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The Optometry Drug Guide

anadem — Fri, 01 May 2009 17:49:52 +0000

Antiallergy Medications

Antihistamines

Emadine

(Alcon)

Components - Emedastine difumarate 0.05% soln

Indications - Acute allergic conjunctivitis

Typical Dosing - 1 gtt up to qid

Cautions & Side Effects - Do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

How Supplied - 5mL

Livostin

(Novartis) (Novartis)

Components - Levocabastine HCl 0.05% susp

Indications - Acute allergic conjunctivitis

Typical Dosing - 1 gtt bid to qid

Cautions & Side Effects - Transient ocular irritation, do not use with soft CLs

Other Considerations - Pediatric: >12 yrs

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

10mL

Discontinued in US

Antihistamines & Mast Cell Stabilizers

Alaway

(Bausch & Lomb)

Components - Ketotifen fumarate 0.025% soln

Indications - Acute allergic conjunctivitis, GPC

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Transient conjunctival injection, do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

Available OTC

How Supplied - 10 mL

Elestat

(Allergan & Inspire Pharmaceuticals)

Components - Epinastine HCl 0.05% soln

Indications - Allergic conjunctivitis & ocular symptoms

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Burning sensation on instillation, do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

How Supplied - 5mL

Optivar (MedPointe)

Components - Azelastine HCl 0.05% soln

Indications - Acute allergic conjunctivitis, GPC, inhibits eosinophil chemotaxis

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Transient burning & stinging, bitter taste, do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

Available OTC

How Supplied - 6mL

Pataday

(Alcon) (Alcon)

Components - Olopatadine HCl 0.2% soln

Indications - Acute allergic conjunctivitis, GPC

Typical Dosing - 1 gtt once/day

Cautions & Side Effects - Do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

How Supplied - 2.5mL

Patanol

(Alcon)

Components - Olopatadine HCl 0.1% soln

Indications - Acute allergic conjunctivitis, GPC

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Do not use with soft CLs

Cautions & Side Effects - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

How Supplied - 5mL

Refresh Allergies

(Allergan)

Components - Ketotifen fumarate 0.025% soln

Indications - Acute allergic conjunctivitis, GPC

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Transient conjunctival injection, do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

Available OTC

How Supplied - 5mL

Zaditor
(Novartis)

Components - Ketotifen fumarate 0.025% soln

Indications - Acute allergic conjunctivitis, GPC

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Transient conjunctival injection, do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category C

Nursing: not established

Available OTC

How Supplied - 5mL

Mast Cell Stabilizers

Alocril (Allergan)

Components - Nedocromil HCl 2.0% soln

Indications - Chronic allergic conjunctivitis

Typical Dosing - 1 gtt bid

Cautions & Side Effects - Do not use with soft CLs

Other Considerations - Pediatric: >3 yrs

Pregnancy: category B

Nursing: not established

How Supplied - 5mL

Alomide

(Alcon)

Components - Lodoxamide tromethamine 0.1% soln

Indications - Vernal keratoconjunctivitis, chronic allergic conjunctivitis

Typical Dosing - 1 gtt qid

Cautions & Side Effects - Do not use with soft CLs

Other Considerations - Pediatric: >2 yrs

Pregnancy: category B

Nursing: not established

How Supplied - 10mL

Crolom
(Bausch & Lomb)

Opticrom (Allergan)

Components - Cromolyn sodium 4.0% soln

Indications - Chronic allergic conjunctivitis, GPC, vernal keratoconjunctivitis, conjunctivitis, keratitis

Typical Dosing - 1 gtt 4–6 ×/d

Cautions & Side Effects - Do not use with soft CLs

Other Considerations - Pediatric: >4 yrs

Pregnancy: category B

Nursing: not established

How Supplied - 10mL

Corticosteroids

Alrex

(Bausch & Lomb)

Components - Loteprednol etabonate 0.2% susp

Indications - Allergic conjunctivitis

Typical Dosing - 1 gtt qid up to 2wks

Cautions & Side Effects - Hypersensitivity, contraindi-cated in case of viral, fungal, or mycobacterial infection, cautioncaution with glaucoma or corneal/scleral thinning. Monitor IOP

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Anesthetics

Alcaine (Alcon)

Ophthetic

AK-Taine

Ocu-Caine

Ophthaine

Spectro-Caine

Components - Proparacaine HCl 0.5% soln

Indications - Topical ocular anesthesia

Typical Dosing - 1–2 gtts for diagnostic procedures,

Typical Dosing - 2–4 gtts for superficial foreign body removal

Cautions & Side Effects - Hypersensitivity, should be avoided if sensitive to other ester-type local anesthetics or PABA*, ocular irritation, transient stinging & hyperemia upon instillation

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 15mL

*PABA = para-amino benzoic acid

ComfortMax Flurox

(OcuSoft, Inc.)

Components - Benoxinate 0.4% & Fluorexon disodium 0.25% soln.

Indications - Topical ocular anesthesia, applanation tonometry, soft contact lens trial fitting

Typical Dosing - 1–2 gtts before procedure

Cautions & Side Effects - Hypersensitivity, ocular irritation, transient stinging & hyperemia upon instillation. Less stinging reported for most individuals

Other Considerations - Contains 0.1% Methylparaben as preservative

Pediatric: unknown

Pregnancy: unknown

Nursing: unknown

How Supplied - 5mL

Fluoracaine

(Alcon)

Components - Proparacaine HCl 0.5% & Sodium fluorescein 0.25% soln

Indications - Topical ocular anesthesia, applanation tonometry

Typical Dosing - 1–2 gtts before procedure

Cautions & Side Effects - Hypersensitivity, should be avoided if sensitive to other ester-type local anesthetics or PABA*, ocular irritation, transient stinging & hyperemia upon instillation

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 5mL

*PABA = para-amino benzoic acid

Flura-Safe
(Altaire)

Components - Benoxinate 0.4% & Fluorexon disodium 0.35% soln

Indications - Topical ocular anesthesia, applanation tonometry, soft contact lens trial fitting

Typical Dosing - 1–2 gtts before procedure

Cautions & Side Effects - Hypersensitivity, ocular irritation, transient stinging & hyperemia upon instillation

Other Considerations - Pediatric: not available

Pregnancy: not available

Nursing: not available

How Supplied - 6mL

Fluress

(Barnes Hind)

Fluorox

Components - Benoxinate 0.4% & Sodium fluorescein 0.25% soln

Indications - Applanation tonometry, topical ocular anesthesia

Typical Dosing - 1–2 gtts before procedure

Cautions & Side Effects - Hypersensitivity, ocular irritation, transient stinging & hyperemia upon instillation

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - Fluress currently out of pro-duction, generic: 5mL

Pontocaine

(Abbott)

Ak-T-Caine-PF

(Akorn)

Opticaine

Components - Tetracaine HCl 0.5% soln, 0.5% ung

Indications - Topical ocular anesthesia

Typical Dosing - ½” ribbon before procedure, 1 gtt

Cautions & Side Effects - potent & potentially toxic (7 gtts dosage exceeds toxic threshold)

Other Considerations - Hypersensitivity, ocular irritation, transient stinging & hyperemia upon instillation

How Supplied - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 5mL

Tetracaine

(Alcon Surgical)

Components - Tetracaine HCl 0.5% Unit Dose

Indications - Topical ocular anesthesia

Typical Dosing - 1 gtt potent & potentially toxic (7 gtts dosage exceeds toxic threshold)

Cautions & Side Effects - Hypersensitivity, ocular irritation, transient stinging & hyperemia upon instillation Non Ppreserved

How Supplied - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 12 units x 0.7mL dropper-ettes

*PABA = para-amino benzoic acid

Anti-Infective Medications

Antibiotics

Ak-Sporin

(Akorn)

Components - Neomycin, Polymyxin B 10,000 U/g, Bacitracin 400 U/g ung

Indications - Cell wall/membrane disruption/aminoglycoside–inhibits protein synthesis Eyelid disease

Typical Dosing - ½” ribbon applied to affected area qhs up to q3h

Cautions & Side Effects - Hypersensitivity

Other Considerations - Pediatric: not established

Pregnancy: not available

Nursing: not established

How Supplied - 3.5g

AzaSite

(Inspire Pharmaceuticals)

Components - Azythromycin 1% soln

Indications - Macrolide–inhibits protein synthesis Bacterial conjunctivitis

Typical Dosing - 1 gtt bid first 2 days, then 1 gtt once daily x 5d

Cautions & Side Effects - Hypersensitivity to macrolides ophthalmic or systemic use

Other Considerations - Pediatric: >1 yr

Pregnancy: category B

Nursing: use with caution

How Supplied - 2.5mL

Bacitracin

(Fougera)

Components - Bacitracin 500 U/g ung

Indications - Cell wall/membrane disruption Eyelid disease

Typical Dosing - ½” ribbon applied to affected area qhs up to q3h

Cautions & Side Effects - Hypersensitivity

Other Considerations - Pediatric: not established

Pregnancy: not available

Nursing: not established

How Supplied - 3.5g

Bleph-10

(Allergan)

Components - 10%, 15%, 30% Sulfacetamide sodium soln, ung

Indications - Inhibits folic acid synthesis Conjunctivitis, blepharitis

Typical Dosing - ½” ribbon applied to affected area 1 gtt qhs up to q2h

Cautions & Side Effects - Hypersensitivity, poor potency with mucopurulent discharge, high bacterial resistance

Other Considerations - Pediatric: >2 months

Pregnancy: category C

Nursing: avoid

How Supplied - 5mL

How Supplied - 15mL

How Supplied - 3.5g

Ciloxan

(Alcon)

(Generic)

Components - Ciprofloxacin HCl 0.3% soln, ung

Indications - 2^nd generation fluoroquinolone–inhibits DNA synthesis Bacterial corneal ulcer, bacterial conjunctivitis

Typical Dosing - Ulcers: 2 gtts q15min × 6h, then q30min × 18h, q1h × 1d. Treat up to 14d, ½” ribbon applied to affected area

Conjunctivitis: 1–2 gtts q2h × 2d, then q4h × 5d or ung tid × 2d, bid × 5d

Cautions & Side Effects - Hypersensitivity, precipitation of medication with high dosage frequency, less than qid dosing causes resistance to fluoroquinolones

Other Considerations - Pediatric: >1 yr

Pregnancy: category C

Nursing: avoid

How Supplied - 2.5mL

How Supplied - 5mL

Erythromycin

(Generic)

Ilotycin
(Dista/Lilly)

Components - Erythromycin 0.5% ung

Indications - Macrolide–inhibits protein synthesis Blepharitis, conjunctivitis, neonatal prophylaxis, lubrication/prophylaxis with corneal abrasion

Typical Dosing - ½” ribbon applied to involved area qhs up to q4h

Cautions & Side Effects - Hypersensitivity, high (gram +) bacterial resistance

Other Considerations - Pediatric: neonate

Pregnancy: category B

Nursing: no reported adverse effects

How Supplied - 3.5g

Gentamicin

(Akorn)

Garamycin

(Schering-Plough)

Components - Gentamicin sulfate 0.3% ung, Gentamicin 0.3% soln

Indications - Aminoglycoside–inhibits protein synthesis Bacterial conjunctivitis & keratitis

Typical Dosing - 1 gtt q4h up to q1h max, ½” ribbon applied to involved area

Cautions & Side Effects - Hypersensitivity, cross sensitivity with other aminoglycosides, contact dermatitis

Other Considerations - Pediatric: >6 yr

Pregnancy: category C

Nursing: not established

How Supplied - 3.5g

How Supplied - 5mL

Iquix
(Santen)

Components - Levofloxacin hemihydrate 1.5% soln

Indications - 3^rd generation fluoroquinolone–inhibits DNA synthesis Corneal ulcer caused by bacteria

Typical Dosing - 1 gtt q30min–2h × 1–3d, then q1–4h at day 4 & so on,1 gtt q4–6h after bedtime × all days used

Cautions & Side Effects - Hypersensitivity, ocular irritation, taste disturbance Nonpreserved

