Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 17:

Ophthalmic Disorders

Blepharitis

Definition: eyelid margin infection.

Causes: bacterial infection (staphylococcal blepharitis), inflammation or hypersecretion of the sebaceous glands (seborrheic blepharitis), meibomian gland dysfunction (MGD blepharitis), or a combination of these.

Pathophysiology: toxin production, immunologic mechanisms, Demodex folliculorum mite infestation, and antigen-induced inflammatory reactions have all been reported with blepharitis.

Blepharitis (cont.)

Manifestations: thickening of the eyelid margin, plugging of the meibomian orifices, prominent blood vessels crossing the mucocutaneous junction, and formation of chalazia (painless firm lumps on the eyelid)

Diagnostic criteria: based on symptoms: irritated red eyes and burning sensation; increases in tearing, blinking, photophobia, eyelid sticking, and contact lens intolerance

Treatment: strict eyelid hygiene and warm compresses

Drug Therapy for Blepharitis: Single-Agent Products

Sulfacetamide sodium 10% solution (Bleph-10)

Bacitracin 500 units/g ointment

Erythromycin 0.5% ointment

Gentamicin 0.3% solution or ointment (Gentak)

Tobramycin 0.3% solution or ointment (Tobrex)

Besifloxacin 0.6% suspension (Besivance)

Ciprofloxacin 0.3% solution or ointment (Ciloxan)

Drug Therapy for Blepharitis: Single-Agent Products (cont.)

Gatifloxacin 0.3% solution (Zymaxid)

Levofloxacin 0.5% solution (Quixin)

Moxifloxacin 0.5% solution (Moxeza, Vigamox)

Ofloxacin 0.3% solution (Ocuflox)

Drug Therapy for Blepharitis: Combination Products

Polymyxin B sulfate, bacitracin ointment: apply every 3 to 4 hours for 7 to 10 days

Polymyxin B sulfate, trimethoprim sulfate solution (Polytrim): 1 drop in the affected eye(s) every 3 hours (maximum 6 doses a day) for 7 to 10 days

Polymyxin B sulfate, gramicidin, neomycin solution (Neosporin): 1 to 2 drops in the affected eye(s) every 4 hours for 7 to 10 days

Polymyxin B sulfate, bacitracin zinc, and neomycin ointment: apply every 3 to 4 hours for 7 to 10 days

Recommended Order of Treatment for Blepharitis

First line:

Erythromycin 0.5% ophthalmic ointment or

Bacitracin 500 units/g ointment or

An ophthalmic fluoroquinolone solution (besifloxacin, gatifloxacin, levofloxacin, or moxifloxacin)

Second line: referral to an ophthalmologist

Question

A practitioner prescribes polymyxin B sulfate gramicidin, neomycin solution (Neosporin) for a patient with blepharitis. What would be the appropriate dosage?

1 to 2 drops in the affected eye(s) every 4 hours for 7 to 10 days

1 drop twice daily for 2 days

1 drop in the affected eye(s) every 3 hours for 7 to 10 days

1 drop in the affected eye(s) twice daily for 2 days

Answer

A. 1 to 2 drops in the affected eye(s) every 4 hours for 7 to 10 days

Rationale: Polymyxin B sulfate, gramicidin, neomycin solution (Neosporin) is dosed: 1 to 2 drops into the affected eye(s) every 4 hours for 7 to 10 days.

Patient Education for Blepharitis

Educate about chronic nature

Teach eyelid hygiene, warm compresses, and occasional antibiotic use

Counsel contact wears to refrain from wearing contacts during acute cases

Conjunctivitis

Most common cause of a red, painful eye in the United States

Common causes

Gram-positive Staphylococcus and Streptococcus species and the gram-negative Moraxella and Haemophilus species; the adenovirus causes the majority of conjunctivitis cases in adults

Allergic conjunctivitis: seasonal, vernal, atopic

Mechanical or chemical irritants

Diagnostic Criteria for Conjunctivitis

Hallmark: red or pink eye

Itching or burning sensation of eyes

Ocular discharge (“leaky eye”)

Viral: profuse watery

Bacterial: sticky purulent

Eyelids stuck together in the morning

Sensation that a foreign body is lodged in the eye; fullness around the eye

Initiating Drug Therapy for Conjunctivitis

Highly contagious: good hand-washing and instrument-cleansing techniques are imperative.

