CHAPTER 57
Ophthalmic Drugs
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Structures of the Eye
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


Eyebrows, eyelids, eyelashes
Palpebral fissure
Sclera
Uvea



Choroid
Iris
Ciliary body
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Structures of the Eye (cont’d)
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


Conjunctiva
Pupil
Medial canthus
Lacrimal caruncle


Lacrimal glands
Lateral canthus
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Layers of the Eye


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





Anterior chamber
Posterior chamber
Canal of Schlemm
Aqueous humor
Vitreous humor
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Interior of the Eyeball (cont’d)
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Retina



Rods
Cones
Optic nerve
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Lens
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
Accommodation
Cataracts
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Drugs That Affect the Eye

Mydriatics


Miotics


Dilate the pupil
Constrict the pupil
Cycloplegics



Paralyze the ciliary body
Have mydriatic properties
Cycloplegia: paralysis of accommodation
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Ocular Drugs
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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



Angle-closure glaucoma
Open-angle glaucoma
Also characterized by underlying cause



Primary
Secondary
Congenital
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Drugs Used to Reduce IOP
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



Beta-blockers (antiadrenergic)
Osmotic diuretics
Carbonic anhydrase inhibitors
Direct-acting and indirect-acting
parasympathomimetics (cholinergic)
Prostaglandin agonists
Sympathomimetics (adrenergics, mydriatics)
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Cholinergic Drugs




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




acetylcholine (Miochol-E)
carbachol (Carboptic)
pilocarpine (Pilocar) (also ocular insert form)
Indirect-acting drugs

echothiophate (Phospholine Iodide)
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Cholinergic Drugs: Indications





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)




brimonidine (Alphagan)
apraclonidine (Iopidine)
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




Burning
Eye pain
Lacrimation
Rare systemic effects




Hypertension
Tachycardia
Headache
Faintness
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Beta-Adrenergic Blockers

Selective beta1-blocker


betaxolol (Betoptic)
Nonselective beta1- and beta2-blockers




carteolol (Ocupress)
levobunolol (Betagan Liquifilm)
metipranolol (Optipranolol)
timolol (Timoptic, Betimol)
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Beta-Adrenergic Blockers
(cont’d)
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Reduce IOP by



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






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



Available in oral forms for treatment of
glaucoma
Inhibit the enzyme carbonic anhydrase, which
reduces aqueous humor formation in the eye
Result is decreased IOP
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Carbonic Anhydrase Inhibitors
(cont’d)

Topical ophthalmic preparations



brinzolamide (Azopt)
dorzolamide (Trusopt)
Oral forms


acetazolamide (Diamox)
Others
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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
cross-sensitivities
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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


Newer class of drugs for glaucoma
Three drugs



latanoprost (Xalatan)
• Most popular
travoprost (Travatan)
bimatoprost (Lumigan)
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Prostaglandin Agonists (cont’d)
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


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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Ocular Antimicrobial Drugs

Topical and systemic administration



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, tobramycin
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Ocular Antibacterial Drugs
(cont’d)

Macrolides

Antibacterial
 Erythromycin, azithromycin, others
 Erythromycin also is used for prevention of
Neisseria gonorrhoeae eye infections in newborns
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Ocular Antibacterial Drugs
(cont’d)

Polypeptides


Antibacterial
Bacitracin, polymyxin B
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Ocular Antibacterial Drugs
(cont’d)

Quinolones



ciprofloxacin (Ciloxan)
Four others
Sulfonamides


sulfacetamide (Bleph-10)
Others
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Ocular Antifungal Drugs

natamycin

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 posterior of
the eye
fomivirsen (Vitravene)

Treatment of ocular CMV
 Administered by intravitreal injection
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Ocular Antiviral Drugs (cont’d)

trifluridine (Viroptic)


Used in the treatment of types 1 and 2 herpes
simplex virus (HSV)
Applied topically as drops
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Ocular Antiinflammatory Drugs

NSAIDs



ketorolac (Acular)
flurbiprofen (Ocufen)
Corticosteroids

dexamethasone (Decadron, AK-Dex)
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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)



Applied topically
Used to treat various ophthalmic
inflammatory conditions
Should not be used for minor abrasions or
wounds—may suppress the eye’s ability to
resist infections
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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
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

Atropine sulfate

Results in
• Mydriasis
• Cycloplegia
 Used for
• Ophthalmic examinations
• Uveitis (which benefits from pupillary dilation)
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Ophthalmic Diagnostic
Drugs (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)

Mydriatic-reversal drug


dapiprazole (Rev-Eyes)
• Alpha-adrenergic blocker
Used to
• Reverse the effects of mydriatic drugs
• Restore normal pupillary function when sustained
mydriasis is not desired
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Ophthalmic Diagnostic
Drugs (cont’d)

fluorescein (AK-Fluor)


Ophthalmic diagnostic dye
Used to
• Identify corneal defects
• Locate foreign bodies in the eye
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Ophthalmic Antiallergic Drugs

Ophthalmic antihistamines


Used to treat symptoms of allergic conjunctivitis
(“hay fever”)
azelastine (Optivar), olopatadine (Patanol), others
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Ophthalmic Antiallergic Drugs
(cont’d)

Used for seasonal allergy symptoms


Mast cell stabilizers
• cromolyn sodium (Crolom)
• pemirolast (Alamast)
• Others
Decongestants
• tetrahydrozoline
• phenylephrine
• Others
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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
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Lubricants and Moisturizers
(cont’d)

Restasis



Ophthalmic form of cyclosporine
Immunosuppressant drug
Used to treat “dry eyes”
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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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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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