Other Considerations - Pediatric: >5 yr

Pregnancy: category C

Nursing: not established

How Supplied - 5mL

Neosporin ung

(Monarch)

Ak-Spore Neocidin

Neotal

Ocu-Spor-B

Ocusporin Ocutricin

Spectro-Sporin

Triple Antibiotic

Components - Bacitracin zinc 400 U/g, Neomycin sulfate 0.35%, Polymyxin B 10,000 U/g ung

Indications - Aminoglycoside–inhibits protein synthesis/cell wall/membrane disruption Blepharitis, conjunctivitis

Typical Dosing - 1 gtt q4h × 7–10d, 2 gtts q1h max, ½” ribbon applied to involved area qhs up to q4h

Cautions & Side Effects - Hypersensitivity, cross sensitivity with other aminoglycosides, contact dermatitis Preserved with thimerosal

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 10mL

How Supplied - 3.5g

NutriDox

(Advanced Vision Research)

Components - Doxycycline monohydrate

Indications - Blepharitis, conjunctivitis, keratitis

Typical Dosing - 1 capsule by mouth qd

Cautions & Side Effects - Hypersensitivity, tetracyclines can cause permanent staining of teeth, enamel hypoplasia & decreased skeletal growth

Other Considerations - Pediatric: ³8

Pregnancy: category D

Nursing: not established

How Supplied - 75mg

Ocuflox
(Allergan)

Components - Ofloxacin 0.3% soln

Indications - 2^nd generation fluoroquinolone–inhibits DNA synthesis Bacterial corneal ulcer, bacterial conjunctivitis

Typical Dosing - Ulcers: 2 gtts q15min × 6h, then q30min × 18h, q1h × 1d. Treat up to 14d

Conjunctivitis: 1–2 gtts q2h × 2d, then q4h × 5d or Ung: tid × 2d, bid × 5d

Cautions & Side Effects - Hypersensitivity, less than qid dosing causes resistance to fluoroquinolones

Other Considerations - Pediatric: >1 yr

Pregnancy: category C

Nursing: avoid

How Supplied - 1mL

How Supplied - 5mL

How Supplied - 10mL

Polymycin

(Bausch & Lomb)

Components - Gramicidin 0.0025%, Neomycin sulfate 0.175%, Polymyxin B 10,000 U/mL soln

Indications - aminoglycoside-inhibit protein synthesis/cell wall/membrane disruption Blepharitis, conjunctivitis

Typical Dosing - 1 gtt q4h × 7–10d, 2 gtts q1h max, ½” ribbon applied to affected area qhs–q3h

Other Considerations - Hypersensitivity, cross sensitivity with other aminoglycosides, contact dermatitis

How Supplied - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 10mL

Polysporin

(Monarch)

Components - Polymyxin B 10,000 U/g, Bacitracin 500 U/g ung

Indications - cell wall/membrane disruption Blepharitis, superficial keratitis or conjunctivitis, prophylaxis with abrasions

Typical Dosing - ½” ribbon applied qhs up to q4h

Cautions & Side Effects - Hypersensitivity

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 3.5g

Polytrim
(Allergan)

(Generic)

Components - Polymyxin B 10,000 U/mL, Trimethoprim 1mg/mL soln

Indications - cell wall/membrane disruption/inhibits folic acid synthesis Bacterial conjunctivitis, prophylaxis for corneal abrasion

Typical Dosing - 1 gtt q3h × 7–10d (6 doses/d max)

Cautions & Side Effects - Hypersensitivity, blepharedema, burning, itching

Other Considerations - Pediatric: >2 months Pregnancy: category C

Nursing: not established

How Supplied - 10mL

Quixin
(Vistakon Pharma/Santen)

Components - Levofloxacin 0.5% soln

Indications - 3^rd generation fluoroquinolone–inhibits DNA synthesis Bacterial conjunctivitis

Typical Dosing - 1 gtt q2h × 2d (up to 8 doses), then q4h × 5d (up to 4 doses)

Cautions & Side Effects - Less than qid dosing causes resistance to fluoroquinolones

Other Considerations - Pediatric: >1 yr

Pregnancy: category C

Nursing: not established

How Supplied - 2.5mL

How Supplied - 5mL

Terramycin

(Pfizer)

Components - Oxytetracycline HCl 5mg/g, Polymyxin B 10,000 U/g ung

Indications - cell wall/membrane disruption/inhibits protein synthesis Blepharitis, conjunctivitis

Typical Dosing - ½” ribbon applied to affected area 4–6 ×/d

Cautions & Side Effects - Tetracyclines can cause permanent staining of teeth, enamel hypoplasia, & decreased skeletal growth

Other Considerations - Pediatric: >8 yr

Pregnancy: category D

Nursing: avoid

How Supplied - 3.5g

Tobrex

(Alcon)

(Generic)

Components - Tobramycin sulfate 0.3% soln, ung

Indications - aminoglycoside–inhibits protein synthesis Blepharitis, conjunctivitis, bacterial keratitis

Typical Dosing - Conjunctivitis:1 gtt q4–6h × 7–10d,

Keratitis: up to q1h depending upon severity,

Ung: ½” ribbon tid–qid

Cautions & Side Effects - Hypersensitivity, cross sensitivity with other aminoglycosides, ocular irritation, redness, burning

Other Considerations - Pediatric: >2 months

Pregnancy: category B

Nursing: not established

How Supplied - 5mL

How Supplied - 3.5g

Vigamox

(Alcon)

Components - Moxifloxacin HCl 0.5% soln

Indications - 4^th generation fluoroquinolone–inhibits DNA synthesis Bacterial conjunctivitis

Typical Dosing - 1 gtt tid × 7d

Cautions & Side Effects - Ocular irritation, keratitis, subconjunctival hemorrhage, less than qid dosing causes resistance to fluoroquinolones Self-preserved

Other Considerations - Pediatric: >1 yr

Pregnancy: category C

Nursing: not established

How Supplied - 3mL

Zymar

(Allergan)

Components - Gatifloxacin 0.3% soln

Indications - 4^th generation fluoroquinolone–inhibits DNA synthesis Bacterial conjunctivitis

Typical Dosing - 1 gtt qid × 7d, 1 gtt q2h × 2d up to 8 ×/d, then qid × 5d for severe infection

Cautions & Side Effects - Ocular irritation, keratitis, lacrimation, chemosis, hyperemia, bitter aftertaste, less than qid dosing causes resistance to fluoroquinolones

Other Considerations - Pediatric: >1 yr

Pregnancy: category C

Nursing: not established

How Supplied - 2.5mL

How Supplied - 5mL

Antifungals

Natacyn

(Alcon)

Components - Natamycin 5% susp

Indications - Inhibits protein synthesis Fungal blepharitis or conjunctivitis, keratitis caused by yeast or filamentous fungi (Fusarium, Candida, Aspergillus)

Typical Dosing - Blepharitis or conjunctivitis:1 gtt 4–6/d × 14–21d, Keratitis: 1gtt q1–2h × 3–4d, then 6–8 ×/d for total of 14–21d or until resolution. Gradual taper suggested

Cautions & Side Effects - Ocular toxicity (e.g., conjunctival hyperemia, chemosis), must monitor status closely, consider another pathogen if not resolving by 7–10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 15mL

Antivirals

Viroptic
(Monarch)

(Generic)

Components - Trifluridine 1% soln

Indications - Inhibits DNA synthesis Herpes simplex keratitis associated with HSV type 1 & 2

Typical Dosing - 1 gtt up to 9 ×/d × 7d, then qid × 7d until re-epitheliali-zation is complete

Cautions & Side Effects - Hypersensitivity, corneal toxicity with use >21d Preserved with thimerosal

Other Considerations - Pediatric: >6 yr

Pregnancy: category C

Nursing: use with caution

How Supplied - 7.5mL

Anti-Inflammatory Medications

Alrex

(Bausch & Lomb)

Components - Loteprednol etabonate 0.2% susp

Indications - Allergic conjunctivitis

Typical Dosing - 1 gtt qid up to 2wks

Cautions & Side Effects - Hypersensitivity, contrain-dicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Decadron Ocumeter
(Merck)

Dexamethasone

(Generic)

Components - Dexamethasone phosphate 0.1% soln, Dexamethasone phosphate 0.1% susp,+ 0.05% ung

Indications - Mild ocular inflammation

Typical Dosing - Soln/susp:1 gtt q1–6h × 1–2d with taper over 7–10d, Ung: ½” ribbon applied qhs up to qid × 7–10d with taper

Cautions & Side Effects - Hypersensitivity, contrain-dicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

How Supplied - 5mL

How Supplied - 3.5g

Durezol

(Sirion)

Components - Difluprednate 0.05% emulsion

Indications - Ocular inflammation and pain associated with ocular surgery

Typical Dosing - 1gtt qid after surgery x 14 d, then bid x 7d with further taper based on response

Cautions & Side Effects - Hypersensitivity, contrain-dicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Preserved with Sorbic acid

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 2.5mL

How Supplied - 5mL

Econopred Plus

(Alcon)

Components - Prednisolone acetate 1.0% susp

Indications - Ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Eflone
(Novartis)

Flarex

(Alcon)

Components - Fluorometholone acetate 0.1% susp

Indications - Ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contrain-dicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 2.5mL

How Supplied - 5mL

How Supplied - 10mL

Fluor-Op

(Novartis)

FML

susp, ung

(Allergan)

Components - Fluorometholone 0.1% susp

Indications - Ocular inflammation

Typical Dosing - Susp:1 gtt q1–6h × 1–2d with taper over 7–10d Ung: ½” ribbon applied to cul-de-sac tid × 1–2d, then q4h until improvement, then taper

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: >2 yr

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 15mL

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 15mL

How Supplied - 3.5g

FML Forte

(Allergan)

Components - Fluorometholone alcohol 0.25% susp

Indications - Ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: >2 yr

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 2mL

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 15mL

FML SOP

(Allergan)

Components - Fluorometholone 0.1% ung

Indications - Ocular inflammation

Typical Dosing - ½” ribbon applied to cul-de-sac tid × 1–2d, then q4h until improvement, then taper

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d,

preservative Preservative contains mercury

Other Considerations - Pediatric: >2 yr

Pregnancy: category C

Nursing: not established

How Supplied - 3.5g

HMS

(Allergan)

Components - Medrysone alcohol 1.0% susp

Indications - Mild ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity,contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10dHypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: >3 yr

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Inflamase Forte

(Novartis)

Components - Prednisolone sodium phosphate 1% soln

Indications - Mild ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 3mL

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 15mL

Inflamase Mild

(Novartis)

Components - Prednisolone sodium phosphate 0.125% soln

Indications - Mild ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

How Supplied - 3mL

How Supplied - 5mL

How Supplied - 10mL

Lotemax
(Bausch & Lomb)

Components - Loteprednol etabonate 0.5% susp

Indications - Ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 2.5mL

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 15mL

Maxidex

(Alcon)

Components - Dexamethasone acetate 0.1% susp,+ ung

Indications - Ocular inflammation

Typical Dosing - Susp:1 gtt q1–6h × 1–2d with taper over 7–10d Ung: ½” ribbon applied to cul-de-sac tid × 1–2d, then q4h until improvement, then taper

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

How Supplied - 5mL

How Supplied - 15mL

How Supplied - 3.5g

NutriDox

(Advanced Vision Research)

Components - Doxycycline monohydrate

Indications - Blepharitis, conjunctivitis, keratitis

Typical Dosing - 1 capsule by mouth qd

Cautions & Side Effects - Hypersensitivity, tetracyclines can cause permanent staining of teeth, enamel hypoplasia & decreased skeletal growth

Other Considerations - Pediatric: ³8

Pregnancy: category D

Nursing: not established

How Supplied - 75mg

Pred Forte

(Allergan)

Components - Prednisolone acetate 1% susp

Indications - Ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

How Supplied - 15mL

Pred Mild

(Allergan)

Components - Prednisolone acetate 0.125% susp

Indications - Mild ocular inflammation

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Vexol

(Alcon)

