Download Pharmacology and the Nursing Process, 4th ed. Lilley/Harrington

Chapter 57
Ophthalmic Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Structures of the Eye




Eyebrows, eyelids, eyelashes
Palpebral fissure
Sclera
Uvea



Choroid
Iris
Ciliary body
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Structures of the Eye (cont’d)




Conjunctiva
Pupil
Medial canthus
Lacrimal caruncle


Lacrimal glands
Lateral canthus
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Layers of the Eye
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
All protected by the eyelid
Protective external layer


Middle layer


Cornea and sclera
Choroid, iris, ciliary body
Internal layer

Light-sensitive retina
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Eye Muscles

Each eye is held in place and moved by six
muscles


Rectus (four total)
Oblique (two total)
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Interior of the Eyeball



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
Anterior chamber
Posterior chamber
Canal of Schlemm
Aqueous humor
Vitreous humor
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Interior of the Eyeball (cont’d)

Retina
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

Rods
Cones
Optic nerve
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Lens


Accommodation
Cataracts
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Drugs That Affect the Eye

Mydriatics (apraclonidine)
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
Miotics (acetylcholine, pilocarpine)


Dilate the pupil
Constrict the pupil
Cycloplegics (atropine, cyclopentolate)

Paralyze the ciliary body
 Have mydriatic properties
 Cycloplegia: paralysis of accommodation
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Ocular Drugs
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
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Antiglaucoma drugs
Antimicrobial and antiinflammatory drugs
Topical anesthetics
Diagnostic drugs
Antiallergic drugs
Lubricants and moisturizers
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Glaucoma



Inhibition of the normal flow and drainage of
aqueous humor
Results in increased intraocular pressure (IOP)
Pressure against the retina destroys neurons,
leading to impaired vision and eventual
blindness
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Types of Glaucoma


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Angle-closure glaucoma
Open-angle glaucoma
Also characterized by underlying cause



Primary
Secondary
Congenital
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Classroom Response Question
When administering eyedrops for glaucoma, the
nurse understands the desired drug effect causes:
A. increased intraocular pressure.
B. decreased intraocular pressure.
C. reduced cycloplegia.
D. decreased inflammation.
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Drugs Used to Reduce IOP
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Direct-acting cholinergics
Indirect-acting cholinergics
Adrenergics
Antiadrenergics
Carbonic anhydrase inhibitors
Osmotic diuretics
Prostaglandin agonists
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Cholinergic Drugs


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Mimic the PSNS neurotransmitter ACh
Also called miotics, cholinergics
Direct-acting and indirect-acting drugs
Cause pupillary constriction (miosis), which
leads to reduced IOP caused by increased
outflow of aqueous humor
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Cholinergic Drugs (cont’d)

Direct-acting drugs
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
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
acetylcholine (Miochol-E)
carbachol (Carboptic)
pilocarpine (Pilocar) (also ocular insert form)
Indirect-acting drugs

echothiophate (Phospholine Iodide)
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Cholinergic Drugs: Indications
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
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
Open-angle glaucoma
Angle-closure glaucoma
Ocular surgery
Convergent strabismus (“cross-eye”)
Ophthalmologic exams
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Cholinergic Drugs:
Adverse Effects


Most limited to local effects
If sufficient amounts enter the bloodstream,
systemic effect may occur (most likely with
indirect-acting)



Hypotension, bradycardia, or tachycardia
Headache, nausea, vomiting, diarrhea, abdominal
cramps, asthma attacks
Others
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Sympathomimetics


Mimic the sympathetic neurotransmitters
epinephrine and norepinephrine
Stimulate the dilator muscle to contract


Result is increased pupil size (mydriasis)
Enhance aqueous humor outflow through the
canal of Schlemm

IOP is reduced
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Sympathomimetics (cont’d)
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


apraclonidine (Iopidine)
brimonidine (Alphagan P)
epinephryl (Epinal)
dipivefrin (Propine)


Prodrug of epinephrine
When applied topically
• Hydrolyzed to epinephrine
• Penetrates tissues better
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Sympathomimetics: Indications



Chronic, open-angle glaucoma (to reduce IOP)
Reduction of perioperative IOP
Reduction of ocular hypertension
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Sympathomimetics:
Adverse Effects

Primarily limited to ocular effects
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Burning
Eye pain
Lacrimation
Rare systemic effects

