Module 15 - Pharmacotherapy for Ophthalmological Disorders

GeriatricPharmacyReview Module15 PharmacotherapyforOphthalmologicalDisorders

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Accreditation Information

ASCP is accredited by by the Accreditation Accreditation Council for Pharmacy Education as as a provider of continuing continuing pharmacy education.

This home study web activity has been assigned 3 credit hours. ACPE UPN: 0203-0000-10-008-H01-P 0203-0000-10-008-H01-P Release Date: 2/17/2010 Expiration Date:2/17/2013

To receive continuing education credit for this course, participants must complete an on-line evaluation form and pass the online assessment with a score of 70% or better. If you do not receive a minimum score of 70% or better on the assessment, you are permitted 4 retakes. After passing the assessment, you can print and track your continuing education statements of

















Content Experts

Current Content Expert: Charlie Waters, PharmD, BCPS, CGP Clinical Manager Cardinal Health

Legacy Content Experts: J. William Doyle, MD, PhD College of Medicine University of Florida Mary Fran Smith, MD College of Medicine University of Florida

















Degenerative Diseases of the Elderly Eye

Learning Objectives:

By the end of this review concept, you should be able to: •

Describe the basic intraocular pressure and aqueous humor dynamics of the human eye.

• Explain the pathophysiological changes that can occur in the elderly eye, specific to dry eye, cataracts, and macular degeneration. • Examine and apply patient, disease, and medication-related factors influencing the choice of treatment intervention for degenerative diseases of the eye. •

Review the effects of systemic diseases on the eye.

















Age-related Changes Changes in the the Eye

•Decrease in tear production •Drooping eyelids (ptosis) •Corneal decompensation (natural i.e. Fuchs dystrophy, dystrophy, or post surgical) • Atrophy Atrophy of iris and ciliary muscles •Opacity in the crystalline lens •Liquefaction, cavitation, detachment of vitreous •Degenerative processes of retina (age related macular degeneration) •Damage to the retina by other diseases of aging •Damage to the optic nerve by diseases of the elderly, elderly, i.e. glaucoma, vasculopathy

















Age-related Changes Changes in the the Eye

Natural age-related changes to the eye account for most of the ophthalmological disorders seen in elderly patients. These changes are usually bilateral, symmetrical, and typical for each age group. Some of the more common changes include a decrease in basal tear production, dry lids from loss of oily secretions resulting in decreased vision and discomfort, thinning of the conjunctiva, and discoloration of the sclera. Sclerosis of the lens substance, causing blurred vision, and decreased elasticity of its capsule contribute to loss of accommodation. Degenerative Degenerative diseases can affect the retina such as age related macular degeneration and the loss of sharp acuity. Also, many systemic diseases, diseases, such as diabetes, diabetes, or hypertension, hypertension, can damage the retina and cause profound profound visual loss. Lastly, Lastly, the optic nerve is susceptible to diseases in the elderly such as glaucoma or arteriosclerosis and infarction.



















Signs and Symptoms of Dry Eye Syndrome •Conjunctival injection •Unhealthy cornea •Dry or scratchy feeling in the eye •Impaired vision •Poor blink •Foreign body sensation •Pain and intermittent epiphora

















Risk Factors for Dry Eye Syndrome

•Elderly •Female • Any Any surface trauma trauma i.e., burns •Connective tissue disease •Long term use of medications such as for glaucoma •Multiple surgeries •Exposure (Bell’s palsy)

















Treatment of Dry Eye Syndrome There are a multitude of over-the-counter tear preparations for dry eye which range from then to very viscous Bottled Tears with Preservatives: •Polyvinyl alcohol 1% (Hypotears®) – thin •Polyethylene glycol 2%/dextran 1% (AquaSite®) – thicker •Generic (usually 3% methylcellulose)

Initially, Initially, dry eye syndrome is best treated through the use of polyethylene glycol solutions. These solutions contain preservatives for the occasional user. Individual use, preservative-free tears are more expensive, but are recommended for patients who require daily treatment for the entire year. Newer, Newer, less expensive bottled tear products contain a preservative that breaks down after application, so the preparation is effectively preservative-free. preservative-free.

















Degenerative Diseases of the Lens and Retina

Diseases of the Lens •Cataracts

Primary diseases of the Retina • Age Age related macular macular degeneration (AMD) (AMD) •Retinal detachment

















Effects of Cataracts on Vision

•Impairment of near vision •Impairment of far vision •Sensitivity to glare outdoors •Monocular diplopia (from cleft or vacuole) •Lens swelling and refractive changes



















Steps in Cataract Extraction (Phacoemulsification) (Phacoemulsification)



















Pre-operative Preparation for Cataract Extraction



















Post-operative Management for Cataract Extraction – Topical Antibiotics



















Post-operative Management for Cataract Extraction – Anti-inflammatory Drugs



















Post-operative Post-operative Red Eye



















































































































































































































Other Causes of “Red Eye”

•Toxins (physostigmine) •Reaction to topical medications •Contact lens problems •Pollution • Alcohol Alcohol •Ultraviolet exposure •Lack of sleep • Allergies Allergies •Foreign bodies •Chemical burns •Intraocular inflammation (uveitis)

Not every red eye is caused by infection. Conjunctival congestion can also be caused by air pollution, ultraviolet exposure, alcohol and lack of sleep. Allergic conjunctivitis, experienced by fifteen percent of the population, often results when an antigen, such as pollen, mediates a local immunoglobulin A or immunoglobulin immunoglobulin E response. Use of topical medications or contact lens problems may also cause a red eye. A persistent “achy” red eye may signify uveal inflammation, and requires evaluation by an eye specialist.

















