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Ocular Pharmacology > Mydriatics and Cycloplegics > Flashcards

Mydriatics and Cycloplegics Flashcards

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1
Q

What are catecholamines?

A

hormones including dopamine, epinephrine, and norepinephrine = produced from tyrosine in post-ganglionic fibers in ANS and adrenal medulla

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2
Q

What are the 2 enzymes for catecholamine metabolism?

A

COMT and MAO

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3
Q

What is cycloplegia?

A

paralysis of ciliary body musculature responsible for accommodation

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4
Q

What is anaphylaxis?

A

an acute, systemic allergic hypersensitivity reaction to a previously sensitized allergen

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5
Q

What causes histamine release, bronchoconstriction, vasodilation, and swelling during anaphylaxis?

A

IgE in bloodstream reacting with the antigen

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6
Q

What are the treatments for anaphylaxis?

A

O2, IV steriods, airway management (intubation) and EpiPen

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7
Q

Why is an Epipen effective for anaphylaxis reactions?

A

Epinephrine will counteract the anaphylaxis symptoms and restore normal BP and prevent shock

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8
Q

What conditions should you use caution in when administering an EpiPen?

A

heart disease, high BP, Parkinson’s disease, diabetes, and thyroid disorders

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9
Q

What regulates the fight or flight response?

A

sympathetic or adrenergic branch of ANS

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10
Q

What regulates the rest and digest response?

A

parasympathetic or cholinergic branch of ANS

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11
Q

What are the neurotransmitters in the sympathetic system?

A

epinephrine and norepinephrine

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12
Q

what is the neurotransmitter of the parasympathetic system?

A

acetylcholine

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13
Q

What is the receptor type for ganglia within the sympathetic system? (post-ganglionic neurons)

A

nicotinic receptors

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14
Q

What is the receptor type(s) for sympathetic adrenergic system?

A

alpha and beta

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15
Q

what is the receptor type for the sympathetic cholinergic system at the terminal organs?

A

muscarinic receptors

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16
Q

what is the receptor type for parasympathetic cholinergic system at the terminal organ?

A

muscarinic receptors

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17
Q

where are alpha 2 receptors primarily located?

A

pre-synaptic and stimulation causes inhibition of signal propagation

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18
Q

What are 2 things that occur with stimulation of alpha 2?

A

decreased insulin release and decreased aqueous production

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19
Q

What are 2 things that occur with stimulation of alpha 1?

A

vasoconstriction, mydriasis

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20
Q

what are 5 things that occur with stimulation of beta 2?

A

vasodilation, bronchodilation, glucogenolysis, increased insulin release, and relaxation of ciliary body with increased aqueous production

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21
Q

what occurs with beta 1 stimulation?

A

increased cardiac contractility and conduction

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22
Q

what is alpha 1 selective for?

A

NE>E

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23
Q

what is alpha 2 selective for?

A

E greater than or equal to NE

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24
Q

what is beta 1 selective for?

