eye and ear medication

Glaucoma Medications and Photophobia

• Instruct clients experiencing photophobia due to glaucoma medication to wear dark sunglasses and avoid bright lights.
• Discontinuing glaucoma medication is not warranted without more information.
• Avoid wiping eyes with a tissue immediately after instilling eye drops.
• Special glasses are not typically required for glaucoma treatment.

Pilocarpine (Isopto Carpine)

• Clients taking pilocarpine may have trouble adjusting to darkness because of miosis.
• Pilocarpine's miotic effect causes difficulty in adapting quickly to changes in illumination.
• Pilocarpine makes it more difficult to see at night.
• Nighttime driving might not be possible due to miosis.

Methazolamide (Neptazane)

• Monitor for hypokalemia and hypernatremia in clients taking methazolamide.
• Methazolamide's diuretic effects can lead to electrolyte disturbances.

Otic Chloramphenicol (Chloromycetin)

• The client needs further instruction when stating they will inform their doctor if their ear has not improved in seven days.
• Superinfections are known to occur with Chloramphenicol, so 7 days is too long to seek further evaluation and treatment.
• The client should inform the doctor of increased ear pain, drainage, or hearing disturbances.

Systemic Absorption of Pilocarpine (Isopto Carpine)

• Diaphoresis is a symptom associated with systemic absorption of pilocarpine.
• Other symptoms of systemic absorption of pilocarpine include diarrhea, bradycardia, and hypotension.

Cyclopentolate and Phenylephrine (Cyclomydril)

• Explain to client that Cyclomydril dilates the pupil to facilitate ocular examination.
• Cyclomydril and other mydriatics do not provide anesthesia or prevent infection.

Systemic Side Effects of Atropine Ophthalmic Solution

• Tachycardia, slurred speech, and confusion are systemic side effects of ophthalmic atropine.

Proper Administration of Ophthalmic Solutions

• Discard ophthalmic medication if it has turned brown.
• Consult a physician before discontinuing eye medication that causes burning.
• Do not to use swabs to apply ophthalmic medications.
• Ophthalmic medications generally have a shelf life of 3 months.

Ototoxicity of Over-the-Counter Medications

• Salicylates (aspirin) and ibuprofen can cause ototoxicity.
• High doses of salicylates can cause tinnitus, vertigo, and hearing loss.
• High doses of ibuprofen may also lead to ototoxicity.

Otic Solution Administration Technique

• The medication dropper should not be inserted into the ear canal.
• Inserting objects into the ear canal can perforate the tympanic membrane.

Self-Administering Ophthalmic Medication

• Administer two different ophthalmic solutions 5 minutes apart.
• If ophthalmic ointment is instilled, wait 10 minutes between the ointment and the next medication.

Return Demonstration of Eye Drop Administration

• The eye should be cleansed with sterile irrigation solution or sterile normal saline, not tap water.
• Drainage of the medication should be directed toward the outer canthus and gentle pressure applied to the inner canthus to prevent systemic absorption of the medication.

Timolol (Timoptic) for Open-Angle Glaucoma

• Timolol decreases aqueous humor production, reducing intraocular pressure.
• A decrease in the outflow of aqueous humor is contraindicated for a client with glaucoma.
• Prostaglandins increase the outflow of aqueous humor to decrease intraocular pressure.

Carbachol (Carboptic) Safety Measures

• Carbachol causes miosis, making quick changes in illumination difficult.
• Nighttime is particularly hazardous for the elderly client causing quick changes in illumination difficult.
• Instruct on methods such as lighting hallways and bathrooms at night, to reduce the potential for injury.

Vidarabine (Vira-A) Side Effects

• Discontinue vidarabine immediately if eye redness and swelling occur, and return to clinic.
• Redness and swelling are signs of hypersensitivity to vidarabine.

Trifluridine (Viroptic) Instructions

• Continue trifluridine for 5-7 days after healing has occurred.
• Viroptic, used in treatment of viral infections such as herpes.
• Immediately discontinuing the medication is contraindicated and stopping at 7 days is too limited of a time frame.
• Ophthalmic medications are stored in a cool, dry place, and some are recommended for refrigeration.

