Eye Disorder Presentation

I Eye Disorder Bin Deng, PharmD, BCACP, BC-ADM, CDCES Spring 2025 Question 1 What is the first line of therapy for dye eyes? to milddryad 094 a) Artificial tear b) Cyclosporineme Moreseize c) Surgery d) Punctal occlusion Symptoms/Clinical Presentation 6 5 2 3 u 3 Red Flags (Exclusion criteria) Rule out for any red flags: • Discharge • Blurry vision • Difficulty with vision Patients with those symptoms should be referred to a medical provider for further evaluation If no red flags: discuss patient options based on cost, dosage forms (suspension vs solution), preservative vs nonpreservative, previous experience with a product, allergies, single dosed vial vs multi dosed vial Patients with moderate to severe dry eye disease or those whose symptoms do not improve with over-the-counter treatments within 72 hours should be referred for an ophthalmology evaluation. 4 Dry Eyes-Non-Pharmacological Treatment Aerobic Exercise (increases tear secretion) Ingestion of 2 low glycemic index foods (e.g. veg, whole grains) 3 Decrease frequency of contact lens use (or complete cessation) O•Try to avoid smoke, wind, and air conditioning •UseSa humidifier to keep the air in your home from getting too dry 6 screen time and take breaks from staring at screens •Limit •Wear7wraparound sunglasses when you're outside •Drink plenty of water — try for 8 to 10 glasses every day tear production and Egon improve blood flow to the eyes. •Warm compresses: stimulate 5 Dry Eyes-Pharmacological Treatment Discontinuation of the causative agent, if possible, or switching to preservativefree ophthalmic drops and products can help alleviate symptoms. 1st Line: Artificial Tear A. may include cellulose (hydroxyethylcellulose, carboxymethylcellulose, and hydroxypropyl methylcellulose)Lubricant B. Polyethylene glycol (lubricant) C. Petrolatum (Lubricant) D. Preservative (If using contact lenses, recommended to use without preservatives) Artificial tear helps: 5h •Treat dryness by adding moisture, reduce friction on the cornea by adding lubrication, soothe irritation, Reduce redness and swelling. Dose: 1-2 drop as needed (If using products with preservatives, limit to 4 times daily) Formulations: Drops, gels, ointments (gels & ointments-apply before bedtime due to blurry vision) 6 Preservatives vs. Preservative Free Preservatives helps increase shelf-life Pay attention to Expiration Date on the bottle Regardless, you should discard any open artificial tear product when it’s 3-4 months old or use single-vials If using contact lenses or using more than 3-4 times daily use preservative-free (recommended) If HAVE TO use artificial tear with preservatives remove contact lenses prior to application and wait for 15 minute (15 minute-rule) 7 Other therapies and Rx medications for Dry Eyes Moderate-Severe Symptoms Topical anti-inflammatories (e.g. steroids, cyclopsporine (Restatsis ®, Cequa ®), lifitegrast (Xiidra ®) Topical Antibiotics Punctal Occlusion (insertion of plugs to prevent drainage of tears) Scleral contact lenses (reservoir of tears) Surgery (if abnormal eyelid function or anatomy) 8 Counselling points for Rx Eye Drops Cyclopsporine (Restatsis ®, Cequa ®) & lifitegrast (Xiidra ®) • Instill 1 drop in each eye twice daily approximately 12 hours apart; if used with other eye drops • Ensure a 15-minute interval between eye drop instillations for Restasis • Remove contact lenses prior to dose and reinsert 15 minutes following dose • Side Effects (Restasis, Cequa): Application site reaction/irritation, Burning sensation in eye, Conjunctival hyperemia, Pain in eye (higher w/ solution vs emulsion) • Side effects (Xiidra) may include instillation site irritation, reduced visual acuity, blurred vision, conjunctival hyperemia, increased lacrimation, eye discharge or discomfort, dysgeusia, or headache 9 Question 2 pinflommotions Which of the following statement is true in regard to blepharitis? a) It is an acute eyelid inflammation b) Posterior blepharitis is commonly caused by bacteria c) The pharmacological treatment for blepharitis is artificial tear d) Apply hot compress to loosen up crest Clinical Presentation Inflammation of eyelid Irritation Redness, swelling of eyelid Sensitivity to light Swollen, itchy eye lid Eyelid sticking More frequent blinking Itchy, and appear greasy and crusted with scales that cling to the lashes. • Dry eye or excess tearing • • • • • • • • 11 Blepharitis-Non-Pharmacological Treatment Warm (NOT