Components - Rimexolone 1% susp

Indications - Postoperative inflammation, anterior uveitis

Typical Dosing - 1 gtt q1–6h × 1–2d with taper over 7–10d

Cautions & Side Effects - Hypersensitivity, contraindicated in case of viral, fungal, or mycobacterial infection, caution with glaucoma or corneal/scleral thinning. Monitor IOP if used >10d

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Ak-Cide*

(Akorn)

Blephamide^ Blephamide SOP^&

(Allergan)

Cetapred^#

(Alcon)

Isopto Cetapred^@

(Alcon)

Metimyd^~

(Shering)

Vasocidin+

(Cooper Vision)

Components - Prednisolone 0.25%, Sulfacetamide 10% soln, susp+, ung

Indications - Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Typical Dosing - Soln/Susp: 1–2 gtts q4h during waking hrs × 1–2d, then taper over total of 7d Ung: ½” ribbon q3–4h applied to eyelids or in lower cul-de-sac for 7–10d

Cautions & Side Effects - Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hypersensitivity, caution if glaucoma or corneal/scleral thinning, avoid if sulfa allergies exist

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: avoid

+Shake well prior to use

How Supplied - 5mL, 15mL*

5mL, 15mL

soln^

5mL, 10mL^

3.5g^&

15mL^#

15mL soln^@

5mL, 3.5g^~

5mL+

Bacitracin/

Hydrocortisone/

Neomycin/

Polymyxin B

(Generics)

Ak-Spore HC

(Generic)

Cortisporin*

(Monarch)

Components - Bacitracin zinc 400 U/g, Hydrocortisone 1%, Neomycin 3.5mg/g, Polymyxin B 10,000 U/g ung Hydrocortisone 1%, Neomycin 3.5mg/g, Polymyxin B 10,000 U/mL susp+, ung

Indications - Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Typical Dosing - Susp: 1–2 gtts q4h during waking hrs × 1–2d, then taper over total of 7d Ung: ½” ribbon q3–4h applied to eyelids or in lower cul-de-sac for 7–10d

Preserved with thimerosal*

Other Considerations - Pediatric: >10yrs old

Pregnancy: not established

Nursing: not established

+Shake well prior to use

How Supplied - 3.5g

How Supplied - 5mL

FML-S
(Allergan)

Components - Fluorometholone 0.1%, Sulfacetamide 10% susp

Indications - Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Typical Dosing - 1–2 gtts q4h during waking hrs × 1–2d, then taper over total of 7d

Cautions & Side Effects - Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hyper-sensitivity, caution if glaucoma or corneal/scleral thinning

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Maxitrol

(Alcon)

Components - Polymyxin B 10,000 U/g, Neomycin sulfate 0.35%, Dexamethasone 0.1% susp+, ung

Indications - Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Typical Dosing - Susp: 1–2 gtts q4h during waking hrs × 1–2d (up to 6 ×/d), then taper over total of 7d Ung: ½” ribbon applied to lower cul-de-sac 1–3 ×/d

Cautions & Side Effects - Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hyper-sensitivity, caution if glaucoma or corneal/scleral thinning

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

How Supplied - 5mL

How Supplied - 3.5g

Poly-Pred

(Allergan)

Components - Prednisolone acetate 0.5%, Neomycin sulfate 0.35%, Polymyxin B 10,000 U/mL susp+

Indications - Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Typical Dosing - 1–2 gtts q3–4h

Cautions & Side Effects - Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hypersensitivity, caution if glaucoma or corneal/scleral thinning.

Preserved with thimerosal

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

How Supplied - 5mL

How Supplied - 10mL

Pred-G
(Allergan)

Components - Gentamicin 0.3%, Prednisolone acetate 1.0% susp,+ Gentamicin 0.3%, Prednisolone acetate 0.6% ung

Indications - Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Typical Dosing - Susp: 1–2 gtts 2–4 ×/d, up to 1 gtt q1h if needed Ung: ½” ribbon applied to lower cul-de-sac 1–3 ×/d

Cautions & Side Effects - Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hypersensitivity, caution if glaucoma or corneal/scleral thinning

Other Considerations - Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

2mL

5mL

10mL

3.5g

TobraDex
(Alcon)

Dexamethasone 0.1%, Tobramycin 0.3% susp+, ung

Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

Susp: 1–2 gtts 2–4 ×/d, up to 1 gtt q1h if needed

Ung: ½” ribbon applied to lower cul-de-sac 1–3 ×/d

Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hypersensitivity, caution if glaucoma or corneal/scleral thinning

Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

2.5mL

5mL

10mL

3.5g

Zylet

(Bausch & Lomb)

Loteprednol etabonate 0.5%, Tobramycin sulfate 0.3% susp+

Mild ocular inflammation (e.g., blepharitis, conjunctivitis) & secondary infection is a concern

1–2 gtts q4–6h

Monitor IOP if >10d use, contraindicated in cases of viral, fungal, or TB infection, hypersensitivity, caution if glaucoma or corneal/scleral thinning

Pediatric: not established

Pregnancy: category C

Nursing: not established

+Shake well prior to use

2.5mL

5mL

10mL

Clinical Pearls for Optometry Edition 2.1 - Chapter 1

anadem — Fri, 24 Apr 2009 20:47:17 +0000

Orals for Eye Care

Consult a definitive reference if you lack experience with a drug or if the patient has serious co-morbidity, reduced liver or renal function, or is pregnant or nursing.

A) Convert lbs to kilograms: (lb. −10%)/2 = kg

B) Antibiotic recommendations: listed in order of preference. See notes and warnings below

1) Lid problems

· Ocular rosacea

· Meibomian gland dysfunction

· Hordeolum

· Chlamydia

a) Doxycycline: inexpensive, effective, classic

b) Zithromax: moderate price, use if tetracycline problems or you want simple dosing for an acute problem

c) Biaxin: expensive, third choice

d) Tetracycline and erythromycin, inexpensive but not recommended

2) Acute infections with no fever or systemic Sx

· Preseptal cellulitis

· Dacryocystitis

· Hyperacute conjunctivitis

· Sinusitis

· Ear infections

a) Keflex: inexpensive, effective

b) Zithromax: moderate price, use for penicillin allergies

c) Dicloxacillin: moderate price

d) Augmentin: expensive, very effective, may cause diarrhea

e) Ceftin: expensive, good for deep complicated infections with multiple organisms

f ) Penicillin, amoxicillin, ampicillin, Bactrim: inexpensive but less effective

C) Penicillins

1) Dicloxacillin 250 or 500 mg

a) Indications: broad-spectrum bacterial infections, especially cellulitis. Little staph resistance

b) Contraindications: penicillin allergy

c) Adults: 250 – 500 mg qid 1 hr before or 2 hrs after meals

d) Children: 12 – 25 mg/kg daily, divided qid

e) Common side effects: allergy

2) Amoxicillin 250 or 500 mg

a) Indications: non-serious broad-spectrum bacterial infections, especially sinusitis

b) Contraindications: penicillin allergy, resistant staph

c) Adults: 250 – 500 mg qid, OK with meals

d) Children <20 kg: 20 – 40 mg/kg daily, divided qid

e) Common side effects: allergy, occasional GI upset and hyperactivity

3) Augmentin 250 or 500 mg (amoxicillin + clavulanic acid): now also in 200 and 400 mg strengths

a) Indications: serious or resistant broad-spectrum bacterial infections including beta lactamase staph, a more effective drug

b) Contraindications: penicillin allergy

c) Adults and children >40 kg: 500 mg bid

d) Children <40 kg: 20 – 40 mg/kg daily, divided bid

e) Common side effects: GI upset, diarrhea, allergy, rash

4) Penicillin VK 250 or 500 mg

a) Indications: gonorrhea, strep throat

b) Contraindications: penicillin allergy, organisms other than gonorrhea or strep

c) Adults: 500 mg qid, OK with food

d) Children: 15 – 50 mg/kg daily divided qid

e) Common side effects: allergy

D) Cephalosporins

1) Cephalexin (Keflex) 1st generation, 250 or 500 mg

a) Indications: most gram+ bacterial infections, cellulitis

b) Contraindications: 10% cross reaction with penicillin allergy, colitis

c) Adults: 250 – 500 mg qid, OK with food

d) Children: 25 – 50 mg/kg daily, divided qid

e) Common side effects: allergy, rash, polyarthritis, diarrhea

2) Cefuroxime (Ceftin) 2nd generation, 125, 250, 500 mg

a) Indications: deep and complicated infections by multiple organisms such as in sinusitis and ear infections

b) Contraindications: 10% cross reaction with penicillin allergy

c) Adults: 250 – 500 mg bid

d) Children: 250 mg bid with meal

e) Common side effects: diarrhea, nausea, vomiting

E) Sulfa

1) Bactrim (sulfa 400 mg + trimethoprim 80 mg), Bactrim DS (sulfa 800 mg + trimethoprim 160 mg), suspension (sulfa 200 mg + trimethoprim 40 mg, per 5 mL)

a) Indications: bacterial infection, consider if penicillin allergy and erythromycin causes nausea

b) Contraindications: many resistant organisms, sulfa allergies

c) Adults: 2 Bactrim bid or 1 Bactrim DS bid

d) Children: 40 mg/kg of sulfa, divided bid

e) Common side effects: Stevens-Johnson syndrome, colitis (rarely peripheral neuritis, depression, convulsions)

F) Macrolides

1) Zithromax 250 or 500 mg tablets, Z-Pack

a) Indications: broad-spectrum bacterial infections. Especially good as a back up for infected patients with penicillin allergies and ocular rosacea/meibomianitis patients intolerant of doxycycline. Drug of choice for chlamydia, 1, 1000 mg dose

b) Relative contraindications (coordinate with the medical doctor): concurrent use of theophylline, digoxin, warfarin

c) Adults: 500 mg qd first day, then 250 mg qd for 4 days, avoiding antacids, 1 hr before or 2 hrs after meals. Lasts 2 weeks in the body

d) Children >6 months: 10 mg/kg qd first day, then 5 mg/kg qd for 4 days

e) Common side effects: GI upset, abdominal pain, colitis

2) Biaxin 250 or 500 mg tabs

a) Indications: broad-spectrum bacterial infections. For more serious infections than Zithromax

b) Contraindications: concurrent use of theophylline, digoxin, lovastatin, cyclosporine, Norpace

c) Adults: 250 or 500 mg bid

d) Children >20 months:15 mg/kg/day divided bid

e) Common side effects: GI upset, headache, taste changes

3) Erythromycin 250, 333, 500 mg

a) Indications: chlamydia in young and child-bearing women, broad-spectrum infection and rosacea/meibomianitis. Inexpensive alternate drug for penicillin allergy patients and doxycycline intolerant patients

b) Relative contraindications (coordinate with medical doctor): concurrent use of theophylline, digoxin, cyclosporine, Norpace, prednisone

c) Adults: 1000 mg/day divided bid, tid, or qid, OK with meals

d) Children: 30 – 50 mg/kg daily divided qid

e) Common side effects: nausea is common

G) Tetracyclines

1) Doxycycline 50, 75, 100 mg

a) Indications: use in place of tetracycline for chlamydia, acne rosacea, meibomian gland disease, good broad-spectrum coverage for infections, good for penicillin allergic patients

b) Contraindications: children

c) Adults or >100 lbs: 100 mg bid, avoid milk

d) Children >age 8: day 1, 2 mg/kg divided bid, then 1 mg/kg qd subsequent days

e) Common side effects: GI problems, pseudotumor, rashes, Candida vaginitis overgrowth, nail discoloration, anemia, dizziness, headache, loss of oral contraceptive effectiveness, photosensitivity (cover skin, wear sunglasses)

H) Antivirals

1) Acyclovir (Zovirax) 200 mg

a) Indications: for inexpensive treatment of herpes zoster and herpes simplex infection

b) Contraindications: difficulty with 5x dosing

c) Adults with herpes simplex: initially 200 mg 5x/day for 10 days, then 400 mg bid for up to 12 months

d) Adults with herpes zoster: 800 mg 5x/day for 10 days

e) Children >2 yrs: 20 mg/kg 5x/day up to 800 mg total per day

f ) Common side effects: headache, CNS changes in elderly, GI upset, vertigo, fatigue

