Copyright © 2017, Elsevier Inc. All rights reserved.

Structures of the Eye (Cont.)
Conjunctiva Pupil Medial canthus Lacrimal caruncle Lacrimal glands Lateral canthus Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Extrinsic muscles of the right eye, lateral view. The medial rectus muscle is hidden from view in this figure but is directly across from the lateral rectus muscle. Copyright © 2017, Elsevier Inc. All rights reserved.

Interior of the Eyeball
Anterior chamber Posterior chamber Canal of Schlemm Aqueous humor Vitreous humor Copyright © 2017, Elsevier Inc. All rights reserved.

Interior of the Eyeball (Cont.)
Retina Rods Cones Optic nerve Copyright © 2017, Elsevier Inc. All rights reserved.

Different Nervous Systems Control Pupil Size
Copyright © 2017, Elsevier Inc. All rights reserved.

Function of Rods and Cones in Relation to Color Vision

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 © 2017, Elsevier Inc. All rights reserved.

Drug Classes and Their Effects on Pupil Size

Ocular Drugs Antiglaucoma drugs Antimicrobial Antiinflammatory drugs Topical anesthetics Diagnostic drugs Antiallergic drugs Lubricants and moisturizers Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

How Increased Aqueous Humor Can Result in Impaired Vision

Audience Response System Question
When administering eyedrops for glaucoma, the nurse understands the desired drug effect causes: increased IOP. decreased IOP. reduced cycloplegia. decreased inflammation. Correct answer: B Rationale: The desired effect of ophthalmic drops for glaucoma is decreased IOP. Copyright © 2017, Elsevier Inc. All rights reserved.

Drugs Used to Reduce Intraocular Pressure
Direct-acting cholinergics Indirect-acting cholinergics Adrenergics: sympathomimetics Anti-adrenergics: beta blockers Carbonic anhydrase inhibitors Osmotic diuretics Prostaglandin agonists Copyright © 2017, Elsevier Inc. All rights reserved.

Cholinergic Drugs Mimic the parasympathetic nervous system neurotransmitter acetylcholine 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 © 2017, Elsevier Inc. All rights reserved.

Cholinergic Response of Miosis to Parasympathomimetic Drugs

Therapeutic Effects of Direct- and Indirect-acting Miotics on Glaucoma

Cholinergic Drugs (Cont.)
Direct-acting cholinergic drugs acetylcholine (Miochol-E) carbachol (Carboptic) pilocarpine (Pilocar) (also ocular insert form) Indirect-acting cholinergic drugs echothiophate (Phospholine Iodide) Copyright © 2017, Elsevier Inc. All rights reserved.

Cholinergic Drugs: Indications
Open-angle glaucoma Angle-closure glaucoma Ocular surgery Convergent strabismus (“cross-eye”) Ophthalmologic exams Copyright © 2017, Elsevier Inc. All rights reserved.

Cholinergic Drugs: Adverse Effects
Most limited to local effects If sufficient amounts enter the bloodstream, systemic effect may occur (most likely with indirect-acting agents): Hypotension, bradycardia, or tachycardia Headache, nausea, vomiting, diarrhea, abdominal cramps, asthma attacks Others Copyright © 2017, Elsevier Inc. All rights reserved.

Cholinergic Drugs: Direct-Acting Miotics
Acetylcholine (Miochol-E) is a direct-acting cholinergic drug. Used to produce miosis during ophthalmic surgery Copyright © 2017, Elsevier Inc. All rights reserved.

Cholinergic Drugs: Direct-Acting Miotics (Cont.)
Pilocarpine (Pilocar) Used as a miotic in the treatment of glaucoma Pilocarpine ocular insert system (Ocusert Pilo-20): applied once weekly by the patient Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Ocular Effects of Alpha (α) and Beta (β) Stimulation

Sympathomimetics (Cont.)
Apraclonidine (Iopidine) Dipivefrin (Propine) Prodrug of epinephrine When applied topically: Hydrolyzed to epinephrine Penetrates tissues better Copyright © 2017, Elsevier Inc. All rights reserved.