Optic Solutions for 2-Year-Olds

• The child's pinna is pulled down and back before administering the medication.
• Droppers should never be inserted into the ear canal.

Acetazolamide (Diamox) and Nocturia

• The client takes oral acetazolamide (Diamox) before supper, instruct the client to take the medication early in the day, to avoid nocturia.
• Acetazolamide, a carbonic anhydrase inhibitor, causes diuresis.
• Clients receiving acetazolamide are encouraged to consume at least 2000 mL of fluid per day to avoid fluid depletion.
• Acetazolamide may be taken with juice to minimize gastrointestinal irritation.

Nursing Care Before Ophthalmic Medication

• Checking the client's history of hypersensitivity to medications is the priority.
• Hypersensitivity responses can occur with ophthalmic medications, and severe adverse reactions can occur with hypersensitivity to the medication because it is systemically absorbed.

Appropriate Administration of Ophthalmic Medications

• One should pull the lower lid down, and instills the medication into the conjunctival sac.
• Correct technique for administration of ophthalmic medications.
• Medication is not applied directly to the eye.

Cholinesterase Inhibitors

• Pilocarpine (Isopto Carpine), Carbachol, Acetylcholine (Micochol-E) are cholinesterase inhibitors.
• Cholinesterase inhibitors reduce reduces intraocular pressure by constricting the pupil (miosis) and contracting ciliary muscle.
• It increases blood flow to retina and decreases retinal damage and loss of vision.
• They open the anterior chamber angle and Increases the outflow of of aqueous humor.
• May be used to achieve miosis during surgery.
• Cholinesterase Inhibitors are contraindicated in clients with retinal detachment or inflammatory diseases.
• Use with caution in clients with asthma, hypertension, corneal abrasion, hyperthyroidism, coronary vascular disease, urinary tract obstruction.
• Monitor vital signs and breath sounds when using cholinesterase inhibitors
• Atropine Sulfate is antidote for cholinesterase inhibitors.
• Monitor postural hypotension
• Long-term pilocarpine can cause systemic responses, including pulmonary edema, and precipitate an asthmatic attack.

Mydriatic Drugs

• Sympathomimetic and Anticholinergic are two major classes of mydriatic drugs.
• Epinephrine HCL, Dipivefrin (Propine), Apraclonidine (Lopidine), Brimonidine (Alphagan P) are Sympathomimetic drugs
• Atropine sulfate, Cyclopentolate, Tropicamide are Anticholinergic drugs

Ophthalmic agents such as mydriatic drugs

• Are used to facilitate eye examinations.
• They are used to dilate the pupils during an eye exam.
• They are used treat infection, inflammation, and glaucoma.

Patient Teaching Mydriatic Drugs or Ophthalmic Agents

• Wear sunglasses
• Report palpations
• Monitor BP
• Avoid MAOI agents

Anticholinergic Action

• block the sphincter iris muscle; this action also produces pupil dilation.
• They prevent the eye from adapting to and focusing on changes in the environment.
• It is advisable for the client to wear dark glasses until the effects of the anticholinergic wear off.
• Used preoperatively and postoperatively for intraocular surgery

Anticholinergic Mydriatics

• Use cautiously with primary glaucoma
• Apply ointment several hours before vision examination
• Compress lacrimal duct during administration for 2 -3 minutes after administration
• Monitor for tachycardia, confusion, slurred speech, dry mouth and skin, weakness, drowsiness
• Photosensitivity due to dilation

Gentamicin

• Gentamicin is classified aminoglycoside
• Bacterial keratitis is a bacterial infection of the cornea, and medications should never to applied directly on the cornea

Ophthalmic Anti-Infectives

• gentamicin and gramicidin/neomycin/polymixin (Neosporin Ophthalmic) are antibacterial
• Azithromycin (AzaSite) and Gentamicin are antimicrobials.
• Ciprofloxacin is a Fluoroquinole
• Natamycin (Natacyn) is Antifungal and treats bepharitis, fungal conjunctivitis, and keratitis.