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
Hypertension
Tachycardia
Extrasystoles
Headache
Faintness
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Beta-Adrenergic Blockers

Selective beta1 blocker



betaxolol (Betoptic)
levobetaxolol (Betaxon)
Nonselective beta1 and beta2 blockers




carteolol (Ocupress)
levobunolol (Betagan)
metipranolol (OptiPranolol)
timolol (Timoptic)
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Beta-Adrenergic Blockers (cont’d)
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Reduce IOP by
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
Reducing aqueous humor formation
Increasing aqueous humor outflow
Do not affect pupil size, accommodation, or night
vision
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Beta-Adrenergic Blockers:
Indications

Reduction of elevated IOP



Chronic open-angle glaucoma
Ocular hypertension
Treatment of some forms of angle-closure
glaucoma
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Beta-Adrenergic Blockers:
Adverse Effects

Primarily ocular effects
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Transient burning and discomfort
Blurred vision
Pain
Photophobia
Others
Limited systemic effects




Headache
Dizziness
Cardiac irregularities
Bronchospasm
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Beta-Adrenergic Blockers:
Interactions

Administration of systemic beta blockers with
high doses of ophthalmic beta blockers may
result in additive effects
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Carbonic Anhydrase Inhibitors


brinzolamide (Azopt)
dorzolamide (Trusopt)
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Carbonic Anhydrase Inhibitors
(cont’d)


Inhibit the enzyme carbonic anhydrase, which
reduces aqueous humor formation in the eye
Result is decreased IOP
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Carbonic Anhydrase Inhibitors:
Indications

Treatment of glaucoma



Open angle
Angle closure
Preoperatively to reduce intraocular pressure
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Carbonic Anhydrase Inhibitors:
Adverse Effects

Oral forms can produce systemic effects

Drowsiness, confusion
 Transient myopia, tinnitus
 Anorexia, vomiting, diarrhea
 Several others

Patients with sulfa allergies may develop crosssensitivities
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Osmotic Diuretics



Create ocular hypotension by producing an
osmotic gradient
Water is forced from the aqueous and vitreous
humors into the bloodstream
Result is reduced volume of intraocular fluid,
thus reduced IOP
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Osmotic Diuretics (cont’d)


Administered IV, PO, or topically
Glycerin usually tried first



Can cause hyperglycemia
Mannitol used if glycerin is unsuccessful
Isosorbide and urea may also be used
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Osmotic Diuretics (cont’d)
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Indications



Acute glaucoma episodes
Before and after ocular surgery to reduce IOP
Adverse effects


Nausea, vomiting, headache
May cause fluid and electrolyte imbalance
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Prostaglandin Agonists


Newest class of drugs for glaucoma
Three drugs

latanoprost (Xalatan)
 travoprost (Travatan-Z)
 bimatoprost (Lumigan)
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Prostaglandin Agonists (cont’d)




Reduce IOP by increasing the outflow of
aqueous fluid
Increase uveoscleral outflow of fluid
Used in the treatment of glaucoma
Most drugs allow for single daily dosing because
of effects lasting for 20 to 24 hours
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Prostaglandin Agonists (cont’d)

Effects on eye color


In some persons with hazel, green, or blue/brown
eyes, eye color will change permanently to brown
Color change occurs even if medication stopped
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Classroom Response Question
Which antiglaucoma drug works by increasing the
outflow of aqueous humor between the uvea and
sclera as well as via the usual exit through the
trabecular meshwork?
A.
B.
C.
D.
Prostaglandins
Osmotic diuretics
Carbonic anhydrase inhibitors
Ophthalmic beta blockers
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Ocular Antimicrobial Drugs
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Topical and systemic administration
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

Antibacterial
Antiviral
Antifungal
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Ocular Antimicrobial Drugs (cont’d)


Topical application may cause transient and
local inflammation, burning, and stinging
Use of ophthalmic antibiotics with corticosteroids
may make it more difficult to rid the eye of
infection
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Ocular Antibacterial Drugs

Aminoglycosides


Antibacterial
gentamicin (Garamycin) , tobramycin (Tobrex)
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Ocular Antibacterial Drugs (cont’d)
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Macrolides
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
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
Antibacterial
erythromycin, azithromycin, others
Erythromycin also is used for prevention of Neisseria
gonorrhoeae eye infections in newborns
Treatment of neonatal conjunctivitis caused by
Chlamydia trachomatis
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Ocular Antibacterial Drugs (cont’d)

