Pharm

Question 1

What was the 1st glaucoma drug invented?

Answer 1

Pilocarpine

NOTE: short half life so need frequent admin (QID). Reduces pressures by 30%

Question 2

MOA of Pilocarpine?

Answer 2

(+) longitudinal muscles of CB (corneo-scleral pathway) –> pulls posteriorly on scleral spur & secondarily opens up trabecular spaces for INC outflow & DEC IOP

Question 3

Pilocarpine is considered what kind of drug?

Answer 3

Direct cholinergic agonist

Question 4

Uses for pilocarpine?

Answer 4

1. After an angle closure attack in prep for LPI
2. 1% –> DDx 3rd nerve palsy from sphincter tear in pt w fixed, dilated pupil - 3rd nerve palsy WILL constrict
3. 0.125% DDx Adie’s Tonic Pupil (acute dilated pupil); iris sphincter is super sensitized

Question 5

ADEs of pilocarpine?

Answer 5

1. Browaches, HA, myopic shift (pt will INC their accom bc it is paralyzed causing shift)
2. Miosis
3. Cataracts
4. Retinal Detachments
5. Secondary angle closure

Question 6

Neostigmine, edrophonium, echothiophate, and pyridostigmine are considered what kind of medications?

Answer 6

Indirect Cholinergic Agnoists: Anti-cholinesterase agents

NOTE: this is considered “indirect” bc it inhibits AchE which is the enzyme that breaks down ACh

Question 7

Which is the most dangerous cholinergic antagonist?

Answer 7

Scopolamine

NOTE: similar clinical indications as atropine but rarely used side effects

Question 8

ADEs of scopolamine?

Answer 8

Hallucinations, amnesia, unconsciousness, confusion, restlessness, incoherence, vomiting, urinary incontinence

Question 9

Major actions of parasympathetic nervous system?

Answer 9

1. Broncho-constriction
2. Miosis
3. Rest and digest
4. INC in secretions (SLUD): salivation, lacrimation, urination, defecation

Question 10

Major actions of sympathetic nervous system?

Answer 10

1. Broncho-DILATION
2. Mydriasis
3. Fight or flight
4. Overall DEC in secretions (anti-SLUDGE)

Question 11

What receptors are on the iris sphincter?

Answer 11

M3

Effect = miosis

RECALL: the iris muscles develop from NEURAL ECTODERM

Question 12

What receptors are located on the ciliary muscle?

Answer 12

M2, M3

Effect = accommodation

RECALL: ciliary muscles develop from the neural crest. Abnormal neural crest development –> irregular iridocorneal adhesions

Question 13

What receptors are located on the lacrimal gland?

Answer 13

M2, M3

Effect = tear production

RECALL: lacrimal gland is derived from surface ectoderm. Surface ectoderm gives rise to “surface” structures.

Question 14

What receptor is located on the iris dilator?

a. Alpha 1
b. Alpha 2
c. Beta 1
d. Beta 2
e. M2
f. M2 & M3

Answer 14

a. Alpha 1

RECALL:
Alpha 2 --> CB vasculature
Beta 1 /2 --> NPCE
Beta 2 + M2/M3 --> Ciliary muscles, TM
M3 --> Iris sphincter
M2/M3 --> Lacrimal gland

Question 15

What receptors are located on the Ciliary Muscles & Trabecular meshwork?

Answer 15

Ciliary Muscles: M2/M3 + Beta 2

Trabecular Meshwork: Beta 2

Question 16

Beta 2 agonists cause what to the TM & CM & NPCE?

Answer 16

RELAXATION

INC outflow & DEC Accommodation & INC IOP

Question 17

Which cholinergic antagonist works the fastest and has the shortest duration of MYDRIATIC effect?

Answer 17

Tropicamide

Question 18

What are the ADEs of Atropine?

Answer 18

1 is DRY MOUTH

Dry skin

Rapid pulse

Disorientation

Fever due to CNS effects of hypothalamus

NOTE: do NOT give to pts w DOWN’s SYNDROME, small children, and elderly

Question 19

Which anti-cholinergic antagonist has the fastest onset & shortest duration of CYCLOPLEGIC effects?

