PATIENT CASE HISTORY. General Health Medications Allergies

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1 OCULAR PHARMACOLOGY What I Need to Know Before I Medicate A Patient Lynn Lawrence, CPOT, ABOC, COA, OSC ROLE of the ASSISTANT AND TECHNICIAN Accurate documentation/recording Patient Education can assist in preventing mistakes NEVER Work in Doubt! Read and re-read the medication request Be careful with hand-offs! The Medication Check For Ophthalmic Use, must be on the container Check name Check dosage Check expiration date Check for contamination The Patient Checks Reason for visit Check patient s current health condition Verify patient allergies Provider medication request Check visual acuity Check IOP Check the patients angles Do not leave the patient unattended and routinely monitor PATIENT CASE HISTORY The best way to prevent an adverse reaction is to perform an excellent case Hx? General Health Medications Allergies Application Procedures Wash hands thoroughly before administration Give medications with patient in lying position Tilt head backward or lie down and gaze upward Gently grasp lower eyelid below eyelashes and pull the eyelid away from the eye to form a pouch Place dropper directly over the eye. Avoid contact of the dropper with the eye, finger or any other surface Release the lid slowly and close the eye Occlude puncta for 2-3 minutes Wait 5 minutes before administering a second medication or drop 1

2 Preparation 1. Wash your hands. 2. Triple check the medication you are going to instill to ensure it is what the doctor ordered. 3. Advise the patient of what you are going to do. 4. Recline the patient or gently tilt the patient s head back. Always ask the patient about neck or back problems before tilting his or her head. Do not tilt a Down s syndrome patient s neck due to the high risk of cervical fracture. 5. With one hand, hold the upper lid and, with a finger of the other hand (the one holding the little bottle of medication), pull down gently on the lower lid. 6. Have the patient look down. 7. Keep the bottle about ½ above the eye. This should be high enough to avoid contamination by the patient s eyelashes in the event the patient inadvertently blinks, while still allowing good control of where the drop goes. 8.Now, squeeze the bottle to dispense a drop in the eye. Ideally, the drop hits just above the upper limbus, causing minimal reaction by the patient (since the very sensitive cornea isn t hit directly), but allowing a good percentage of medication to flow across the cornea before it gets diluted by tears. CAUTION: Keep the eye dropper tip well away from the eye so, even if the patient blinks, the lashes do not touch it. If the dropper tip comes into contact with the patient s eyes, lids, or lashes, the bottle is considered contaminated and must be thrown away after you finish with the patient. Do not attempt to use it on another patient. Cont 9. Advise the patient not to squeeze his or her eyes tightly closed nor dab his or her eyes with tissue. Squeezing and dabbing eliminates some of the medication from the eye, minimizing the medication s effectiveness. 10. Once the drop is in, plug the punctal area by gently squeezing in the nasal canthus. You are squeezing in the right place if you feel a little bump under your finger tips. If the medication is to be put in both eyes, quickly instill the drop into the second eye, and then perform punctal occlusion to both eyes at the same time. Essentially, you want the eye to absorb all the medicine. You don t want the puncta to suck up the drug and pass it through the canaliculi, into the lacrimal sac, and go down the nasal lacrimal duct into the throat. Eye medications swallowed can affect a patient s heart rate and breathing. You don t want this to happen, so perform punctal occlusion for about one minute after instillation of an eye drop. Attempting to instill an ophthalmic drug into a child s eyes can be challenging. A good method to minimize most problems you have when placing drops in a child s eye is to lay the child back and ask the child to close both eyes. Put one drop of the ophthalmic drug in each medial canthal area. Have the child blink once or twice, and the task is done with little or no fuss. Don t forget to do the punctal occlusion to minimize systemic absorption. Instilling an ointment is essentially the same, except the ointment is squeezed into the lower conjunctival sac until a ¼ -worth is administered. Punctal occlusion is unnecessary. As with drops, do not allow the medication dispenser to touch the patient or it is considered contaminated. 2