Signs and Symptoms of Allergic Conjunctivitis

•Itching •Occasional burning •Conjunctival injection, chemosis •Watery or ropy discharge •Lid swelling •Redness •Papillary response •Possible eczema

















Treatment of Allergic Conjunctivitis •Oral antihistamines (OTC) •Thin tear preparation (OTC) •Topical nonspecific antihistamine/vasoconstrictor antihistamine/vasoconstrictor drop (OTC): naphazoline (Vasocon®, (Vasocon®, Naphcon®) •Specific antihistamine drop: Levocabastine (Livostin®), an H1 blocker, 1 drop four times a day up to 2 weeks •Mast cell stabilizer drop:4% cromolyn drops (Crolom®) qid, nedocromil sodium (Alocril®) or lodoxamide (Alomide®), 1 – 2 drops four times a day •Do not exceed 3 months use •Olapatadine hydrochloride 1% (Patanol®) drop :bid •Epinastine HCl (Elestat®) and ketotifen fumarate (Zaditor®) •Both have antihistamine and mast cell stabilizing actions •Both are bid medications •Ketorolac (Acular ®), an NSAID drop, 1 drop four times a day for 7 days •Or as a last resort: •Mild topical steroids: •Loteprednol etabonate (Alrex®) or fluorometholone (last resort)

Allergic conjunctivitis can be treated with oral oral antihistamines. One drawback to the use use of over-the-counter over-the-counter antihistamines is that they may exacerbate any underlying “dry eye” state. In addition, diphenhydramine may cause confusion in older

















Etiology of Corneal and Uveal Tract Disease

CORENAL DISEASE

UVEITIS

Infection (H. simplex, zoster)

Infection (herpes, TB, etc.)

Toxic reaction

Foreign bodies

Metabolic changes

Systemic processes, such as rheumatologic disease

Tear deficiency deficien cy

Drug hypersensitivity hypersens itivity

Trigeminal Trigeminal involvement

Severe ischemia

Trauma

Surgical trauma

Neoplasms

Intraocular tumors

















Signs and Symptoms of Corneal Disease

•Pain •Photophobia •Tearing •Impaired vision •Corneal immune precipitates •Corneal edema •Dendritic ulcers in the corneal epithelium (viral) •“Soupy” ulcers (bacterial) •Recurring lesions

The signs and symptoms of corneal disease are many and varied. Pain, caused by irritation of the ciliary nerves, is common, and often aggravated by light and pressure. Tearing Tearing is usually observed, secondary to reflex irritation of the cornea and ciliary nerves. Impaired vision may result from excessive light scatter, clouding of the stroma, epithelial edema, and scarring. Corneal disease may initially present as a superficial keratitis or a localized stromal edema, followed by the development of deep ulceration. Herpetic corneal disease may be recurrent, so inquiring about a history of prior lesions is important.



















Signs and Symptoms of Uveitis

•Pain •Photophobia •Tearing •Impaired vision •Corneal immune precipitates •Corneal edema •Bleeding into anterior chamber •Vitreous opacities (posterior uveitis)

















Treatment of Corneal Infections Bacterial Infections: •Fluoroquinolones - e.g., Gatifloxacin (Zymar®) and moxifloxacin (Vigamox®) offer good broad spectrum coverage •Fortified Antibiotics Antibiotics - e.g., cefazolin (Kefzol®) 5% or tobramycin (Tobrex®) (Tobrex®) 1.4% drops are made by injection of IV antibiotics into tear or standard preparations Viral Infections: • Antiviral Antiviral drops - e.g., e.g., trifluridine (Viroptic®) (Viroptic®) 1% solution

















Treatment of Uveitis

•NSAID drops - e.g., diclofenac (Voltaren (Voltaren ®), ketorolac (Acular ®), flurbiprofen (Ocufen ®) •Topical steroid - e.g., prednisolone acetate (Pred Forte®) 1%, dexamethasone (Ocu-Dex ®) •Rare: systemic immunosuppressant - e.g., oral prednisone, methotrexate

The mainstay of uveitis treatment is a strong anti-inflammatory eyedrop such as prednisolone acetate one percent. Subconjunctival injections of steroid prescribed by an eye specialist may supplement therapy. therapy. More rarely, oral prednisone or other systemic immunosuppressant such as methotrexate are used to treat uveitis in very refractive patients.

