A

E=NE

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25
what is beta 2 selective for?
E
26
What is the backbone of catecholamines?
tyrosine
27
what is tyrosine converted to once inside a pre-synaptic nerve terminal in sympathetic system?
converted to dopamine
28
what happens to dopamine after being converted from tyrosine?
placed in vesicles (stable and remains stored until needed) --> converts to NE when needed
29
What are the steps following a nerve impulse in the sympathetic system?
Ca++ uptake is facilitated and enters terminal --> with elevated Ca levels = degranulation of vesicles into synaptic cleft
30
what happens if NE acts as bio-feedback and stimulates an alpha 2 receptor?
interferes with Ca++ ability to cause degranulation and stops NE release
31
Where are MAO and COMT located to help metabolize NE?
MAO is in pre-synaptic terminal and COMT is in post-synaptic terminal
32
what happens to NE with cocaine and amphetamines?
blocks NE in synaptic cleft
33
what are the 5 ocular adrenergic effects (fight or flight)?
mydriasis, increased IP aperature, modulate aqueous production, modulate vascular tone, receptors in trabeculum and schlemms canal suppress accommodation
34
what are some examples of cases with reduced sensitivity for dilation?
age-related miosis, unstable diabetes, post-op pupils, posterior synechiae, dark iris, pseudoexfoliation syndrome
35
what is an example of a case with increased sensitivity to dilation?
down syndrome
36
what are some cases you need to use caution before dilation?
homocystinuria and marfan's syndrome, pregnancy, pigmentary or exfoliative glaucoma
37
what are some examples of contraindications for dilating?
iris supported IOL, subluxated lens or IOL, extremely narrow angle, angle closure history w/o PI
38
how soon will a patient have an iatrogenic angle closure after dilation?
4-8 hours post instillation
39
what occurs to the ciliary body with cycloplegia?
prevents the ciliary body from contracting = disables accommodative function
40
what are some examples of times you would want to use cycloplegia?
strabismus (esotropia), pseudomyopia/accommodative spasm, latent hyperopia, anisometropia, amblyopia, malingerers, unexplained refractive error or un-responsive patients
41
what are 2 sympathetic mydriatics?
phenylephrine and hydroxyamphetamine (PAREMYD)
42
what is the activity of phenylephrine?
alpha 1 selectivity and some indirect effects via NE release
43
What are some actions of phenylephrine?
mydriasis (45-60min), conjunctival blanching (vasoconstriction), mild accommodation suppression (2D), lid retraction, IOP reduction **fight or flight actions
44
What are 4 special indications that Phenylephrine can be used for (other than mydriasis)?
posterior synechiae breakage, pre-Lasik vasoconstriction, inhibition of iris cysts (caused by echothiophate), horner's evaluation
45
How can phenylephrine help diagnose Horner's syndrome?
use 1% - it will dilate the pupil with post-ganglionic sympathetic denervation and cause no/minimal dilation in the normal eye
46
What are some adverse effects of phenylephrine?
photophobia/glare, allergic dermatoconjunctivitis, rebound miosis, anterior chamber pigment liberation, hypertension/bradycardia
47
What is rebound myosis?
patient responds to agent with mydriasis but when effect wears off the miotic response is bigger (pupil is smaller than normal)
48
What are some contraindications for phenylephrine?
avoid 10% in neonates/elderly, history of CVD/MI, DM1, aneurysm, arteriosclerosis, hypotension, drugs: atropine, TCAD, MAOI, reserpine, guanethidine, methyldopa
49
What is hydroxyamphetamine used for?
mydriasis without suppressing accommodation - can be used to differentiate between pre-ganglionic and post-ganglionic sympathetic denervations (PAREYMD can too)
50
What does hydroxyamphetamine act on?
indirect acting - promotes NE release from nerve terminals (blocks uptake of NE and keeps it in synaptic cleft)
51
What is PAREMYD?
1% hydroxyamphetamine and 0.25% Tropicamide
52
What are 3 benefits of PAREMYD?
mydriasis independent of age or pigmentation, faster recovery then phenylephrine/tropicamide (better for shallow angles), no benefit to anesthetic before use
53
What is different about the adverse effects of PAREMYD vs. Phenylephrine?
leads to tachycardia instead of bradycardia
54
Which types of patients is PAREMYD safer in vs. phenylephrine?
diabetics, hypotension, chemical sympathectomy agents
55
Are the parasympathetic receptors inhibitory or stimulatory?
all are stimulatory (sympathetic receptors are both)
56
What is the M1 receptor associated with?
memory
57
Which parasympathetic receptor is better at miosis and ciliary body contraction/increased aqueous production?
M3
58
Which parasympathetic receptor is responsible for salivary glands and vasodilation?
M3
59
Which parasympathetic receptor is better at cardiac contractility and conduction?
M2
60
Which parasympathetic receptor is responsible for emesis?
M3
61
Which parasympathetic receptor is responsible for bronchoconstriction and secretion?
M2 = M3
62
What 2 things does Acetylcholine break down into? (2 esters)
acetate and choline (broken down by esterases = AChE)
63
What happens when choline enters a nerve terminal?
choline adds with acetyl-CoA to make ACh and placed into vesicles
64
What happens in the parasympathetic system when Ca++ enters a nerve terminal?
triggers degranulation and the ACh vesicles are released into the synaptic cleft where AChE breaks it down into acetate + choline
65
Name 6 anticholinergic agents?
atropine, scopolamine, homatropine, tropicamide, cyclopentolate and cyclomydril
66
Which parasympathetic receptors does Atropine use?
non-selective M receptors
67
which anticholinergic agent is selective for M4 only?
Tropicamide
68
what is cyclomydril made of?
0.2% cyclopentolate + 1% phenylephrine
69
What is atropine used for?
cycloplegia, severe uveitis, amblyopia, ciliary body spasm, synechiae, lens advancement, vessel permeability, myopic progression
70
what is scopolamine used for?
travel sickness (emesis) - pronounced CNS effects
71
what is homatropine used for?
moderate uveitis, corneal abrasions, mydriasis
72
what is cyclopentolate used for?
cycloplegia, moderate uveitis, corneal abrasions | delayed/sustained effects in dark pigment iris (less flushing and dryness than atropine)
73
what is tropicamide used for?
cycloplegia, mydriasis, mild uveitis
74
What are 3 ocular adverse effects for anticholinergics?
increased IOP, angle closure risk and allergy
75
What are the ABCDs (systemic) adverse effects of anticholinergics?
Anorexia, blue, constipation/confusion, dryness, sedation/stasis of urine
76
What are 2 adverse effects for anticholinergics in the CNS (medulla)?
decreased Parkinson tremor and decreased heart rate
77
what are some contraindications for anticholinergics?
classic antihistamines, TCADs, anti-psychotics, Down syndrome, albinism, cerebral palsy, narrow angle, iris supported IOL, spastic paralysis, OAG, ACG
78
What combination of drugs gives the best mydriasis outcome?
0.25% tropicamide + 1% PAREMYD
79
what is the safest dilation drop to use?
tropicamide (only lasts about 6 hours = shortest duration)
80
which drop do you administer 1 drop initially then another 15-25 min later?
cyclopentolate
81
which cycloplegic drop lasts the longest?
Atropine (7-12 days)

Ocular Pharmacology (10 decks)

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