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  • 1. 1 Unit 13: Ophthalmic and Dermatologic Agents Introduction The eyes and skin are subject to influences from both internal and external sources. There are several disease processes and illnesses which affect the eyes and skin. A brief review of normal anatomy and physiology of the eyes and skin is presented. Drug classes which are used to treat selected disease processes and illnesses of the eyes and skin, along with applicable laboratory tests and patient education, are discussed. Objectives Upon completion of this unit, the student will: 1. Briefly review the normal anatomy and physiology of the eye and skin. 2. Define glaucoma. 3. Explain the basic pathophysiology of glaucoma. 4. State the mechanism of action, therapeutic effects, indications, precautions, contraindications, main side effects, and nursing actions associated with agents used for glaucoma. 5. Identify selected inflammatory and infectious conditions of the eye. 6. State the mechanism of action, therapeutic effects, indications, precautions, contraindications, main side effects, and nursing actions associated with the use of commonly used anti-inflammatory agents for the eye. 7. State the mechanism of action, therapeutic effects, indications, precautions, contraindications, main side effects, and nursing actions associated with the use of commonly used antiinfective agents for the eye. 8. State the mechanism of action, therapeutic effects, indications, precautions, contraindications, main side effects, and nursing actions associated with the use of antihistamine agents for the eye. 9. Explain the use of fluoroscein. 10. Describe the basic pathophysiology of acne. 11. State the mechanism of action, therapeutic effects, indications, precautions, contraindications, main side effects, and nursing actions associated with agents used for acne. 12. Describe the use and side effects of agents to treat lice and scabies. 2009 – 2010: 13 / JSM
  • 2. 2 13. Identify the main points regarding client education for the various agents used with ophthalmic and dermatologic disorders. 14. Discuss specific tests which must be monitored when administering ophthalmic and dermatologic agents. 15. Identify prototype medications representative of ophthalmic and dermatologic agents, as well as applicable reversal / antidote drugs, as assigned. Assignment 1. Review anatomy and physiology of the eye and skin as needed. 2. Read: Chapter 57 (Dermatologic Drugs). Chapter 58 (Ophthalmic Drugs). 2009 – 2010: 13 / JSM
  • 3. 3 Unit 13: Lecture Outline EYES I. Review anatomy and physiology. A. Anatomy. 1. “External.” a. Sclera; musculature. b. Eye lids; conjunctiva. 2. “Internal.” a. Cornea / anterior chamber. b. Lens / iris. c. Posterior chamber and cavity. d. Optic nerve. e. Retina – artery, vein. B. Physiology. 1. Fluid. a. Blood flow – artery, vein. b. Vitreous humor. c. Aqueous humor. d. Tears – lacrimal glands / ducts. 2. Vision – rods and cones. 3. Muscle movement. 4. Nervous system. II. Glaucoma. A. Definition. 1. Increased intraocular pressure (IOP). a. Optic nerve atrophy. b. Peripheral visual field loss. 2. Causes – congenital, trauma, age. 3. Closed angle. Angle and canal of Schlemm. 4. Open angle. Angle and canal of Schlemm. B. Pathophysiology. 1. Production of aqueous humor greater than outflow. 2. Retention of fluid ↑ volume → ↑ IOP. 3. ↑ IOP → ↑ pressure on structures of the eyeball…optic nerve / vessels /retina. 2009 – 2010: 13 / JSM
  • 4. 4 C. Pharmacological treatment. 1. Terms. a. Mydriatric – dilate. b. Miotic – constrict. c. Cycloplegic – paralyze. 2. Cholinergic agents. a. Mechanism of action. 1. Stimulates pupil constriction. 2. Dilates blood vessels. 3. Increases aqueous humor drainage. b. Therapeutic effects. ↓ IOP. c. Indications. 1. Open and closed angle glaucoma. 2. Surgical procedures. 3. Reverse mydriatics. d. Precautions / contraindications. Conditions aggravated by agents / actions. e. Side effects. 1. Blurred vision. 2. Nearsightedness. 3. Systemic: ↓ heart rate, ↓ blood pressure. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Minimize systemic absorption. 3. Patient education – dosing, timing. g. Examples of drugs. 1. Miochol – E (acetylcholine). 2. Pilocar (pilocarpine).* 3. Sympathomimetic agents. a. Mechanism of action. 1. Mimic epinephrine / norepinephrine. 2. Stimulate α and β receptors – mydriasis. 3. ↓ aqueous humor production – mechanism unknown. b. Therapeutic effects. ↓ IOP. c. Indications. 1. Open and closed angle glaucoma. 2. Surgical procedures. d. Precautions / contraindications. Conditions aggravated by agents / actions. e. Side effects. 1. Burning, pain, lacrimation. 2. Systemic: ↑ heart rate, ↑ blood pressure, dysrhythmias. 2009 – 2010: 13 / JSM
