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Gtts, Ungs, Tabs
COMPREHENSIVE REVIEW OF
DROPS, OINTMENTS, AND PILLS
THAT YOUR DOCS RX FOR THE EYES
Mindy J Dickinson, OD
Midwest Eye Care, PC
Learning Objectives
 Abbreviation Review
 Color Coded Caps Associated with each Class of Drops
 Basic Dosage and Side Effects of the Drug Classes
 Topical and Oral Agents
 Become Familiar with Which Products Belong to Which Class of Drugs
1)
2)
3)
4)
5)
6)
7)
8)
Antibiotics
Anti-Inflammatories
Combination Drops
Antivirals
Anti-Allergy Agents
Eye Pressure Lowering Agents (Anti-Glaucoma)
Dilation/Cycloplegic Drops
Other
Abbreviation Review
 Gtt (gutta)
 Ung (unguentum)
 Tab
 OD (oculus dexter)
 OS (oculus sinister)
 OU (oculus uterique)
 PO (per os)
Dosing Schedules
 QD
 BID
 TID
 QID
 QHS
 QOD
 Q15 min, Q1h, Q2h,…
 PRN
Things that must be on a Rx
1.
2.
3.
4.
5.
6.
7.
8.
Drug Name (brand name or drug name)
Recommended Dosage
Dispense Quantity
Number of Refills
Generic allowed or not
Dr’s Signature
Date
Dr’s Contact Information
Cap Color-Coding
 Most drug classes have a special color of cap to signify
what it does





Antibiotics: tan
Steroids: pink
NSAIDS: grey
Dilation drops: red
Glaucoma: turquoise, yellow, orange, purple, blue
 Helpful for patient education
 Helpful when taking patient history to understand what drops
they are using and how often
** Not all generic drops will follow this rule of thumb
Antibiotic Drops
 Purpose: kill bugs
 Used for corneal ulcers, bacterial conjunctivitis, blepharitis,
prevent infection in setting of recent eye surgery, corneal
abrasions, foreign bodies, etc
 Cap Color: tan
 Dosage: variable
 May be as low as BID



Don’t usually dose any lower due to increased chance of bug
resistance
Most frequently is QID
May be as much as Q15 min x 4 doses (a loading dose) or Q1h
Before Rxing any Antibiotics…
 Always confirm if patient has any known
allergies !!
 Common: penicillin, sulfa
**Role of technician: must have this
documented in every chart that you reviewed
allergies with patient
Antibiotics
 ZYMAXID, VIGAMOX (TID), MOXEZA (BID) , BESIVANCE (TID)



Newest, “strongest”, brand name only, most $$$
No ung possible
Usually save for more serious infections, corneal ulcers
 CILOXAN (ciprofloxacin), OCUFLOX


Older, still broad spectrum, generic, less $
CILOXAN ung – but no generic, very $
 TOBREX (tobramycin)

Less $, Ung available as well
 POLYTRIM (polymixin B sulfate and trimethoprim)

Great for conjunctivitis, safe in small children, cheap
 AZASITE

Azithromycin drop, very $$, mostly used for blepharitis, conjunctivitis (BID x 2 d, QD x 5 d)
 GENTAK (gentamycin)


Irritating to ocular surface, often from PCP or ER docs
Ung available as well
 Can have fortified antibiotic drops compounded as well


Specialty pharmacy makes extra strength sterile drops
Usually in stetting for serious infection – corneal ulcer, endophthalmitis
Antibiotic Ungs
 Benefits:
 Adhere longer to ocular surface
 Offer increased comfort since greases up ocular surface so less friction between
eyelid and cornea
 May be dosed less often since sits on eye longer
 Cons:
 Blur vision
 May be more difficult to instill
** may be helpful role as the technician to offer tips to patients/parents on how to
instill ointment
 Common ungs:
 Polysporin (polymixin B/bacitracin)
 CILOXAN
 TOBREX (tobramycin)
 GENTAK (gentamycin)
Oral Antibiotics
 Used for ocular/peri-ocular infections where drops
not going to be effective
 Need to make sure not allergic to
 Pre-septal cellulitis, hordeolum (stye)
 Eyelid disease (chronic blepharitis, meibomitis)
 Peri-ocular abcesses
 Chlamydial conjunctivitis
 In fractured orbit to prevent spread of sinus germs
 ? Sinus infection causing peri-orbital pain
Oral Antibiotics
 Doxycycline
 Used for blepharitis/meibomitis, recurrent styes
 Has an enzyme in it that cleans the glands out from the inside and reduces
inflammation in the eyelid glands as well
 Dosage:




