Pharm Exam 2: Ear/Eye/Health Promotion

Eyelid margin infection/inflammation Complications: dry eyes Symptoms: irritated red eyes, burning sensation, increases tearing, blinking, photophobia, eyelid sticking, contact lens intolerance, eyelid margins are red, greasy, crusted, eyelid dermatitis, matted scaly eyelids More common in adults; chronic in nature Rarely cause vision troubles Causes: Staphylococcus aureus, eye makeup, contact lens buildup, smoke, smog, chemicals, meibomian glands, inflammation/hypersecretion of sebaceous glands No cure Goal of treatment: control symptoms and prevent secondary complications

Bacitracin (Baciguent-polypeptide antibiotic Apply fingertip size amount to affected are 1-3 times daily Side effects: itching, burning, inflammation Erythromycin Ophthalmic Ointment 0.5% (macrolide abx) Apply 1cm to infected eye up to 6x daily Side effects: minor ocular irritation, redness, hypersensitivity Pregnancy Cat B

First line: Erythromycin 0.5% ophthalmic ointment (cause blurry vision) Bacitracin 500 units ointment (cause blurry vision) Ophthalmic fluoroquinolone solution (Besifloxacin, gatifloxacin, levofloxacin, moxifloxacin Second line: refer to ophthalmologist

Improve eyelid hygiene: warm massages, occasional abx use, no contact lens use during flareups

Most common cause of red, painful eye Inflammation of bulbar conjunctiva or palpebral conjunctival. Symptoms: consistent inflammation of conjunctiva, red eyes, swollen conjunctiva, discharge from eyes Normal pupil exam, normal vision All types are self-limiting and usually resolve without tx in 2-5 days. Meds can speed up process, but abx NOT necessary usually Pts should use cold compress and lubricants (artificial tears) for comfort Topical vasoconstrictors and antihistamines can be used for severe itching (not usually indicated)

Cause: gram-positive Staph or Strep, gram-negative Moroxella/Haemophilus, Chlamydia or Gonorrhoeae Transmission: contact with eye by fingertip, neonates by infected mother, contaminated pool Symptoms: rapid onset of conjunctival redness swelling of the eyelid usually in one eye first and spread to other eye in 2-5 days Grittiness/irritation, stringy, opaque, grayish or yellowish mucopurulent discharge, sticky lids, lid crusts Foreign body sensation

Cause: upper resp tract infection, common cold, sore throat. Symptoms: excessive watery discharge, itchiness foreign body sensation, peripheral injection, usually starts in one eye Treatment: no effective tx Risk of spreading infection Topical antihistamines, artificial tears, cool compress

Cause: immunoglobulin-E mediated release of mast cells in conjunctiva Symptoms: watery discharge, itching, burning, both eyes, excessive blinking Treatment Minimize allergen First line: ophthalmic antihistamines alcaftadine or emedastine Second line: topical corticosteroid Third line: mast cell stabilizer -> azelastine, epinastine, ketotifen, olopatadine; opthalmic ketorolac All pts can use cool compress and artificial tears

First Line Erythromycin Ophthalmic Ointment 0.5% (macrolide) 1cm directly to eyes up to 6x daily Side effects: minor ocular irritation, redness, hypersensitivity Preg Cat B Polymyxin B sulfate & trimethoprim Ophthalmic solution Aeroci gram-positive and gram-negative tx 1 gtt q3h for 7-10 days Side effects: local irritation, redness, burning, stinging, itching Preg Cat C Second line- Fluoroquinolones Moxifloxin (Vigamox) 1 gtt in 3x daily for 7 days Side effects: eye burning, stinging, irritation, itching, dryness, redness tearing, blurred vision 1st line for contact lens wearers due to high incidence of pseudomonas Preg Cat C Gonococcal (treat immediately) Ceftriaxone (Rocephin) 1g single IM dose plus azithromycinin those who weigh 45 kg < 45kg reduced dose ceftriaxone Plus saline lavage of eye Chlamydia: tx w/ systemic abx Neonate: erythromycin taken PO for 14 days Adults: single PO azithromycin dose plus topical saline lavage of eye

