DPA Part 2

Question 1

1 cause for malpractice in optometry

Answer 1

Failure to properly diagnose intraocular disease-majority involved OD’s who failed to use diagnostic drops. Not approved in all states until 1980s-90s

Question 2

BEFORE dilating the pt, always do the following:

Answer 2

Check visual acuities (distance)
Check pupils
Check IOP
Check angles- Van Herick/Shadow test

Question 3

If gonio shows ___ or less of the trabecular meshwork visible in all 4 quadrants, pt is at risk of angle closure

Answer 3

Half or less!

Question 4

Less than grade __ van heroic angle= risk of angle closure. Do gonio. If you only see ____ of the trabecular meshwork, pt is at risk of an angle closure

Answer 4

Grade II

Half or less of the trabecular meshwork in all 4 quadrants.

Question 5

5 Signs and symptoms of a closed angle attack

Answer 5

1. Does pt see halos around light?
2. Intermittent eye pain especially going from dim to bright illumination
3. Intermittent blur
4. Intermittent ocular redness due to inflammation
5. Nausea- affects vagus nerve

Question 6

If your patient is at risk for angle closure and you choose to dilate, what should you do?

Answer 6

Check IOP following dilation. If IOP increases more than 5mmHg, it should be monitored and/or treated until the IOP is normal. Use drops to bring pressure down- don’t let them leave until pressure decreases.

Question 7

What you should ask your patients before dilating?

Answer 7

Have you dilated safely before?
Have you been told you are at risk for angle closure?
Any complications from previous dilations?

Question 8

How do you know what drops to use? 2 goals

Answer 8

Agent producing least possible adverse affects

Lowest concentration that will allow you to attain sufficient pupil mydriasis

Question 9

What to tell pt before instilling drops?

Answer 9

They will sting
How long they will last
Light sensitivity, near blur
Answer any questions pt has

Question 10

Cycloplegia

Answer 10

Paralysis of the ciliary muscle- Reduction of accommodation

Question 11

Mydriasis

Answer 11

Dilation of the pupil. Contract dilator muscle.

Question 12

Function of pharmaceutical agents on iris dilator, sphincter, and ciliary body

Answer 12

Iris dilator muscle contracts
Iris sphincter muscle paralyzed
Ciliary body- partial or total paralysis

Question 13

Phenylephrine hydrochloride is what type of pharmacological agent and how does it work

Answer 13

Direct acting sympathomimetic. Alpha 1 Agonist. Causes dilation.
Works by contraction of the radial dilator muscle of the iris.
Pupil will constrict when you shine light in it!

Question 14

Phenylephrine dosages

Answer 14

0. 12% OTC vasoconstrictor for allergies. Gets red out by shrinking conj blood vessels.
1. 5% Routine pupil dilation. Mydriasis only, no cycloplegia. Widening of palpebral aperture

10% Break synechia. Serious side effects, but rare.

Question 15

Does phenylephrine have any cycloplegia

Answer 15

No. No affect on accommodation. Only mydriasis.

Question 16

10% phenylephrine systemic side effects

Be caution in pts with conditions such as:

Answer 16

Serious, but rare.
Sympathetic side effect: Dizzy, achy, increased sweating, increased BP, pale.

Use with caution in pts with: Cardiac, HTN, diabetes, aneurysms and arteriosclerosis.

Question 17

More common side effects of phenylephrine

Answer 17

More common: burning, stinging, brow ache, HA, increased tears, photophobia.

Question 18

Tropicamde Hydrochloride. How does it work?

Answer 18

Muscarinic antag/cholinergic antag.

Blocks muscarinic receptor in iris sphincter muscle

Question 19

How does tropicamide work?

Answer 19

Causes mydriasis- strong
and cycloplegia- weak

Affects receptors on the iris sphincter and ciliary body muscles. Eye will not constrict when you shine light into it!

Question 20

Tropicamide side effects for uncorrected hyperope

Answer 20

Blurry distance vision.

Question 21

When should you be cautious about eye drops and pregnancy

Answer 21

Earlier in pregnancy- when baby is developing the most.