2) Valtrex 500 mg caps (pro drug of acyclovir)

a) Indications: more convenient treatment of herpes zoster and herpes simplex infection

b) Contraindications: cost, concurrent use of probenecid (gout Tx), cimetidine (Tagamet)

c) Adults with herpes simplex: 1000 mg bid for 10 days, then 500 mg bid for acute ocular herpes. 500 mg bid for suppression of recurrences

d) Adults with herpes zoster: 1000 mg tid for 7 days

e) Children: not recommended

f ) Common side effects: GI upset, headache, dizziness

3) Famvir 125, 250, 500 mg tabs

a) Indications: more convenient treatment of herpes simplex and herpes zoster infections

b) Contraindications: cost

c) Adults with herpes simplex: 125 mg bid until cleared

d) Adults with herpes zoster: 500 mg tid for 7 days

e) Children: not recommended

f ) Common side effects: GI upset, insomnia, dizziness, nervousness, fatigue

I) Antihistamines

1) Loratadine (Claritin) 10 mg: now over-the-counter (OTC)

a) Indications: non-sedating antihistamine for the relief of seasonal allergic Sx. Onset within 1 hr, lasts 24 hrs

b) Contraindications: non-specific

c) Adults and >age 6: 1, 10 mg tab 1 hr before or 2 hrs after meal qd

d) Children

e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, sleepiness, hyperkinesia

2) Loratadine + pseudoephedrine sulfate Claritin-D 24 hr 10/240 mg and Claritin-D 12 hr 5/120 mg)

a) Indications: non-sedating antihistamine and decongestant for the relief of seasonal allergic Sx. If decongestant causes insomnia, use 12 hr version in a.m. and Benadryl in p.m. to aid sleep

b) Relative contraindications: hypertension, diabetes, ischemic heart disease, narrow angle glaucoma, hyperthyroidism, seizures

c) Adults and >age 6: 1 tab, 1 hr before or 2 hrs after meal. Once per day for the 24 hr version and bid for the 12 hr version

d) Children

e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, insomnia, sleepiness, hyperkinesia, appetite suppression, bronchospasm

3) Cetirizine hydrochloride (Zyrtec) 5 or 10 mg tablets and syrup

a) Indications: non-sedating antihistamine for the relief of allergic Sx

b) Contraindications: pregnancy, nursing mothers, renal failure

c) Adults: 10 mg qd

d) Children 6 – 11 yrs: 5 –10 mg qd

e) Children 2 – 5 yrs: ½ – 1 teaspoon per day

f ) Common side effects: sleepiness, fatigue, dry mouth

4) Cetirizine hydrochloride 5 mg and pseudoephrine hydrochloride 120 mg (Zyrtec-D 12 hour)

a) Indications: relief of allergic Sx with nasal congestion

b) Contraindications: narrow angle glaucoma, hypertension, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 tablet bid

d) Children <12: not recommended

e) Common side effects: sleepiness, fatigue, dry mouth

5) Diphenhydramine (Benadryl) caps 25 mg OTC

a) Indications: inexpensive relief of allergic Sx, especially acute and medication induced Sx, sedating

b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction

c) Adults: 25 – 50 mg qid

d) Children >6: 25 mg qid

e) Common side effects: sedation, dizziness, excitement, hypotension, GI upset

6) Diphenhydramine + pseudoephedrine (Benadryl allergy/congestion) caps 25 mg OTC

a) Indications: inexpensive relief of allergic Sx with nasal congestion

b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction within 2 weeks of MAO inhibitors (obsolete antidepressant)

c) Adults: 2 caps qid

d) Children >6: 1 cap qid

e) Common side effects: sedation, dizziness, excitement, hypotension, rash, GI upset, palpitations

J) Carbonic anhydrase inhibitors: (topical Trusopt is usually a better choice)

1) Methazolamide (Neptazane) 25 or 50 mg, 100 per bottle

a) Indications: for reduction of IOP. Fewer side effects than Diamox. Consider Trusopt or Azopt instead

b) Contraindications: sulfa allergy, concurrent steroid or aspirin use

c) Adults: 50 – 100 mg bid or tid

d) Children: not recommended

e) Common side effects: “tingling” of extremities, tinnitus, fatigue, taste change, GI upset

2) Acetazolamide (Diamox) 125 or 250 mg tabs, or 500 mg Diamox Sequels

a) Indications: for IOP reduction. Consider Trusopt or Azopt instead

b) Contraindications: sulfa allergy, chronic obstructive pulmonary disease, diabetes

c) Adults, chronic use: Diamox tablets 125 – 250 mg qid or Diamox Sequels 500 mg bid. In angle closure start with a 500 mg loading dose of Diamox (not Sequels)

d) Children: not recommended

e) Common side effects: drowsiness, fever, diuresis, malaise, paresthesias, tinnitus, GI distress, blood dyscrasias; half of Diamox patients drop out due to side effects. Diamox Sequels better tolerated

K) Osmotics

1) Glycerin (Osmoglyn) 50% solution

a) Indications: urgent relief of angle closure in non-diabetics. Maximum effect in 1 hr. Most effective

b) Contraindications: diabetes

c) Adults: 2 – 3 mL/kg of solution, flavored on ice

d) Children: 2 – 3 mL/kg of solution flavored on ice

e) Common side effects: nausea, diuresis, vomiting

L) Analgesics & anti-inflammatories

1) Ibuprofen (Advil, Medipren, Midol 200, Motrin, Nuprin) 200 mg per tab

a) Indications: relief of pain and inflammation

b) Contraindications: aspirin allergy, alcoholism, gastritis, ulcers, 3rd trimester of pregnancy (use Tylenol instead), concurrent use of other anti-inflammatories such as Celebrex

c) Adults: 600 – 800 mg tid with food

d) Children: 10 – 40 mg/kg tid with food

e) Common side effects: GI upset, dizziness, visual disturbances, photophobia

2) Naproxen (Naprosyn, Naprelan 250 mg, 375 mg, 500 mg) (Aleve 220 mg)

a) Indications: long acting inflammation and arthritis relief. Less effective than ibuprofen for pain

b) Contraindications: aspirin allergy, 3rd trimester of pregnancy (see ibuprofen)

c) Adults: 250 – 500 mg bid, up to 750 mg bid for short term if tolerated

d) Children: 10 mg/kg divided bid (usually ½ of 250 mg tabs)

e) Common side effects: GI upset, headache, dizziness, drowsiness, tinnitus, peptic ulcers and bleeding problems, photophobia, heart disease, stroke

3) Tylenol #3 (30 mg codeine + 325 mg acetaminophen)

a) Indications: inexpensive relief of moderately severe pain

b) Contraindications: drug abuser, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 – 2 caps every 4 hrs

d) Children: 0.5 mg/kg of codeine component

e) Common side effects: sedation, drowsiness, vomiting, constipation, respiratory depression, syncope

4) Celebrex 100 or 200 mg

a) Indications: arthritis and relief of acute pain. Similar to NSAIDs without stomach problems

b) Contraindications: sulfa, aspirin, or NSAID allergy

c) Adults: 200 mg bid with initial loading dose of 400 mg

d) Children: not recommended <18 yrs

e) Common side effects: GI upset or pain, blurred vision, increased IOP, cataracts, heart disease, stroke

5) Ultram 50 mg

a) Indications: relief of moderately severe pain. Non-narcotic but works like narcotics with low risk of addiction. Easy on stomach

b) Contraindications: opioid allergy, intoxication

c) Adults 16 – 75 yrs: 50 – 100 mg every 4 – 6 hrs unless liver disease: consider ½ of 50 mg tab for small women and elderly

d) Children: not recommended

e) Common side effects: dizziness, nausea, constipation, headache, somnolence, vomiting

6) Vicodin (5 mg hydrocodone bitartrate and 500 mg acetaminophen)

a) Indications: for relief of moderately severe pain

b) Contraindications: drug abusers, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 tab every 4 hrs

d) Children: not approved

e) Common side effects: depression of respiration and cough reflex, sleepiness

Clinical Pearls for Optometry Edition 2.1 - Chapter 2

anadem — Fri, 24 Apr 2009 20:36:08 +0000

Orals for Eye Care

Consult a definitive reference if you lack experience with a drug or if the patient has serious co-morbidity, reduced liver or renal function, or is pregnant or nursing.

A) Convert lbs to kilograms: (lb. −10%)/2 = kg

B) Antibiotic recommendations: listed in order of preference. See notes and warnings below

1) Lid problems

· Ocular rosacea

· Meibomian gland dysfunction

· Hordeolum

· Chlamydia

a) Doxycycline: inexpensive, effective, classic

b) Zithromax: moderate price, use if tetracycline problems or you want simple dosing for an acute problem

c) Biaxin: expensive, third choice

d) Tetracycline and erythromycin, inexpensive but not recommended

2) Acute infections with no fever or systemic Sx

· Preseptal cellulitis

· Dacryocystitis

· Hyperacute conjunctivitis

· Sinusitis

· Ear infections

a) Keflex: inexpensive, effective

b) Zithromax: moderate price, use for penicillin allergies

c) Dicloxacillin: moderate price

d) Augmentin: expensive, very effective, may cause diarrhea

e) Ceftin: expensive, good for deep complicated infections with multiple organisms

f ) Penicillin, amoxicillin, ampicillin, Bactrim: inexpensive but less effective

C) Penicillins

1) Dicloxacillin 250 or 500 mg

a) Indications: broad-spectrum bacterial infections, especially cellulitis. Little staph resistance

b) Contraindications: penicillin allergy

c) Adults: 250 – 500 mg qid 1 hr before or 2 hrs after meals

d) Children: 12 – 25 mg/kg daily, divided qid

e) Common side effects: allergy

2) Amoxicillin 250 or 500 mg

a) Indications: non-serious broad-spectrum bacterial infections, especially sinusitis

b) Contraindications: penicillin allergy, resistant staph

c) Adults: 250 – 500 mg qid, OK with meals

d) Children <20 kg: 20 – 40 mg/kg daily, divided qid

e) Common side effects: allergy, occasional GI upset and hyperactivity

3) Augmentin 250 or 500 mg (amoxicillin + clavulanic acid): now also in 200 and 400 mg strengths

a) Indications: serious or resistant broad-spectrum bacterial infections including beta lactamase staph, a more effective drug

b) Contraindications: penicillin allergy

c) Adults and children >40 kg: 500 mg bid

d) Children <40 kg: 20 – 40 mg/kg daily, divided bid

e) Common side effects: GI upset, diarrhea, allergy, rash

4) Penicillin VK 250 or 500 mg

a) Indications: gonorrhea, strep throat

b) Contraindications: penicillin allergy, organisms other than gonorrhea or strep

c) Adults: 500 mg qid, OK with food

d) Children: 15 – 50 mg/kg daily divided qid

e) Common side effects: allergy

D) Cephalosporins

1) Cephalexin (Keflex) 1st generation, 250 or 500 mg

a) Indications: most gram+ bacterial infections, cellulitis

b) Contraindications: 10% cross reaction with penicillin allergy, colitis

c) Adults: 250 – 500 mg qid, OK with food

d) Children: 25 – 50 mg/kg daily, divided qid

e) Common side effects: allergy, rash, polyarthritis, diarrhea

2) Cefuroxime (Ceftin) 2nd generation, 125, 250, 500 mg

a) Indications: deep and complicated infections by multiple organisms such as in sinusitis and ear infections

b) Contraindications: 10% cross reaction with penicillin allergy

c) Adults: 250 – 500 mg bid

d) Children: 250 mg bid with meal

e) Common side effects: diarrhea, nausea, vomiting

E) Sulfa

1) Bactrim (sulfa 400 mg + trimethoprim 80 mg), Bactrim DS (sulfa 800 mg + trimethoprim 160 mg), suspension (sulfa 200 mg + trimethoprim 40 mg, per 5 mL)

a) Indications: bacterial infection, consider if penicillin allergy and erythromycin causes nausea

b) Contraindications: many resistant organisms, sulfa allergies

c) Adults: 2 Bactrim bid or 1 Bactrim DS bid

d) Children: 40 mg/kg of sulfa, divided bid

e) Common side effects: Stevens-Johnson syndrome, colitis (rarely peripheral neuritis, depression, convulsions)