May get as a convenience pack ($$) that also includes eyelid scrubs, heated
goggles



20, 40 , 50, 100 mg tablets
1 tab po QD x 30 days or 1 tab po BID x 2 weeks, then QD x 2 weeks
May dose for several months at a time so may need refills
ALODOX, OCUDOX
Cannot give if pregnant or if a child (permanently discolors teeth)
Side effects:



GI upset
More likely to sunburn
Females: ? Increased risk for yeast infection, reduced efficacy of BCP
 Minocycline
 50 or 100 mg – good alternative if doxycycline not available
Oral Antibiotics
 Azithromycin



Chlamydial conjunctivitis – 1 gram tab po x 1 dose
ZPAK – 1 day, 3 days or 5 days
Cannot give if heart beat issues
 Augmentin (amoxicillin + clavulanate)


Cannot give in PCN allergy
500 mg PO BID or TID or 875 mg PO BID
 Amoxicillin


Cannot give if PCN allergy
250-500 mg PO TID or 500-875 PO BID
 Keflex

250 mg QID or 500 mg BID
 Cipro


250 mg QID or 500 mg BID
fluoroquinolone
 Bactrim DS (trimethoprim sulfamethoxazole)


Cannot give in sulfa allergy
1 tab po BID
Antiviral Drops
 Purpose: kill viruses on ocular surface
 Used for Herpes Simplex dendritic keratitis, possibly viral conjunctivitis
 Cap color: white
 2 options:
 VIROPTIC (trifluridine) –



Older, not as expensive (still >$100), more toxic/irritating to eye
Dosage: variable - Q2hr while awake, QID, sometimes tapered
ZIRGAN


Newer, $$$$, comes in tube, more gel-like, not all pharmacies carry, much
less toxic/irritating to eye
Dosage: 5x per day until ulcer healed, then reduce to TID x 1 more week
Oral Anti-Virals
 Purpose:
 Used to reduce recurrences of Herpes Simplex (Cold Sore) flare-ups
 Used upon first evidence of a Herpes Zoster (Shingles) outbreak
 Options:
 ZOVIRAX (acyclovir)




VALTREX (valacyclovir)




400 mg BID long term for HSV
800 mg 5x/day x 1 wk for active Shingles
can get made into suspension for a child
500 mg QD long term for HSV
1000 mg TID x 1 wk for active Shingles
can get made into suspension for a child
FAMVIR


500 mg QD long term for HSV
500 mg TID x 1 week for active Shingles
Anti-Inflammatory Drops - Steroids
 Purpose: reduce inflammation
 Used for conjunctival/corneal/anterior chamber inflammation
– perhaps related to allergies, chemical exposure, recent
infection, trauma, contact lenses or surgery; iritis/uveitis; as
both prevention and treatment of post-operative swelling in
front of eye and/or in macula; reduce chance of rejecting
transplanted corneal tissue
 Cap Color: pink
 Dosage: variable
 QD all the way up to Q1hr
 Often start more aggressive and then slowly taper
Steroids Facts
 Most are suspensions – separate in bottle
 MUST SHAKE before each use

particularly generics
 Cloudy in color, “milk”
 Usually important to taper, not stop suddenly
 Potential Side Effects:




Increase in eye pressure
Early cataract formation
Increased risk of infection
Bad taste in back of mouth after instilling
Steroid Eye Drops (+)
 Stongest
 DUREZOL



PRED FORTE, OMNIPRED (prednisolone acetate 1%)



Suspension – MUST SHAKE
Brand name thought to penetrate into eye better
LOTEMAX





Emulsion – only one you don’t have to shake
More expensive, but more potent
Suspension – must shake
Not as potent, but less potential side effects
Can get in gel or in ung ($)
Often used more in more chronic situation
 Preventing an iritis flare up, anti-rejection, dry eye syndrome
ALREX, FLAREX, VEXOL, FML (fluometholone 0.1%)



