Pharm II Lecture 2 Outline PDF

1. Tear Supplementation 2. Tear Conservation a. Reduce evaporation i. Ointment 1. Petrolatum, mineral, lanolin 2. Causes blurry vision – use at bedtime ii. Goggles, moisture chambers iii. Humidifiers iv. Tarsorrhaphy b. Obstruction of lacrimal drainage i. Surgery, cautery, laser ii. Canalicular occl...

1. Tear Supplementation 2. Tear Conservation a. Reduce evaporation i. Ointment 1. Petrolatum, mineral, lanolin 2. Causes blurry vision – use at bedtime ii. Goggles, moisture chambers iii. Humidifiers iv. Tarsorrhaphy b. Obstruction of lacrimal drainage i. Surgery, cautery, laser ii. Canalicular occlusion, punctal plugs 1. We can occlude people with aqueous deficiency, ocular surface problems, and neurotropic related issues like LASIK 2. We cannot occlude people with inflammatory etiology to dry eye – at least initially a. Would cause pooling of inflammatory mediators iii. Temporary 1. Collagen rods a. Dissolve 4-7 days 2. Extended dissolvable a. Dissolve 2-6 months b. Use post surgery c. UltraPlug Extended Wear Synthetic Absorbable Plug i. 2-6 mo d. Extended Duration Absorbable Plug (Oasis) i. 3 mo iv. Permanent 1. Silicone plugs – do not use with dacryocystitis a. Intracanalicular i. Remove with irrigation b. Freeman plugs i. Remove with forceps, has a stopper c. Probability of plug loss i. 1 mo – 17% ii. 3 mo – 36% iii. 6 mo – 37% iv. Most lost in first 3 mo, most common complication d. Dextenza – punctal plug – releases dexamethasone for 1 mo, clears via nasolacrimal duct i. Tx for ocular inflammation and pain after surgery ii. Tx for ocular itching due to allergic conjunctivitis 2. Other a. Smart plugs i. Thermodynamic hydrophobic acrylic polymer ii. One size fits all iii. No inserter needed iv. Cannot see it or be rubbed out v. No foreign body sensation vi. Remove by probe or irrigation b. Form fit i. One size fits all ii. Hydrogel material – expands when in contact with tear film iii. Fills vertical canalicula iv. Remove by irrigation 3. Surgery/cautery a. Often not permanent 3. Tear Stimulation a. Oral Pilocarpine – Salagen i. Parasympathomimetic with muscarinic secretagogue effect ii. Cholinergic stimulation to improve lacrimation and salivation iii. Used in Sjogren's Syndrome and Radiation induced xerostomia iv. Sweat is most common side effect b. Neurostimulation i. Application of electromagnetic energy or chemical stimulus to specific anatomic targets ii. How it works: 1. Afferent sensory nerves activated in cornea and conjunctiva → cause efferent parasympathetic and sympathetic nerves to stimulate the lacrimal gland → cause release of water, electrolytes, and protein to ocular surface 2. Stimulation of anterior ethmoidal nerve (part of ophthalmic branch of CN V trigeminal) → causes increase superior salivatory nucleus activation → causes control of natural lacrimation 3. BASICALLY CN V is stimulated and CN VII is efferent to cause secretions iii. Trigeminal nerves (ethmoid) → trigeminal nucleus and CNS → meibomian, lacrimal, and goblet cells iv. iTear100 device 1. Oscillates on side of nose to stimulate ethmoidal nerve 2. Studies support its use in tx for DED v. Tyrvaya – varenicline solution nasal spray 1. Selective nicotinic acetylcholine agonist 2. Affects all 3 – meibomian, lacrimal, and goblet 3. Preservative free 4. Causes sneezing 4. Anti-Inflammatory Drugs a. Steroids i. Their effectiveness and side effects are inconclusive b. Cyclosporine i. MOA: inhibits activation of T lymphocytes, inhibits apoptosis of conjunctival epithelial cells, and affects calcineurin/nuclear factor for T cell activation ii. Systemic cyclosporine may cause serious adverse reactions compared to topical 1. Nephrotoxicity 2. Hypertension 3. Gingival hyperplasia 4. Hypertrichosis 5. Liver toxicity 6. Paresthesias with hand tremors 7. GI symptoms such as nausea and vomiting iii. Topical – anti-inflammatory, lipophilic so does not penetrate stroma 1. Restasis – 0.05% a. Emulsion, non preserved b. Increases tear