F) Macrolides

1) Zithromax 250 or 500 mg tablets, Z-Pack

b) Relative contraindications (coordinate with the medical doctor): concurrent use of theophylline, digoxin, warfarin

c) Adults: 500 mg qd first day, then 250 mg qd for 4 days, avoiding antacids, 1 hr before or 2 hrs after meals. Lasts 2 weeks in the body

d) Children >6 months: 10 mg/kg qd first day, then 5 mg/kg qd for 4 days

e) Common side effects: GI upset, abdominal pain, colitis

2) Biaxin 250 or 500 mg tabs

a) Indications: broad-spectrum bacterial infections. For more serious infections than Zithromax

b) Contraindications: concurrent use of theophylline, digoxin, lovastatin, cyclosporine, Norpace

c) Adults: 250 or 500 mg bid

d) Children >20 months:15 mg/kg/day divided bid

e) Common side effects: GI upset, headache, taste changes

3) Erythromycin 250, 333, 500 mg

b) Relative contraindications (coordinate with medical doctor): concurrent use of theophylline, digoxin, cyclosporine, Norpace, prednisone

c) Adults: 1000 mg/day divided bid, tid, or qid, OK with meals

d) Children: 30 – 50 mg/kg daily divided qid

e) Common side effects: nausea is common

G) Tetracyclines

1) Doxycycline 50, 75, 100 mg

a) Indications: use in place of tetracycline for chlamydia, acne rosacea, meibomian gland disease, good broad-spectrum coverage for infections, good for penicillin allergic patients

b) Contraindications: children

c) Adults or >100 lbs: 100 mg bid, avoid milk

d) Children >age 8: day 1, 2 mg/kg divided bid, then 1 mg/kg qd subsequent days

H) Antivirals

1) Acyclovir (Zovirax) 200 mg

a) Indications: for inexpensive treatment of herpes zoster and herpes simplex infection

b) Contraindications: difficulty with 5x dosing

c) Adults with herpes simplex: initially 200 mg 5x/day for 10 days, then 400 mg bid for up to 12 months

d) Adults with herpes zoster: 800 mg 5x/day for 10 days

e) Children >2 yrs: 20 mg/kg 5x/day up to 800 mg total per day

f ) Common side effects: headache, CNS changes in elderly, GI upset, vertigo, fatigue

2) Valtrex 500 mg caps (pro drug of acyclovir)

a) Indications: more convenient treatment of herpes zoster and herpes simplex infection

b) Contraindications: cost, concurrent use of probenecid (gout Tx), cimetidine (Tagamet)

c) Adults with herpes simplex: 1000 mg bid for 10 days, then 500 mg bid for acute ocular herpes. 500 mg bid for suppression of recurrences

d) Adults with herpes zoster: 1000 mg tid for 7 days

e) Children: not recommended

f ) Common side effects: GI upset, headache, dizziness

3) Famvir 125, 250, 500 mg tabs

a) Indications: more convenient treatment of herpes simplex and herpes zoster infections

b) Contraindications: cost

c) Adults with herpes simplex: 125 mg bid until cleared

d) Adults with herpes zoster: 500 mg tid for 7 days

e) Children: not recommended

f ) Common side effects: GI upset, insomnia, dizziness, nervousness, fatigue

I) Antihistamines

1) Loratadine (Claritin) 10 mg: now over-the-counter (OTC)

a) Indications: non-sedating antihistamine for the relief of seasonal allergic Sx. Onset within 1 hr, lasts 24 hrs

b) Contraindications: non-specific

c) Adults and >age 6: 1, 10 mg tab 1 hr before or 2 hrs after meal qd

d) Children

e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, sleepiness, hyperkinesia

2) Loratadine + pseudoephedrine sulfate Claritin-D 24 hr 10/240 mg and Claritin-D 12 hr 5/120 mg)

a) Indications: non-sedating antihistamine and decongestant for the relief of seasonal allergic Sx. If decongestant causes insomnia, use 12 hr version in a.m. and Benadryl in p.m. to aid sleep

b) Relative contraindications: hypertension, diabetes, ischemic heart disease, narrow angle glaucoma, hyperthyroidism, seizures

c) Adults and >age 6: 1 tab, 1 hr before or 2 hrs after meal. Once per day for the 24 hr version and bid for the 12 hr version

d) Children

e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, insomnia, sleepiness, hyperkinesia, appetite suppression, bronchospasm

3) Cetirizine hydrochloride (Zyrtec) 5 or 10 mg tablets and syrup

a) Indications: non-sedating antihistamine for the relief of allergic Sx

b) Contraindications: pregnancy, nursing mothers, renal failure

c) Adults: 10 mg qd

d) Children 6 – 11 yrs: 5 –10 mg qd

e) Children 2 – 5 yrs: ½ – 1 teaspoon per day

f ) Common side effects: sleepiness, fatigue, dry mouth

4) Cetirizine hydrochloride 5 mg and pseudoephrine hydrochloride 120 mg (Zyrtec-D 12 hour)

a) Indications: relief of allergic Sx with nasal congestion

b) Contraindications: narrow angle glaucoma, hypertension, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 tablet bid

d) Children <12: not recommended

e) Common side effects: sleepiness, fatigue, dry mouth

5) Diphenhydramine (Benadryl) caps 25 mg OTC

a) Indications: inexpensive relief of allergic Sx, especially acute and medication induced Sx, sedating

b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction

c) Adults: 25 – 50 mg qid

d) Children >6: 25 mg qid

e) Common side effects: sedation, dizziness, excitement, hypotension, GI upset

6) Diphenhydramine + pseudoephedrine (Benadryl allergy/congestion) caps 25 mg OTC

a) Indications: inexpensive relief of allergic Sx with nasal congestion

c) Adults: 2 caps qid

d) Children >6: 1 cap qid

e) Common side effects: sedation, dizziness, excitement, hypotension, rash, GI upset, palpitations

J) Carbonic anhydrase inhibitors: (topical Trusopt is usually a better choice)

1) Methazolamide (Neptazane) 25 or 50 mg, 100 per bottle

a) Indications: for reduction of IOP. Fewer side effects than Diamox. Consider Trusopt or Azopt instead

b) Contraindications: sulfa allergy, concurrent steroid or aspirin use

c) Adults: 50 – 100 mg bid or tid

d) Children: not recommended

e) Common side effects: “tingling” of extremities, tinnitus, fatigue, taste change, GI upset

2) Acetazolamide (Diamox) 125 or 250 mg tabs, or 500 mg Diamox Sequels

a) Indications: for IOP reduction. Consider Trusopt or Azopt instead

b) Contraindications: sulfa allergy, chronic obstructive pulmonary disease, diabetes

c) Adults, chronic use: Diamox tablets 125 – 250 mg qid or Diamox Sequels 500 mg bid. In angle closure start with a 500 mg loading dose of Diamox (not Sequels)

d) Children: not recommended

K) Osmotics

1) Glycerin (Osmoglyn) 50% solution

a) Indications: urgent relief of angle closure in non-diabetics. Maximum effect in 1 hr. Most effective

b) Contraindications: diabetes

c) Adults: 2 – 3 mL/kg of solution, flavored on ice

d) Children: 2 – 3 mL/kg of solution flavored on ice

e) Common side effects: nausea, diuresis, vomiting

L) Analgesics & anti-inflammatories

1) Ibuprofen (Advil, Medipren, Midol 200, Motrin, Nuprin) 200 mg per tab

a) Indications: relief of pain and inflammation

b) Contraindications: aspirin allergy, alcoholism, gastritis, ulcers, 3rd trimester of pregnancy (use Tylenol instead), concurrent use of other anti-inflammatories such as Celebrex

c) Adults: 600 – 800 mg tid with food

d) Children: 10 – 40 mg/kg tid with food

e) Common side effects: GI upset, dizziness, visual disturbances, photophobia

2) Naproxen (Naprosyn, Naprelan 250 mg, 375 mg, 500 mg) (Aleve 220 mg)

a) Indications: long acting inflammation and arthritis relief. Less effective than ibuprofen for pain

b) Contraindications: aspirin allergy, 3rd trimester of pregnancy (see ibuprofen)

c) Adults: 250 – 500 mg bid, up to 750 mg bid for short term if tolerated

d) Children: 10 mg/kg divided bid (usually ½ of 250 mg tabs)

e) Common side effects: GI upset, headache, dizziness, drowsiness, tinnitus, peptic ulcers and bleeding problems, photophobia, heart disease, stroke

3) Tylenol #3 (30 mg codeine + 325 mg acetaminophen)

a) Indications: inexpensive relief of moderately severe pain

b) Contraindications: drug abuser, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 – 2 caps every 4 hrs

d) Children: 0.5 mg/kg of codeine component

e) Common side effects: sedation, drowsiness, vomiting, constipation, respiratory depression, syncope

4) Celebrex 100 or 200 mg

a) Indications: arthritis and relief of acute pain. Similar to NSAIDs without stomach problems

b) Contraindications: sulfa, aspirin, or NSAID allergy

c) Adults: 200 mg bid with initial loading dose of 400 mg

d) Children: not recommended <18 yrs

e) Common side effects: GI upset or pain, blurred vision, increased IOP, cataracts, heart disease, stroke

5) Ultram 50 mg

a) Indications: relief of moderately severe pain. Non-narcotic but works like narcotics with low risk of addiction. Easy on stomach

b) Contraindications: opioid allergy, intoxication

c) Adults 16 – 75 yrs: 50 – 100 mg every 4 – 6 hrs unless liver disease: consider ½ of 50 mg tab for small women and elderly

d) Children: not recommended

e) Common side effects: dizziness, nausea, constipation, headache, somnolence, vomiting

6) Vicodin (5 mg hydrocodone bitartrate and 500 mg acetaminophen)

a) Indications: for relief of moderately severe pain

b) Contraindications: drug abusers, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 tab every 4 hrs

d) Children: not approved

e) Common side effects: depression of respiration and cough reflex, sleepiness

Clinical Pearls for Optometry Edition 2.1 - Chapter 3

anadem — Fri, 24 Apr 2009 20:32:28 +0000

Systemic Medications and Ocular Side Effects

A) Chloroquine derivatives

1) Chloroquine

a) Old antirheumatic drug

b) Still used for malaria

c) Cause depigmentation of macular retinal pigment epithelium (RPE) and bull’s eye maculopathy

d) Retinal damage usually appears after 100 grams cumulative dose

e) Monitor closely with baseline photos, frequent dilated exams, Amsler monocular color vision and macular vision field testing

f ) Meds for troops in Persian Gulf, Afghanistan

2) Hydroxychloroquine (Plaquenil)

a) Replaced chloroquine for arthritis treatment

b) Less toxic

c) Antirheumatic

d) 400 mg/day is standard dose

e) Less than 750 mg/day is unlikely to cause chloroquine retinopathy

f ) Yearly exams in healthy patients are sufficient (previously, 6 month exams were recommended)

B) Antihistamines

1) OTC: Benadryl and various brands

a) Dryness of mucosal membranes, including eyes

b) Sedation: combining with decongestants (which are stimulants and labeled with -D), minimize drowsiness

c) Dilation of pupils and loss of accommodation in borderline presbyopes is possible

2) Non-sedating (Allegra, Claritin, Zyrtec, Clarinex)

a) Dryness of mucosal membranes

b) Rarely: sedation is possible

c) Dilation and loss of accommodation is possible

C) Phenothiazines and promethazine: Compazine, Phenergan, Thorazine

1) Several uses

a) Antiemetics

b) Antipsychotics

c) Antihiccup

d) Antitussive

2) Anticholinergic side effects: including dryness, sedation, pupil dilation and reduced accommodation