  • 5. 5 f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Minimize systemic absorption. 3. Patient education – dosing, timing. g. Examples of drugs. 1. Alphagan P (brimonidine).* 2. Iopidine (apraclonidine). 3. Propine (dipivefrin). 4. β adrenergic blocker agents. a. Mechanism of action. 1. ↓ aqueous humor production. 2. May increase outflow. b. Therapeutic effects. ↓ IOP. c. Indications. Open and closed angle glaucoma. d. Precautions / contraindications. Other conditions in which β adrenergic blocking may be harmful. e. Side effects. 1. Localized pain, blurred vision, inflammation. 2. Systemic: ↓ heart rate, ↓ blood pressure, bronchoconstriction. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Minimize systemic absorption. 3. Patient education – dosing, timing. g. Examples of drugs. 1. Betoptic (betaxolol)* – selective. 2. Timoptic (timolol)* – non selective. 5. Carbonic anhydrase inhibitor agents. a. Mechanism of action. Decreases production of aqueous humor. b. Therapeutic effects. ↓ IOP. c. Indications. Open and closed angle glaucoma. d. Precautions / contraindications. Conditions aggravated by agents / actions. e. Side effects. 1. Localized blurred vision. 2. Systemic: acid base influence, electrolyte imbalance. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Minimize systemic absorption. 3. Patient education – dosing, timing. 2009 – 2010: 13 / JSM
  • 6. 6 g. Examples of drugs. 1. Azopt (brinzolamide). 2. Trusopt (dorzolamide).* 3. Oral / IV: Diamox (acetazolamide).* 6. Prostaglandin agonist agents. a. Mechanism of action. Direct ↑ of aqueous humor outflow. b. Therapeutic effects. ↓ IOP. c. Indications. Open angle glaucoma. d. Precautions / contraindications. 1. Conditions aggravated by agents / actions. 2. Physical contact with other eye drops – precipitation. e. Side effects. 1. Burning, stinging. 2. Blood shot eyes 3. Permanent eye color change in those with hazel, green, blue brown eye color to brown. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Minimize systemic absorption. 3. Patient education – dosing, timing, use with other drops, eye color. g. Examples of drugs. 1. Lumigan (bimatoprost). 2. Travatan (travoprost). 3. Xalatan (latanoprost).* III. Inflammatory and infectious conditions of the eye. A. Inflammatory / allergy. 1. Sensitivity response. 2. Allergy: histamine release → mediator for inflammation, secretions, itching. B. Infection. 1. Most commonly staphylococcus, streptococcus, Haemophylus 2. Selected conditions. a. Conjunctivitis. b. Pink eye. 2009 – 2010: 13 / JSM
  • 7. 7 C. Pharmacological treatment. 1. Anti – inflammatory agents. a. Mechanism of action. 1. Action in arachidonic acid pathway. 2. Block phospholipase or arachidonic acid. b. Therapeutic effects. ↓ inflammation. c. Indications. 1. Corneal / conjunctival injury. Immunosuppressant activity can limit scarring. 2. Seasonal conjunctivitis. 3. ↓ surgical trauma. d. Precautions / contraindications. Not recommended for minor abrasions – may ↓ resistance to infection. e. Side effects. 1. Burning, stinging. 2. Over time – steroids may induce cataracts, nerve damage, ↑IOP. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Patient education – correct use, duration, effect of rubbing eyes. g. Examples of drugs. 1. Acular (ketorolac).* 2. PredForte (prednisolone ophthalmic solution).* 3. Restasis (cyclosporine). 4. Combinations (anti – inflammatory and antimicrobial). a. Cortisporin (neomycin / polymixin / hydrocortisone). b. Pred G (prednisolone / gentamicin). c. TobraDex (tobramycin / dexamethasone).* 2. Antihistamine agents. a. Mechanism of action. 1. Competes for histamine receptor sites. 2. Limits release of mediators from mast cells. b. Therapeutic effects. Decreases itching, redness, tearing. c. Indications. 1. Allergic conjunctivitis. 2. Seasonal / allergic keratitis. d. Precautions / contraindications. e. Side effects. Localized burning, stinging. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Patient education – correct use, need for follow up treatment, effect of rubbing eyes. 2009 – 2010: 13 / JSM
