1 Top Ten Drugs: What’s in Your Cabinet J. JAMES THIMONS, O.D.,FAAO MEDICAL DIRECTOR / OPHTHALMIC CONSULTANTS OF CONNECTICUT [email protected]Disclosure I am a consultant for or am on the Medical Advisory Board of: ◦ Allergan ◦ Alcon ◦ AMO ◦ Advanced Vision Research ◦ Inspire ◦ TLC Laser Center ◦ Carl Zeiss Meditec ◦ Synemed ANTI-VIRALS ACYCLOVIR FAMVIR VALTREX ANTI-VIRALS CLINICAL APPLICATIONS ◦ ACUTE VS CHRONIC INFECTION ◦ PRIMARY LESIONS ◦ EPITHELIAL HERPES SIMPLEX ◦ STROMAL HERPES SIMPLEX ◦ HERPES ZOSTAR ◦ HERPETIC IRIDOCYCLITIS OD Course 10 Saturday 4:00 - 5:00 pm
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Top Ten Drugs: What’s in Your CabinetJ . J A M E S T H I M O N S , O . D . , F A A O
M E D I C A L D I R E C TO R / O P H T H A L M I C C O N S U LTA N TS O F C O N N E C T I C U T
J I M T H I M O N S @G M A I L . CO M
DisclosureI am a consultant for or am on the Medical Advisory Board of: ◦ Allergan
◦ Alcon
◦ AMO
◦ Advanced Vision Research
◦ Inspire
◦ TLC Laser Center
◦ Carl Zeiss Meditec
◦ Synemed
ANTI-VIRALSACYCLOVIR
FAMVIR
VALTREX
ANTI-VIRALSCLINICAL APPLICATIONS
◦ ACUTE VS CHRONIC INFECTION
◦ PRIMARY LESIONS
◦ EPITHELIAL HERPES SIMPLEX
◦ STROMAL HERPES SIMPLEX
◦ HERPES ZOSTAR
◦ HERPETIC IRIDOCYCLITIS
OD Course 10 Saturday 4:00 - 5:00 pm
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ANTI-VIRALSSIDE EFFECTS
◦ RENAL FAILURE/ IMPAIRMENT
◦ HYPERSENSITIVITY REACTIONS
◦ FACIAL EDEMA
◦ VISUAL HALLUCINATIONS
OD Course 10 Saturday 4:00 - 5:00 pm
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VARICELLA ZOSTAR- KERATITISPRIMARY INFECTION
◦ CHICKEN POX
◦ VACCINATION RECOMMENDED BY AMERICAN ACAD of PEDIATRICS
RECURRENT INFECTION
◦ OPHTHALMIC INVOLVEMENT 10-255
◦ OPHTHLAMIC ZOSTAR > OVER AGE 60
◦ UNDER 40 50% IIMMUNOCOMPRIMISED
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The CyclinesTetracycline, Doxycycline and Minocycline
◦ Isolated from Streptomyces
◦ Effective against Gram +/ Gram -/Aerobic/ Anerobic/ Spirochetes/Rickettsia/Chlamydia
“How could I ever get mad at you”GS a 33 y/o Caucasian female presented with a complaint of discomfort, watering and light sensitivity following blunt trauma.
PEX:
◦ VA: 20/20 OD – 20/30- OS
◦ SLE: 2 mm area of epithelial damage with staining at 12:00
◦ Occasional A/C cell
◦ 2+ injection
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“How could I be mad at you”Treatment:
◦ BCL
◦ 4th Generation FQ
◦ Acular PF
Symptoms resolved after 1 week of Tx
Patient dismissed with instructions and Systane q4 hours
Muro 128 Unguent hs
“ How could I be mad at you”Patient returned to office 10 weeks later with c/o AM pain and return of symptoms.
D/C gtts after 4 weeks
PEX:
◦ VA: 20/30
◦ SLE: As shown
◦ 2+ injection
Recurrent Erosions
Medical Management◦Nocturnal lubrication
◦Nocturnal hypertonic saline
◦Bandage contact lens
◦Treat underlying conditions
Recurrent Erosions
Contributing Factors◦Dry eyes
◦Blepharitis
◦External disease / tear film abnormalities
OD Course 10 Saturday 4:00 - 5:00 pm
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Obvious, Active Disease Identification Is Crucial
3838
NOMGD with recalcitrant obstruction despite forceful expression
NOMGD yielding secretion with forceful expression
Lipid Secretion: Meibomian Glands
Meibomian gland dysfunctionTransillumination of
meibomian glands
Meibomian Gland
Expression
Bacterial Lipases BreakdownLipids to Soap
Digital Heat
OD Course 10 Saturday 4:00 - 5:00 pm
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Meibomian Gland Expression
Arita Meibomian Gland Expression System
With or without anesthesia
Grade I-IV
Non- billable
More difficult at the punctal region.