3 Dilation Hazards Cross Contamination Narrow anterior chamber angle Potential risk in dilating opt vs oph CLINICAL ADMINISTRATION Patient History Clinical Procedures Which May Be Influenced by Medications The ERx Option Plan for acute angle glaucoma attack Make sure you are far enough away not to touch the patient Bio-Tissue A medical device used by eye doctors around the world to protect, repair and heal damaged or inflamed eye surfaces Amniotic membrane is part of the placenta. It is the tissue closest to the baby throughout development in the womb. Amniotic membrane protects the baby from any harm and it has natural therapeutic actions which help the baby develop. Methods of medication delivery Ocular medications can be administered in several different ways. Each method has advantages and disadvantages, so the method of medication delivery depends on the desired outcome, type of drug being administered, and type of problem being treated. Primary methods of ocular medication delivery are: - Topical application - Continuous release delivery - Subconjunctival - Sub-tenon s - Retrobulbar - Intravitreal injections The most common method of medication delivery used in the eye clinic is topical application. Ophthalmic Drug Complications Giving people medications may seem routine, but there are possible negative consequences. Not all people are tolerant of all medications. If given a drug they can t tolerate, a patient may have an allergic or toxic reaction. As an eye technician administering drugs to people on a daily basis, it s important you understand and recognize what is occurring if a patient does have a reaction. You also need to understand how drugs affect the body s autonomic nervous system (ANS), to include the sympathetic and parasympathetic divisions. VITAMIN SUPPLEMENTS Not all supplements are the same 3

4 CLASSIFICATIONS Solutions Suspensions Ointments OCULAR ALLERGIES Over the counter medications Artificial Tears Antihistamine Decongestants Corticosteroids DIAGNOSTIC AGENTS Topical Anesthetics Topical Anesthestics Mydriatics Cycloplegics Dyes/Stains Fluress Gonioscopic Solutions Proparacaine Tetracaine Cocaine Mydriatics & Cycloplegics Tropicamide Phenylephrine Cyclogyl Atropine Homatropine Scopalomine Mydriatic Mydriasis is the dilation of the pupils, so, logically, a mydriatic drug causes dilation. The main reason the eyes is dilated is to allow the doctor to perform a thorough exam of the posterior portion of a patient s eyes. A big pupil allows a wider field of view and gives the examiner a chance to see the vast majority of the retina, rather than the very small amount seen in an undilated eye. Mydriasis is also useful in allowing you to take fundus photographs of the macula, optic nerve, and any retinal anomalies present. 4

5 Cycloplegics These drugs cause mydriasis like mydriatics, but they also cause cycloplegia, which is paralysis of the ciliary muscle. Remember, the ciliary muscle controls focusing of the light rays entering the eye by changing the shape of the crystalline lens. Cycloplegics are used in dilating the pupils to facilitate examination of the fundus, prevent ciliary spasm and pain in iritis patients, and prevent a patient (usually a suspected hyperope) from constantly accommodating while the doctor is trying to refract the patient and figure out the prescription. Cycloplegics are also used to perform entrance eye exams on flyers to find what their true refractive error is. Again, this is accomplished by paralyzing the focusing mechanism of the eyes (temporarily) while the doctor refracts the patient. Cycloplegics almost always come in bottles with red caps. Tropicamide (Mydriacyl ; Opticyl ) The information you need to know about tropicamide is: Preparation: Solution, percent (most common usage is 1 percent). Dosage: Instill one drop in each eye. Repeat if the doctor requests it. Action and uses: Produces mydriasis and cycloplegia. Onset of action is rapid (20 30 mins) and duration varies from one-half to four hours. Used primarily in conjunction with phenylephrine when dilating patients for routine fundus exams. GLAUCOMA MANAGEMENT Gonioscopy Solutions Pilocarpine Beta-Blockers Carbonic Anhydrase Inhibitors Adrenergic Agonists These are use in Gonioscopy Goniosol Gonioscopic Celluvisc Beta Blockers Beta Blockers Beta-blockers are the current drugs of choice in lowering IOP. Timoptic, Betoptic, and Betagan are some of the most popular drugs being used to lower IOP today. Introduced in the late 1970s, they quickly became the initial drug of choice for lowering IOP. One reason beta-blockers are so popular is, on average, they reduce IOP by 25 percent. Another reason is they can be used once or twice daily, unlike most previous medications that were used up to four times a day. Finally, most of the previous drugs used to lower IOP caused miosis (pupillary constriction), dim vision (due to constricted pupil size), eyebrow ache, and stimulation of accommodation (which can blur vision). Fortunately, beta-blockers work without these side effects. However, this does not mean they are perfect, as they also have some side effects. Beta-blockers block the beta 1 and beta 2 receptors from doing their jobs in the body. This is good Thus, patients with certain systemic diseases warrant special consideration by a doctor trying to decide whether the person should use beta-blockers or not. The following is a very general list of systemic conditions contraindicating betablocking medication usage. Asthma. Heart or circulatory problems. Chronic obstructive pulmonary disease (COPD). 5