3) Rare adverse side effect (temporary): severe eye movement disorders

D) Cardiovascular drugs

1) Diuretics: all can cause transient blur due to fluid loss

a) Thiazides (Diuril, Hydrochlorothiazide)

1) Sulfa drugs: beware of sulfa allergies

2) Cause potassium depletion

b) Loop diuretics (Lasix, Bumex, Demadex)

1) Not sulfa, but cross-react with sulfa allergies [except ethacrynic acid (Edecrin)]

2) Cause potassium depletion

c) Potassium sparing diuretics (Diazide, Aldactone, Midamer, Moduretic): combinations with hydrochlorothiazide

d) Carbonic anhydrase inhibitors: acetazolamide (Diamox), methazolamide (Neptazane)

1) Sulfa drugs: beware of sulfa allergies

2) Common side effects: kidney stones, loss of appetite, paresthesia, fatigue, headache, bone marrow depression

3) Cause decreased aqueous production in glaucoma

4) Cause decreased cerebral spinal fluid in pseudotumor cerebri

5) Avoid Neptazane in reduced liver function

2) Cardiac glycosides: digitalis, digoxin (Lanoxin)

a) Used for congestive heart failure, atrial fibrillation, atrial flutter, supraventricular tachycardia

b) Very low therapeutic index, easy to overdose and kill

c) First signs of overdose

1) Visual disturbances, including hallucinations and color vision changes

2) Nausea

3) Diarrhea

3) Antianginals: nitrates

a) Any nitrate combined with Viagra, Levitra or Cialis is additive; can cause heart stoppage

1) Short acting sublingual pills: (Nitrostat, Nitrolingual)

2) Long acting pills: (Imdur, Ismo, Dilatrate SR, Isordil)

3) Patches: (Minitran, Nitrodisk, Nitro-Dur)

4) Can cause syncope and color vision disturbances due to vasodilation effects

4) Antiarrhythmics

a) Local anesthetics or membrane stabilizers: quinidine (Lidocaine, Rythmol, Propafenone)

1) Can produce reversible central vision loss

2) Can produce cognitive impairment

b) Beta blockers: see examples below in section 5

1) Will negate effectiveness of topical beta blocker

c) Repolarization prolongation: amiodarone (Cordarone)

1) Cause corneal verticillata (linear pigment streaks in corneal epithelium)

2) Can cause pseudotumor cerebri or optic neuritis

3) Rarely cause sudden permanent retinal damage

4) Can cause pulmonary fibrosis

d) Calcium channel blockers

1) Examples

a) Diltiazem (Cardizem, Dilacor, Tiazac)

b) Amlodipine (Norvasc, Lotrel)

c) Felodipine (Plendil, Lexxel)

d) Isradipine (Dynacirc)

e) Nicardipine (Cardene)

f ) Nifedipine (Adalat, Procardia)

g) Nisoldipine (Sular)

h) Verapamil (Calan, Isoptin, Verelan, Tarka)

2) Indications

a) Arrhythmia

b) Angina

c) Hypertension

d) Migraines

e) Raynaud’s syndrome

f ) Congestive heart failure

g) May improve optic nerve perfusion in glaucoma

3) Mechanism: vasodilatation of coronary and peripheral vasculature

4) Common side effects: make beta blockers’ side effects worse, make the antiplatelet (bleeding) side effect of aspirin worse, possible atrial-ventricular block, possible severe hypotension

5) Beta adrenergic blockers

a) Examples

1) Acebutolol (Sectral)

2) Atenolol (Tenormin, Tenoretic)

3) Betaxolol (Kerlone)

4) Carteolol: less effect on heart

5) Metoprolol (Toprol, Lopressor)

6) Nadolol (Corgard)

7) Propranolol (Inderal)

8) Timolol (Blocadren)

9) Carvedilol (Coreg)

b) Indications

1) Angina

2) Anxiety

3) Arrhythmia

4) Hypertension

5) Migraine

6) Myocardial infarction

7) Supraventricular and sinus tachycardia

c) Mechanism

1) Block beta 1 receptors in the heart; slows it

2) Block beta 2 receptors in lungs and eyes; constrict bronchioles and reduce aqueous production

3) Dilate blood vessels

d) Common side effects: bradycardia, asthma exacerbation, fatigue, depression, IOP reduction, will minimize any further IOP reduction from topical beta blockers

6) Angiotensin converting enzyme (ACE ) inhibitors

a) Examples

1) Benazepril (Lotensin)

2) Captopril (Capoten)

3) Enalapril (Vasotec)

4) Fosinopril (Monopril)

5) Lisinopril (Prinivil, Zestril)

6) Quinapril (Accupril)

7) Ramipril (Altace)

b) Indications: hypertension, congestive heart failure

c) Mechanism: intercept the body’s natural vasoconstriction mechanism to reduce blood pressure (BP)

d) Common side effects: rarely blurred vision, cough

7) Angiotensin receptor blockers (ARB)

a) Example: valsartan (Diovan)

b) Indications: hypertension, congestive heart failure; fewer side effects than ACE inhibitors

c) Mechanism: block the body’s vasoconstriction mechanism to reduce BP

d) Common side effects: vertigo, blurred vision

8) Blood thinners

a) Examples

1) Aspirin (Bayer, Bufferin, Ecotrin, Plavix)

2) Heparin (Lovenox)

3) Warfarin (Coumadin)

b) Indications

1) Improve circulation

2) Decrease clotting

c) Mechanisms vary

d) Common side effects: hemorrhage, including ocular. Contraindicated with active intraocular bleeding

9) Cholesterol lowering agents

a) Bile acid sequestrants

1) Niacin in megadoses (Niaspan, Nicolar)

a) Indications: hyperlipidemia

b) Mechanism: slow bile reabsorption, cholesterol is used to replace bile

c) Common side effects: flushing (aspirin helps), hypotension, toxic amblyopia, GI upset

2) Cholestyramine resin (Questran Light)

a) Indications: hyperlipidemia

b) Mechanism: slows bile reabsorption, cholesterol is used to replace bile

c) Common side effects: GI disturbances, vitamin deficiencies could affect vision as well as other health problems

b) Cholesterol synthesis inhibitors

1) Examples

a) Lovastatin (Mevacor)

b) Pravastatin (Pravachol)

c) Simvastatin (Zocor)

d) Atorvastatin (Lipitor)

e) Rosuvastatin (Crestor)

f ) Ezetimibe/simvastatin combination (Vytorin)

2) Indications: hyperlipidemia

3) Mechanism: inhibition of cholesterol synthesis in the liver

4) Common side effects: early reports of cataract stimulation are not true; rarely conjunctivitis, tearing, blurred vision

E) Isoniazid

1) Used as part of combination antituberculosis drugs

a) Examples

1) Rifamate

2) Rifater

b) Common side effects: hepatitis, can cause optic neuropathy

F) Aredia

1) Used to treat osteoporosis and bone cancer

2) Reported 17% incidence of scleritis within 2 days of starting medication

3) Also ocular pain, conjunctivitis, uveitis, episcleritis

4) Scleritis requires stopping Aredia; the other conditions can be managed

5) Monitor every 6 months

G) Accutane

1) Used for severe acne

2) Usually causes dry eye

3) Watch for pseudotumor, visual disturbances, decreased night vision, photophobia

4) Contact lenses contraindicated

H) Tamoxifen

1) Used to prevent the recurrence of breast cancer and preventively in high-risk women

2) Causes drusen-like deposits in the macula in 1 – 6% of users within 6 months. May also cause keratopathy and optic neuritis

3) VA loss is reversible if tamoxifen is discontinued before vision drops below 20/70. Retinal changes are permanent

4) Monitor carefully

I) Flomax

1) Used to increase urine flow in BPH (benign prostatic hypertrophy) in men and urinary retention in women

2) Causes floppy iris syndrome and poor dilation, both of which make cataract surgery more difficult

3) The changes appear to be permanent, and discontinuing the drug before surgery does not help

Clinical Pearls for Optometry Edition 2.1 - Chapter 4

anadem — Fri, 24 Apr 2009 20:22:26 +0000

Injuries

A) Metallic foreign bodies

1) Subjective

a) Complaints of pain or a foreign body sensation

b) Ask about a high speed projectile history because penetration can be occult and self-sealing

c) Ask if occurred at work and if patient was wearing safety glasses because of possible Worker’s Compensation insurance questions

d) Ask about tetanus shot history. If the wound was dirty and bloody and the last booster >10 yrs ago, or did not receive all of boosters, refer for booster shot

2) Objective

a) VA and pinhole or best corrected VA

b) Pupils

c) External

d) Slit lamp

1) Instill topical anesthetic if necessary in both eyes to facilitate examination

2) Look carefully for penetration, dilate if necessary to look for lens penetration and to look at the retina (no scleral depression)

3) Assessment

a) You must R/O the need for a computerized tomography (CT) or x-ray (no magnetic resonance imaging (MRI))

4) Plan

a) For limbal or deep conjunctival foreign bodies, soaking a pledget in topical anesthetic and 2.5% phenylephrine and holding on the affected tissue for 1 min will give deeper anesthesia (cocaine in 4% solution or lidocaine 4% are more effective for painful limbal foreign bodies)

b) Use a foreign body spud, a 1 mm chalazion curette, to remove the foreign body

c) When using a burr to remove a deep rust ring, rinse and clean the bit frequently

d) Remove all rust except the lightest staining

e) Remove all necrotic and edematous material

f ) For stromal wounds, instill 5% homatropine. It relieves ciliary spasm for 2 – 3 days, about as long as it takes to heal

g) Instill Acular or Voltaren for pain

h) Instill Polysporin or Ciloxan ointment for prophylaxis and lubrication

i ) Pressure patching is becoming controversial, but is still a simple way to relieve pain. If you patch in the morning, have the patient remove it before bed. Afternoon patches need to come off by the next morning. Bandage contact lenses are an alternative

j ) Except for non-stromal wounds, prescribe (Rx) Polytrim qid after the patch comes off. If you suspect a contaminated wound, Rx Vigamox or Zymar qid

k) Order a CT whenever an intraocular or orbital foreign body cannot be ruled out (not an MRI)

l ) Refer all intraocular foreign bodies to a retina specialist immediately

5) Return to clinic (RTC) in 2 days

a) Subjective: what % of subjective improvement? Should be at least 50%

b) Objective: visual acuity (VA), pupils, external, slit lamp

c) Assessment

1) Epithelial healing

2) Stromal edema is likely but no infiltrates should be visible

3) Watch striae, may indicate edema or early ulcer

4) Anterior chamber (AC) reaction should be rare cell at most

d) Plan

1) Continue the antibiotic x5d

2) RTC as needed (prn) if Sx worsen or foreign body sensation does not resolve in 3 – 5 days (follow until the epithelium heals)

3) Consider tears prn if a significant foreign body (FB) sensation exists

B) Abrasions, UV burns, welding burns, chemical splashes

1) Subjective

a) Severe pain or foreign body Sx

b) Known history: UV and welding burn symptoms appear several hrs after exposure

2) Objective: (if a chemical burn, irrigate as per Plan below before doing anything else)

a) Instill topical anesthetic for examination comfort

b) VA and pinhole or best corrected VA

c) External

d) Slit lamp with fluorescein

3) Assessment

a) Alkali burns (fertilizer, household bleach) are more persistent and destructive than acidic burns

b) Grade the corneal damage and draw it

4) Plan

a) For chemical splashes, always be sure the patient has 30 min of effective irrigation including that done before patient comes to the office. Be sure the lids are held open, or use a speculum

b) Consider a roll of pH paper. Stop irrigating for 5 min before use. Repeat irrigation until the pH is 7.0

c) 5% homatropine bid for comfort

d) Acular or Voltaren qid for comfort

e) Bacitracin ointment (ung) tid

f ) Pressure patch as needed between ung instillation

g) Alkali burns with epithelial defects may need up to 1 week of steroid to minimize scarring. Refer if severe or central

5) RTC in 2 days

a) Subjective: at least 50% better

b) Objective

1) Re-epithelizing

2) Symblepharon/conjunctival scarring possible with chemical burns

3) Stromal haze possible

4) AC reaction possible

c) Assessment

1) If central scarring, refer or treat with a steroid

2) If AC reaction, cycloplegia, consider steroid

d) Plan: monitor and treat as above until healed

1) Use bacitracin liberally to lubricate and facilitate healing

2) If only stromal haze, monitor

3) If stromal scarring exists after a chemical burn, consider a referral to a cornea specialist or Rx steroids to control

C) Blunt orbital trauma

1) Subjective

a) Known history of blunt trauma

b) Pain?

c) Decreased vision?

d) Diplopia?

e) Flashes or floaters?

