Debrox
Dose / Indication / Ingredient + strength
Carbamide Peroxide 6.5%
prepared in anhydrous glycerol
5-10 drops BID
for 3-4 days if needed
>12 y/o
indicated for IMPACTED EARWAX
Visine
(Tetrahydrozoline HCL / oxymetazoline HCL / naphazoline HCL / pheniramine maleate)
Dose / Indication
Opthalmic DECONGESTANT / ANTIHISTAMINE
1-2 Drops < QID
Third line therapy for Allergic Conjungtivitis
Systane
(PEG 400 / propylene glycol)
Dose / Indication
Artificial Tears
1-2 Drops
First line therapy for Allergic Conjunctivitis
Also treatment for Dry Eye Syndrome
NonPharmacologic Treatment
of Water-Clogged Ears
-
Tilt affected ear DOWNWARD
- manipulate the auricle gently
-
Blow Dryer
-
on LOW HEAT & SPEED
- (NOT DIRECTLY INTO EAR)
-
on LOW HEAT & SPEED
-
One-Time use of WATER-ABSORBING EAR PLUGS
- remove after 10 min
- for use for patients >16 y/o
Ocular Irrigants
Cleanse ocular tissues of unwanted debris
while still maintaining MOISTURE
Chemical Burn / Loose Foreign Object
Specifically balanced pH & Osmolality
EX-ST for self treatment
of OTIC DISORDERS
- SUDDEN hearing loss
- Signs of infection
- Sharp / severe PAIN
-
Bleeding or signs of trauma
- presence of ruptured tympanic membrane
- <12 y/o
- Ear surgery within 6 weeks
- Tympanostomy tubes present
- Hypersensitivity to recommended angents
- Incapable of following proper instructions
Purpose of Earwax
(Cerumen)
Lubricates ear canal
Traps debris
WATERPROOF BARRIER
Antimicrobial properties = Contains lysosimes / ACIDIC pH
Key Points for
OTIC DISORDERS
Know EX-ST
Limit self-treatment to minor symptoms
Contact PCP if symptoms persist or worsen >4 days
Provide instructions on proper use / effective products
Proper ear hygiene & importance of earwax
Treatments that we DO NOT RECOMMEND
for Impacted Earwax
-
Docusate
- conflicting data
-
Hydrogen Peroxide 3%
- contains WATER –> ear infection possible
-
Olive Oil
- delay seeking proper treatment
-
Ear Candles
- INEFFECTIVE –> ear injury / burns
-
Garlic Oil / Willow Bark / Chamomilla
- lacking data on efficacy / safety
S/Sx + Goals
Allergic Conjuctivitis
RED eyes + Watery discharge
Remove / Avoid ALLERGEN
Limit or reduce the severity of allergic rxn
symptomatic relief
S/Sx of
IMPACTED EARWAX
MOST common cause of temporary hear loss
- Feeling of fullness/pressure
- GRADUAL HEARING LOSS
- Dull Pain
- Vertigo / Tinnitus
- Chronic Cough
Debrox
Carbamide Peroxide 6.5%
ADR / CI-P / Consult
- DNU if h/o of perforation of eardrum or prior ear surgery*
- discharge / drainage / SEVERE ear pain*
- AIDS / DM*
Mild Tingling + CRACKLING NOISES are normal
DNU for more than <4 days
avoid eye contact
S/Sx of
WATER-CLOGGED EARS
NOT THE SAME AS SWIMMER’S EAR
- Feeling of wetness / fullness
- GRADUAL HEARING LOSS
- Ear exposed to excessive moisture
- Trappped moisture –>
- –> itching / pain / inflammation / infection
- Trappped moisture –>
Zaditor
KETOTIFEN FUMARATE
Dose / Indication
Opthalmic Antihistamine / Mast Cell Stabilizer
0.035% Ketotifen
1 Drop BID q8-12hrs
2nd line therapy for Allergic Conjunctivitis
EX-ST for Self-Treatment of
Ocular Disorders
- Eye PAIN
- Blurred vision, not associated with ointment/drops
- Light sensistivity
- History of contact lens wear
- Blunt trauma to eye
- Chemical exposure to eye
- HEAT - eye exposure ( excluding sun exposure )
-
Lack of response to therapy
- in >72hours
Adult vs Child
Ear Canal
Adult = S-Shaped canal
Eutachian tube lengthens DOWNWARD (towards mouth/nose)
Child = normal
- SHORTER / STRAIGHTER*
- FLATTER ear canal*
What goes first, Solutions or Suspensions?
And how long do you wait?
Solutions FIRST > suspensions
wait 5 minutes between drops
shake SUSPENSIONS well
ADR / CIs
Opthalmic Antihistamine / Mast Cell Stabilizer
Ketotifen Fumarate (Zaditor)
Can cause Burning / Stinging / Discomfort
can cause Pupil DILATION
esp w/ light-colored irises & contact wearers
CI in ppl w/ risk for angle closure glaucoma
Flowsheet of Impacted Earwax
- Complaint of consistant earwax excess / impact
- Obtain medical/medication history
- intended use / previous use / length&history of use
-
Any EX-ST?
- yes –> SEE MD
- If no, Ask if using IMPROPER removal methods / unapproved meds
- yes –> S/Sx of infection –> SEE MD
- If no, use Carbamide Peroxide
- if treatment didnt work –> SEE MD
- Counsel on proper ear hygiene
Opthalmic DECONGESTANTS
Visine Redness Relief
Treatment for Allergic Conjuctivitis
- A-adrenergic agonist -> constriction -> reduced redness
- Can cause eye dryness
- and REBOUND CONGESTION, limit use to 72 hours
- oxymetazoline/PE > naphazoline/tetrahydrozoline
- and REBOUND CONGESTION, limit use to 72 hours
- Contraindicated in angle closure glaucoma
- Use in caution in:
- HTN / DM
- CVD / Arteriosclerosis
- HYPEthyroidism
Risk factors for Dry Eye Syndrome
Female!
