prednisone: 2, 5, 10, 20 mg tab
MEDROL DOSEPAK: ( mg tabs, directs you to take 6 the first day and reduce to 1 per day over 6 days) – “take as directed”

20. Combination Antibiotic/Steroid Drops
Purpose: offer both anti-infective and anti-inflammatory properties in single drop
Used for settings when need antibiotic protection such as missing skin on eye, but need to calm down swelling,
Corneal abrasion, chemical burns, foreign body, traumatic iritis, some conjunctivitis
Not supposed to be used when active infection is not yet controlled as steroid will reduce ability of immune system to fight it off and can make it worse
Corneal ulcers !
Cap Color: pink or white
Dosage:
Usually QID or perhaps up to Q2hr

21. Combinations of Antibiotic/Steroid
TOBRADEX ST (tobradex) (tobramycin/dexamethazone)
Drops or ung
Need to be careful with name – tobrex vs tobradex – big deal if you rx it wrong and gave a steroid to someone that should not have it!!
More $
MAXITROL (neomycin/polymixin B/dexamethasone)
Much less expensive
Higher chance of irritation/allergy to neomycin

22. Non-Steroidal Anti-Inflammatory Drugs
NSAIDs
Purpose: to reduce inflammation of ocular tissue, reduce pain,
Used for surface inflammation such as episcleritis, pain associated with corneal abrasions/recurrent corneal erosions
Used for the prevention/treatment of pain and inflammation associated with ocular surgery (cataract, refractive surgery)
Cap Color: gray
Dosage:
Variable – QD to QID

23. Topical NSAIDs ILEVRO, PROLENSA, BROMDAY NEVANAC XIBROM ACUVAIL
Newest, $$, QD dosage, great penetration into back of eye
Usually dosed day before cataract surgery, day of surgery, and 2 weeks after
NEVANAC
TID dosage, also great penetration into back of eye
XIBROM
BID dosage
ACUVAIL
PF vials, BID, meant for post-surgery care
ACULAR LS (Ketoralac)
QID, Generic, cheap, stings like crazy
Flurbiprofen

24. Oral NSAIDs OTC: Rx only: ADVIL, MOTRIN (ibuprofen)
Pain associated with corneal abrasions/foreign bodies, etc
Reduce inflammation associated with conjunctivitis
Reduce inflammation associated with episcleritis
Dosage: 600 mg po TID with food
In Rx form can get 800 mg tablets, otherwise 200 mg tablets OTC
ALEVE (naproxen)
Aspirin
81 mg (baby) – reduce risk of stoke, heart attack
325 mg
TYLENOL (acetaminophen)
Does not thin blood
Pain associated with blunt trauma to eye that has a hyphema (since don’t want them to rebleed)
Patients who cannot take ibuprofen
Rx only:
Indomethacin
Used for more severe inflammation – severe epicleritis/scleritis/orbital pseudotumor

25. Anti-Allergy Drops
Purpose: to treat itchy, watery, puffy, red eyes associated with allergic conjunctivitis
Work either as anti-histamine or as a mast cell stabilizer
Cap color: white
Dosage:
QD or BID/PRN
Some Rx only, some OTC
Beneficial over OTC Visine-A, Naphcon A, etc products
Side Effects: sting, bad taste in back of mouth

26. Anti-Allergy Eye Drops
PATADAY
QD, more $, very effective, little to no sting
PATANOL
BID
BEPREVE
OPTIVAR (azelastine)
Only rx with generic option, BID
ELESTAT
LASTACAFT
QD, stings
ZADITOR/ALAWAY (ketotifen)
OTC, BID, many additional names out there, stings, not always as effective, but cheaper than most
ALOCRIL, ALOMIDE, cromolyn
Less often used, have to be dosed QID

27. Glaucoma Drops
Purpose: to lower intraocular pressure and thereby reduce the risk of further nerve damage by glaucoma
Work by either decreasing aqueous production and/or increasing aqueous outflow
Cap color: depends on mechanism of action
Dosage: depends on which class of drug (QD, BID, TID, QID)
Side Effects: depends on which class of drugs

28. Glaucoma Drops Prostaglandin Analogs Increase outflow of aqueous humor
Brands:
XALATAN (latanoprost)
TRAVATAN Z
LUMIGAN
ZIOPTAN (new and preservative free, $$$)
RESCULA (only one with dosing BID)
Cap Color: turquoise
Dosage: 1 gtt QHS
“First line” therapy, % IOP reduction
Side effects:
darkening of iris and skin around eye, thickening/lengthening of lashes, red eye, inflammation in eye

29. Glaucoma Drops ßeta- Blockers Decrease production of aqueous humor
Brands
Timolol 0.25% or 0.5%
BETIMOL, ISTALOL, TIMOPTIC XE (gel)
TIMOPTIC in OCUDOSE (preservative free vials)
BETAGAN, BETOPTIC
Cap Color: yellow
Dosage: 1 gtt QAM or 1 gtt BID
25-30% IOP reduction
Can be 1st line
$, Cheap, generic available
Side effects: difficulty breathing, decreased heart rate
don’t give if history of COPD, emphysema, asthma, bradycardia

30. Glaucoma Drops Alpha Adrenergics Decrease production of aqueous humor
Brands:
ALPHAGAN P (0.1%)
Brimonidine (generic – 0.15%, 0.2%)
Cap Color: Purple, if brand name also has a green bottle
Dosage: 1 gtt BID or TID
15-20% IOP reduction
Great additional med, also use post-operatively for IOP spikes
Side effects: red irritated eyes, itching, follicular conjunctivitis
Particularly more likely in generics and at higher concentration

