OPHTHALMOLOGICAL DRUGS AND EYEDROPS AND EYE OINTMENTS CLASSIFICATIONS @NURSESOUTLOOK

OPHTHALMOLOGY DRUGS

Ophthalmic drug administration is the administration of a drug through the eyes, most typically as an eye drop formulation.

What are eye drops?

Eye drops are a sterile solution or suspension of medicine. They are used to produce a local effect directly on the eye.

How to use your eye drops?

1. If your eye drops are a suspension,shake the bottle before using the drops.
2. Wash your hands.
3. Wipe eyes with a clean tissue to clear any residual wateriness or discharge.
4. Take the lid off the bottle.
5. Tip your head back.
6. Gently pull down your lower eyelid and look up.
7. Hold the dropper or bottle above the eye and gently squeeze one drop onto the inside of the lower eyelid, taking care not to touch the eye or eyelashes with the dropper or bottle.
8. Blink your eyes so the liquid spreads over the surface of the eyeball.
9. Wipe away any excess liquid with a clean tissue

Drop (Gutta)‐
⦁ Simplest and more convenient
⦁ Mainly for day time use
⦁ 1 drop=50 microlitre
⦁ Conjuctival sac capacity=7‐13 micro liter
So, even 1 drop is more than enough
 

Measures to increase drop absorption:
‐Wait 5‐10 minutes between drops
‐Compress lacrimal sac
‐Keep lids closed for 5 minutes after instillation
⦁ 50% drug remains 4 min. after instillation
⦁ 10% drug reach aqueous humour
⦁ Compress NLD to decrease systemic absorption

How to use your eye ointment

1. Wash your hands.
2. Take the lid off the ointment.
3. Tip your head back.
4. Gently pull down your lower eyelid and look up.
5. Hold the tube above the eye and gently squeeze a 1cm line of ointment along the inside of the lower eyelid, taking care not to touch the eye or eyelashes with the tip of the tube.
6. Blink your eyes to spread the ointment over the surface of the eyeball.
7. Wipe away any excess ointment with a clean tissue
Your vision may be blurred when you open your eyes - DON'T rub your eyes. The blurring will clear after a few moments if you keep blinking.

COMMON OPHTHALMOLOGICAL DRUGS

⦁ Antibacterials (antibiotics)
⦁ Antivirals
⦁ Antifungal
⦁ Mydriatics and cycloplegics
⦁ Antiglaucoma
⦁ Anti‐inflammatory agents
Cortico Steroids And NSAIDS
⦁ Ocular Lubricants
⦁ Antihistaminics
⦁ Ocular diagnostic drugs
⦁ Local anesthetics
⦁ Corticosteroids NSAIDs


ANTIBACTERIALS (ANTIBIOTICS)


  Penicillins
¡Cephalosporins
 Sulfonamides
 Tetracyclines
 Chloramphenicol
 Aminoglycosides
 Fluoroquinolones
 Vancomycin


1. Used topically in prophylaxis (pre and
postoperatively) and treatment of
ocular bacterial infections.

2. Used orally for the treatment of
preseptal cellulitis  e.g. amoxycillin with clavulonate


1. Used intravenously for the treatment
of orbital cellulitis e.g. gentamicin, cephalosporin,vancomycin, flagyl
2. Can be injected intravitrally for the
treatment of endophthalmitis

CEPHALOSPORIN

1 st generation

⦁ Cephalothin, cefazolin, cephalexin
⦁ Active against G+ve and G‐ve
⦁ Not active against MRSA, Enterobacter, Proteus spp, P aeruginosa, Serratia, enterococci

2 nd generation

⦁ Cefamandole, cefoxitin, cefuroxime
⦁ Greater activity against G‐ve : H.influenzae, Enterobacter, Neisseria

3 rd generation

⦁ Cefotaxime, Ceftriaxone, Cefoperazone
⦁ Active against GNR > G+ve cocci : Serratia, Proteus, Ⱦ‐lactamase H influenzae, anaerobe
⦁ P.aeruginosa : ceftazidime, cefoperazone
⦁ Cefotaxime : good penetration blood‐ocular barrier

4 th generation

⦁ Extended spectrum
⦁ Against gram‐positive organisms as 1 st generation
⦁ Greater resistance to beta‐lactamases than 3 rd generation
⦁ Can cross blood brain barrier
⦁ Against nosocomial pathogens
⦁ Cefepime, Cefluprenam, Cefozopran, Cefpirome, Cefquinome