Etiology must be determined, as treatment is different for bacterial, viral, and allergic conjunctivitis.

The goals of drug therapy are to eradicate the offending organism (for bacterial conjunctivitis), to relieve symptoms, and to quicken the resolution of the disease.

Use of Antibiotics for Treating Conjunctivitis

Justified because it can shorten the course of the disease, which reduces person-to-person spread, and lowers the risk of sight-threatening complications.

Five to seven days of therapy with agents such as erythromycin ointment or bacitracin–polymyxin B ointment, or solution is usually effective.

Sulfacetamide has weak to moderate activity against many organisms.

Use of Antibiotics for Treating Conjunctivitis (cont.)

The aminoglycosides have good gram-negative coverage but incomplete coverage of Streptococcus and Staphylococcus species and a relatively high incidence of corneal toxicity.

The fluoroquinolones also have good gram-negative coverage; the older fluoroquinolones (ciprofloxacin, norfloxacin, and ofloxacin) have poor coverage of Streptococcus species, while the newer fluoroquinolones (besifloxacin, gatifloxacin, levofloxacin, and moxifloxacin) offer improved gram-positive coverage.

Use of Antibiotics for Treating Conjunctivitis (cont.)

N. gonorrhoeae: 250-mg intramuscular (IM) injection of ceftriaxone (Rocephin) plus a single 1-g dose of oral azithromycin for adults and children who weigh at least 45 kg. Children who weigh less than 45 kg: a single 125-mg IM injection of ceftriaxone; 25 to 50 mg/kg of ceftriaxone intravenous or IM for neonates.

C. trachomatis: single 1-g dose of azithromycin or 7 days of doxycycline 100 mg twice daily. Children who weigh at least 45 kg but are less than 8 years old: single dose of azithromycin 1 g. Neonates and children who weigh less than 45 kg: 50 mg/kg/d of erythromycin base or erythromycin ethylsuccinate (4 doses/day for 14 days).

Drug Therapy for Conjunctivitis

Antibiotics

Antihistamines

Mast cell stabilizers

Antihistamine/mast cell stabilizer

Nonsteroidal anti-inflammatory ophthalmic drugs

Vasoconstrictors (decongestants)

Topical corticosteroids

Recommended Order of Treatment for Conjunctivitis

A patient presents with conjunctivitis. What is the recommended third line of therapy for the condition?

Topical antihistamine

Low-potency topical corticosteroid

Ophthalmic ketorolac

Antihistamine/mast cell stabilizer

Question

C. Ophthalmic ketorolac

Rationale: Ophthalmic ketorolac is used as a third line of therapy for patients with conjunctivitis. Topical antihistamines are first-line therapy. Addition of a brief course of low-potency topical corticosteroid to the first-line agent or for recurrent or persistent disease: a product with antihistamine/mast cell stabilizer properties is second-line therapy.

Answer

Commonly called dry eye syndrome (DES)

Can occur intermittently or chronically

Causes: decreased tear production, increased tear evaporation, or a combination of these factors can initiate an inflammatory response on the ocular surface

Risk factors: advanced age, female gender, and a history of LASIK surgery

Dry Eye Syndrome: Keratoconjunctivitis SICCA

Pathophysiology of Tears

Signs and Symptoms of DES

Dry eye sensation

Ocular irritation

Redness, burning, and stinging

A foreign body or gritty sensation

Blurred vision

Contact lens intolerance

An increased frequency of blinking, and, paradoxically, increased tearing

Drug Therapy for DES

Artificial tears and lubricants

Cholinergic agonists

Topical cyclosporine

Topical corticosteroids

Glaucoma (Primary Open-Angle Glaucoma)

Group of eye diseases involving optic neuropathy characterized by irreversible damage to the optic nerve and retinal ganglion cells