6 Cap Color Drug Class CAP Colors Tan Antibiotics, Antivirals, Antifungals In addition, patients already on systemic beta-blockers (e.g., Inderal for high blood pressure) should be considered highrisk candidates for use of any of the beta-blocker medications. Patients may be better off using one of the cholinergic medications, carbonic anhydrase inhibitors, or prostaglandin inhibitors instead. Some of the common side effects of beta-blockers (especially the more medication the patient systemically absorbs) are: Bradycardia the slowing down of the heart rhythm (leading to low blood pressure and dizziness). Induced asthma. Mood changes. Pink Red Grey Green Yellow or Blue Purple Orange Turquoise Anti-inflammatory/Steroids treats allergic reactions, swelling, redness (slows healing can cause cataracts and glaucoma). Do not use on fungal infections Mydriatics/Cycloplegics (dilate pupil) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) control inflammation caused by ocular allergies without steroidal sideeffects Miotics (stimulates sphincter and causes pupil constriction) Beta-Blockers traditionally used to treat glaucoma, reduce IOP by decreasing aqueous humor Adrenic Agonists (reduce IOP) Carbonic Anhydrase Inhibitors (reduce IOP) Prostaglandin Analogues (reduce IOP by increasing aqueous outflow) Dyes & Stains Fluorescein Rose Bengal Lissamine Green Fluress OCULAR SURFACE Artificial Tears Different ingredients Allergies Lubricating Ointments Punctal Occlusion CLINICAL ADMINISTRATION Patient History Clinical Procedures Which May Be Influenced by Medications Antibiotic Biotic means relating to, produced by, or caused by living organisms The prefix anti "against" the referent of the stem to which the prefix is affixed 6

7 THERAPEUTIC AGENTS OCULAR INFLAMMATION Antibiotics Anti-virals Drugs that lower IOP Anti-inflammatory agents Non-Steroidal Combinations Corticosteroids Steroid-Antibiotic Combinations Non-Steroidal Anti-inflammatory Drugs (NSAIDS) Oral Analgesics OCULAR INFECTIONS OCULAR SURFACE Topical Antibiotics Oral Antibiotics Anti-Viral Analgesics Artificial Tears Lubricating Ointments Punctal Occlusion OCULAR ALLERGIES IN-OFFICE PROCEDURES Artificial Tears Antihistamine-Decongestants Corticosteroids 7

8 Patient Instruction- Solutions and Suspensions Wash hands thoroughly before administration Tilt head backward or lie down and gaze upward Gently grasp lower eyelid below eyelashes and pull the eyelid away from the eye to form a pouch Place dropper directly over the eye. Avoid contact of the dropper with the eye, finger or any other surface Release the lid slowly and close the eye Occlude punta for 2-3 minutes Wait 5 minutes before administering a second medication or drop Patient Instruction- Ointment Wash hands thoroughly Tilt head backward or lie down and gaze upward Gently pull down the lower lid to form a pouch Place.25 to.50 inch of ointment with a sweeping motion Close the eye for 1-2 minutes Temporary blurring of vision may occur. Remove excess ointment with a tissue Wait 10 minutes before applying the second ointment Topical application As stated earlier, topical drugs are dropped directly in the eye. Topical medications are chemically designed in four major forms: 1. Solutions are one or more substances dissolved in a liquid medium. They work well, but have minimal contact time with the eye. 2. Suspensions are drops containing finely divided drug particles suspended in a liquid medium. Since the drug is not dissolved into the fluid (the little particles settle at the bottom of the bottle), drugs in suspension must be shaken before use. If they are not shaken, the drug is not distributed evenly and is not very effective. Topical Applications Cont 3. Ointments (abbreviated ung in prescription form) are drugs suspended in a petroleum base. They are a good delivery method as they prolong a drug s contact time with the cornea. On the down side, they smear the cornea with goo and blur vision. Because of this, ointments usually are prescribed for patients to use just before bed. 4. Continuous release delivery is sandwiched in a membrane. The membrane is placed inside the lower conjunctival sac, where it dissolves throughout the day, releasing medication to the eye. Continuous release delivery is actually a separate system, but is included here since it occurs topically. Continuous release delivery A medication device placed in the eye, in the conjunctiva and lasting for a week is quite a benefit to patients who have trouble keeping up with their drops. The most common of these devices is the Pilocarpine Ocusert, which permits continuous delivery of medication 24 hours a day for seven days. Subconjunctival injections Injections may be administered under the conjunctiva to deliver medications in large doses and longer durations (fig. 4 4). The subconjunctival medication gains access to the eye by absorption into the bloodstream through the episcleral and conjunctival vessels. Subconjunctival injections are used primarily in the treatment of intraocular infection or acute uveitis cases. 8

