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Transcript
Chapter 40 AGENTS USED IN THE TREATMENT OF CONDITIONS OF THE EYES The eyes draw images from the light reacting off the retina, and these images are transmitted by way of the optic nerve for interpretation by the brain. The lens is divided by the iris into an anterior and a posterior chamber that are filled with water aqueous humor that bathes the eye constantly to prevent it from drying, which would cause its fragility. Mydriatic Agents Mydriatic drugs are agents that dilate the pupil Sympathomimetic Mydriatics ◦ Produce pupillary dilation, increase the outflow of aqueous humor, cause vasoconstriction, relax the ciliary muscle, and decrease the formation of aqueous humor ◦ Moderate strength: used in management of narrow-angled glaucoma ◦ Weaker solution: used as opthlamic decongestants for symptomatic relief of minor eye irritants Anticholinergic Mydriatics ◦ Blocks the response of the sphincter muscle of the iris and the muscle of the ciliary body to cholinergic stimulation ◦ Produces dilation of the pupil and may interfere with the ability of the eye to focus properly ◦ Should NOT be used with patients with glaucoma Ophthalmic Anti-Infectives Antibacterial Agents Antifungal Agents Antiviral Agents Ophthalmic Antibacterial Agents Used in the eye to treat superficial infections caused by strains of microorganisms susceptible to the antibiotic in the product Classified into: ◦ Macrolides ◦ Aminoglycosides ◦ Fluoroquinolones ◦ sulfonamids Ophthalmic Antibacterial Agents Azithromycin (AzaSite) ◦ Macrolide antibacterial ophthalmic solution used for treatment of bacterial conjunctivitis ◦ Broad-spectrum ◦ Prolong use can result in resistant organisms Ophthalmic Antibacterial Agents Fluoroquinolone agents ◦ floxacin HCl (Besivance) ◦ Used to treat bacterial conjunctivitis caused by susceptible bacteria ◦ Approved for use in clients as young as 1 year of age ◦ Most common adverse effect: conjunctival redness ◦ Prolonged use may present a risk of superinfection ◦ Ciprofloxacin (Ciloxan) ◦ Available as an ophthalmic solution and ointment forms ◦ Effective against both gram-positive and gram-negative ocular pathogens ◦ Used in the treatment of corneal ulcers and conjunctivitis caused by susceptible organisms ◦ Adverse effects: local burning, margin crusting, foreign body sensation, itching, conjunctival hyperemia, and bad taste after ocular instillation ◦ gatiflocaxin (Zymaxid) ◦ Used for the treatment of bacterial conjunctivitis ◦ Effective agin certain aerobic gram-positive microorganisms and aerobic gram-negative bacteria ◦ Common adverse effects: headache, unpleasant taste, decreased visual acuity, eye pain, eye discharge, eyelid edema, dry eye, headache, and red eye Ophthalmic Antibacterial Agents Aminoglycoside ◦ Gentamicin ophthalmic ointment/solution ◦ Used in the treatment of conjunctivitis, keratitis, keratoconjunctivitis, corneal ulcers, blepharitis, blepharoconjunctivis, acute meibomianitis, and dacryocystitis caused susceptible strains of microorganisms ◦ Most common adverse effects: ocular burning and irritation, conjunctivitis, conjunctival hyperemia, allergic reactions, thrombocytopenia purpura, and hallucinations Antifungal Agents Natamycin (Natacyn) ◦ Effective in treatment of blepharitis, fungal conjunctivitis, and keratitis caused by certain fungal organisms ◦ If no improvement after 7-10 days of therapy, it is concluded that the infection is not cause by an organism susceptible to natamycin Antiviral Agents Idoxuridine (Herplex) ◦ Indicated for the treatment of keratitis caused by the herpes simplex virus ◦ Important to monitor the progress of the diseases carefully to determine if the client is responding Vidarabine (Vira-A) ◦ Active against herpes simplex type 1 and 2, varicella zoster, and several other viruses ◦ Client should be monitored for the development of burning, irritation, or any other adverse changes in the eye while using this medication Trifluridine (Viroptic) ◦ An agent that also mayyy be used to treat viral infections of the eye ◦ Effective in the treatment of hepes simplex types 1 and 2 infections ◦ Ocular toxicity may result if used for longer than 21 days Antisepticspg 1304 Solutions of boric acid, zinc sulfate, and some of the surface-wetting agents are used primarily as ocular irrigants Solutions of silver nitrate or mild silver protein are used to precipitate and remove accumulated mucus from the eye Antiseptic action may be attributed to precipitation of bacterial protein by liberated silver ions Ocular irrigationpg1309 Most often used to flush chemical irritant's, blood splatters or small particles from the eye. Sterile 0.9% Sodium Chloride is commonly used Navstel (balanced salt ophthalmic solution with hypromellose, dextrose and glutathione disulfide), for use during ocular surgical procedures involving perfusion of the eye Anytime ocular irrigation is performed great care must be taken to prevent excessive