HOT) compresses (to loosen up crust). Eyelid cleansing (commercially available products, sterile water, boiled (cool) water or baby shampoo) Patients with suspected blepharitis who do not achieve relief within a few days should be referred for medical evaluation 12 Question 3 Which of the following agent is indicated for bacterial conjunctivitis? Too whitepartof the eye a) Tetrahydrolazine b) Ketoprofen c) Moxifloxacin d) Azelastine Conjunctivitis (Pink Eye) What is it? inflammation of the conjunctiva within the eye Types of Conjunctivitis: • Viral: Self-limiting. often clears within 7-14 days without tx (some cases 2-3 weeks) • Bacterial: Self-limiting. More common in children. Usually improves in 2-5 days without tx but can take 2 wks to go away completely. • Allergic: pollen, dust, cosmetics • Others: Pollution, chemicals, contact lens, foreign body in the eye 15 Clinical Presentation: Conjunctivitis Pink/red color in the whites of the eye(s) Itching especially in allergic conjunctivitis Irritation/grittiness 2 Crusting of the eyelids usually in the early morning upon awakening: Likely bacterial or viral Tear production Blurred vision 3 Discharge (green/yellow): likely bacterial 16 Bacterial Allergic Viral What is it More rare. Contagious Also thru, improper Contact lens use. More common in kids than adults. Common among people with other allergic conditions, such as asthma, and eczema 80% of conjunctivitis cases. Commonly caused by adenovirus (common cold), contagious. Self limiting. Often mild. For severe cases caused by Herpes by varicella-zoster, referral needed Contagious? Yes No Yes Season Winter (Dec-April) Seasonal or year round due to indoor allergens Fall/Spring Cause Bacteria: Eg. Staph aureus, Strep pneumoniae, H. influenzae, M. catarrhalis pollen from trees, plants, grasses, and weeds; dust mites; molds; dander from pets; medicines; or cosmetics Virus e.g. Adenovirus (upto 60%) Clinical Presentation One eye or both eyes. More commonly associated with thick discharge (pus), which can lead to eyelids sticking together Sometimes occurs with an ear infection Usually occurs in both eyes Can produce intense itching, tearing, and swelling in the eyes May occur with symptoms of allergies, such as an itchy nose, sneezing, a scratchy throat, or asthma or eczema Can occur with symptoms of a cold, flu, or other respiratory infection Usually begins in one eye and may spread to the other eye within days Discharge from the eye is usually watery rather than thick 17 Conjunctivitis-Treatment Strategy Viral: self-limiting. Management is through supportive care to provide relief but medication will NOT affect viral activity. In severe cases caused by Herpes, varicellazoster, referral needed for oral anti-viral medications e.g. acyclovir Bacterial: Antibiotic eye drops/ointments can shorten length of infection. For STI, oral/IM ABX may be used. Referral to MD required for bacterial conjunctivitis Allergic: Allergy medications and eye drops (topical antihistamine and vasoconstrictors) 18 Conjunctivitis- Non-Pharmacological Treatment Eyelid cleansing if crusting Cold/warm Compress • Warm compresses help to reduce the sticky buildup of discharge on the eyelids or crust that forms on your eyelashes, • Cold compress to relieve itching and inflammation Do not wear contact lenses for 48 hours after sx have subsided 19 Conjunctivitis- Treatment • Artificial Tear (some products come in combination with decongestants) • Topical Decongestants/antihistamine: 1-2 drops QID PRN Antihistamines: ketoprofen (Zaditor ®), olapatidine (Pataday ®), alcafatdine (Lastacaft ®), azelastine, pheniramine (no mast cell stabilizing effect) Decongestants (alpha adrenergic agonists): tetrahydrolazine 0.05% or Naphazoline 0.012-0.03% (often in combination with antihistamines), brimonidine 0.025% (Lumify ®) in to overuse. Not available OTC • Topical corticosteroids: effective for ocular allergies but prone • Topical Rx ophthalmic Antibiotics (only for bacterial conjunctivitis): Chloramphenicol, Azithromycin, Gentamycin, Levofloxacin, Moxifloxacin Duration: 1 week 20 Question 4 Which of the following is first line therapy for glaucoma? (Select All that apply) a) Latanoprostor talented b) Timololto Blagden c) Dorzolamide d) Brimonidine Glaucoma -Pharmacological Treatment no Lanoprost Prostaglandin analogs- 1st line Beta Blockers- 1st line Alpha-2 agonists to MOLE Carbonic Anhydrous Inhibitors (CAI) Rho Kinase Inhibitors Parasympathomimetic