Older Age!
Postmenopausal estrogen therapy
Medications :
Antihistamines / Antidepressants / Decongestants
Diuretics / Beta Blockers
Steps to Instill
Eye OINTMENT
- Wash hands
- Tilt head back
- grasp lower outer lid below lashes,
- pull down form pocket
- Place ointment tube over eye, look up
- place 1/4in to 1/2in of ointment into LOWER EYELID pocket
- using a sweeping motion
- place 1/4in to 1/2in of ointment into LOWER EYELID pocket
- Close eye for 1-2 minutes
-
Vision may be temporarily blurred
- prefer to use ointment at night
Visine - Decongestant/AH
(Tetrahydrozoline HCL / oxymetazoline HCL / naphazoline HCL / pheniramine maleate)
ADR / CI+P / Consult
MILD STINGING
Limit use to <72 hours, Rebound Congestion
>6y/o, remove contact lenses
- Contraindicated in angle closure glaucoma
- Use in caution in:
- HTN / DM
- CVD / Arteriosclerosis
- HYPERthyroidism
Steps to Instill
EYE DROPS
- WASH HANDS
- Tilt head back
- Grasp lower eyelid below lash line, pull away to make pouch
- Place dropper over eye by looking directly at it
- Before applying drop, LOOK UP
- Release eyelid after drop is applied
- Use finger to put pressure over tear duct
- Wait 5 min b4 instilling next drop
Pharmacologic Treatment for
Dry Eye Syndrome
Artificial Tears
Stabilize tear film / reduce tear evaporation / lubricate occular surface
Non-Medicated Ointments
INCREASE retention time in eye / enhance tear film integrity
Topical Cyclosporine
RX only, long term benefit nclear
Drops or ointments first
and how long do you wait?
DROPS FIRST >> ointments
wait 10 MINUTES between products
Non-pharmacologic Treatment
for Dry Eye Syndrome
AVOID- dry/dusty places + prolonged computer use
Use humidifiers + Eye Protection outdoors
Elmininate offending medications
Reposition work station away from air vents
Refresh
(carboxymethhylcellulose sodium, glycerin, mineral oil, petrolatum, povidone, polysorb80)
Dose / Indication
NON-MEDICATED OINTMENT
Use as often as needed
used for Dry-Eye Treatment
Opthalmic Antihistamines
Treatment for Allergic Conjunctivitis
More effective when taken w/ Opthalmic Decongestant
- Histamine1 receptor antagonist
- Pheniramine maleate & Antazoline phosphate
- SUDDEN hearing loss
- Signs of infection
- Sharp / severe PAIN
-
Bleeding or signs of trauma
- presence of ruptured tympanic membrane
- <12 y/o
- Ear surgery within 6 weeks
- Tympanostomy tubes present
- Hypersensitivity to recommended angents
- Incapable of following proper instructions
EX-ST for self treatment
of OTIC DISORDERS
- Eye PAIN
- Blurred vision, not associated with ointment/drops
- Light sensistivity
- History of contact lens wear
- Blunt trauma to eye
- Chemical exposure to eye
- HEAT - eye exposure ( excluding sun exposure )
-
Lack of response to therapy
- in >72hours
EX-ST for Self-Treatment of
Ocular Disorders
Non-pharmacologic Treatment
Allergic Conjuctivitis
Remove / Avoid offending ALLERGEN
Apply Cold Compress TID/QID
Use air conditioning
Use / replace air filters
S/Sx of Dry Eye Syndrome
White / mildly Red eye
Sands / Gritty feeling
Chronic & Incurable
Pharmacologic Treatment for
WATER-CLOGGED EARS
-
Isopropyl Alcohol 95% in anhydrous glycerin 5%
- ONLY agent FDA approved as ear-drying age
- glycerin prevents over drying in ear canal
- may sting or burn
- 50-50 mix of Acetic Acid 5% & Isopropyl Alcohol 95%
- DO NOT use apple cider vinegar
- may sting or burn
Steps on how to use an
EAR DROP
- Wash Hands
-
Warm ear drops to body temp (hold in PALM of hand)
- shake if indicated
- Tilt head on side or lie down, with ear up
- Position dropper tip NEAR the ear canal
- To open ear canal:
- pull ear BACK & UPward
- Place proper dose/drops into the ear canal opening
- You may gently press flap over ear canal oepening
- to force out air bubbbles / push drops down the canal.
- Stay in same position ~3 minutes
- depends on product
- Gently wipe away excess medication off the outside of ear
Opthalmic Antihistamine / Mast Cell Stabilizer
Ketotifen Fumarate (Zaditor)
Treatment for Allergic Conjuctivitis
Last up to 12 hours
- POTENT Histamine 1 receptor antagonist
-
Inhibits mast cell degrauluation
- –> stops release of inflammatory mediators
-
Inhibits eosinophils
- **–> stops release of **late-phase mediators
-
Inhibits mast cell degrauluation
ORDER OF USE
Pharmacologic Treatment options
for Allergic Conjuctivitis
FIRST USE: Artificial Tears
Second = Opthalmic Antihistamine / Mast cell stabilizer
THIRD, USE BOTH:
Opthalmic Decongestant
Opthalmic Antihistamine
Pharmacologic Treatment of
IMPACTED EARWAX
DEBROX
Carbamide Peroxide 6.5% in anhydrous glycerin
- Hydrogen peroxide + moisture
- slow release of O2 –> effervescent (bubbles)
- Urea debirdes tissue
- Glycerin softens earway