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Chapter 57
Ophthalmic Drugs
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Structures of the Eye
Eyebrows, eyelids, eyelashes
Palpebral fissure
Sclera
Uvea
Choroid
Iris
Ciliary body
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3. Structures of the Eye (cont’d)
Conjunctiva
Pupil
Medial canthus
Lacrimal caruncle
Lacrimal glands
Lateral canthus
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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
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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
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9. Interior of the Eyeball (cont’d)
Retina
Rods
Cones
Optic nerve
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Lens
Accommodation
Cataracts
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13. 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
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Ocular Drugs
Antiglaucoma drugs
Antimicrobial and antiinflammatory drugs
Topical anesthetics
Diagnostic drugs
Antiallergic drugs
Lubricants and moisturizers
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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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Types of Glaucoma
Angle-closure glaucoma
Open-angle glaucoma
Also characterized by underlying cause
Primary
Secondary
Congenital
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20. 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.
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21. Drugs Used to Reduce IOP
Direct-acting cholinergics
Indirect-acting cholinergics
Adrenergics
Antiadrenergics
Carbonic anhydrase inhibitors
Osmotic diuretics
Prostaglandin agonists
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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
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25. Cholinergic Drugs (cont’d)
Direct-acting drugs
acetylcholine (Miochol-E)
carbachol (Carboptic)
pilocarpine (Pilocar) (also ocular insert form)
Indirect-acting drugs
echothiophate (Phospholine Iodide)
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26. Cholinergic Drugs: Indications
Open-angle glaucoma
Angle-closure glaucoma
Ocular surgery
Convergent strabismus (“cross-eye”)
Ophthalmologic exams
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27. 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
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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
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31. Sympathomimetics (cont’d)
apraclonidine (Iopidine)
brimonidine (Alphagan P)
epinephryl (Epinal)
dipivefrin (Propine)
Prodrug of epinephrine
When applied topically
Hydrolyzed to epinephrine
Penetrates tissues better
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32. Sympathomimetics: Indications
Chronic, open-angle glaucoma (to reduce IOP)
Reduction of perioperative IOP
Reduction of ocular hypertension
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33. Sympathomimetics: Adverse Effects
Primarily limited to ocular effects
Burning
Eye pain
Lacrimation
Rare systemic effects
Hypertension
Tachycardia
Extrasystoles
Headache
Faintness
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34. Beta-Adrenergic Blockers
Selective beta1 blocker
betaxolol (Betoptic)
levobetaxolol (Betaxon)
Nonselective beta1 and beta2 blockers
carteolol (Ocupress)
levobunolol (Betagan)
metipranolol (OptiPranolol)
timolol (Timoptic)
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35. 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
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36. Beta-Adrenergic Blockers: Indications
Reduction of elevated IOP
Chronic open-angle glaucoma
Ocular hypertension
Treatment of some forms of angle-closure glaucoma
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37. 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
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38. Beta-Adrenergic Blockers: Interactions
Administration of systemic beta blockers with high doses of ophthalmic beta blockers may result in additive effects
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39. Carbonic Anhydrase Inhibitors
brinzolamide (Azopt)
dorzolamide (Trusopt)
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40. Carbonic Anhydrase Inhibitors (cont’d)
Inhibit the enzyme carbonic anhydrase, which reduces aqueous humor formation in the eye
Result is decreased IOP
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42. Carbonic Anhydrase Inhibitors: Indications
Treatment of glaucoma
Open angle
Angle closure
Preoperatively to reduce intraocular pressure
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43. 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
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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
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45. 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
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46. 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
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47. Prostaglandin Agonists
Newest class of drugs for glaucoma
Three drugs
latanoprost (Xalatan)
travoprost (Travatan-Z)
bimatoprost (Lumigan)
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48. 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
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49. 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
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50. 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.
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51. Ocular Antimicrobial Drugs
Topical and systemic administration
Antibacterial
Antiviral
Antifungal
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52. 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
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53. Ocular Antibacterial Drugs
Aminoglycosides
Antibacterial
gentamicin (Garamycin) , tobramycin (Tobrex)
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54. 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
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55. Ocular Antibacterial Drugs (cont’d)
Polypeptides
Antibacterial
bacitracin (AK-Tracin), polymyxin B
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56. Ocular Antibacterial Drugs (cont’d)
Quinolones
ciprofloxacin (Ciloxan)
gatifloxacin (Zymar)
moxifloxacin (Vigamox)
levofloxacin (Quixin)
ofloxacin (Ocuflox)
Sulfonamides
sulfacetamide (Bleph-10)
sulfisoxazole (Gantrisin)
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57. Ocular Antifungal Drugs
natamycin (Natacyn)
Used topically to treat
Blepharitis
Conjunctivitis
Keratitis
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58. Ocular Antiviral Drugs
ganciclovir (Vitrasert)
Treatment of ocular cytomegalovirus (CMV)
Administered by surgical implant in the eye
fomivirsen (Vitravene)
Treatment of ocular CMV
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59. 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)
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60. Ocular Antiinflammatory Drugs
NSAIDs
ketorolac (Acular)
flurbiprofen (Ocufen)
bromfenac (Xibrom)
diclofenac (Voltaren)
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61. Ocular Antiinflammatory Drugs
Corticosteroids
dexamethasone (Decadron, AK-Dex)
fluocinonide (Retisert)
fluorometholone (Fluor-Op)
loteprednol (Lotemax)
medrysone (HMS)
prednisolone (Pred Forte)
rimexolone (Vexol)
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62. 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.
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63. 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
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64. Ocular Antiinflammatory Drugs (cont’d)
Used prophylactically after surgery to prevent inflammation and scarring
NSAIDs used for symptomatic treatment of seasonal allergic conjunctivitis
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65. 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
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66. Ophthalmic Diagnostic Drugs
Cycloplegic mydratics
atropine sulfate (Isopto Atropine)
Results in
Mydriasis
Cycloplegia
Used for
Ophthalmic examinations
Uveitis (which benefits from pupillary dilation)
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67. Ophthalmic Diagnostic Drugs (cont’d)
Cycloplegic mydratics (cont’d)
cyclopentolate (Cyclogyl)
Causes mydriasis and cycloplegia
Used for diagnostic examinations
Not used for uveitis
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68. Ophthalmic Diagnostic Drugs (cont’d)
Other cycloplegic mydriatics
scopolamine (Isopto Hyoscine)
homatropine (Isopto Homatropine)
tropicamide (Mydriacyl)
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69. 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
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70. Ophthalmic Antiallergic Drugs
Ophthalmic antihistamines
Used to treat symptoms of allergic conjunctivitis (“hay fever”)
azelastine (Optivar)
olopatadine (Patanol)
emedastine (Emadine)
ketotifen (Zaditor)
epinastine (Elestat)
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71. 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)
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72. 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.
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73. 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
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74. 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
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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
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76. 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
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77. 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.
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78. 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
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79. 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
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80. Nursing Implications (cont’d)
Provide patient/family education on correct procedures for administration of eye medications
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81. Nursing Implications (cont’d)
Monitor for adverse effects
Monitor for therapeutic response to therapy
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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.
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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.
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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.
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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.
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