Antifungal Patient Teaching

• Hand washing before and after instilling.
• Avoid touching solution tip to eye or lashes.
• Instill solution in the conjunctival sac.
• Continue the medication as prescribed, even though symptoms may seem to have improved

Bacterial Keratitis

• Bacterial infection of the cornea.
• Never apply medication directly on the cornea.
• Apply an eye patch after ophthalmic ointment to control drainage from the eye
• Teach the patient to continue the medication as prescribe even though symptoms may have improved.

Hypopyon

• a collection of pus cells in the aqueous humor of the eye, forming a visible white layer between the cornea and the iris

Viral: Herpes Simplex Keratitis

• Once herpes on the eyelid is present, it infects not only the eyelids but also the cornea, conjunctiva.

Antiviral ophthalmic

• acyclovir (Zovirax) ointment, applied four times a day
• trifluridine (Viroptic) drops, is instilled every 2 hours while awake
• If apply two medications wait 5 minutes before applying the other medication

Ocular Irrigation

• Flush chemical irritants, blood splatters, or small particles:
• Sterile 0.9% Sodium Chloride (NS)
• Morgan Lens ocular irrigation
• Navstel solution

Occular Irrigation

• Sterile 0.9% Sodium Chloride (NS)
• flush the eyes repeatedly with water or sterile saline for at least 20-30 minutes
• About 95% of ERs us Morgan Lens for ocular irrigation
• NAVSTEL® (balanced salt ophthalmic solution) Solution is a sterile intraocular irrigating solution for use during ophthalmic surgical procedures
• The solution does not contain a preservative and should be prepared just prior to use in surgery.

Anesthetize the eye

• Reduce the blinking reflex
• Prevent initiation and transmission of nerve impulses to remove Chemicals and/or Foreign objects.

Eye anesthetics

• proparacine HCL
• tetracaine HCL (Altacaine, Pontocaine) Tetracaine HCL can cause systemic toxicity
• lidocaine HCL (Akten) (Is a gel form) ointments should be applied from inner canthus towards outer canthus.
• ketorolac tromethamine - effective in managing postoperative pain.

Eye anesthetics

• Rapid Onset within 20 seconds, durations 15 - 20 minutes
• Tetracaine HCL can cause systemic toxicity

Eye Anesthetics Nursing Interventions

• Assess for allergic reaction
• Explain that the blink reflex will be temporarily eliminated
• Protect the eye from injury to avoid corneal damage:(Apply a eye patch until blink reflex returns)
• Patient teaching: Do not touch or rub the eye until anesthesia has worn off, tears and edges of eyelids and lashes will be temporarily yellow, the color washes out with tears.

Corticosteroids

• Useful for eye allergic and inflammatory ophthalmic disorders of the conjunctiva, cornea, and anterior segment of eye
• Short term use only for Bulbar conjunctiva, allergic conjunctivitis, and herpes zoster keratitis
• Use cautiously with patients with cataracts and chronic open-angle glaucoma
• monitor the client for headache and blurred vision

Corticosteroids:

• loteprednol etabonate (Lotemax)
• Topical anti-inflammatory corticosteroid for ophthalmic use

Glaucoma

• Increased intraocular pressure (IOP)
• Aqueous humor buildup
• Pressure pushes the vitreous humor against the retina
• Constant pressure destroys the retina, which leads to blindness

Open angel glaucoma

• The angel in your eye where the iris meets the cornea is as wide and open as it should be, but the eye's drainage canals become clogged over time, causing an increase in internal eye pressure and subsequent damage to the optic nerve
• Loss of peripheral vision, mild headaches, difficulty adaption to the dark, seeing halos around light. Symptoms may be vague

Angle closure

• Is triggered by pupil dilation, symptoms of an acute angle-closure glaucoma attack include severe ocular pain and redness, decreased vision, colored halos, headache, nausea and vomiting. Because raised eye pressure can rapidly damage the optic nerve and lead to vision loss, an angle-closure glaucoma attack must be treated immediately.

Closed Angle Glaucoma

• Is very painful because of the suddenness of the build up of pressure within the eye.