Suspension – must shake
Weakest, but least side effects
Often in less inflamed, more chronic conditions
 Indicated for allergic conjunctivitis, dry eye syndrome
 Weakest
Oral Steroids
 Used in severe allergic and inflammatory conditions where drops not
effective enough

Immune-mediated corneal melts/ulcers, Scleritis/Severe Episcleritis,
Severe Uveitis (both in front or back of eye), Inflammatory Orbital Pseudotumor ,
Giant Cell Arteritis (optic nerve swelling)
 Optometrists cannot Rx oral steroids in all states
 Side Effects a big deal
 Increase blood sugars (concern in diabetics)
 Change in mood, sleeping habits, appetite
 Weight gain, acne, outbreaks of other problems (cold sores, shingles, genital herpes)
 Prednisone: 2, 5, 10, 20 mg tab
 MEDROL DOSEPAK: (21 - 4 mg tabs, directs you to take 6 the first day
and reduce to 1 per day over 6 days) – “take as directed”
Combination Antibiotic/Steroid Drops
 Purpose: offer both anti-infective and anti-inflammatory
properties in single drop

Used for settings when need antibiotic protection such as missing
skin on eye, but need to calm down swelling,


Corneal abrasion, chemical burns, foreign body, traumatic iritis, some
conjunctivitis
Not supposed to be used when active infection is not yet controlled as
steroid will reduce ability of immune system to fight it off and can
make it worse

Corneal ulcers !
 Cap Color: pink or white
 Dosage:

Usually QID or perhaps up to Q2hr
Combinations of Antibiotic/Steroid
 TOBRADEX ST (tobradex) (tobramycin/dexamethazone)
 Drops or ung
 Need to be careful with name – tobrex vs tobradex – big deal if
you rx it wrong and gave a steroid to someone that should not
have it!!
 More $
 MAXITROL (neomycin/polymixin B/dexamethasone)
 Drops or ung
 Much less expensive
 Higher chance of irritation/allergy to neomycin
Non-Steroidal Anti-Inflammatory Drugs
 NSAIDs
 Purpose: to reduce inflammation of ocular tissue, reduce
pain,


Used for surface inflammation such as episcleritis, pain associated
with corneal abrasions/recurrent corneal erosions
Used for the prevention/treatment of pain and inflammation
associated with ocular surgery (cataract, refractive surgery)
 Cap Color: gray
 Dosage:

Variable – QD to QID
Topical NSAIDs
 ILEVRO, PROLENSA, BROMDAY


Newest, $$, QD dosage, great penetration into back of eye
Usually dosed day before cataract surgery, day of surgery, and 2
weeks after
 NEVANAC

TID dosage, also great penetration into back of eye
 XIBROM

BID dosage
 ACUVAIL

PF vials, BID, meant for post-surgery care
 ACULAR LS (Ketoralac)

QID, Generic, cheap, stings like crazy
 Flurbiprofen

QID, Generic, cheap, stings like crazy
Oral NSAIDs
 OTC:
 ADVIL, MOTRIN (ibuprofen)
 Pain associated with corneal abrasions/foreign bodies, etc
 Reduce inflammation associated with conjunctivitis
 Reduce inflammation associated with episcleritis
 Dosage: 600 mg po TID with food
 In Rx form can get 800 mg tablets, otherwise 200 mg tablets OTC
 ALEVE (naproxen)
 Aspirin
 81 mg (baby) – reduce risk of stoke, heart attack
 325 mg
 TYLENOL (acetaminophen)
 Does not thin blood
 Pain associated with blunt trauma to eye that has a hyphema (since don’t want
them to rebleed)
 Patients who cannot take ibuprofen
 Rx only:
 Indomethacin