Resources

For additional information, see: Age related Eye Disease Study Research Group.A Group.A randomized, randomized, placebo-controlled, placebo-controlled, clinical trial of high dose supplementation with vitamins C and E, beta carotene and zinc for ARMD and vision loss.Report #8.Arch. Ophthalmol. 2001Oct;119(10):1417-36. Douglas, R., Jr., Cullom, B., & Chang.(1994). The Wills eye manual:Office and emergency room diagnosis and treatment of eye disease, 2nd ed.Philadelphia:Lippincott-Raven. ed.Philadelphia:Lippincott-Raven.

















Glaucoma

Learning Objectives:

By the end of this Review Concept you should be able to: •Cite the epidemiologic trends associated with glaucoma. •Differentiate between open angle glaucoma and angle closure glaucoma.



















Incidence and Morbidity Associated with Glaucoma



















Four Types of Glaucoma



















Pathophysiology of Open Angle Glaucoma



















Risk factors for Open Angle Glaucoma



















Diagnosis of Open Angle Glaucoma



















































































































































































































When Pharmaceutical Treatment Fails

Various Various surgical options should be considered: Laser trabeculoplasty with open angle glaucoma Trabeculectomy Glaucoma drainage device

Many cases of advanced glaucoma cannot be controlled by topical medications alone. In cases where progressive optic nerve atrophy continues to occur despite maximum tolerated medicine therapy, then surgical options should be considered. Surgical options for open angle glaucoma patients include laser trabeculoplasty in open angle glaucoma, and for all types of glaucoma, trabeculectomy and glaucoma drainage device surgery. surgery.

















Laser Trabeculoplasty •Uses a laser to treat the eyes natural drain so that it drains more efficiently • Argon Argon laser trabeculoplasty trabeculoplasty (since 1980), 1980), not repeatable •Selective laser trabeculoplasty (since 2001), is repeatable •Success rates of laser trabeculoplasty range from 66%-90% depending on the type of glaucoma and the nature of the drain

If an open angle glaucoma patient is not controlled on medications, the next step considered by the ophthalmologist is laser trabeculoplasty. trabeculoplasty. This procedure is done in the office and works by applying just enough energy to the surface of the eye’s drain that it opens up more on a microscopic level. Both argon and the newer Selecta (YAG laser) are used for this surgery. surgery. The success rate for laser trabeculoplasty ranges from 66-90%.

















Trabeculectomy Trabeculectomy Surgery, (a.k.a. filter surgery)

Incisional surgery in the operating room Makes a new “drain hole” for the eye’s fluid to “filter” out of the eye Results in a “bleb,” i.e.:collection of eye fluid (aqueous) in the subconjucntival space

If laser trabeculoplasty fails in the open angle glaucoma patient, of if a closed angle patient needs additional treatment beyond the initial laser iridectomy and subsequent medicine treatment, then trabeculectomy surgery is performed. The patient is treated in the operating room where the surgeon makes a new drain hole for the eye’s fluid to drain out, thus reducing the eye’s pressure.

















Repeat Warning •If a patient presents with a red eye, they need to be asked if they have a history of glaucoma surgery •The new drain facilitates entry of bacterial into the eye, risking endophthalmitis (infection inside the eye) •If the answer is “yes”, then refer the patient emergently to the eye doctor

It cannot be emphasized enough, that a red eye in a patient with an existing trabeculectomy can be associated with progression to blindness due to infection, if appropriate treatment is not immediately instituted.

















Glaucoma Drainage Device Surgery

• An An alternative glaucoma glaucoma incisional surgery surgery is glaucoma drainage drainage device surgery • A A hollow 22 gauge tube is placed placed inside of the eye •Fluid drains through this tube to a plate sutured in the subconjunctival space in the back of the eye

Not all eyes are trabeculectomy candidates (patients with uveitic glaucoma, or juvenile glaucoma); other eyes progressive glaucoma fail trabeculectomy surgery (the new drain heals up).In these cases, the next step usually involves insertion of a hollow drainage tube into the eye, a glaucoma drainage device.



















Different Glaucoma Drainage Devices •Baerveldt tubes • Ahmed Ahmed tubes •Molteno tubes •Krupin tubes

Multiple different drainage devices are available to help drain fluid out of the eye, and lower the intraocular pressure. They all work similarly.

















Post-Op Glaucoma Surgery Patients Any patient in the postoperative postoperative period following following glaucoma surgery: surgery: • Should be encouraged to use their prescribed topical medications: 1. Usually a topical antibiotic 2. A topical steroid 3. Occasionally a topical cycloplegic •

They should call their surgeon if any change in vision occurs, if redness develops, or if pain or discharge develops

















Resources

For additional information, see: Kertes, P.& P.& Conway, M. D. (Eds.).Clinical trials in Ophthalmology: A summary summary and practice guide.Baltimore:William & Williams. Kunimoto, D, et al. (2002) The Wills eye manual:Office and emergency room diagnosis and treatment of eye disease, 3rd ed.Philadelphia:Lippincott-Raven.

Module 15 - Pharmacotherapy for Ophthalmological Disorders

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