Sympathomimetics: Indications
Chronic, open-angle glaucoma (to reduce IOP) Reduction of perioperative IOP Reduction of ocular hypertension Copyright © 2017, Elsevier Inc. All rights reserved.

Sympathomimetics: Adverse Effects
Primarily limited to ocular effects Burning Eye pain Lacrimation Rare systemic effects Hypertension Tachycardia Extrasystoles Headache Faintness Copyright © 2017, Elsevier Inc. All rights reserved.

Sympathomimetics: Apraclonidine (Iopidine)
Structurally and pharmacologically related to the alpha2 stimulant clonidine Reduces IOP 23% to 39% by stimulating alpha2 and beta2 receptors Prevents ocular vasoconstriction, which reduces ocular blood pressure as well as aqueous humor formation Used to inhibit perioperative IOP increases rather than treat glaucoma Copyright © 2017, Elsevier Inc. All rights reserved.

Sympathomimetics: Apraclonidine (Iopidine) (Cont.)
Brimonidine (Alphagan P) is a similar drug but is used primarily for glaucoma. Burning Eye pain Lacrimation Rare systemic effects Hypertension Tachycardia Extrasystoles Headache Faintness Copyright © 2017, Elsevier Inc. All rights reserved.

Beta-Adrenergic Blockers
Betaxolol (Betoptic) Carteolol (Ocupress) Levobunolol (Betagan) Levobetaxolol (Betaxon) Metipranolol (OptiPranolol) Timolol (Timoptic) Copyright © 2017, Elsevier Inc. All rights reserved.

Beta-Adrenergic Blockers (Cont.)
Reduce IOP by: Reducing aqueous humor formation Increasing aqueous humor outflow Do not affect pupil size, accommodation, or night vision Copyright © 2017, Elsevier Inc. All rights reserved.

Beta-Adrenergic Blockers: Indications
Reduction of elevated IOP Chronic open-angle glaucoma Ocular hypertension Treatment of some forms of angle-closure glaucoma Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Beta-Adrenergic Blockers: Interactions
Administration of systemic beta blockers with high doses of ophthalmic beta blockers may result in additive effects. Copyright © 2017, Elsevier Inc. All rights reserved.

Beta-Adrenergic Blockers: Timolol (Timoptic)
May increase the outflow of aqueous humor as well as decrease its formation Act at both beta1 and beta2 receptors and are indicated for the treatment of open-angle glaucoma and ocular hypertension Copyright © 2017, Elsevier Inc. All rights reserved.

Carbonic Anhydrase Inhibitors
Brinzolamide (Azopt) Dorzolamide (Trusopt) Copyright © 2017, Elsevier Inc. All rights reserved.

Carbonic Anhydrase Inhibitors (Cont.)
Inhibit the enzyme carbonic anhydrase, which reduces aqueous humor formation in the eye Result is decreased IOP Copyright © 2017, Elsevier Inc. All rights reserved.

Mechanism and Ocular Effects of Osmotic Diuretics

Carbonic Anhydrase Inhibitors: Indications
Treatment of glaucoma Open angle Angle closure Preoperatively to reduce IOP Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

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 and thus reduced IOP Copyright © 2017, Elsevier Inc. All rights reserved.

Osmotic Diuretics (Cont.)
Administered intravenously, orally, or topically Glycerin usually tried first Can cause hyperglycemia Mannitol used if glycerin is unsuccessful Isosorbide and urea may also be used Copyright © 2017, Elsevier Inc. All rights reserved.

Osmotic Diuretics (Cont.)
Indications Acute glaucoma episodes Before and after ocular surgery to reduce IOP Adverse effects Nausea, vomiting, headache May cause fluid and electrolyte imbalance Copyright © 2017, Elsevier Inc. All rights reserved.

Prostaglandin Agonists
Newest class of drugs for glaucoma Three drugs latanoprost (Xalatan) travoprost (Travatan-Z) bimatoprost (Lumigan) Copyright © 2017, Elsevier Inc. All rights reserved.

Prostaglandin Agonists (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

Prostaglandin Agonists (Cont.)
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 the medication is stopped. Copyright © 2017, Elsevier Inc. All rights reserved.