Recurrent ErosionsTreatment
◦ Doxycycline 50 mg po bid
◦ OM3’s
◦ Azasite qd hs
◦ BCL 30 day wear
◦ Restasis
A Challenger for the Title� Kashkouli, MB BJO 8/2014
�110 patients with MGD randomly assigned to:� Doxy 200mg/ day x 1 month�Azithromycin 500mg x1 then250mg x4
� Significant improvement in both groups
� Bulbar hyperemia and ocular surface staining better in Azith group
� Azith group showed significantly betteroverall clinical response
� Doxy group showed increased GI symptoms
The Way to a Man’s Eyelid is Thru His Stomach!
� BMJ Aug 2013
� 44 randomized trial meta-analysis
� 22 trials/ 5000 patients� Sequential therapy ( 2x daily PPI with Amoxicillan) was
significantly better than triple therapy ( PPI, Clarithromycin, Metronidizole)
� 87% vs 72% outcome
� 14 trials 2750 patients� 84% vs 75%
� Resitent to Tx sub Levofloxacin
OD Course 10 Saturday 4:00 - 5:00 pm
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Take Your Time: It’s Worth it!Fraunfelder, FW et al: Cornea 2010
12 subjects/ failed on initial therapy of lubrication/ NaCl
Treated with bandage lens x 3 months
75 % had complete resolution at one year from initial Tx
2 had symptoms but no signs
1 patient had symptoms and signs
Omega 3 Fatty AcidsRe-esterized OM3
Ethyl Ester
Interim Analysis
�Tear Osmolarity (mOsm/L)
Omega
-3
Placeb
o
325.82
320.30
Wk 0 Wk 6 Wk
12
316.79
318.85
312.42
320.70
Interim Analysis
• Corneal staining (measured on 0-
5 scale)
Interim Analysis
� Ocular Symptom Disease Questionnaire
Omega
-3
Placeb
o
34.95
22.05
Wk 0 Wk 6 Wk
12
22.92
15.44
15.54
15.93
Interim Analysis
Omega Index levels (%)
Omega
-3
Placeb
o
4.48
4.79
Wk 0 Wk
12
8.49
4.49
OD Course 10 Saturday 4:00 - 5:00 pm
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Re-Esterified OM3’s
: http://prnomegahealth.com/glaucomasociety/
Oral AntibioticsPCN’s
Cephalosporin’s
Macrolides
Oral Agent Therapy
Posterior Blepharitis
�Hordeola
�Canaliculitis
�Conjunctivitis
�Keratitis
�Dacryocystitis
�Dacroadenitis
�Preseptal/orbital cellulitis
�Endophthalmitis
Bacterial Flora of the Normal Eye/Adults
Staphylococcus epidermidis 75-90%*
Diphteroids (C. xerosis) 20-33%
Staphylococcus Aureus 20-25%*
Streptococcus (S. viridan) 2-6%
Hemophilus influenza 3% or more
Streptococcus pneumoniae 1-3%*
Gram negative rods 1% or more*
Pseudomonas aeruginosa 0-5%*
* Dominant organisms in microbial keratitis
Body Depots of Bacterial Organisms
� Skin: Lids/hands: Staph/Gr. (+)
� Nose/nasopharynx: Staph and GR (+)
� Kids: Hemophilus
� Oropharynx: Staph and StrepGr (+)
� Mouth: Strep/Bacteroides
� Stomach: Helicobacter pylori and rosaceae
� Small Intestine: Gr (+) cocci and bacilli
� Large intestine: Greatest conc of bacteria in body (10 organisms/gm) anerobes-enterobacteria, enterococcus feacalis, E. coli
� Genito-urinary tract: Chlamydia, E. coli, Neisseria gonorrhea (Ophthalmia neonatorum)
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Bacterial ConjunctivitisIn adults, 75% of cases caused by Gram positive pathogens
◦ Staphylococcus epidermidis, S. aureus, Streptococcus pneumoniae
Very common in children under 6 years
Causal agents of pediatric cases:
◦ 42% Haemophilus influenzae