31. Glaucoma Drops Carbonic Anhydrase Inhibitors (CAIs)
Decreases production of aqueous
Brands:
AZOPT
TRUSOPT
Cap Color: Orange
Dosage: 1 gtt BID or TID
15-20% IOP reduction
2nd or 3rd med add – not usually mono therapy
Side Effects: red irritated eyes, burn like crazy, unpleasant taste
Avoid if serious kidney problems, allergy to sulfa

32. Glaucoma Drops Combination Drops 2 medicines in 1 bottle
More effective on IOP without much more work on patients behalf, increases compliance
Brands:
COSOPT (timolol and trusopt), COSOPT PF (preservative-free)
Generic available still $, stings
COMBIGAN (timolol and alphagan)
Newer, no generic, most find to be comfortable to use
Cap Color: dark blue
Dosage: 1 gtt BID
Side Effects: due to timolol cannot give if breathing problems (COPD, asthma, bradycardia)
SIMBRINZA (brinzolamide and brimonidine)
Newest, no generic, only one without timolol
Cap Color: white
Dosage: 1 gtt BID or TID

33. Glaucoma Drops Sympathomimetics
Increase outflow by pulling on drain to help it open
Brands:
Pilocarpine (1, 2, 4%)
Carbachol
Cap Color: Green
Dosage: 1 gtt BID to QID
Very rarely use any more now that have more options
Side Effects: miosis (constrict) of pupil, peripheral retina pathology (tear, RD), accommodative spasm so eyes shift near-sighted, headache

34. Oral Meds to Lower Eye Pressure
Used when IOP rises suddenly to a very high level (50+)
Acute glaucoma – angle closure
Severe inflammation – sometimes see in Shingles
Recent Trauma – blood blocking drain
Not meant for long term maintenance
Carbonic Anhydrase Inhibitors
Decreases aqueous (and CSF) production
Diamox
250 mg 1 tab PO QID or 500 mg Sequel 1 tab PO BID
Neptazine
25 mg 1 tab PO QD or BID or TID
Optometerists in some states may not be able to Rx this
Side Effects: tingling of skin, metallic taste, cannot give if kidney disease

35. Dilation/Cycloplegic Drops
Purpose:
To dilate pupil to allow better viewing of the back of the eye
To relax ciliary muscle and thereby relax accommodation – allowing full hyperopic refractive error to be found on refraction (use for examining children)
To treat amblyopia (lazy eye)
To temporarily paralyze the iris and ciliary muscle
to reduce pain in setting of trauma/inflammation
(Corneal abrasion/foreign body, chemical burn, welding burn, iritis, recent surgery, etc)
to reduce chances of inflamed iris from sticking to the lens behind it and forming synechiae

36. Dilation/Cycloplegic Drops
Cap Color: red
Dosage: variable
Depends of duration of action of the drug
Side Effects:
Stinging upon instillation, photophobia, blurred near vision

37. Dilation/Cycloplegic Drops
MYDRIACYL (tropicamide)
0.5% or 1 %
Best dilator, some limited effect on accommodation (approx 4 hrs)
Used in office, not really Rx’d
MYDFRIN, NEO-SYNEPHRINE (phenylephrine)
2.5% or 10%
Aides in dilation, not really any effect on accommodation
Use with tropicamide, not by itself
Also constricts blood vessels on surface of eye – can help determine how deep inflammation is in setting of episcleritis vs. sclertitis
10% rarely used, can increase blood pressure, need to punctally occlude, used to break synechiae in setting of bad uveitis

38. Dilation/Cycloplegic Drops
CYCLOGYL (cyclopentolate)
Most often used for pediatric eye exams to relax accommodation
Get more accurate refraction – especially if concern for eye turn
0.5% (< 1 year old); 1% (> 1 year old) – 1 gtt OU, repeat 5 min later
Takes minutes to fully relax accommodation and lasts approx hrs
Can also be used post trauma/surgical procedure – 1 gtt in office or up to QID
Scopolamine (0.25%)
1 gtt TID
Used for paralyzing iris/ciliary muscle in trauma/inflammation
Homatropine (5%)
1 gtt BID
Lasts for 24 hours +
Atropine (1%)
1 gtt QD
Used for treatment of amblyopia
Used for paralyzing iris/ciliary muscle in trauma/inflammation/or post surgery
Dilation/loss of accommodation last approx 1 week!

39. Other
RESTASIS
Used for treating inflammatory forms of dry eye syndrome
Goal is to increase patient’ tear production
Not a quick fix – can take 3-6 month to get effects
Comes in “single use” preservative-free vials
Dosage: 1 gtt BID OU
Write Rx as “30 vials = 1 box = 1 month” with refills
$, rebates often available, cheaper if can use vial more than once
Side Effects: redness, burning/stinging upon instillation
** role of technician in patient education – how to use vials, that it takes a while to work, that it will likely sting, try artificial tears first, stick with it for at least 3 months

40. Other MURO (Sodium Chloride) Artificial Lubricants OTC
2% or 5% drops – 1 gtt QD up to QID
5% ung – apply QHS
Used to dehydrate cornea in setting of corneal edema
Fuch’s dystrophy
Post-Operatively
Ung also used to help reduce chances of recurrent corneal erosions
Drops sting, ung does not
Artificial Lubricants
gtts, gels, ungs – OTC, not going to cover here

41. FUN at “The Heart”
Dosage: as much as possible PRN
Refills: unlimited
No expiration
Mindy J Dickinson, OD