FLUOROQUINOLONES


1st generation
 ▪ Nalidixic acid

2nd generation

Ciprofloxacin,ofloxacin,    lomefloxacin
⦁ Active against G‐ including Pseudomonas spp, some G+
⦁ Not active against Strep pneumoniae

3rd generation
⦁ Levofloxacin
⦁ Same as 2nd
⦁ Active against more G+, Strep pneumoniae

4th generation

⦁ Gatifloxacin (Zymar®), moxifloxacin (Vigamox®)
⦁ Same as 3rd , active against anaerobe
⦁ Useful in bacterial conjunctivitis, corneal ulcer

AMINO GLYCOSIDES

⦁ Mainly against Gm negative bacilli
⦁ Bacterial protein synthesis inhibitors
⦁ Gentamycin—0.3% eye drop
⦁ Tobramycin‐ Pseudomonas 1% eye drop
⦁ Neomycin—0.3‐0.5% eye drop

TETRACYCLINE

⦁ Inhibit protein synthesis
⦁ Active against both gm+ and gm ‐, some fungi and Chlamydia

CHLOROMPHENICOL

⦁ Broad spectrum ,bacteriostatic, gm+/gm‐, Chlamydia
⦁ 0.5% Eye drop, ointment


VANCOMYCIN
⦁ Against MRSA or strep
⦁ Useful in corneal ulcer, endophthalmitis
Polymyxin B + Neomycin
⦁ Against Staph. aureus, Strep spp, GNR
⦁ Useful in surface bacterial infection e.g. conjunctivitis, blepharitis

ANTIVIRALS


Acyclovir
⦁ Inhibits viral DNA synthesis
⦁ Active against HSV I & II, HZV
⦁ Oral, ointment
⦁ Interact with viral thymidine kinase (selective)
⦁ Used in herpetic keratitis


Ganciclovir
⦁ Active against CMV
⦁ Oral, iv, intravitreal
⦁ Useful in CMV retinitis
⦁ SE: BM suppression, renal failure
⦁ Used intravenously for CMV retinitis



Basic fungal classification

a. Filamentous fungi

⦁ Septate = Fusarium, Aspergillus
⦁ Nonseptate = Mucor
b. Yeasts

⦁ Candida, Cryptococcus

Most antifungal drugs act by attacking the membrane sterols of fungi (ergosterol), leaving mammalian sterols (cholesterol) unaffected


INDICATIONS

Fungal corneal ulcer
Fungal retinitis/ Endophthalmitis

Commonly used drugs are
⦁ Polyenes
Damage cell membrane of susceptible fungi E.g. Amphotericin B, Natamycin, nystatin
Side effect: nephrotoxicity
⦁ Imidazoles
Increase fungal cell membrane permeability
E.g. Miconazole, ketoconazole,fluconazole

⦁ Flucytocine
⦁ Act by inhibiting DNA synthesis
⦁ Dilate the pupil, ciliary muscle paralysis.

MYDYRIATICS AND CYCLOPLEGICS

Dilate the pupil, ciliary muscle paralysis
 Classification
⦁ Short acting‐ Tropicamide (4‐6 hours)
⦁ Intermediate‐ Homatropine ( 24 hours)
⦁ Long acting‐ Atropine (2 weeks)
 Indications
1. Corneal ulcer
2. Uveitis
3. Cycloplegic refraction


Directly acting agonists:
⦁ E.g. pilocarpine, acetylcholine (miochol), carbachol (miostat)
⦁ Uses: miosis, glaucoma
Mechanisms:
⦁ Miosis by contraction of the iris sphincter muscle
⦁ Increases aqueous outflow through the trabecular meshwork by longitudinal ciliary muscle contraction
⦁ Accommodation by circular ciliary muscle contraction
Side effects:

⦁ Local: diminished vision (myopia), headache, cataract, miotic cysts, and rarely retinal detachment
⦁ Systemic side effects: lacrimation, salivation, perspiration, bronchial spasm, urinary urgency, nausea, vomiting, and diarrhea


⦁ Indirectly acting: (anticholinesterases)
⦁ More potent with longer duration of action
⦁ Reversible inhibitors
E.g. Physostigmine
⦁ Used in glaucoma and lice infestation of lashes
⦁ Can cause CNS side effects

ANTIGLAUCOMA DRUGS

Mechanisms of action of antiglaucoma agents
The antiglaucoma agents act on the aqueous humor dynamics to reduce the intraocular pressure mainly by three mechanisms.
1. Decrease aqueous production in the ciliary body
2. Increase aqueous humor outflow through the trabecular meshwork
3. Increase aqueous humor outflow via the uveoscleral pathway.
Pharmacotherapy of Glaucoma

Prevention or modification of risk factors, particularly the raised intraocular pressure is the primary goal in the management of glaucoma. The disease needs to be managed medically, by laser therapy or by conventional
surgery as the case may be.