◦ 35% S. pneumoniae
Everett et al, 1995
Block et al, 2000
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Gram (-) speciesPseudomonas
Hemophilus
Klebsiella
Serratia
Moraxella
Neiserria
Important Penicillin's
� Ampicillin: Broad spectrum oral-QID dosing
� Amoxicillin: Pro-drug of Ampicillin, improved absorption with lower GI side-effects
◦ Also a component of Qsymia (weight loss drug FDA-approved on July 18, 2012)
Mechanism
New Weight-Loss Drug Containing Topiramate
Narcotic AgentsDirectly affect opioid receptor
Agonist, partial agonist, or mixed
Bind to opioid receptors in brainstem, corticol areas and spinal cord
Mimic endorphins, producing a morphine like effect whether natural or synthetic
Important notification for patients
Drowsiness
Dizziness
Blurred vision
Nausea/vomiting/constipation
Take with food to avoid GI distress
Avoid Etoh or other CNS agents
Breathing distress
Contraindications�Bronchial asthma
�COPD
�Emphysema
�Pregnancy
�Hypersensitivity
�Prior addiction
�Renal/Liver dysfunction
�H/O Etoh use, Concurrent use of CNS agents(Tricyclic antidepressants, Phenothiazines)
OD Course 10 Saturday 4:00 - 5:00 pm
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Narcotic AgentsHydrocodone
1. 5/10 mg -325 mg Acetaminophen
. Vicodin/ Lortab
Oxycodone
1. 5/10 mg -325 mg Acetaminophen
2. Percoset
NSAID’sIbuprofen
Tramadol
NSAID’SCLINICAL APPLICATIONS
◦ ANALGESIA
◦ ANTI-INFLAMMATORY
◦ MUSCULOSKELATAL/ MYOSITIS
◦ ACUTE GOUT
◦ DYSMENNORRHEA
◦ CME
NSAID’SCORNEAL OPACITIES( WHORL)
TINNITUS
FLUID RETENTION
EPISTAXIS
BREAST CHANGES
ANEMIA/BLEEDING
CONSTIPATION
NSAIDS , H Pylori and Gastric UlcersLancet 2002 Jan 5; 359: 14-22
◦ 1625 NSAID users
◦ Peptic ulcer disease
◦ 42 % H Pylori patients
◦ 26% of non-infected patients
◦ Peptic ulcer disease
◦ 36 % of NSAID users
◦ 8% of non users
◦ Risk of bleeding ulcer (6.1x> in H Pylori on NSAIDS0
ORAL CONTRACEPTIVESCLINICAL APPLICATIONS
◦ BIRTH CONTROL
◦ HORMONE REPLACEMENT THERAPY
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ORAL CONTRACEPTIVESINCREASED CORNEAL CURVATURE
MIGRAINE / OPTIC NERVE EDEMA
DRY EYE
PHLEBITIS/ CVA
CRVO/BRVO
CRAO/BRAO
Vein Occlusions
•Bilateral Optic Nerve Swelling
Anti-Allergy Agents
AntihistaminesDiphenhydramine (Benadryl)
Chlopheniramine (Chlor-Trimentron)
______________________________
Desloratidine (Clarinex)
Loratidine (Claritin)
Fexofenadine (Allegra)
Cetirizine (Zyrtec)
Antihistamines
Sedating Agents - more effective for acute conditions, fast acting◦ Diphenhydramine (Benadryl) 25-50 mg qhs or q4-6h
◦ Clemastine (Tavist-1) 1 mg q12h
◦ Chlorpheniramine (Chlor-Trimeton) 4 mg q4-6h
OD Course 10 Saturday 4:00 - 5:00 pm
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Diphenhydramine (Benadryl)Formulations
◦ 25mg and 50mg tablets/capsules 12.5mg/5ml elexir
Dosages
◦ 25 to 50mg q6 to 8h
Antihistamines
Nonsedating Agents - more effective for seasonal allergy, maintenance dosing◦ Loratadine (Claritin) 10 mg qd
◦ Cetirizine (Zyrtec) 5-10 mg qd
◦ Fexofenadine (Allegra) 60 mg bid
◦ Desloratadine (Clarinex) 10 mg qd
Desloratidine (Clarinex)Formulations
◦ 5mg tablets: 0.5mg/ml syrup
Dosages
◦ 5mg q.d.