9 Ophthalmic Drug Complications Giving people medications may seem routine, but there are possible negative consequences. Not all people are tolerant of all medications. If given a drug they can t tolerate, a patient may have an allergic or toxic reaction. As an eye technician administering drugs to people on a daily basis, it s important you understand and recognize what is occurring if a patient does have a reaction. You also need to understand how drugs affect the body s autonomic nervous system (ANS), to include the sympathetic and parasympathetic divisions. Allergic Reaction An allergic response is the most frequent type of drug reaction. Signs and symptoms vary from moderate swelling and redness (most common) to convulsions and death (less common). Because of the wide range of symptoms possible, recognition of a drug reaction is based on the degree and type of change the patient has as a result of the administration of a drug. Allergic reactions usually follow repeated application of a medication, since the patient must be exposed to the agent to develop a hypersensitivity to it. Thus, a delay in time occurs between the reaction to a particular drug and the development of a hypersensitivity state. This delay, referred to as the induction period, can be days, weeks, months, or years. Toxic Reactions The chemical structures of some medications can lead to toxic reactions in certain organs of the body. Toxic chemical reactions can cause death, destruction, or changes to tissue (e.g., formation of deposits or discoloration). For example, topical use of epinephrine can form black deposits in the lower conjunctival sac inside the lid; Argyrol (a silver protein) can cause a graying of the conjunctiva. Some drugs can produce irreversible damage within the eye or cause systemic disturbances within the patient s body. Drug Reaction Prevention The single most effective way to avoid an adverse drug reaction in a patient is to take a good case history. Inquire about any drug sensitivities experienced in the past. If the patient had a reaction to sulfa drugs, it is foolish to administer them sulfacetamide to cure conjunctivitis. A patient with an anterior chamber intraocular lens placed in the eye may not react well to drops constricting or dilating the pupil excessively. Pupillary movement could displace the lens or cause the iris to become irritated from rubbing against the lens, possibly causing an iritis. Drug Reaction Prevention Find out if the patient is currently taking any other medications. If so, it s important to avoid using a drug that could cause a reaction with the other medication. If in doubt, it s always good practice to check with the doctor before administering anything. Wait between drops, you will reduce the risk of adverse interaction between the two different medications. In addition, eye drops will need this time to be absorbed completely and work effectively before the instillation of another drop. Things to Remember The actual drug name. Mydriacyl is a trade name for tropicamide, which is a cycloplegic,not a simple mydriatic. The drug percentage. Phenylephrine is phenylephrine, right? Wrong. The 2.5 percent dosage is a whole lot safer than the 10 percent version. You could literally kill someone by using the wrong type. If in doubt, double check with the doctor. The word ophthalmic (for use in the eyes). Some drugs you use on the eyes are also made for use on other parts of the body. For example, the antibiotic erythromycin is used on cuts and burns. If the tube doesn t say ophthalmic on it, the medication is not used in the eye. Only ophthalmic-quality drugs should be put in the eye. The manufacturer s expiration date. If the date stamped on the bottle or tube is JUNE 2018; do not use on 01 JULY 2018! 9

10 Things to Remember The date the medication was opened. If someone has already removed the manufacturer s seal and opened the drug, this person should have put the date the container was opened on the label. If a drug has been opened, but there is no date on it, throw it away. If it has been over 90 days since the drug was opened, throw it away. If the manufacturer s date has passed, but the drug was only opened 20 days ago, throw it away. ABBREVIATIONS If the drug container looks old or dirty, throw it away. Abbreviatio Meaning Abbreviatio n n Prescription abbreviations Meaning ac (ante cibum) before meals q (quaque) every ad lib (ad libitum) as much as wanted qd (quaque die) every day HOW TO WRITE AN Rx aq Water qh (quaque hora) every hour bid (bis in die) twice a day qid (quater in die) 4 times a day gt; gtt (gutta; guttae) drop; ql (quantum libet) as much as desired h hora) hour qqh or q4h (quaque quarta hora) every four hours hs (hora somni) at bedtime qs quantity sufficient mg Milligram Rx (recipe) prescription non rep (non repetatur) do not repeat Sol solution pc (post cibum) after meals Tid (ter in die) three times a day po (per os) by mouth, orally ung (unguentum) ointment Make sure that you include: Full name of patient Address can be optional Date of Rx Inscription: name of drug; concentration Subscription: amount to be dispensed Instructions: route of administration; number of drops or tablets; frequency of use; refill What else? Make sure that it is legible if you are writing in a chart! 10

11 References and resources THANK YOU! Ophthalmic Drug Facts 2002 Ophthalmic Medications and Pharmacology Review of Optometry: 2002 Clinical Guide to Ophthalmic Drugs (Melton and Thomas) May issue 11