Classification of antiglaucoma agents
Depending on their route of administration antiglaucoma agents may be classified as
Topical drugs:
1. Cholinergic agents e.g. pilocarpine, carbachol,demecarium bromide and echothiophate iodide.
2. Adrenergic agonists e.g. epinephrine, dipivefrin,brimonidine and apraclonidine.
3. Beta blockers e.g. timolol, carteolol, betaxolol,levobunolol and metoprolol
4. Prostaglandin analogs e.g. PGF2α, latanoprost,
unoprostone and PHXA-85.
5. Carbonic anhydrase inhibitors e.g. dorzolamide
and brinzolamide.
Systemic drugs:
1. Carbonic anhydrase inhibitors e.g. acetazolamide and methazolamide.
2. Osmotic agents e.g. glycerine, mannitol and urea.

CORTICOSTEROIDS
Classification
1. Short acting
Hydrocortisone, cortisone, prednisolone
2. Intermediate acting
Triamcinolone, Fluprednisolone
3. Long acting
Dexamethasone ,betamethasone
INDICATIONS FOR CORTICOSTEROIDS
Topical

1. Allergic conjunctivitis,
2. Scleritis,
3. Uveitis,
4. allergic keratitis
5. After intraocular and extra ocular surgeries

Systemic (pathology behind the Lens)
1. Posterior uveitis
2. Optic neuritis
3. Corneal graft rejection


NEVER GIVE STEROID IFYOU ARE SUSPECTING ACTIVE INFECTION


SIDE EFFECTS OF CORTICOSTEROIDS
OCULAR

1. Glaucoma
2. Cataract
3. Activation of infection
4. Delayed wound healing

SYSTEMIC
1. Peptic ulcer
2. Hypertension
3. Increased blood sugar
4. Osteoporosis
5. Mental changes
6. Activation of tuberculosis and other infections

ORBITAL TUMOR OF EYE @NURSESOUTLOOK

ORBITAL TUMOR

An orbital tumor refers to any tumor located in the “orbit,” which is the bony socket in the front of the skull that contains the eye. The socket is a complicated structure that includes the eye itself along with muscles, nerves, and connective tissue.

             

OVERVIEW

The orbit is the cone-shaped bony socket that contains the eyeball; the orbital contents include the extraocular muscles that move the eye, the optic nerve, the nerves and blood vessels supplying these structures and the fat inbetween. Tumors that develop in any of the tissues that surround the eyeball are referred to as orbital tumors

COMMON TYPES OF ORBITAL TUMOUR

Orbital tumors may affect both adults and children. Fortunately, in both age groups most orbital tumors are benign.

 The most common orbital tumors in children are

Rhabdomyosarcoma is the most common cancer that starts in the orbit in children.

Retinoblastoma is the most common tumor inside the eyeball in children.

Neuroblastoma is the most common cancer to spread to the orbit in children.

Dermoids and vascular lesions such as capillary hemangiomas, lymphangiomas and cavernous hemangiomas

Adult orbital tumors are usually malignant and can include:

Lymphoma: This is the most common type of  orbit tumor that starts in adults. Lymphoma is a cancer of the blood in which specific white blood cells (called lymphocytes) become cancerous. Even though lymphoma is a blood cancer, it usually presents as a solid tumor in the body.

Lacrimal gland cancers: These are very similar to salivary gland cancers, and they can be of the same type, including:

1.   Adenoid cystic carcinoma

2.   malignant mixed tumor (carcinosarcoma)

3.   Adenocarcinoma

Lacrimal sac cancers: These can include squamous cell carcinoma, adenocarcinoma, transitional cell carcinoma, salivary gland carcinoma and poorly differentiated carcinoma.