Polypeptides


Antibacterial
bacitracin (AK-Tracin), polymyxin B
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Ocular Antibacterial Drugs (cont’d)

Quinolones

ciprofloxacin (Ciloxan)
 gatifloxacin (Zymar)
 moxifloxacin (Vigamox)
 levofloxacin (Quixin)
 ofloxacin (Ocuflox)

Sulfonamides


sulfacetamide (Bleph-10)
sulfisoxazole (Gantrisin)
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Ocular Antifungal Drugs

natamycin (Natacyn)

Used topically to treat
• Blepharitis
• Conjunctivitis
• Keratitis
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Ocular Antiviral Drugs

ganciclovir (Vitrasert)



Treatment of ocular cytomegalovirus (CMV)
Administered by surgical implant in the eye
fomivirsen (Vitravene)


Treatment of ocular CMV
Administered by surgical implant in the eye
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Ocular Antiviral Drugs (cont’d)

trifluridine (Viroptic,1% ophthalmic drops)



Used for ocular infections (keratitis and
keratoconjunctivitis) caused by types 1 and 2 of the
herpes simplex virus
Applied topically as drops
Significant adverse effects include secondary
glaucoma, corneal punctate defects, uveitis, and
stromal edema (edema in the tough, fibrous,
transparent portion of the cornea known as the
stroma)
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Ocular Antiinflammatory Drugs

NSAIDs

ketorolac (Acular)
 flurbiprofen (Ocufen)
 bromfenac (Xibrom)
 diclofenac (Voltaren)
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Ocular Antiinflammatory Drugs

Corticosteroids

dexamethasone (Decadron, AK-Dex)
 fluocinonide (Retisert)
 fluorometholone (Fluor-Op)
 loteprednol (Lotemax)
 medrysone (HMS)
 prednisolone (Pred Forte)
 rimexolone (Vexol)
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Classroom Response Question
Which statement about use of corticosteroids for ocular
inflammation does the nurse identify as being true?
A. They are used during the acute phase of the injury
process to prevent fibrosis and scarring, which result in
visual impairment.
B. Corticosteroids produce a lesser immunosuppressant
effect than the NSAIDs.
C. They are used for the treatment of minor abrasions and
wounds of the eye.
D. Use of corticosteroids for ocular inflammation results in
discoloration of the iris.
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Ocular Antiinflammatory Drugs
(cont’d)



Act on various parts of the arachidonic acid
metabolic pathway
Reduce the production of various inflammatory
mediators
As a result, pain, erythema, and other
inflammatory processes are reduced
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Ocular Antiinflammatory
Drugs (cont’d)


Used prophylactically after surgery to prevent
inflammation and scarring
NSAIDs used for symptomatic treatment of
seasonal allergic conjunctivitis
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Topical Ophthalmic Anesthetics



tetracaine
proparacaine (Alcaine)
Used to prevent eye pain during






Surgery
Ophthalmic examinations
Removal of foreign bodies or sutures
Diagnostic testing and procedures
Short-term use only
Not for self-administration
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Ophthalmic Diagnostic Drugs
Cycloplegic mydratics
 atropine sulfate (Isopto Atropine)


Results in
• Mydriasis
• Cycloplegia
Used for
• Ophthalmic examinations
• Uveitis (which benefits from pupillary dilation)
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Ophthalmic Diagnostic
Drugs (cont’d)
Cycloplegic mydratics (cont’d)
 cyclopentolate (Cyclogyl)

Causes mydriasis and cycloplegia
 Used for diagnostic examinations
 Not used for uveitis
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Ophthalmic Diagnostic
Drugs (cont’d)

Other cycloplegic mydriatics



scopolamine (Isopto Hyoscine)
homatropine (Isopto Homatropine)
tropicamide (Mydriacyl)
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Ophthalmic Diagnostic
Drugs (cont’d)
Ophthalmic dye
 fluorescein (AK-Fluor)

Diagnostic dye used to identify corneal defects and to
locate foreign objects in the eye
 Used in fitting hard contact lenses
 Various defects are highlighted in either bright green
or yellow-orange, and foreign objects have a green
halo around them
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Ophthalmic Antiallergic Drugs