Used for more severe inflammation – severe epicleritis/scleritis/orbital pseudotumor
Anti-Allergy Drops
 Purpose: to treat itchy, watery, puffy, red eyes associated with
allergic conjunctivitis
 Work either as anti-histamine or as a mast cell stabilizer
 Cap color: white
 Dosage:
 QD or BID/PRN
 Some Rx only, some OTC
 Beneficial over OTC Visine-A, Naphcon A, etc products
 Side Effects: sting, bad taste in back of mouth
Anti-Allergy Eye Drops
 PATADAY
 QD, more $, very effective, little to no sting
 PATANOL
 BID
 BEPREVE
 BID
 OPTIVAR (azelastine)
 Only rx with generic option, BID
 ELESTAT
 BID
 LASTACAFT
 QD, stings
 ZADITOR/ALAWAY (ketotifen)
 OTC, BID, many additional names out there, stings, not always as effective, but
cheaper than most
 ALOCRIL, ALOMIDE, cromolyn
 Less often used, have to be dosed QID
Glaucoma Drops
 Purpose: to lower intraocular pressure and thereby
reduce the risk of further nerve damage by glaucoma
 Work by either decreasing aqueous production and/or
increasing aqueous outflow
 Cap color: depends on mechanism of action
 Dosage: depends on which class of drug (QD, BID, TID, QID)
 Side Effects: depends on which class of drugs
Glaucoma Drops
 Prostaglandin Analogs
 Increase outflow of aqueous humor
 Brands:
•
•
•
•
•
XALATAN (latanoprost)
TRAVATAN Z
LUMIGAN
ZIOPTAN (new and preservative free, $$$)
RESCULA (only one with dosing BID)

Cap Color: turquoise

Dosage: 1 gtt QHS

“First line” therapy, 25-30+ % IOP reduction

Side effects:

darkening of iris and skin around eye, thickening/lengthening of lashes, red
eye, inflammation in eye
Glaucoma Drops
 ßeta- Blockers


Decrease production of aqueous humor
Brands
 Timolol 0.25% or 0.5%
 BETIMOL, ISTALOL, TIMOPTIC XE (gel)
 TIMOPTIC in OCUDOSE (preservative free vials)
 BETAGAN, BETOPTIC

Cap Color: yellow

Dosage: 1 gtt QAM or 1 gtt BID



25-30% IOP reduction
Can be 1st line
$, Cheap, generic available

Side effects: difficulty breathing, decreased heart rate

don’t give if history of COPD, emphysema, asthma, bradycardia
Glaucoma Drops
 Alpha Adrenergics

Decrease production of aqueous humor

Brands:
• ALPHAGAN P (0.1%)
• Brimonidine (generic – 0.15%, 0.2%)

Cap Color: Purple, if brand name also has a green bottle

Dosage: 1 gtt BID or TID


15-20% IOP reduction
Great additional med, also use post-operatively for IOP spikes

Side effects: red irritated eyes, itching, follicular conjunctivitis

Particularly more likely in generics and at higher concentration
Glaucoma Drops
 Carbonic Anhydrase Inhibitors (CAIs)
 Decreases production of aqueous

Brands:
• AZOPT
• TRUSOPT

Cap Color: Orange

Dosage: 1 gtt BID or TID


15-20% IOP reduction
2nd or 3rd med add – not usually mono therapy

Side Effects: red irritated eyes, burn like crazy, unpleasant taste

Avoid if serious kidney problems, allergy to sulfa
Glaucoma Drops
 Combination Drops
 2 medicines in 1 bottle
 More effective on IOP without much more work on patients behalf,
increases compliance

Brands:


COSOPT (timolol and trusopt), COSOPT PF (preservative-free)
 Generic available still $, stings
COMBIGAN (timolol and alphagan)
 Newer, no generic, most find to be comfortable to use
• Cap Color: dark blue
• Dosage: 1 gtt BID
• Side Effects: due to timolol cannot give if breathing problems (COPD, asthma,
bradycardia)

SIMBRINZA (brinzolamide and brimonidine)
 Newest, no generic, only one without timolol
• Cap Color: white
• Dosage: 1 gtt BID or TID
Glaucoma Drops
 Sympathomimetics

Increase outflow by pulling on drain to help it open

Brands:
• Pilocarpine (1, 2, 4%)
• Carbachol


Cap Color: Green
Dosage: 1 gtt BID to QID

Very rarely use any more now that have more options

Side Effects: miosis (constrict) of pupil, peripheral retina pathology
(tear, RD), accommodative spasm so eyes shift near-sighted, headache
Oral Meds to Lower Eye Pressure
 Used when IOP rises suddenly to a very high level (50+)
 Acute glaucoma – angle closure
 Severe inflammation – sometimes see in Shingles
 Recent Trauma – blood blocking drain
 Not meant for long term maintenance
 Carbonic Anhydrase Inhibitors