Common; bilateral disruption of tear film Most affected > 40 years More common in women Causes: decreased tear production, excessive tear evaporation, abnormal production of mucus or lipids in tear duct Symptoms: dryness, burning, sandy-gritty eye irritation that gets worse as day goes on, pain, redness, pulling sensation, pressure behind eye Damage to eye surface increases discomfort and sensitivity to bright light Both eyes affected Tx: First line Environmental adjustment: humidity Artificial tears and lubricants Second line Cyclosporine (Restasis) - prevents T cell activation 1-2 gtt q 12hrs Side effects: burning, stinging, redness, pain, itching, burning, blurred vision, foreign body sensation, eye discharge Preg Cat C

Intraocular pressure -> optic neuropathy Can permanently damage vision in affected areas of eye -> blindness if untreated

Appears suddenly, painful , visual loss can be quick Discomfort causes pt to seek help before permanent damage occurs

Progress slower at a slower pace; pts do not notice vision loss until disease has progressed significantly Leading cause of irreversible blindness Progressive visual loss -> central field loss Increase aqueous and/or decreased outflow -> increased intraocular pressure Intraocular Pressure Measurement: best test to dx glaucoma Acceptable IOP = 10-21 Glaucoma dx = IOP > 15 IOP > 40 = emergency referral

Beta blockers: non-selective (decrease production of aqueous humor) Tomolol (Cosopt) Levonbunolol (Betagan) Carteolol 1 gtt 2x daily Side effects: transient eye irritation, burning, tearing, conjunctival hyperemia, edema Systemic effects: HA, hypotension, bronchospasm Preg Cat C Beta blockers: selective Betaxolol (Betopic) 1 gtt 2x daily Side effects: blurred vision, itching, swelling, eye pain, dryness Systemic effects rare: fatigue, insomnia, nausea, dizziness, lightheadedness, bradycardia, hypotension, cold extremities, SOB, wheezing, depression Safe use NOT established during pregnancy Prostaglandins: improve outflow of aqueous humor Bimatoprost (Lumigan) Latanoprost (Xalatan) Travoprost (Travatan) 1 gtt 1x daily at BEDTIME Side effects: blurred vision, eye redness, discomfort, itchiness, foreign body sensation, dry eyes, tearing, eyelid crusting, increase in eyelash number number/length/thickness, darkens eyelashes and lids, eyelid changes, increased light sensitivity Preg Cat C Carbonic Anhydrase Inhibitors: inhibit carbonic anhydrase -> decreased aqueous fluid formation Brinzolamide (Azopt) Dorzolamide (Trust) 1 gtt 3x daily Side effects: ocular burning, stinging, discomfort, bitter taste in mouth Preg Cat C Adrenergic Agonist: decrease norepi release from alpha receptors -> decrease aqueous humor Apraclonidine (Lopidine) Brimonidine (Alphaga) 1 gtt Q8h Side effects: dry eyes, red eyes, eye irritation, HA, blurred vision, foreign body sensation, drowsiness. Less common: corneal staining, increased sensitivity to light, eyelid redness, eye pain, tearing, eyelid swelling, low BP Pre Gat B Cholinergic blocking agents: increase aqueous outflow Pilocarpine (Akarpine, isopto, pilocar) 1-2 gtt 3-4x/day Side effects: transient stinging, burning, ciliary spasm, conjunctival vascular congestion, temporal/supraorbital HA, lacrimation, induced myopia Systemic reactions: HTN, tachycardia, bronchiolar spasm, pulmonary edema, salivation, sweating, n/v/d Preg cat C

First line: prostaglandins -> beta blocker can be substituted if pt can’t afford prostaglandins Second line: Substitution or addition of beta blocker (if failure to decreased IOP) Third line: Addition of Carbonic Anhydrase Inhibitor or Brimonidine

Localized loss of epithelium Most common eye injury Symptoms: severe eye pain with photophobia with/out foreign body sensation preventing opening eye reduced visual acuity lacrimation blepharospasm Causes: direct trauma, foreign body, contact lens Fluorescein dye uptake (give pt tissue to wipe excess) Seidel’s sign: possible foreign body does not stain -> streaming dye after insertion * Do penlight exam prior to fluorescein Rx treatment: relieve pain, reduce risk of bacterial infection, promote healing Usually heal within 48 hrs AVOID steroids (increase risk of infection)