Ophthalmic antihistamines
Used to treat symptoms of allergic conjunctivitis (“hay
fever”)
 azelastine (Optivar)
 olopatadine (Patanol)
 emedastine (Emadine)
 ketotifen (Zaditor)
 epinastine (Elestat)

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Ophthalmic Antiallergic Drugs
(cont’d)

Used for seasonal allergy symptoms


Mast cell stabilizers
• cromolyn sodium (Crolom)
• pemirolast (Alamast)
• nedocromil (Alocril)
• lodoxamide (Alomide)
Decongestants
• phenylephrine (Neo-Synephrine)
• oxymetazoline (Visine LR)
• naphazoline (Clear Eyes)
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Classroom Response Question
A patient receiving tetrahydrozoline asks how the drug
works. The best response by the nurse will include that the
drug works by
A. pulling fluid from the eye tissue to the blood stream.
B. decreasing the amount of fluid produced by the eye.
C. promoting vasoconstriction of blood vessels in and
around the eye.
D. causing the pupil to constrict.
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Ophthalmic Lubricants and
Moisturizers

Artificial tears

Over-the-counter products
 Provide lubrication or moisture for dry or irritated eyes
 Available in drops or ointment
 Brand names include: Murine, Nu-Tears, Moisture
Drops, Tears Plus, Akwa Tears
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Ophthalmic Lubricants and
Moisturizers (cont’d)

Restasis

Ophthalmic form of cyclosporine
 Immunosuppressant drug
 Used to treat keratoconjunctivitis sicca (dry eyes)
 It can be used together with artificial tears, if the drugs
are given 15 minutes apart
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Nursing Implications



Assess the patient’s history, including
medication history
Assess patient’s baseline vital signs and visual
acuity, and perform a physical assessment of the
eye and surrounding structures
Assess for contraindications to specific drugs
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Nursing Implications (cont’d)



Follow specific guidelines for administration of
ophthalmic drugs
Avoid touching the eye with the tip of the
dropper or container
Apply ointments as a thin layer in the
conjunctival sac
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Classroom Response Question
When administering eyedrops to a patient, the
nurse places the drop
A. directly onto the cornea.
B. in the inner canthus.
C. into the lower conjunctival sac.
D. onto the sclera.
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Nursing Implications (cont’d)


When applying eyedrops, have the patient look
up to the ceiling, and place the drop in the
conjunctival sac
Pressure may be applied to the inner canthus for
at least 1 minute to reduce systemic absorption
of the drug
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Nursing Implications (cont’d)


If more than one eye medication is ordered,
clarify the correct order and intervals for
administration
If the patient wears contact lenses, check to see
if they should be removed during therapy with
eye medications
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Nursing Implications (cont’d)

Provide patient/family education on correct
procedures for administration of eye medications
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Nursing Implications (cont’d)


Monitor for adverse effects
Monitor for therapeutic response to therapy
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Case Study
A 60-year-old male with a history of benign prostatic
hypertrophy and hypertension is seen in the Emergency
Department because he was trimming his shrubs and got
something in his right eye. He complains of a pain rating of
8 on a scale of 1 to 10 in the right eye. Which medication
does the nurse anticipate administering via eyedrop to help
control the patient’s pain?
A. tetracaine
B. atropine
C. morphine
D. lidocaine
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Case Study (cont’d)
After administering an ophthalmic anesthetic drug,
which adverse effects does the nurse anticipate as
possibly developing in the patient? (Select all that
apply.)
A. Stinging
B. Burning
C. Redness
D. Lacrimation
E. Blurred vision
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Case Study (cont’d)
The ophthamologist tells the patient that she is going to
place a dye onto the patient’s eye to help identify the
location of the foreign object. Which drug does the nurse
anticipate the ophthamologist will use?
A. olopatadine (Patanol)
B. cromolyn sodium (Crolom)
C. tetrahydrozoline
D. fluorescein (AK-Fluor)
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Case Study (cont’d)
A foreign particle is removed from the patient’s eye. He tells
the nurse that he previously forgot to mention that he takes
eyedrops for glaucoma. He can’t remember the name of
the drug, but he knows the eyedrop bottle has a purple lid.
The nurse identifies a purple lid as most likely containing
which type of antiglaucoma drug?
A. Direct-acting cholinergic
B. Sympathomimetics
C. Prostaglandin agonist
D. Carbonic anhydrase inhibitor
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