Decreases aqueous (and CSF) production
 Diamox


250 mg 1 tab PO QID or 500 mg Sequel 1 tab PO BID
Neptazine

25 mg 1 tab PO QD or BID or TID

Optometerists in some states may not be able to Rx this

Side Effects: tingling of skin, metallic taste, cannot give if kidney disease
Dilation/Cycloplegic Drops
 Purpose:
1)
To dilate pupil to allow better viewing of the back of the eye
2)
To relax ciliary muscle and thereby relax accommodation –
allowing full hyperopic refractive error to be found on refraction
(use for examining children)
3)
To treat amblyopia (lazy eye)
4)
To temporarily paralyze the iris and ciliary muscle
a)
b)
to reduce pain in setting of trauma/inflammation
(Corneal abrasion/foreign body, chemical burn, welding burn,
iritis, recent surgery, etc)
to reduce chances of inflamed iris from sticking to the lens behind it
and forming synechiae
Dilation/Cycloplegic Drops
 Cap Color: red
 Dosage: variable
 Depends of duration of action of the drug
 Side Effects:
 Stinging upon instillation, photophobia, blurred near vision
Dilation/Cycloplegic Drops
 MYDRIACYL (tropicamide)



0.5% or 1 %
Best dilator, some limited effect on accommodation (approx 4 hrs)
Used in office, not really Rx’d
 MYDFRIN, NEO-SYNEPHRINE (phenylephrine)





2.5% or 10%
Aides in dilation, not really any effect on accommodation
Use with tropicamide, not by itself
Also constricts blood vessels on surface of eye – can help determine
how deep inflammation is in setting of episcleritis vs. sclertitis
10% rarely used, can increase blood pressure, need to punctally
occlude, used to break synechiae in setting of bad uveitis
Dilation/Cycloplegic Drops
 CYCLOGYL (cyclopentolate)
 Most often used for pediatric eye exams to relax accommodation
 Get more accurate refraction – especially if concern for eye turn
 0.5% (< 1 year old); 1% (> 1 year old) – 1 gtt OU, repeat 5 min later
 Takes 30-40 minutes to fully relax accommodation and lasts approx 12-24 hrs
 Can also be used post trauma/surgical procedure – 1 gtt in office or up to QID
 Scopolamine (0.25%)
 1 gtt TID
 Used for paralyzing iris/ciliary muscle in trauma/inflammation
 Homatropine (5%)
 1 gtt BID
 Used for paralyzing iris/ciliary muscle in trauma/inflammation
 Lasts for 24 hours +
 Atropine (1%)
 1 gtt QD
 Used for treatment of amblyopia
 Used for paralyzing iris/ciliary muscle in trauma/inflammation/or post surgery
 Dilation/loss of accommodation last approx 1 week!
Other
 RESTASIS








Used for treating inflammatory forms of dry eye syndrome
Goal is to increase patient’ tear production
Not a quick fix – can take 3-6 month to get effects
Comes in “single use” preservative-free vials
Dosage: 1 gtt BID OU
Write Rx as “30 vials = 1 box = 1 month” with refills
$, rebates often available, cheaper if can use vial more than once
Side Effects: redness, burning/stinging upon instillation
** role of technician in patient education – how to use vials, that it
takes a while to work, that it will likely sting, try artificial tears first,
stick with it for at least 3 months
Other
 MURO (Sodium Chloride)
 OTC
 2% or 5% drops – 1 gtt QD up to QID
 5% ung – apply QHS
 Used to dehydrate cornea in setting of corneal edema
Fuch’s dystrophy
 Post-Operatively



Ung also used to help reduce chances of recurrent corneal
erosions
Drops sting, ung does not
 Artificial Lubricants
 gtts, gels, ungs – OTC, not going to cover here
 FUN at “The Heart”
 Dosage: as much as possible PRN
 Refills: unlimited
 No expiration
Mindy J Dickinson, OD