Loratidine (Claritin)Formulations
◦ 10mg tablets: 1mg/ml syrup
Dosages
◦ 10mg q.d
Fexofenadine (Allegra)Formulations
◦ 30mg, 60mg and 180mg tablets: 60mg capsules: 60mg and 120mg extended-release tablets
Dosages
◦ 60mg b.i.d: extended-release q.d.
Cetirizine (Zyrtec)Formulations
◦ 5mg and 10mg tablets, chewable tablets: 5mg/5ml syrup
Dosages
◦ 5to 10mg q.d
OD Course 10 Saturday 4:00 - 5:00 pm
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Sildenafil
Sildenafil (Viagra)
Several dozen published cases of optic neuropathy
Etiology for NAION with ED drugs is controversial and unproven
NAION associated with sildenafil is considered “possible” by WHO causality classification
Sildenafil (Viagra)
Mild, transient, dose-related impairment of color vision
Peak effect is 30 min to 2 hr after ingestion
Visual side effects occur in 3-10% of users
Bluish-tinged, pink-tinged, or yellowish-tinged vision
Symptoms last several min to several hours
Effects are due to inhibition of PDE-6, involved in retinal phototransduction
OTC ED Food “Supplements”
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Other Products with Undeclared ED Components
Cannabinoids
Pssst… Hey Doc between you and me…
Cannabinoids
Smoking and ingesting marijuana significantly reduces IOP
Have been administered orally, topically, and by inhalation as a means of reducing IOP
After smoking a single marijuana cigarette, maximal ocular hypotensive response occurs 60 to 90 min. after inhalation and lasts approximately 4 hours
Side Effects
Postural hypotension
Tachycardia
Anxiety
Drowsiness
Euphoria
Hunger
OD Course 10 Saturday 4:00 - 5:00 pm
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Marijuana and Glaucoma
Cannabis sativa
Small study of 11 patients, IOP was reduced 30% in 82% of the patients
Duration 3-4 hours
---(one drop of Xalatan up to 84 hours)
local and systemic side effects associated with marijuana use. These include conjunctival hyperemia, diminished tear production (leading to dry eye), pupillary mydriasis, alteration of blood pressure and cardiac arrhythmias
Marijuana and Glaucoma
The Bottom Line
What can we tell patients who ask about marijuana use as a glaucoma treatment? Perhaps the most precise answer is this:
• Organizations such as the American Academy of Ophthalmology and the National Eye Institute have determined that marijuana is not better or saferthan other medical and surgical options available to manage glaucoma today.
• No studies have been published regarding the long-term ocular and systemic effects of marijuana use by glaucoma patients.
• The duration of action of smoked marijuana necessitates frequent use (four to six times daily), which is impractical.
• The psychogenic effects of regular marijuana use have been shown to hinder daily activity. –Review of Optometry, Sowka and Kabat 2007
WHAT’S IN A WORDSurgery 2002 Jul; 132: 5-9
◦ 57 surgeons / 114 office encounters
◦ Relationship between tone of voice and malpractice experience was evaluated
◦ audio clips were collected and reviewed for ten traits ( warmth, interest, hostility, concern, sincerity etc.)
◦ Surgeons with a Hx of malpractice were 5x more likely to demonstrate dominant voice tones
Alcohol and DementiaRottenberg A etal
Lancet 2002 Jan 26:359:281-6
7983 males/females/ 5395 non-dementia @ baseline
6 year f/u standardized questionaire
Suspected dementia- neuro consult/MRI
197 - dementia/ 0.58 risk ratio for 1-3 drinks /day
I don’t drink should I?Wannamethee,SG etal
Heart 2002 Jan;87:32-6
◦ 7735 males ( 40 -59 y/o)
◦ 6503 without CAD/ 874 CAD events
Outcomes
◦ stable ,moderate, etoh- lowest CHD/Mortality
◦ new regular drinkers- no change in CAD
◦ no protection for CAD/ Increased risk of other cause of death
Friendship and longevityFratigioni, L etal
Lancet 2000 Apr 15: 355; 1315-9
“Influence of Social Network on occurance of Dementia”