Question 22

iris color and eye drops

Answer 22

Darker irides have more pigment
Melanin competes with receptor sites for active ingredient in eye drop. Takes longer to dilate and undulate.
Reduces the overall affect of some drops.

Question 23

Dilating drops in pts with senile meiosis

Answer 23

May need more drops since their pupils are much smaller to begin with. Especially if they have dark iris.

Question 24

Systemic conditions that may mess with dilation drops

Answer 24

Diabetic pts may need more drops due to denervated pupil.
Low birth weight/premature. Benefits outweigh risk because need to make sure they don’t have detachments.
Down syndrome could be aggravated by drops.

Question 25

Paremyd - Combo of what? - Benefits - Down sides - May not work as well on:

Answer 25

Combo of 0.25% tropicamide and 1% hydroxyamphetamine. (sympathomimetic) Works on both muscles in iris. Provides good dilation with minimal affect on accommodation! more expensive. may not work well on pts with: - Dark brown iris - Older pts - Diabetic pts

Question 26

Tropicamide and cyclo MOA

Answer 26

Compete with each at the affected receptor sites of the iris sphincter and ciliary muscle Paralyzes iris sphincter and ciliary body muscle.

Question 27

Doses of cyclo

Answer 27

0.5%, 1%, 2%

Question 28

Why is cyclo good for uveitis tx

Answer 28

Prevents posterior synechiae- iris attached to anterior lens. Immobilizes iris and reduces pain.

Question 29

Systemic side effects of cyclo

Answer 29

*Anti-cholinergic= anti parasympathetic= sympathetic side effects adults: Clumsiness, confusion, constipatieon, full feeling, passing gas, stomach cramps, achy, skin rash, hallucination, thirst, dry mouth. Kids: Swollen stomach, restlessness, drowsy, weak

Question 30

What eye drop could be used for myopia progression?

Answer 30

Atropine

Question 31

Why would you use atropine?

Answer 31

Myopia progression, uveitis

Question 32

Atropine 1% ointment when to use:

Answer 32

Uveitis Adults- 1 to 2 times Children- 1 to 3 times Dilated eye exams

Question 33

Atropine action duration of Mydriasis Cyclo

Answer 33

Mydriasis: weeks Cyclo: 120 mins

Question 34

Cyclo action duration of Mydriasis Cyclo

Answer 34

Mydriasis: 1 day Cyclo: 20-45 mins

Question 35

Phenylephrine action duration of | Mydriasis

Answer 35

Mydriasis only 4-6 hours

Question 36

Tropicamide action duration of Mydriasis Cyclo

Answer 36

Mydriasis 4-5 hours | Cyclo 15 mins

Question 37

What happens if you close your patients anterior chamber angle? Patient symptoms

Answer 37

``` Pain Blurred vision Colored halos around lights Frontal HA Nausea/vomitting ```

Question 38

Critical signs of anterior chamber angle closure

Answer 38

``` Acute increase in IOP Corneal edema Shallow anterior chamber between iris and cornea Conj injection due to inflam Fixed, mid-dilated pupil. ********** ```

Question 39

How to tx a closed angle

Answer 39

Topical glaucoma meds- faster acting. BB, CAI's, adrenergic agonist (Sympathetic) IV/oral glaucoma meds if urgent- can only see hand movement Topical steroids Topical miotics- pilocarpine. Constricts pupil, but IOP must be lower than 40.

Question 40

If pt has closed angle attack, when you you use topical miotics

Answer 40

if their IOP is less than 40

Question 41

Miotics have what color cap

Answer 41

Dark green

Question 42

Beta blocker combo has what color cap

Answer 42

Dark blue

Question 43

Red caps

Answer 43

Mydriatics and cyclo

Question 44

Pink caps

Answer 44

Steroids and anti inflam

Question 45

Dark blue

Answer 45

BB combo

Question 46

Dark green cap

Answer 46

Miotics

Question 47

Duresta implant

Answer 47

Implant that lasts 12 weeks and then lowers IOP by 30% Inserted into anterior chamber