Cycloplegic therapy: paralyze ciliary muscle Anticholinergics (cause pupillary dilation and paralysis of accommodation) * Rapid action, but shorter duration than atropine Maximal cycloplegia: 25-75 min after instillation Accommodation recovery: 6-24 hrs Homatropine (more cost effective) Cyclopentolate 1-2 gtt before abx Side effects: burning, stinging, redness, eye irritation, temporary blurred vision C/I: narrow angle glaucoma Preg Cat B/C *Consider if pt will have to work, drive, use heavy machinery bc blurred vision lasts several hours

Antipseudomonal agents: used only for contact lens wearers Gentamicin: most inexpensive Can cause pseudomonas resistance Aminoglycoside: (gram negative and positive) 1-2 gtt q4h for 7-10 days Side effects: ocular burning, irritations, conjunctivitis Preg Cat C Tobramycin: used in place of gentamicin secondary to resistance 1-2 gtt q4h for 7-10 days Side effects: localized ocular toxicity and hypersensitivity, lid itching, swelling, conjunctival erythema Preg Cat B Sulfonamides (inhibit bacterial synthesis) Sulfacetamide 1-2 gtt into conjunctival sac q2-3 hrs for 7-10 days Side effects: local irritation, stinging, burning Preg Cat C

Acute infection of secretory glands of eyelid, abscess of eyelid Cause: Staph aureus; obstructed orifices of oil glands in eyelid • incomplete removal of eye makeup, use of outdates or infected cosmetics, poor eyelid hygiene, inflammatory diseases of eyelid, stress and hormonal changes Resolve on their own, pt w/ underlying skin issue are more prone Use warm compress -> stimulates drainage of gland if still present -> drain w/ lancet Moxfloxin (vigamox): fluorquinolone 1 gtt 3x daily for 7 days Side effects: eye burning, stinging, irritation, itching, dryness, redness, tearing, blurred vision Preg Cat C

Eustachian tube blockage: trapped air in middle ear is absorbed in surrounding tissues -> vacuum in middle ear Effusion: fluid from surrounding tissues is sucked into middle ear cavity -> middle ear effusion Cause: Strep pna (most common), Haemophillus influenza, Moraxella, Staph aureus (resp inf) Risk: cigarette smoke exposure, daycare, non-breast fed children, allergies Common < 15 yo, most common <2yo Symptoms: ear pain, trouble sleeping, cranky, pulling on ear, fever, irritability Diagnosis: • Acute onset of s/s • Signs of middle ear effusion: bulging TM, limited or absent TM mobility, otorrhea, air-fluid level behind TM • s/s of middle ear inflammation: TM erythema, pain, tugging ear Tx: only when symptoms of infection present, bilateral presentation, or otorrhea Observe unless: bilateral s/s, < 6 yo, otorrhea, severe/prolonged s/s, fever > 102.2F

First line - unless allergy PCNs or use within 30 days Amoxicillin/clavulanate: well tolerated, tastes like bubblegum (can change flavor to <88 lbs: 90mg/kg divide into 2 daily doses q 12 hrs >88 lbs: 875mg q 12 hrs Side effects: stomach pain, n/v, vaginal itching/discharge, HA, swollen or black or hair tongue Preg Cat B 2nd line allergy to PCN Cefuroxime (Ceftin) Ceftriaxone (Rocephin) Azithromycin (Zithromax) Clindamycin Bactrim

Cellulitis of ear canal skin and subdermis Occurs suddenly Risk factors: eczema, seborrhea, excessive itching, trauma from cerumen removal, chronic otorrhea, immunocompromised (DM). Causes: swimming, local trauma, hearing aids, high/humid temp * Pseudomonas aeruginosa, Staph aureus, occasionally fungus Wax + swelling -> conductive hearing loss Symptoms: painful outer ear, itching, fullness, tenderness of tragus or pinna (pull on upper ear -> pain, erythematous ear canal

First line Fluoroquinolone gtt Ciprofloxacin + dexamethasone (Ciprodex) tx of bacteria and inflammation Side effects: ear discomfort, itchiness, unusual taste Preg Cat C 2nd line Neomyxin/polymixin B + Hydrocortisone gtt Adults: 4 gtt 3-4x daily for 10 days Infants + children: 3 gtt 3-4x daily for 10 days Side effects: skin sensitization Preg Cat C

ALL DROPS CONTRAINDICATED