agents They all work by decreasing IOP 22 Glaucoma -Prostaglandin analogs i One of the first line agents 2 IN Improved nocturnal IOP compared to timolol 3 Greater reduction in IOP compared to BID timolol. Can be used in combination w/ other agents for additional IOP control Generally well tolerated w/ fewer ADR compared to timolol Bimatoprost may be slightly more effective in lowering IOP, getting a larger percentage of patients to lower IOPs, and for patients unresponsive to latanoprost Tafluprost is preservative free solution; bimatoprost available as an implant If the patient does not respond to one prostaglandin agonist, a switch to another may be beneficial 23 Counselling Points Once daily eye drops, administered at night Altered iris pigmentation (15-30%) • Cosmetic but irreversible upon discontinuation Eye-lash growth (left eye) Eyelash hypertrichosis (hair growth) is common and reverses upon discontinuation of the drug Hyperpigmentation around the lids and lashes has also been reported and appears to reverse upon discontinuation Loss of periorbital fat has been reported, which may lead to sunken eye appearance Sunken eye 24 Daytime Glaucoma –Beta Blockers One of the most commonly used antiglaucoma medications • These are commonly one of the agents of first choice—along with prostaglandin analogs—in treating POAG if no contraindications exist Lower IOP by 20% to 30% ; Have minimum effect on nocturnal IOP MOA: produce ocular hypotensive effects by decreasing the production of aqueous humor Generally, they are dosed BID (except Timoptic XE gel) They all produce similar IOP lowering effect (choice based on cost, ADR, response) Tachyphylaxis in 20-25% of pts Risk of systemic absorption • Timolol gel, fewer drops per day, therefore lower chance 25 Glaucoma –Alpha-2 agonist-2nd line Drugs: Brimonidine, apraclonidine Effective for prevention or control of postop increases in IOP Combination product: Timolol + brimonidine= Combigan ®….dosed BID Considered second line (after PG analog or beta blocker use) or as adjunct Allergic type rxn more common w/ apraclonidine (up to 30%), therefore only used short term after surgery Systemic adverse effects with brimonidine include dizziness, fatigue, somnolence, dry mouth, and possibly a slight reduction in blood pressure and pulse Dose: TID 26 Carbonic Anhydrase Inhibitors CAIs reduce IOP (by 15-26%) by decreasing aqueous humor secretion Dorzolamide and brinzolamide are well tolerated and are considered second line (after PG and b-blockers) for monotherapy or adjunctive therapy of POAG and ocular hypertension 0 00 Generally are well tolerated. Local adverse effects include transient bitter taste in mouth, burning and stinging, ocular discomfort and transient blurred vision, tearing, 000 CAIs should be used with some caution in patients (including ophthalmic formulations) with sulfa allergies (cross reactivity risk is low) Systemic ADR is uncommon Dose: BID or TID Beta-blocker combination with CAI are available commercially • Timolol + dorzolamide= Cosopt ®…..dosed BID • Brimonidine + Brinzolamide= Simbrinza ®…dosed TID Systemic CAIs are also available (vs ocular) indicated for patients failing to respond to or tolerate maximum topical therapy. • Very effective but due to intolerable ADR, considered 3rd line • Do not use in combination with ophthalmic CAI (no data on effectiveness) • Hypokalemia may occur when used in combination with diuretics 27 Question 5 *Age related macular degeneration tx** Which of the following vitamin is part of AREDS therapy? a) Vitamin A b) Vitamin B c) Vitamin C d) Vitamin D 29 ARMD –Wet-Type Treatment Treatment options • Anti-VEGF agents retinal injections (typically Q4-6 weeks injections) Improves visual acuity and decreased blindness in about 50% of treated patients Preventing the growth of new blood vessels into the retina by reducing excess VEGF concentration in the retina which causes swelling Can limit the progression of AMD and stabilize or reverse vision loss Bevacizumab (off-label), ranibizumab, Ranibizumab-nuna (biosimilar) and brolucizumab-dbll, Aflibercept, pegaptanib • AREDS Therapy • Photodynamic therapy (PDT)…in patient who fail anti-VEGF IV drug that is activated by light is injected, then a laser is used to prevent leakage of fluid into retina • Surgery Vascular endothelial growth factor (VEGF) is a potent angiogenic factor and was first 30 described as an essential growth factor for vascular endothelial cells.