Answer 19

Cycloplentolate

NOTE: this drug is the standard for cycloplegia in clinic

Question 20

Which anti-cholinergic antagonist is the standard for Treating ANTERIOR Uveitis?

Answer 20

Homatropine

1. Keeps iris MOBILE (DEC likelihood of posterior synechiae formation)
2. REDUCES pain by paralyzing CM & sphincter
3. Stabilizes the BAB by constricting the iris & ciliary body vasculature to limit passage of blood contents into the aqueous humor

Question 21

Which medication is a SOMATIC drug that blocks the release of ACh at the neuromuscular junction, inhibiting muscle contractions?

Answer 21

Botulin A Toxin (Botox)

Single injections have been effective in providing permanent correction for strabismus; cosmetic wrinkles

Used in blepharospasm Tx but effects only laast a couple hours

Question 22

What are the uses of adrenergic agonists?

Answer 22

1. Promote SYMPATHETIC activity
2. Used in dilation, conj constriction, & management of minor allergic conditions
3. Temporary control of IOP spikes (post Sx, angle closure glaucoma, Tx POAG)

Question 23

What receptors does Norepinephrine act on?

Answer 23

A1 (dilator)
A2 (CB vasculature)
B1 (NPCE + heart)

NOT B2

Question 24

What receptors does Epinephrine act on?

Answer 24

A1 (dilator)
A2 (CB vasculature)
B1 (NPCE + heart)
B2 (Lungs)

Question 25

MOA of Phenylephrine (neo-synephrine)?

Answer 25

Alpha-1 Agonist!!!! ONLY dilates. Not effect on Beta receptors so NO cycloplegic effect Alpha-1 receptors are MAINLY on SMOOTH MUSCLE & blood vessels (will cause constriction and INC BP) NOTE: muller's muscle contains alpha-2 receptors and some alpha 1 receptors so it will retract potentially w phenyl use

Question 26

Other uses for Phenylephrine other than to help dilation?

Answer 26

1. DDx scleritis vs episcleritis (blanch = epi) 2. Horner's syndrome 3. 10% to break PS but has adverse CV effects (HTN)

Question 27

CI of phenylephrine?

Answer 27

MAOIs TCAs Grave's Dz

Question 28

What medications is this description describing? - Topical ocular decongestants - Alpha >> Beta effects (potential to depress the CNS) - Fixed dilated pupil potentially

Answer 28

1. Naphazoline (Naphcon) 2. Tetrahydrozoline (Visine) Visine may cause fixed dilated pupil Naphcon-A is a popular OTC combines the reduction of hyperemia & anti-histamine for itch relief

Question 29

What are the two main alpha-2 topical adrenergic agonist used for glaucoma?

Answer 29

1. Brimonidine (Alphagan 0.20%) | 2. Apraclonidine (Iopidine)

Question 30

Which ocular glaucoma medication fits this profile: - Highly selective alpha-2 agonist (30X more selective than the other in its class) - Neuroprotective properties - 30% Follicular conjunctivitis - TID due to short duration - Miosis ADE (helps w post-refractive LASIK, PRK complaints) - Systemic dry mouth (MC) and CI of MAOIs

Answer 30

Brimonidine (Alphagan 0.20%)

Question 31

Which ocular glaucoma medication fits this profile: - BEST eye drop to drop IOP in acute situations - Used: control IOP spike before & after Sx, laser iridotomy, trabeculoplasty, posterior capsulotomy - Also used for Acute Angle Closure; rapid potent DEC IOP - 30 to 40% IOP reduction - Onset: 1 hour, peak 3-5 - Tx: tachyphylaxis - Dx Horner's

Answer 31

Apraclonidine (Iopidine)

Question 32

What are the pharmacological tests for Horner's Syndrome?

Answer 32

1. Cocaine 2. Apraclonidine 3. Hydroxyamphetamine 4. Phenylephrine 1% (Adrenergic receptors are sensitized)