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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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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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Interior of the Eyeball
Anterior chamber Posterior chamber Canal of Schlemm Aqueous humor Vitreous humor
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Interior of the Eyeball (cont’d)
Retina Rods Cones Optic nerve
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Lens Accommodation Cataracts
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Drugs That Affect the Eye
Mydriatics Dilate the pupil Miotics Constrict the pupil Cycloplegics 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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Drugs Used to Reduce IOP
Beta-blockers (antiadrenergic) Osmotic diuretics Carbonic anhydrase inhibitors Direct-acting and indirect-acting parasympathomimetics (cholinergic) Prostaglandin agonists Sympathomimetics (adrenergics, mydriatics)
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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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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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Cholinergic Drugs: Indications
Open-angle glaucoma Angle-closure glaucoma Ocular surgery Convergent strabismus (“cross-eye”) Ophthalmologic exams
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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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Sympathomimetics (cont’d)
brimonidine (Alphagan) apraclonidine (Iopidine) epinephryl (Epinal) dipivefrin (Propine) Prodrug of epinephrine When applied topically Hydrolyzed to epinephrine Penetrates tissues better
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Sympathomimetics: Indications
Chronic, open-angle glaucoma (to reduce IOP) Reduction of perioperative IOP Reduction of ocular hypertension
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Sympathomimetics: Adverse Effects
Primarily limited to ocular effects Burning Eye pain Lacrimation Rare systemic effects Hypertension Tachycardia Headache Faintness
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Beta-Adrenergic Blockers
Selective beta1-blocker betaxolol (Betoptic) Nonselective beta1- and beta2-blockers carteolol (Ocupress) levobunolol (Betagan Liquifilm) metipranolol (Optipranolol) timolol (Timoptic, Betimol)
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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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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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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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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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Carbonic Anhydrase Inhibitors
Available in oral forms for treatment of glaucoma Inhibit the enzyme carbonic anhydrase, which reduces aqueous humor formation in the eye Result is decreased IOP
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Carbonic Anhydrase Inhibitors (cont’d)
Topical ophthalmic preparations brinzolamide (Azopt) dorzolamide (Trusopt) Oral forms acetazolamide (Diamox) Others
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Carbonic Anhydrase Inhibitors: Indications
Treatment of glaucoma Open angle Angle closure Preoperatively to reduce intraocular pressure
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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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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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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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Prostaglandin Agonists
Newer class of drugs for glaucoma Three drugs latanoprost (Xalatan) Most popular travoprost (Travatan) bimatoprost (Lumigan)
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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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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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Ocular Antimicrobial Drugs
Topical and systemic administration Antibacterial Antiviral Antifungal
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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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Ocular Antibacterial Drugs
Aminoglycosides Antibacterial Gentamicin, tobramycin
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Ocular Antibacterial Drugs (cont’d)
Macrolides Antibacterial Erythromycin, azithromycin, others Erythromycin also is used for prevention of Neisseria gonorrhoeae eye infections in newborns
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Ocular Antibacterial Drugs (cont’d)
Polypeptides Antibacterial Bacitracin, polymyxin B
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Ocular Antibacterial Drugs (cont’d)
Quinolones ciprofloxacin (Ciloxan) Four others Sulfonamides sulfacetamide (Bleph-10) Others
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Ocular Antifungal Drugs
natamycin Used topically to treat Blepharitis Conjunctivitis Keratitis
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Ocular Antiviral Drugs
ganciclovir (Vitrasert) Treatment of ocular cytomegalovirus (CMV) Administered by surgical implant in the posterior of the eye fomivirsen (Vitravene) Treatment of ocular CMV Administered by intravitreal injection
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Ocular Antiviral Drugs (cont’d)
trifluridine (Viroptic) Used in the treatment of types 1 and 2 herpes simplex virus (HSV) Applied topically as drops
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Ocular Antiinflammatory Drugs
NSAIDs ketorolac (Acular) flurbiprofen (Ocufen) Corticosteroids dexamethasone (Decadron, AK-Dex)
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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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Ocular Antiinflammatory Drugs (cont’d)
Applied topically Used to treat various ophthalmic inflammatory conditions Should not be used for minor abrasions or wounds—may suppress the eye’s ability to resist infections
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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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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
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Ophthalmic Diagnostic Drugs
Atropine sulfate Results in Mydriasis Cycloplegia Used for Ophthalmic examinations Uveitis (which benefits from pupillary dilation)
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Ophthalmic Diagnostic Drugs (cont’d)
cyclopentolate (Cyclogyl) Causes mydriasis and cycloplegia Used for diagnostic examinations Not used for uveitis
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Ophthalmic Diagnostic Drugs (cont’d)
Mydriatic-reversal drug dapiprazole (Rev-Eyes) Alpha-adrenergic blocker Used to Reverse the effects of mydriatic drugs Restore normal pupillary function when sustained mydriasis is not desired
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Ophthalmic Diagnostic Drugs (cont’d)
fluorescein (AK-Fluor) Ophthalmic diagnostic dye Used to Identify corneal defects Locate foreign bodies in the eye
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Ophthalmic Antiallergic Drugs
Ophthalmic antihistamines Used to treat symptoms of allergic conjunctivitis (“hay fever”) azelastine (Optivar), olopatadine (Patanol), others
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Ophthalmic Antiallergic Drugs (cont’d)
Used for seasonal allergy symptoms Mast cell stabilizers cromolyn sodium (Crolom) pemirolast (Alamast) Others Decongestants tetrahydrozoline phenylephrine
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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
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Lubricants and Moisturizers (cont’d)
Restasis Ophthalmic form of cyclosporine Immunosuppressant drug Used to treat “dry eyes”
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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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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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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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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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Nursing Implications (cont’d)
Provide patient/family education on correct procedures for administration of eye medications
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Nursing Implications (cont’d)
Monitor for adverse effects Monitor for therapeutic response to therapy
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