production in KCS, Sjogren, RA, Lupus c. Expectations i. 1 mo – reduced symptoms ii. 3 mo – improvement iii. 6 mo – significant improvement iv. >6 mo – maintenance d. Will not help if diffuse loss of goblet cells – ocular pemphigoid, SJS, chemical burns e. Must have some response on Schirmer 2 f. Do not use with ocular infection g. Has a generic 2. Cequa – 0.09% – increase tear production in KCS a. Preservative free b. Nanomicellar technology c. A clear solution with 10x increase in aq solubility d. Improvement in as soon as 28 days e. Research is not as conclusive on its effectiveness f. Used for VKC, AKC, HSV, SLK, and contact lens intolerance 3. Verkazia – 0.1% a. Used in VKC b. An emulsion c. Good evidence 4. Vevye – 0.1% a. Tx DED b. Water free solution, no preservatives, pH, or osmolarity c. Works in 4 weeks d. Has immediate T-cell independent anti-inflammatory mechanism – inhibition of conj. Cell apoptosis and T cell apoptosis e. Because there is no surfactant or oil, it has better tolerability and less vision disturbances c. Lifitegrast – Xiidra i. LFA-1 antagonist ii. No data on pregnant women iii. LFA-1 (found on leukocytes) usually binds to ICAM-1 (on DED cornea/conj.) to allow T cell activation iv. Lifitegrast binds to LFA-1 to inhibit cytokine secretion v. Main side effect – Dysgeusia (change in taste) vi. Good evidence vii. Works in 2 weeks d. Other i. Avenova 1. Hypochlorous acid spray a. Chemical is produced naturally as an element of the immune response during oxidative burst, as WBC responds to pathogens b. Oxidant that kills bacteria via protein and lipid peroxidation or halogenation 2. Removes bacteria and debris on eyelid ii. Mucolytics 1. Acetylcysteine 2. Softens mucous, affects goblet cells 3. Use in bronchopulmonary conditions, filamentary keratitis, VKC, GPC iii. Hormones iv. Tetracycline 1. Oral 2. Used for posterior blepharitis 3. Inhibit Matrix metalloproteinases v. Nutrition 1. Omega 3 (Hydroeye) a. May affect clotting time by decreasing platelet aggregation – therefore use with caution and appropriate co-management with clotting time monitored with patients on blood thinners 2. Flaxseed oil 3. Cautions with patients on a. Phenothiazines and evening primrose oil (omega 6) – seizures b. Blood thinners/aspirin and omega 3 and 6 – reduces blood platelet aggregation c. Flaxseed oil (omega 3) – causes intestinal blockage (IBS, diverticular disease, bowel obstruction) 4. EPA and DHA may increase prothrombin time and bleeding a. Omega 3 may lower TA2 and decrease Factor VII 5. DREAM study a. To test the use of omega 3 fatty acids for treatment of DED b. Used olive oil as a placebo c. Found that the omega 3 was no better than olive oil 6. A study found that using omega3 and 6 combined with normal DED treatment enhanced their effectivity 7. Omega 3 considerations a. May have hypotensive effect b. May increase effect of BP meds c. Has a chemotherapy negating effect d. Take 3-6 mo for maximum omega 3 blood level e. Should obtain baseline omega 3 level prior to treatment 5. Neurotrophic Keratitis: a degenerative corneal disease caused by damage of trigeminal innervation, resulting in reduction or loss in corneal sensitivity a. May cause reduced lacrimal reflex, edema, melting and ulceration b. Corneal homeostasis is interplay between corneal nerves and epithelial cells mediated through production of trophic factors c. Most common causes – herpes keratitis, chemical burns, long term use of CLs, corneal surgery, chronic severe blepharitis, and diabetes d. Treatment – D/C meds that can cause NK, artificial tears, corneal or scleral CLs, amniotic membrane, tarsorrhaphy, autologous serum with growth factors, topical NGF e. Oxervate – 1st FDA approved treatment for NK i. E. coli derived recombinant form of human nerve growth factor, structurally identical 1. An endogenous protein involved in the differentiation and maintenance of neurons ii. Shipped in dry ice iii. Topical rhNGF is effective and safe for treating NK