pressure that could damage ocular structures Local Anestheticspg1309 Used in procedures where topical ophthalmic anesthetic is required (i.e. Tonometry, gonioscopy, removal of foreign objects or stitches from the cornea or any other surgical procedure of short duration 1 drop into the eye is generally administered shortly before the measurement or procedure is to be initiated, the blinking reflex is temporarily eliminated while the eye is anesthetized state Most commonly used local anesthetic in the US is proparacaine HCI, however an approved new formulation of lidocaine HCl as an ophthalmic anesthetic, Akten Take care with use of these agents, prolonged exposure to the eye can produce corneal opacification and ulceration accompanied with vision loss Corticosteroids Used in the eye to exert anti-inflammatory action Uses: -Relieves pain and discomfort to the eye due to: trauma, allergic infection. Side effects: -prolonged use may result in glaucoma -damage to structure of the eye -cataract formation -increased susceptibility to infection reaction, and ocular Contraindications and examples Contraindicated in fungal and viral infections because steroids may facilitate their spread. Examples: -Difluprednate -Loteprednol -Rimexolone -Ozurdex Nonsteroidal Anti-Inflammatory Agents Cyclosporine (Topical immunomodulator/ anti-inflammatory) Uses: -Chronic dry eye due to ocular inflammation associated with keratoconjunctivitis sicca. Adverse effects: -Ocular burning, pruritus, stinging -Conjunctival hyperemia -Foreign body sensation, eye pain No known drug interactions Diclofenac Sodium (NSAID) Uses: - postoperative inflammation following cataract surgery. -postoperative pain and photophobia associated with corneal refractive surgery. Adverse effects: -Keratitis, transient burning, stinging on instillation -Nausea and vomiting -Increased IOP, ocular allergy No known drug interactions Flurbiprofen Sodium (NSAID) Uses: -Prevention of intraoperative miosis Adverse effect: -Ocular irritation -Transient burning and stinging No known drug interactions Ketorolac Tromethamine (NSAID) Uses: -Seasonal allergic conjunctivitis, burning -Postoperative pain, stinging following corneal refractive surgery, follow incisional refractive surgery. Adverse effects: -Transient burning and stinging with instillation -Ocular irritation, allergic reaction -Superficial ocular infections and superficial keratitis No know drug interactions photosensitivity Ophthalmic Antihistamines Used to treat conjunctivitis related to allergies Bepotastine (Bepreve) ◦ Allergic conjunctivitis ◦ Indicated in adults and children 2 years and older ◦ Ophthalmic solution ◦ Not used for contact lens irritation Adverse Effects ◦ Mild taste after instillation, eye irritation, headache, & nasopharyngitis Ophthalmic Antihistamines (cont.) Epinastine HCl (Elestat) ◦ Dual action antihistamine ◦ Prophylaxis for itching ◦ Mast cell stabilizer ◦ Administer one drop per eye twice a day Adverse Effects ◦ Burning sensations, pruritus, redness, etc (pg. 1310) Ophthalmic Antihistamines (cont.) Levocabastine HCl (Livostin) ◦ Relieves S/SX of seasonal allergic conjunctivitis ◦ Adults and children 12 years and older ◦ One drop per eye four times per day Adverse Effects ◦ Burning or stinging when administered, dry eyes & mouth, headache, & sleepiness Other Agents Used For The Eyes Dapiprazole HCL (Rev-Eyes) ◦ Alpha-Adrenergic blocking agent to constrict the pupil ◦ Not used more than once a week Artificial Tears (Isopto Tears, Lacril, Tearisol, Tears Naturale) ◦ Provide tear like lubrication for dry & irritated eyes ◦ Can be used to lubricated contact lenses & artificial eyes Ocular Hypertension Any increase in intraocular pressure (IOP) ◦ Described as being greater than 21 mm Hg in one or both eyes (Normal is between 13-20 mm Hg) ◦ No apparent abnormalities with the optic nerve ◦ No signs of glaucoma ◦ Not considered a disease Glaucoma Characterized by an increase IOP that results in damage to the ocular nerve and blindness May be caused by: ◦ An acquired structural defect within the eye (primary glaucoma) ◦ The consequence of another ocular disease or trauma (secondary glaucoma) ◦ The result of a genetic defect (congenital glaucoma) ◦ If left untreated, may lead to optic nerve degeneration, loss of visual field, and eventual blindness Glaucoma Aqueous humor production is produced by an enzyme called carbonic anhydrase, as well as other enzyme systems Normally, production and output of aqueous humor remain within defined limits, usually less than 20 mm In glaucoma, increased intraocular pressure is cause by a blockage of the outflow mechanism If the pressure is unrelieved, the optic nerve eventually is injured and destroyed This degeneration is evidenced symptomatically: ◦ 1. loss of visual field ◦ 2. loss of central visual acuity ◦ 3. total blindness Glaucoma Open-angle glaucoma ◦ The most common form ◦ No change in the chamber angle of the eye ◦ Due to local degenerative