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 IOP 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 IOP. Carbonic anhydrase inhibitors work by inhibiting the enzyme carbonic anhydrase, which results in decreased IOP by reduction of aqueous humor formation. The ophthalmic beta blockers reduce both elevated and normal IOP. They reduce IOP by reducing aqueous humor formation. In addition, timolol may produce a minimal increase in aqueous outflow. Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antimicrobial Drugs
Topical and systemic administration Antibacterial Antiviral Antifungal Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antimicrobial Drugs (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

Ocular Antibacterial Drugs
Aminoglycosides Antibacterial Gentamicin (Garamycin), tobramycin (Tobrex) Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antibacterial Drugs (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

Quinolones ciprofloxacin (Ciloxan) gatifloxacin (Zymar) moxifloxacin (Vigamox) levofloxacin (Quixin) ofloxacin (Ocuflox) Sulfonamides sulfacetamide (Bleph-10) sulfisoxazole (Gantrisin) Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antifungal Drugs
Natamycin (Natacyn) Used topically to treat: Blepharitis Conjunctivitis Keratitis Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antiviral Drugs
Trifluridine (Viroptic) Ganciclovir (Vitrasert) Fomivirsen (Vitravene) Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antiviral Drugs (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

Ocular Antiinflammatory Drugs
Nonsteroidal antiinflammatory drugs (NSAIDs) ketorolac (Acular) flurbiprofen (Ocufen) bromfenac (Xibrom) diclofenac (Voltaren) Copyright © 2017, Elsevier Inc. All rights reserved.

Ocular Antiinflammatory Drugs
Corticosteroids dexamethasone (Decadron) fluocinonide (Retisert) fluorometholone (Fluor-Op, others) loteprednol (Lotemax, others) medrysone (HMS) prednisolone (Pred Forte, others) rimexolone (Vexol) Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Ocular Antiinflammatory Drugs (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

Ocular Antiinflammatory Drugs (Cont.)
Used prophylactically after surgery to prevent inflammation and scarring NSAIDs used for symptomatic treatment of seasonal allergic conjunctivitis Copyright © 2017, Elsevier Inc. All rights reserved.

Topical Ophthalmic Anesthetics
Tetracaine Proparacaine 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 © 2017, Elsevier Inc. All rights reserved.

Ophthalmic Diagnostic Drugs
Cycloplegic mydriatics (Cont.) Atropine sulfate (Isopto Atropine) Results in: Mydriasis Cycloplegia Used for: Ophthalmic examinations Uveitis (which benefits from pupillary dilation) Copyright © 2017, Elsevier Inc. All rights reserved.

Ophthalmic Diagnostic Drugs (Cont.)
Cycloplegic mydriatics (Cont.) Cyclopentolate (Cyclogyl) Causes mydriasis and cycloplegia Used for diagnostic examinations Not used for uveitis Copyright © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Ophthalmic Antiallergic Drugs (Cont.)
Used for seasonal allergy symptoms Mast cell stabilizers Cromolyn sodium (Crolom) Pemirolast (Alamast) Nedocromil (Alocril) Lodoxamide (Alomide) Decongestants Tetrahydrozoline Phenylephrine (Neo-Synephrine) Oxymetazoline (Visine LR) Naphazoline (Clear Eyes) Copyright © 2017, Elsevier Inc. All rights reserved.

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 bloodstream. 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 © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Ophthalmic Lubricants and Moisturizers (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

Nursing Implications Assess the patient’s history, including medication history. Assess the 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 © 2017, Elsevier Inc. All rights reserved.

Nursing Implications (Cont.)
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 © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

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 © 2017, Elsevier Inc. All rights reserved.

Provide patient and family education on correct procedures for administration of eye medications. Monitor for adverse effects. Monitor for therapeutic response to therapy. Copyright © 2017, Elsevier Inc. All rights reserved.

Case Study A 60-year-old man 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 © 2017, Elsevier Inc. All rights reserved.

Case Study (Cont.) 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 through 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 nervouse system (CNS) stimulation or CNS or cardiovascular depression. Copyright © 2017, Elsevier Inc. All rights reserved.

Case Study (Cont.) 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 © 2017, Elsevier Inc. All rights reserved.

Case Study (Cont.) 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 © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved.

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