  • 8. 8 g. Examples of drugs. 1. Alocril (nedocromil). 2. Crolom (cromolyn sodium). 3. Optivar (azelastine). 4. Patanol (olopatadine).* 3. Anti – infective agents. a. Mechanism of action. 1. Similar to systemic agents. 2. Bacteriocidal or bacteriostatic depending on agent. b. Therapeutic effects. Prevention or eradication of infection. c. Indications. 1. Exposure to infection. 2. Identified infection. 3. Prophylaxis – surgical procedures. d. Precautions / contraindications. e. Side effects. 1. Localized inflammatory response. 2. Concurrent use of agents with different actions may ↓ effectiveness. f. Nursing actions. 1. Assess for therapeutic and side effects. 2. Patient education – correct use, duration. g. Examples of drugs in class. 1. Bleph – 10 (sulfacetamide). 2. Ciloxan (ciprofloxacin), 3. Genoptic (gentamicin).* 4. Ilotycin (erythromycin ophthalmic ointment).* 5. Tobrex (tobramycin). IV. Trauma to the cornea. A. Sources of trauma. 1. External. 2. Internal. a. Contact lenses. b. Tears / blinking. Neuromuscular blockade. B. Corneal exam – fluoroscein.* Ophthalmic dye with slit lamp examination. Color dependent on type of trauma or presence of foreign body. 2009 – 2010: 13 / JSM
  • 9. 9 SKIN I. Acne. A. Overview of anatomy and physiology of skin. 1. Layers. a. Epidermis – superficial outer layer. b. Dermis – blood vessels, nerves, hair follicles. c. Subcutaneous – fatty tissue. 2. Sweat glands, sebaceous glands. B. Pathophysiology. 1. Inflammatory process of sebaceous glands. 2. Closed comedones (blackheads), open comedones (whiteheads). inflammatory lesions (papules, pustules). C. Non – pharmacological treatment. 1. Comedone extractor 2. Avoid irritants, diet, laundry. D. Pharmacological treatment. 1. Mechanism of action. a. Bacteriocidal activity against susceptible microbes. b. Oral and topical routes. 2. Therapeutic effects. a. Irradication of infection. b. Clearing of skin. 3. Indications. a. Acne vulgaris, acne caused by bacterial infection. b. Accutane: cystic acne unresponsive to other agents. 4. Precautions / contraindications. a. Accutane: pregnancy category X. b. Retin – A: topical v. oral route. 5. Side effects. a. Localized skin irritation, rash, itching. b. Accutane: depression / suicide, skin dryness, inflammation, conjunctivitis, abdominal pain. 6. Nursing actions. a. Assess for therapeutic and side effects. b. Patient education. 1. Lifestyle changes. 2. Correct use, dosing. 3. Accutane: iPLEDGE, provider registered / active, patient qualified and registered 2009 – 2010: 13 / JSM
  • 10. 10 7. Examples of drugs. a. Accutane (isotretinoin).* b. Benzac (benzoyl peroxide).* c. Cleocin T (clindamycin). d. Retin – A (retinoic acid). II. Lice and scabies (parasites). A. Pathophysiology. 1. Lice: pediculusis. Suck blood, excrement / eggs on skin and hair (nits). 2. Scabies: sarcoptes scabeie Mites penetrate skin, deposit eggs. B. Effects. 1. Lice: Red / noninflammotory – papules, wheals. Itching, excoriations. 2. Scabies: Allergic reaction to eggs. Severe itching, folds / interdigits. C. Pharmacological treatment. 1. Mechanism of action. Ectoparasiticidal: pediculicides and scabicides. 2. Therapeutic effects. Kills! 3. Indications. Correct identification of lice, scabies. 4. Precautions / contraindications. 5. Side effects. a. Skin rash, irritation. b. Kwell (lindane): CNS toxicity (dizzy, seizure), aplastic anemia c. Ovide (malathion): organophosphate anticholinesterase insecticide. Cholinergic toxicity: N / V / D, abdominal cramping, incontinence miosis (pinpoint pupils), bradycardia, ↑ secretions (nasal / lungs). 6. Nursing actions. a. Assess for therapeutic and side effects. b. Lifestyle changes, correct use of drugs, follow up / retreatment. 7. Examples of drugs. a. Elimite (5% permethrin topical cream with formaldehyde).* b. Kwell (lindane) – lotion and shampoo. c. Ovide (malathion). d. RID (pyrethin combination shampoo and foam suspension). 2009 – 2010: 13 / JSM