Antiglaucoma Agents

• Three types: Beta-adrenergic blocking agents, Carbonic anhydrase inhibitors, Osmotic diuretics
• Normal intraocular pressure (IOP) is 10-21 mm Hg
• Reduce the formation of aqueous humor (fluid formed by ciliary body in eye)

Beta-adrenergic blocking agents (antagonists):

• Decrease the formation of aqueous humor
• Commonly used to mange chronic primary open-angle glaucoma
• Beta-blocking drugs ends with -olol or -lol like betaxolol, carteolol, levobunolol, and timolol

Beta-adrenergic blocking agents (antagonists):

• Administration considerations: Nasolacrimal occlusion (press on inner canthus of eye) to minimize systemic absorption
• Use cautiously in patients with cardiac disease, COPD, DM, and Renal failure
• Use cautiously in patients with asthma or bronchospasm, heart failure, other cardiovascular disease, or diabetes mellitus
• Diabetic patients that tachycardia, increased blood pressure that accompany hypoglycemia may be masked by this drug

Carbonic anhydrase inhibitors

• Inhibits carbonic anhydrase to reduce secretions of aqueous humor in eye, causes self-limiting excretion of sodium, potassium, bicarbonate, and water; therefore lowering IOP
• acetazolamide (Diamox), dorzolamide (Trusopt), brinzolamide (Azopt) are all Carbonic anhydrase inhibitors

Carbonic anhydrase inhibitors:

• Used for long term treatment of glaucoma
• contraindicated in clients allergic to sulfonamides
• caution for clients w/ severe renal or liver disease.

Carbonic anhydrase inhibitors:

• Nursing Interventions:
• Assess for eye discomfort, reduced visual acuity, or local adverse effects
• Give in the am to prevent diuresis from disrupting sleep
• Patient teaching
• Avoid driving or other activates requiring alertness if drowsiness occurs
• Use sunscreen to avoid photosensitivity reaction
• Have family routinely screen for glaucoma
• Report tingling in fingers or toes

Osmotic Diuretics:

• Rapidly reduces the production of aqueous humor, reduces IOP,
• osmoglyn (PO) by mouth or mannitol (IV)
• Used for management of Narrow-angle glaucoma & Surgery - Administer 60 to 90 minutes before surgery as ordered.
• Obtain baseline serum electrolytes and monitor throughout treatment
• Side Effects: Hyperglycemia, Dry mouth, dizziness, polydispnea, Infiltration results in tissue damage and necrosis

Osmotic Diuretics Nursing Interventions

• Administer a test dose for severe renal impairment patients
• Monitor serum lithium levels
• Patient teaching
• Take as directed; drug therapy is for life
• Non compliance can lead to loss of vision that can not be regained
• Take PO form with food

Cholinesterase Inhibitors:

• Increase outflow of aqueous humor
• Decreases resistance to aqueous flow in open-angle and angle closure glaucoma
• Produces miosis before ophthalmic exam or after surgery
• Cholinesterase Inhibitors: Pilocarpine (Isopto Carpine), Carbachol (Carboptic, Isopto Carbachol), Acetylcholine (Micochol-E)

Cholinesterase Inhibitors

• Administration considerations:
• Crosses placenta, enters breast milk
• Used with beta-adrenergic blocking agents may increase risk of cardiovascular reactions
• Long-term use can cause a systemic responses, pulmonary edema and asthmatic attack

Cholinesterase inhibitors:

• Side Effects Visual burring, myopia, irritation, reduced visual acuity, and headache
• Systemic: abdominal pain, bronchoconstriction, hypotension, N/V, diuresis, diaphoresis, exacerbation of asthma
• Prolonged use may lead to retinal detachment, tear duct obstruction
• Cholinesterase inhibitors has Antidote: IV Atropine sulfate

Prostaglandin-inhbiting Agents

• Prostaglandin-inhibiting agents: (Reduces obstruction) to aqueous humor outflow, lowering IOP
• Manage open-angle glaucoma and ocular hypertension
• travoprost (Travatan), bimatroprost (Lumigan), and latanoprost (Xalatan) are all Prostaglandin-inhbiting Agents
• Increase aqueous humor outflow

Prostaglandin-inhbiting Agents Patient Teaching

• Side Effects Local: stinging, foreign body sensation; Increased eyelash growth, Increased brown eye pigment, Systemic: palpations
• Do not administer when contact are in the eye
• Hold lacrimal duct for 1 min (systemic)
• Follow up for examinations for visual acuity & IOP