2) Objective

a) VA: open lids manually if necessary. Pinhole because the habitual Rx may be wrong now

b) Pupils: afferent pupillary defect (APD) or anisocoria?

c) Extraocular eye movements

1) Any pain on eye movement?

2) Any restrictions, especially in upgaze?

3) If there is an upgaze restriction, do forced ductions with a cotton tipped applicator soaked in anesthetic if the globe is intact

a) No restriction indicates a superior rectus paresis

b) Restriction indicates a trapped inferior rectus secondary to a blow out fracture

d) Confrontation fields

e) Monocular color vision if optic nerve damage suspected

f ) External

1) Draw and document hemorrhage, ecchymosis, and edema. Many of these cases end up in court and drawings are more useful to lay people on juries

2) Look for ptosis and lid lacerations

3) Palpate the orbital rim for step-off fractures and lids for crepitus (crackling sound from trapped air)

4) Check for hypesthesia of the cheek and upper lip on the affected side compared to the unaffected side

5) Compare retropulsion of globes (push gently with thumbs) if you do not suspect a ruptured globe

g) Hertel exophthalmometry: should be £ 21 mm and equal

1) A receded globe may indicate a blow out fracture

2) A proptotic globe resistant to retropulsion may indicate a retrobulbar hemorrhage

h) Slit lamp

1) Cornea: abrasions, lacerations, or striae?

2) AC: hyphema, free red blood cells, inflammatory cell, pigment or flare?

3) Iris: any irregular pupil, anisocoria, iris hemorrhage, iridodialysis, sphincter tears or traumatic mydriasis? Compare angle depth between eyes to find angle recession

4) Lens: subluxation or traumatic cataract? (cataract may take weeks to form)

5) Pigment or RBC in anterior vitreous

i ) IOP: May be low in a traumatized eye. If very low, consider globe rupture. If high, treat with topical glaucoma meds

j ) Dilated fundus examination (DFE)

1) Disk pallor or hemorrhage? (pallor may take weeks to form in optic nerve damage)

2) Retinal hemorrhage or edema from bruising

3) Macular holes, choroidal rupture, or commotio retinae?

4) Vitreous hemorrhage or detachment?

5) Peripheral holes or tears? Do scleral indentation if feasible and no globe penetration or hyphema is present

k) Gonioscopy: defer for 2 weeks if RBC are present in the AC

3) Assessment

a) Identify the affected tissues

b) If there is decreased vision or color vision without corresponding visible tissue damage, consider traumatic optic neuropathy

c) If a retinal detachment cannot be ruled out due to a hyphema or vitreous hemorrhage, a B-scan ultrasound should be performed

4) Plan and follow up

a) Traumatic iritis: 1% cyclopentolate qid or 5% homatropine bid and Pred Forte qid, RTC in 2 days

b) Hyphema and micro hyphema

1) Strict bed rest with head elevated 30°

2) No aspirin or blood thinners

3) Atropine 1% qid

4) Pred Forte qid

5) No reading (too many saccadic eye movements)

6) TV is good

7) Treat elevated IOP if necessary

8) Use a shield on the affected eye

9) Consider bilateral patching to stop saccades

10) No strenuous activity or lifting for 2 – 4 weeks

11) Monitor vision at home and RTC in 1 – 2 days

a) Monitor fundus as it becomes visible

b) Do gonioscopy and scleral depression 2 – 4 weeks later

c) Commotio retinae: monitor weekly, repeat scleral depression

d) Choroidal rupture: retinal consult, then monitor weekly, then monthly for neovascular membrane formation

e) Orbital blow out, superior rectus paresis, crepitus, rim fracture, hypesthesia, exophthalmos resistant to retropulsion

1) Instruct not to blow nose

2) Immediately (STAT) CT

3) Referral to oculoplastics ophthalmologist, or ENT if CT is positive

4) Start broad-spectrum antibiotics and a nasal decongestant

f ) Traumatic optic neuropathy: STAT referral for CT and possible steroids and optic nerve sheath fenestration

g) Laceration, penetration, or rupture of globe or cornea: STAT referral to appropriate sub specialist, usually retina or cornea, depending on location of injury

Clinical Pearls for Optometry Edition 2.1 - Chapter 5

anadem — Fri, 24 Apr 2009 20:21:13 +0000

Red Eye Miscellaneous

A) Lids and margins

1) Subjective: from no Sx to itching and burning lids to intense pain

2) Objective

a) Blepharitis: flakes to heavy crusting with lid redness and swelling, foam along lid margin

b) Meibomian gland disease (MGD)

1) Telangiectasia: look carefully at lid margins and note facial rosacea

2) Express meibomians on all 4 lids. Note capping

c) Hordeolum (stye) or chalazion: note and draw size and location

3) Assessment

a) Blepharitis: grade for reference as you follow improvement

b) MGD grading scale

1) Grade 0: light, clear, oily secretion easily expressed

2) Grade 1: “milky” secretion easily expressed

3) Grade 2: “chunky, greasy” secretions are expressed, also see chunks floating in tear film after expression

4) Grade 3: “toothpaste” squeeze expressed with resistance

5) Grade 4: “toothpaste” squeeze expressed with high resistance or not at all (use 2 opposing cotton tipped applicators)

c) Hordeolum: note if it is erupting or pointing

d) Chalazion: long standing, non-painful, not red, lump. R/O skin cancer

4) Plan

a) Blepharitis: soak and scrub bid OU

1) Very warm compresses every 5 – 10 min

2) Thorough scrubbing of lid margins with lid scrub soap, preferably anti-bacterial

3) Rinse

4) Severe cases will benefit from bacitracin ung bid on margins

5) If marked lid margin inflammation, use Tobradex ung

6) RTC in 2 weeks

b) MGD

1) Soak and scrub tid if possible. Hot soaks are even more important

2) Squeeze out the meibomian glands in a milking action

3) Topicals are little help

4) In severe cases, Rx doxycycline 100 mg bid po (unless pregnant or growing child) until improves and then 50 – 100 mg qd for long term maintenance

5) RTC in 2 weeks

c) Hordeolum

1) Cannot excise until it quiets

2) For lots of heat delivery, boil an egg or microwave a potato and wrap in a damp washcloth and apply to the lid

3) If painful, Rx doxycycline with heat

4) If pointing: express, open if necessary (only if pointing!)

5) RTC in 2 – 4 days

d) Chalazion

1) Inject 0.2 – 1 mL of Kenalog unless darkly pigmented (this may depigment the skin)

2) Excision is the most common procedure. If recurrent, send to pathology to R/O cancer

3) RTC prn if no procedure done

B) Dry eye

1) Subjective

a) History of dry, scratchy or foreign body sensation, or transient blur improving with blink

b) In teen, ask about Accutane use

c) Possible Sjögren’s Sx such as dry mouth

d) Sx may wax and wane according to environmental conditions such as humidity, air conditioning, etc.

e) 8% of women >age 50 affected

2) Objective

a) May have blepharitis or meibomianitis which may be contributing to a dry eye, or the entire cause for Sx

b) Corneal and/or conjunctival staining with fluorescein

c) Minimal tear prism

d) Poor tear quality or break up time <5 sec

3) Assessment

a) R/O lid disease

b) R/O epithelial basement membrane disease (EBMD), foreign bodies, and other corneal problems

c) Determine if it is a tear quality problem (matter or greasy chunks in tears, poor break up time) or a tear volume problem (small tear prism or reduced Schirmer’s with anesthetic)

4) Plan

a) Tear quality problems are usually caused by meibomianitis

1) Mild to moderate: Rx hot soaks and lid scrubs bid or more with tears prn

2) Severe: oral tear quality treatment for meibomianitis and rosacea. Beware of causing or aggravating cholesterol problems with the oils. Always use non-preserved tears, hot compresses and lid scrubs concurrently

a) Flaxseed oil 1 gram bid po with meal

b) Fish oil 1 – 2 grams per day

c) Doxycycline 100 mg po bid for 1 month then qd for 2 months

b) Tear volume problems, a staged approach

1) Mild: preserved tears 1 – 3x/day

2) Moderate: non, or minimally preserved tears such as Genteal, TheraTears, Refresh Liquigel, Systane, Refresh Plus, or Optive, if dosing of 4x or more is needed to prevent confusion with solution sensitivity problems later. Overnight protection with Refresh Plus gel may also be needed

3) Advanced

a) Punctal plugs with non-preserved lubrication as needed

b) Restasis (cyclosporine 0.05%) bid or topical FML qid as inexpensive trial. Expect 1 – 3 month delay in Sx improvement, especially if inflammatory component suspected

4) Severe tear volume problem or Sjögren’s

a) Use topical anti-inflammatory treatment in addition to plugs and lubrication and possibly goggles

b) Add oral treatment: Salagen (oral pilocarpine) 5 mg bid to start, then qid. Half fail due to GI upset though

C) Conjunctiva: itchy-scratches/red eye differential

1) Subjective: history is very important

a) If history of exposure to someone with a red eye, probably viral etiology and is contagious

b) Ask if recent upper respiratory infection (URI) symptoms such as sore throat or rhinitis

c) For subconjunctival hemorrhage ask about lifting, straining, constipation, blood thinners, aspirin, and supplements such as garlic, ginger, ginseng, ginkgo biloba

d) Ask about itching vs. burning, stinging, scratchiness

e) Ask if lids are matted shut or have purulent discharge. Is there ropy mucus or slippery tears?

2) Objective

a) Palpable or tender pre-auricular nodes (PAN): sometimes helpful, document

b) Look at margins and meibomians

c) Grade the amount of, and color of, injection

d) Grade the chemosis

e) Note any follicles: rarely helpful but document

f ) Note presence of and quality of mucus

g) Draw subconjunctival heme

h) R/O iritis and angle closure

i ) Always take BP with subconjunctival heme

3) Assessment

a) Allergic conjunctivitis: itchy, ropy mucus, slippery tears, mild injection, more chemosis, environmental correlation

b) Viral conjunctivitis: much more common than bacterial, burning, prominent mucus including matting shut is possible, “pink” injection, follicles and PAN may (or may not) be present. History usually indicates contagious exposure and infection starting in one eye followed by the other eye

c) Bacterial conjunctivitis: bacterial conjunctivitis without blepharitis is actually quite rare and usually over diagnosed. Beefy redness and prominent mucus are common

d) Subconjunctival hemorrhage: pooling of blood in an asymptomatic eye

4) Plan

a) Allergic

1) Mild to moderate: Similasan Allergy Eye Relief

2) Moderate to severe: Pataday qd – bid may be necessary (note, higher doses may cause burning and dryness)

3) Severe may need FML or Alrex qid until controlled enough for Patanol

4) RTC in 1 – 2 weeks

b) Viral

1) Counsel about hygiene, frequent hand washing, personal wash cloths, clean pillowcases

2) Counsel that the patient is likely to be contagious as long as the eye is tearing

3) Rx vasoconstrictors or tears as needed

4) FML if serious subjective and objective findings (such as infiltrates in the visual axis)

5) RTC in 1 week

c) Bacterial

1) Treat lids with scrubs even if they look clean; this will reduce the bacteria reservoir around eye where drops are not effective

2) Rx Polytrim qid – q2h

3) RTC in 2 – 5 days

d) Subconjunctival hemorrhages

1) Do not blow them off!

