Pediatric Pharmacology 1 Lecture 10 PDF

§ Decreases corneal sensitivity § Improves transport of other agents across cornea § Indications...

§ Decreases corneal sensitivity § Improves transport of other agents across cornea § Indications § Before administration of other drops** § Corneal foreign body or injury § Tonometry à for glaucoma suspect § 0.5%/1% proparacaine, 0.4% benoxinate § With or without Fluorescein dye -use anesthetics in children when we are about to instill other drops such as tropicamide bc we know it stings so putting an anesthetic helps with comfort 11 Tropicamide § Muscarinic antagonist: paralyzes the iris sphincter and ciliary muscle § Concentrations: 0.5%, 1.0% § 0.5% used in younger than 1 yo and lighter irides § Poor cyclop legia effect with 0.5%! (can use that in albinism) § Rarely can cause C S N disturbance § Onset: 15-30 minutes § Duration 4-6 hours 12  Phenylephrine HCl (Neo-synephrine) § No cycloplegic effect § 2.5% maximum dose: 2 gtts spaced 5 mins apart § Use with caution in children with cardiovascular disease, premature infants and children in the first 6 months of life à 2.5% concentration § D O NOT USE 10% ! § 1% used in Cyclomydril generally safe in all infants § Paremyd (0.25% tropicamide and 1.0% p-hydroxyamphetamine) § Combo spray/drops: 0.5%Tropic + 2.5% Phenyl + 0.5% Cyclo à don’t last very long -don’t use it that much unless pt is a high myope -premature infants have immature kidneys but in general infants have immature kidneys 13  Atropine § Muscarinic antagonist: paralyzes the iris sphincter and ciliary muscle § Approved for 3 months and older CYCLOPLEGICS § 0.5% in light irides; 1.0% in darkly pigmented irides § Ointment or gtts instilled qhs for 3 nights before exam § Onset: 3-6 hours § Duration: 1 week (blur), 2 weeks (pupil dilation) -1% is approved for 3 months an older infants 14  Atropine § FDA approved for: dilation, cycloplegia, penalization (amblyopia), uveitis § Off-label use: myopia management (low CYCLOPLEGICS concentrations) § Children with Down syndrome, spastic paralysis, brain damage and very light pigmentation may be hypersensitive to the cholinergic antagonists § Ocular side effects: photophobia, blurred near vision, dilated pupils -only FDA approved myopia management is Misight aka multifocal CL 15  Atropine § Peripheral Signs of Atropine Toxicity § M u c o u s m em branes: D ry eyes, mouth, throat § Skin: Flushed, dry, hot, rash on face/mask CYCLOPLEGICS § Cardiovascular: Tachycardia, HTN § Respiratory: Tachypnea § G I : D ecreased peristalsis, abdom inal distension in infants § Genitourinary: Bladder distention, urgency § Other: Fever, headache -want to educate the parent on side effects before prescribing 16  Atropine § Central Signs of Atropine Toxicity § N eurologic Dysfunction: M uscle tremors, weakness § C erebellar Dysfunction: Ataxia, dysarthria, muscle incoordination CYCLOPLEGICS § Confusional psychosis: Restlessness, irritability, violent and aggressive behavior, confusion, disorientation, visual and tactile hallucinations § Term inal Phenom ena: convulsions, stupor, com a, death § Antidote: Physostigmine Salicylate -want to educate the parent on side effects before prescribing à put an effort to emphasize how dangerous the medication can be -does cross the BBB 17  Cyclopentolate § Muscarinic antagonist § Concentrations: (2 gtts separated by 5 minutes) § Under 1 year: 0.5% § O ve r 1 year: 1.0% CYCLOPLEGICS § Premature or LBW:1 gtt C yclom yd ril (0.2% C/1% PE) § Down syndrome § Onset: 15-30 minutes § Maximum Cycloplegia: 40 minutes à need to wait the full 40 mins to do cycloplegic testing § Duration: 6-8 hours, up to 24 hours à parents usually complain that child still has blurred vision post drops and ensure parent it is normal § Do N O T use 2% due to risk of side effects -dr. Vaughn uses 1% phenyl in down syndrome children bc they have lower accommodation to being with you don’t need a high dosage 18  Cyclopentolate § Used vs. atropine for shorter duration of action § Used vs. tropicamide for stronger cycloplegic effect CYCLOPLEGICS § Ocular side effects: photophobia, blurred near vision, pupil dilation § Systemic adverse effects: similar to atropine, but occur less frequently § Nervous system alterations have been reported: hallucinations, disorientation, memory loss, confusion 19  Tropicamide 1% § Less potent cycloplegic: very safe, less adverse effects compared to atropine § Onset: 15-30 minutes CYCLOPLEGICS § § Duration 4-6 hours Myopes: 2 gtts 1% T 5 mins apart is as effective in cycloplegia as 1% C (cyclopentolate should still be used in hyperopes!) § Scopolamine and Homatropine: rarely used 20 § Healthy 7-month-old infant: 0.5% cyclopentalate (2 gtt 5 mins apart) § 3-year-old Hispanic child: 1% cyclopentalate (2gtt 5 mins apart) § 3-year-old child with esotropia that did not dilate with 2 gtts 1% cyclo: 1% atropine at bedtime, 3 nights once a night before the exam) § 2-year-old toddler with Down syndrome: 0.5% cyclopentalate (punctal occlude according to the literature) or 1% cyclopentalate can be used 21  § First time patients: tropicamide and cyclopentolate § Amblyogenic dry retinoscopy: cyclopentolate THEN tropicamide § Degenerative myope (s amblyopia): tropicamide and phenylephrine “WHAT DROPS § Low to moderate myopes (s amblyopia): 2 gtts 1% T 5 mins apart DOYOU WANT TO § Low hyperope with 20/20 vision and no systemic issues: tropicamide USE?” § Persistent amblyopia: cyclopentolate THEN tropicamide § Low refractive error with normal DFE last year: no drops! Dilate every 2 years § Pick the most important drop first! 22