Topical Agents for ear disorders

• Minor ear disorders are treated with topical agents such as Antibiotics/antimicrobials , Antifungals, Local anesthetics, Wax emulsifiers, Anti-inflammatory agents, Steroids, and Local analgesics

Children Ear Disorders

• URI (Upper Respiratory Infection), Eustachian tubes downward, Drinking bottle while laying down
• Children are most likely to get ear infections when they are between 3 months and 3 years old. Ear infections are most common during the winter and early spring

Adults Ear disorders

• Dental Caries & Sinus infection

Otitis externa are redness and swelling in the ear canal

• usually occur at sea, or pool, the stagnation of water in the pipe, which promotes the engraftment of germs

Otitis media Middle ear infection

• Children: frequent occurrence, Causes: URI, OTM most common cause of CONDUCTIVE hearing loss in children
• Adults: Allergies, URI, dental caries

Otitis media Signs and Symptoms

• Fever, Ear pain, Fussiness, restlessness, or difficulty sleeping; Difficulty hearing, dizziness or loss of balance
• Drainage from the ear; Diminished hearing; Dull retracted TM

Otitis media Treatment

• Antimicrobials such as ciprofloxacin otic (Cetraxal), ciprofloxacin/hydrocortisone (Cipro HC), ciprofloxacin/dexamethasone (Ciprodex,) and amoxicillin (Oral)
• Ciprofloxacin is the most common ototopical ABT
• Place patient on unaffected side when administering antibiotic eardrops
• As with any antibiotic always check allergies first and monitor for reactions/toxicity

Otitis media other steps

• Decrease pain place warm, clean cloth over the affected ear
• After instilling medication keep head tilted for 5 minutes
• A follow-up appointment should be made for 2 weeks after the beginning of the treatment

Trauma ear disorders include

• Foreign objects like Toys, beds, vegetables, or insects

Treatment of trauma ear disorders includes

• Irrigation, Destroy insect with lidocaine or mineral oil & Alligator forceps
• Anytime you are irrigating or putting medication into the ear make sure that it is room temperature and that you do not blast the eardrum

Wax buildup

• Middle Ear Disorder created by Ceruminous glands which Secretes cerumen, wax substance.
• Clean with corner of wash cloth

Wax buildup Sign and Symptoms

• Hearing loss, Fullness feeling in ear, Pain

Wax buildup Treatment

• Wax emulsifiers: carbamide peroxide (Debrox- OTC) and Cerumenex

Carbamide peroxide (Debrox)

• Important otic agent is the wax emulsifier carbamide peroxide, trade name Debrox
• Wax buildup is often the reason for reduced hearing in adults
• Put several drops in your ear two to three times daily over a period of a few days
• Once the wax is softened, use the syringe filled with water (room temperature or slightly warmer; 100 -105 degrees F) or a water and saline mixture or 50% hydrogen peroxide and water to flush out the wax
• Hot and Cold solutions are uncomfortable and may cause dizziness or nausea as a result of stimulation of the equilibrium sensors in the semicircular canals

Local anesthetics and analgesics

• Pramoxine and benzocaine (Allergen)- Local anesthetic that interferes with the transmission of impulses along sensory nerve fibers to relieve pain, itching, and irritation. Local anesthetics block both the initiation and conduction of nerve.
• Using another person ear plugs or ear buds

Anti-inflammatory agents/steroids

• 1% hydrocortisone & dexamethasone are frequently combined with antimicrobial agents in treatment of otitis media to decrease inflammation.
• Swelling of tissue hinders hearing and may interfere with transport of antimicrobial agent into the middle ear.

Instillation of Otic Medications

• Wash hands, Inspect ear canal, Tilt patient's head toward unaffected side, Gently pull on pinna to straighten ear canal
• Instill eardrops and Gently massage area anterior to ear

Middle and Inner Ear

• The stapes separates the middle and inner ear
• Cerium my accumulate and block the conduction of sound to the middle ear
• Assess external and middle ear for drainage, erythema, edema, and integrity of tympanic membrane