Causes/risk factors: increase in IOP, increased age, black race, family history of glaucoma, thin central cornes, type 2 diabetes; degeneration of the trabecular meshwork and Schlemm canal; decrease in aqueous humor

Classifications: primary open-angle glaucoma (POAG), (70% of cases) acute closed-angle glaucoma, normal-tension glaucoma, and narrow-angle glaucoma

Drug Therapy for POAG

Beta-blockers

Betaxolol 0.25% suspension or 0.5% solution (Betoptic S): 1 to 2 drops in the affected eye(s) twice daily

Carteolol 1% solution: 1 drop in the affected eye BID

Levobunolol 0.25% or 0.5% solution (Betagan): 1 to 2 drops once daily (0.5%) or twice daily (0.25%)

Metipranolol 0.3% solution (OptiPranolol): 1 drop in the affected eye(s) twice a day

Drug Therapy for POAG (cont.)

Beta-blockers (cont.)

Timolol 0.25% or 0.5% solution (Timoptic, Betimol, Istalol) or gel-forming solution (Timoptic-XE): Solution: 1 drop in the affected eye(s) twice daily; Gel-forming solution: 1 drop in the affected eye(s) once daily

Carbonic anhydrase inhibitors

Brinzolamide 1% suspension (Azopt): 1 drop in the affected eye(s) three times a day

Dorzolamide 1% solution (Trusopt): 1 drop in the affected eye(s) three times a day

Drug Therapy for POAG (cont.)

Prostaglandins

Bimatoprost 0.03% solution (Lumigan): 1 drop in the affected eye(s) once daily in the evening

Latanoprost 0.005% solution (Xalatan): 1 drop in the affected eye(s) once daily in the evening

Tafluprost 0.0015% solution (Zioptan): 1 drop in the affected eye(s) once daily in the evening

Travoprost 0.004% solution (Travatan Z): 1 drop in the affected eye(s) once daily in the evening

Drug Therapy for POAG (cont.)

Adrenergic agonists

Apraclonidine 0.5% solution (Iopidine): 1 to 2 drops in the affected eye(s) three times a day

Brimonidine 0.1%, 0.15%, or 0.2% solution (Alphagan P): 1 drop in the affected eye(s) three times a day, approximately 8 hours apart

Cholinergic blocking agents

Pilocarpine 1%, 2%, or 4% solution (Isopto Carpine): 1 to 2 drops three or four times a day

Drug Therapy for POAG (cont.)

Combination products

Brimonidine and timolol 0.2% to 0.5% solution (Combigan): 1 drop in the affected eye(s) every 12 hours

Dorzolamide and timolol 2% to 0.5% solution (Cosopt):1 drop in the affected eye(s) two times a day

Brinzolamide and brimonidine 1% to 0.2% solution (Simbrinza): 1 drop in the affected eye(s) three times a day

Recommended Order of Treatment for Glaucoma

Question

A patient diagnosed with glaucoma is not responding to therapy with bimatoprost. What is the second-line therapy recommended for this patient?

Travoprost

Ophthalmic beta-blocker

Brimonidine

Ophthalmic carbonic anhydrase inhibitor

Answer

B. Ophthalmic beta-blocker

Rationale: The second-line treatment for glaucoma is substitution of an ophthalmic beta-blocker (if failure to decrease IOP to a significant extent) or addition of an ophthalmic beta-blocker (if IOP is significantly decreased but not to goal). First-line treatment is prostaglandin ophthalmic solution (bimatoprost, latanoprost, tafluprost, or travoprost). Third-line treatment is addition of an ophthalmic carbonic anhydrase inhibitor or addition of brimonidine.

Summary

There are many conditions and disorders of the eye, but only a few, such as blepharitis and conjunctivitis, should be diagnosed and treated by a primary care provider.

The remaining ocular conditions are usually treated by eye care specialists.

Nonetheless, prescribers should be familiar with drug therapy for the more common ophthalmic conditions (glaucoma, keratoconjunctivitis sicca), as they are likely to encounter patients being treated for these disorders.