changes, aqueous outflow is impeded ◦ Narrow-angled glaucoma ◦ Iris occludes the anterior chamber angle structures ◦ Normal outflow is prevented ◦ Dilation of the pupil may precipitate an acute glaucoma attack by causing the bunched-up iris to block the outflow of aqueous humor ◦ Generally requires a surgical procedure, iridectomy Agents that Decrease the Formation of Aqueous Humor Carbonic Anhydrase Inhibitor ◦ ◦ ◦ ◦ ◦ Inhibit the action of the enzyme carbonic anhydrase Reduces the amount of humor produced decreasing IOP Treatment for open-angle glaucoma and preoperative management of acute narrow-angle glaucoma All of the drugs in this category are diuretics Do NOT use if sensitive to sulfonamide Osmotic Diuretics ◦ Administered orally or parenteral ◦ Reduce the production of aqueous humor in the eye and thereby reduce IOP ◦ Used to treat acute episodes of narrow-angle glaucoma or in preparation for surgery of glaucoma and other eye disorders ◦ NOT for chronic use ◦ Use with CAUTION in clients with renal impairment Agents that Decrease the Formation of Aqueous Humor Beta-Adrenergic Blocking Agents ◦ ◦ ◦ ◦ ◦ ◦ Applied topically Lower IOP by a mechanism believed to result in reduced formation of aqueous humor Have little effect on pupil size or visual acuity, therefore do not cause blurred vision or night blindness Use with CAUTIOUN in patients with bronchia asthma and congestive heart failure May cause ocular irritation and slightly reduce the rest HR of some clients Drugs: Timolol maleate (Temoptic), timolol hemihydrate (Betimol), betaxolol HCl (Betoptic), levobunolol HCl (Betagan), carteolol (Ocupress), and metipranolol HCl (Optipranolol) Glaucoma Nursing Practice Assessment includes determination of visual acuity and IOP, inquiry about visual changes and headaches, and specific questioning about the use of medications in the eye Carbonic anhydrase inhibitors should not be taken near bed time. Have the client report tingling in the fingers and toes, urticaria, and evidence of weight loss or changes in BP many ophthalmic solutions/drops may cause a temporary dimming or blurring of vision. Provide for client safety Never use an ophthalmic solution that is cloudy or has changed its ways Many ophthalmic solutions/drops may cause a temporary dimming or blurring of vision. Provide for patient safety. Clients with asthma who are taken pilocarpine must be monitored for pulmonary edema and asthmatic attacks Always be certain the proper medication is being used in the correct eye Agents that INCREASE the outflow of Aqueous Humor Direct-Acting Miotics, agents mimic the action of the neurotransmitter acetylcholine and act to constrict the pupil and contract the ciliary muscle (ex. Pilocarpine), acetylcholine may be used Miotics that inhibit Cholinesterase activity, agents prevent enzymatic destruction of acetylcholine within the eye inhibiting the enzyme, cholinesterase, they are more toxic and longer acting than the direct-acting miotics, generally for use in open-angle glaucoma who don’t respond to other forms of drug therapy, cholinesterase inhibitors may cause local or systemic adverse effects Agents that DECREASE formation and INCREASE outflow of Aqueous Humorpg 1325-1326 Progstaglandin Analogs, (ex. Bimatoprost, lantanoprost and travoprost) reduce intraocular pressure by increasing aqueous humor outflow, used for open-angled glaucoma and ocular hypertension and considered 2nd line treatment, because tends to change color of the iris Sympathomimetic Agents, (ex. Epinephrine) stimulate adrenergic receptors within the eye, initially may result in a reduction of aqueous humor production, prolonged therapy with these drugs may result in an increase in the outflow of aqueous humor, caution must be used in older adults and in clients with hypertension, DM, hyperthyroidism, or HD Dipiverfrin HCI (propine) is an agent that penetrates the cornea about 17times faster than epinephrine and once absorbed is converted to epinephrine by enzyme hydrolysis within the human eye; believed to be less irritating than other forms of epinephrine therapy Nursing Interventions Direct-actin Miotics, monitor for flushing, sweating, GI distress, diarrhea and headache Miotics inhibit cholinesterase, monitor for toxicity, atropine sulfate or pralidoxime chloride (2PAM) may be used as an antidote Prostaglandins analogs, advise clients that wear contact lens to remove their contacts prior to instillation of this solution Sympathomimetic agents, use only in open-angled glaucoma because of the mydriatic effect may precipitate an acute glaucoma attack to client who have narrow-angle glaucoma prior to an iridectomy Questions What antidote can be used in toxicity with cholinesterase-inhibiting drugs? What is Ocular Hypertension? Normal range? What is Ocular Hypertension? Normal range? General term to describe any increase in intraocular pressure or pressure inside the eye that is greater than 21 mm Hg in one or both eyes Normal range is between 13-20 mm Hg