Cancers of the skin of the eyelid: These can include squamous cell carcinoma, basal cell carcinoma and even rare tumors such as sebaceous cell carcinoma and Merkel cell carcinoma.

Sarcomas: These can also arise in the orbit and include rhabdomyosarcoma, osteosarcoma, chondrosarcoma, liposarcoma and angiosarcoma.

Other very rare tumors such as malignant neurogenic tumors or peripheral nerve sheath tumors are possible; multiple myeloma, or even spread of cancers from another site, are possible as well.

 TNM staging system

One tool that doctors can use to describe the stage is the TNM system.Factors that go into determining the stage of the cancer in orbital tumour.

T      Characteristics of the main Tumor mass

N     Status of the lymph Nodes in the neck (i.e., evidence of cancer  spread)

M    Metastasis  Status of cancer spread to parts of the body outside of the head and neck

CAUSES OF ORBITAL TUMOUR

The cause of primary orbital tumors is unknown. In children most orbital tumors result from developmental abnormalities. When visual loss or deterioration occurs with an orbital tumor, it may result from either mass effect, compromise of the vasculature to the optic apparatus as a result of the tumor, or invasion of the optic nerve by the tumor.

SYMPTOMS OF ORBITAL TUMOUR CAN INCLUDE:

Many people with tumour don't have symptoms unless the tumour grows in certain parts of the eye or becomes more advanced.

1.               Blurred vision.

2.               Redness of the eye

3.               Shadows, flashes of light

4.               A dark patch in the eye that's getting bigger.

5.               Partial or total loss of vision.

6.               Bulging of one eye ,sudden proptosis

7.               A lump on eyelid or in your eye that's increasing in size.

8.               Pain in or around eye, although this is rare.

Diagnostic tests

In addition to a physical examination, the following tests may be used to diagnose eye cancer: 

Eye examination.

Most cases of melanoma are found during a regular eye examination. The doctor will examine the eye with a lighted instrument called an ophthalmoscope and a slit lamp, which is a microscope with a light attached to it.

Ultrasound. An ultrasound uses sound waves to create a picture of the eye.

Fluorescein angiography. This procedure takes a picture of the blood vessels in the eye. Fluorescein angiography may be used to rule out eye problems other than cancer

Fine needle biopsy. This procedure removes tumor cells from the eye with a needle. This allows the doctor to look at the cells under a microscope.

Cytogenetics and gene expression profiling.  Doctor's may recommend this type of test to help gather more information about your prognosis (chance of recovery) and treatment options. Cytogenetics or gene expression profiling tests are done using a tissue sample removed during either a biopsy or surgery.

Computed tomography (CT) scan. A CT scan creates a three-dimensional picture of the inside of the body . it provides a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields to produce detailed images of the body. MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow.

Positron emission tomography (PET) scan. The doctor may also order a positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into a patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

PROGNOSIS

Surgical removal is curative for many orbital tumors and the cosmetic results can be excellent. The outcome and prognosis ultimately depends on the pathological diagnosis. Some orbital tumors may require additional therapy rather than biopsy or removal this may include conventional "external beam" or Gamma Knife Radiotherapy. Occasionally chemotherapy may also be necessary.

MEDICAL AND SURGICAL MANAGEMENT

GOALS

To prevent a malignancy from progressing to a life-threatening stage

To preserve vision, and preserve the eye

To alleviate the symptoms of an orbital tumor and restore the patient to good health

1.   Radiotherapy

2.   Chemotherapy

3.   Gamma Knife Radiosurgery

4.   Surgical excision

Surgical removal of the cancer is often the first line of treatment for head and neck cancers.

Orbitotomy. A surgical incision made into the orbit to allow the removal of a tumour or foreign body, to treat a lesion, or to drain an abscess.

Evisceration 

Evisceration is the removal of the inside of the eyeball but not the outer layers.

 Exenteration

Orbital exenteration is the removal of the entire eye socket, optic nerve and even bones surrounding the eye.

Enucleation

Enucleation is the removal of the eye but leaving the eye socket in place.

BIBLIOGRAPHY

1.               Brunner and Suddarth’s, “Medical Surgical Nursing” Published by Lippincott, 10th edition.

2.               Lewis, Heitkemper and Dirksen’s , “Medical surgical nursing”, Published by Mosby, 6th edition.

3.               Head and neck cancer guide.com

4.               Nursesoutlook.blogspot.com