2) Take BP!

a) Systolic >220 or diastolic >115 with end organ damage (subconjunctival heme) is an emergency. If the medical doctor cannot see the patient immediately, send to the emergency department

b) If hypertensive, do at least direct ophthalmoscopy to check for papilledema or other retinopathy

c) RTC prn unless eye pathology is found

D) Contact lens associated red eye (CLARE)

1) Subjective

a) History of contact lens wear recently or presently, especially soft or overnight wear (even with silicone hydrogel), dirty lenses, non-compliance with lens replacement schedules

b) Red eye, epiphora

c) Pain or foreign body sensation

d) Photophobia

e) Blur

2) Objective

a) VA may be normal or reduced

b) If the lens is still in, it may be fitting tightly

c) Conjunctival injection, local, limbal, or diffuse

d) Mattering possible

e) Corneal edema, infiltration, staining, and ulceration are all possible

f ) AC cell, flare, or pigmentation are all possible

3) Assessment

a) Is there only epithelial edema or stromal striae?

b) Is there white blood cell infiltration, especially near the limbus?

c) Is there epithelial staining and cell death?

d) Is there a frank ulcer with cloudy infiltration of the stroma vs. an anterior stromal reaction on the surface of the stroma?

4) Plan

a) For edema only, remove the lenses and use lubrication drops prn for comfort. RTC in 2 days. No lens wear for one month, re-check the fit, re-instruct on wearing schedules if necessary

b) For infiltration, stop lens wear and Rx Tobradex qid. RTC in 1 day to be sure not progressing to ulceration or HSV

c) For subepithelial infiltrates with staining, stop lens wear and Rx Vigamox q2h. After re-epithelialization, add Pred Forte qid. Alternatively, Tobradex q2h if there is no suspicion of ulceration. RTC daily until improvement noted

d) For a true corneal ulcer with white blood cells (WBC) or infiltrates in the stroma, striae, AC reaction, but not large or central

1) Remove contacts

2) Rx Vigamox q5 min for 1 hr then q30 min during the day and q1h at night. Alternatively Polysporin ung hs can be used for the nighttime dosing

3) Rx 5% homatropine bid for pain

4) RTC in 1 day

e) Large or central true ulcer

1) Do Gram stain and culture on blood, chocolate, thioglycolate broth and Sabouraud’s or refer to be done. If using culturette, be sure to moisten swab first by breaking vial

2) Refer for fortified antibiotics. Vigamox and Zymar may be as effective, but are not FDA approved for ulcers yet

E) Cornea

1) Subjective: from scratchy, foreign body sensation to intense pain

2) Objective

a) Look carefully with a good slit lamp and white light for epithelial erosions, filaments, epithelial basement membrane disease, striae, infiltrates, endothelial loss or keratitic precipitates (KPs), AC reaction

b) Stain lightly with fluoro-strip and look for the staining pattern. Fluress is too viscous and will hide light staining

3) Assessment

a) Punctate epithelial erosions (PEE): only see after stain. Mild damage

b) Punctate epithelial keratitis (PEK): see white defects before stain. May cause positive or negative stain. More damage. This grading system will allow you to more closely follow healing or deterioration

c) Superficial punctate keratitis (SPK): this term is only correct in Thygeson’s disease

d) Overall pattern: virus, dry eye, eye drop sensitivity

e) Inferior ¹₃ stain line pattern: assume staph marginal keratitis or lagophthalmos

f ) Note if diffuse or confluent stain pattern, draw

g) Do not use too much fluorescein; look carefully for negative stain, indicating an elevated area (epithelial basement membrane disease, HSV keratitis or Thygeson’s)

h) AC reaction up to hypopyon is possible: look at the inferior angle!

i ) Striae

j ) WBC or infiltrate in stroma vs. “anterior stromal reaction”

k) Is the stain pooling in a depression or is it staining cells (dendrite vs. pseudo-dendrite, staining Lasik flap vs. normal flap gutter)?

1) Form a fine strand of cotton on a cotton tip applicator

2) Wick away fluorescein; if pooling, it will disappear, if staining it will stay stained

l ) Deep achy pain and photophobia

m) Prepare slide for Gram stain, culture on blood, chocolate, thioglycolate broth and Sabouraud’s. Use sterile spatula or spud

4) Plan

a) Filaments

1) Remove by rotating a sterile cotton tipped applicator moistened with anesthetic

2) Rx topical antibiotics and aggressive non-preserved tear application

3) Avoid ointments

4) Consider temporary disposable CL with antibiotic use; it will melt filaments beneath the lens

5) Treat the cause of the filaments

6) RTC in 2 days

b) Subepithelial infiltrates: epidemic keratoconjunctivitis

1) Lubricate and counsel if few Sx

2) Probably not infectious at this stage, but wash your hands anyway!

3) Instill topical anesthetic

4) Instill 1 drop of ophthalmic Betadine

5) Irrigate well

6) Rx FML or Tobradex qtt qid

7) RTC in 2 – 4 days

c) Bacterial keratitis

1) Simple bacterial keratitis

a) Polytrim qid – q2h

b) Lid hygiene

c) RTC in 2 days unless CL related, pain increases or vision decreases

2) Staph marginal infiltrates without AC reaction

a) Tobradex q2h or Vigamox qid with Pred Forte qid

b) Lid hygiene

c) RTC in 2 days unless CL related, pain increases, or vision decreases

3) True corneal ulcers or CL related

a) Start on Vigamox q5 min for 1 hr then q30 min during day and q1h at night if bad. Polysporin ung hs if less worrisome. Tobradex ung hs can be used later if need steroid for scarring

b) Rx 5% homatropine bid for pain

c) RTC in 1 day

d) Pred Forte qid after ulcer is healing and sterile

4) Large or central true corneal ulcer

a) Refer or do stain and culture, and then refer for fortified antibiotics

b) Vigamox and Zymar may be as effective as fortified antibiotics without the toxicity for most pathogens, but they are not FDA approved for ulcers yet

5) Fungal ulcer

a) History (Hx) of vegetative abrasion or a chronically sick eye

b) Gray feathery infiltrate, satellite lesions

c) Very painful, little pus

d) Does not respond to antibiotics

e) REFER!

6) Acanthamoeba

a) Ring stromal infiltrate around the ulcer

b) Usually a CL wearer or a swimming Hx

c) Unusually painful!

d) Non-responsive to antibiotics

e) REFER!

d) EBMD

1) If the epithelium is loosely attached

a) Debride it back to healthy margins with a spud, forceps

b) Lightly abrade Bowman’s membrane with an Alger brush to facilitate epithelial attachment

2) Instill cyclopentolate or 5% homatropine for ciliary spasm

3) Instill Voltaren for comfort

4) Instill bacitracin ung and pressure patch for up to 24 hrs, then Rx bacitracin ung tid

5) Alternatively, insert a bandage lens and Rx Polytrim gtt qid

6) RTC in 2 days

7) Use 5% NaCl ung hs for 2 months

8) If recurrent, try stromal micropuncture

9) If still recurrent, consider excimer PTK

F) Herpes simplex virus (HSV)

1) Subjective: usually unilateral, red, photophobic, tearing

2) Objective

a) May have lid or skin involvement

b) May have tender or palpable pre auricular nodes

c) Look for dendrites with end bulbs

d) Compare corneal sensitivities with cotton wisp

e) Look for cells and flare

f ) Measure IOP

3) Assessment: R/O pseudo-dendrite (a healing abrasion line) by

a) History: ask how it felt yesterday. If it was a lot worse, it is a healing abrasion. If pain is worse today, it is a likely HSV dendrite

b) Pseudo-dendrites do not have end bulbs that stain with rose bengal or lissamine green

c) If you are still unsure of diagnosis, lubricate with bacitracin ung and RTC in 1 day. If worse, treat as HSV

4) Plan

a) Be sure patient is off of any steroid

b) Consider gentle debridement of dendrite with sterile cotton tipped applicator to reduce viral load (experts disagree)

c) Rx Viroptic 1% 9x/day (q1h – q2h)

d) Pediatric use: if the child is uncooperative with drops and tearing is diluting the Viroptic, co-manage with pediatrician to Rx acyclovir, Valtrex, or Famvir. 2 or more yrs of slow taper may be necessary

e) Instill 5% homatropine (or atropine 1% if severe)

f ) RTC in 2 days, draw and monitor ulcer size

g) Viroptic 5 – 9x/day for 2 weeks then taper for 1 week, lubricate with bacitracin ung

h) If there is still a remaining defect, need to discontinue Viroptic because it becomes toxic and it may be the reason for the defect. If no rose bengal stain, probably no active virus; lube aggressively and watch

i ) If you need further viral coverage, Rx oral acyclovir 200 mg po 5x/day or Valtrex 500 mg po bid, or Famvir 125 mg po bid. Consult with an internist if kidney problems or pregnancy

j ) Stromal reaction under dendrite, watch carefully, should fade gradually

k) Stromal disease: REFER!

1) Disciform: disk shaped stromal edema with intact epithelium, local KPs, possible mild iritis

2) Necrotizing interstitial: multiple or diffuse infiltrates with thinning, neovascularization, inflammation. Possible hypopyon, iritis and glaucoma

3) Neurotrophic ulcer: a sterile, melting ulcer

G) Herpes zoster (HZO) (shingles)

1) Subjective: pain, usually intense on one side of the face

2) Objective

a) VA and pinhole or best corrected VA

b) External: note and draw vesicles and note if they are wet or dry

c) Versions to R/O extra ocular muscles (EOM) palsy

d) IOP: glaucoma is a common side effect of HZO

e) Slit lamp: conjunctivitis, diffuse corneal staining, pseudo-dendrites from mucus plaques, and iritis may be present

f ) DFE: important to R/O rare but devastating retinitis or vitritis

3) Assessment: HZO respects the midline (vs. HSV)

4) Plan

a) Treat any IOP rise, iritis or corneal staining in the usual way

b) Treat IOP without prostaglandins if iritis is present

c) Be sure the patient is on antivirals or you will need to Rx acyclovir 800 mg 5x/day or Valtrex 1000 mg bid (if not pregnant or renal failure) for 10 days

d) Tylenol 3 and Zostrix may be needed for skin neuralgia (keep out of the eye), very painful

e) If the eye is unaffected, RTC in 1 month and repeat exam for late onset ocular complications

H) Episcleritis

1) Subjective: red eye with painless to moderate pain or tenderness

2) Objective

a) Sectorial or diffuse deep injection of episclera. Nodules are possible, often with pingueculae

b) R/O iritis

3) Assessment

a) R/O conjunctivitis by clinical examination. Also 2.5% Neo-Synephrine will blanch conjunctivitis quickly, but not episcleritis

b) R/O scleritis: scleritis pain is usually deep, severe and radiating. Scleritis causes extreme sensitivity to touch or pressure through the closed lid. Scleritis redness will not blanch with 10% phenylephrine, episcleritis will

4) Plan

a) Mild: tears prn

b) Moderate: FML qid

c) Severe: Pred Forte qid or more, ibuprofen 400 mg po qid

d) RTC in 1 week

e) Consider other connective tissue disease

I) Scleritis

1) Subjective: may be deep, severe, radiating pain, red eye, very sensitive to touch through the closed lid

2) Objective

a) Injection of deep vessels and purple or blue tinge of sclera observed with normal room lighting

b) Nodules may be present

3) Assessment

a) Vessels are not mobile with cotton swab

b) Vessels do not blanch with 10% phenylephrine

c) Pain is usually intense

d) Iritis, corneal, lens, retinal changes may co-exist; do a dilated fundus exam

e) Many have connective tissue disease

4) Plan

a) Internal medicine or rheumatology consult

b) Oral prednisone 80 mg po in divided doses until improvement, then slow taper

c) Ibuprofen 600 mg qid po

d) RTC in 2 days

e) Refer if no improvement in 1 week