PATHO WIZARD
Name an OTC ophth gtt, contraindicated in patients with narrow-angle glaucoma 2/2 to IOP
naphazoline
First-line Rx for acute bacterial conjunctivitis (name two options):
erythromycin ung, polymyxin-bacitracin, polymyxin-trimethoprim (PolyTrim),
aminoglycosides + fluoroquinolones are good for gram-negative species but incomplete for strep and staph.
Newer moxifloxacin ophth will also cover gm neg:))
GM NEG: Pseudomonas; GC (tx with ceftriaxone+azithro or +doxy).
A 4-year-old child develops allergy symptoms that occur during the late summer and fall and which resolve for the remainder of the year. The health care provider recommends seasonal use of cetirizine at what dosage?
2.5 mg orally daily-
Rationale: Cetirizine is appropriate for use in individuals ages 2 years and older. Individuals aged 2 to 5 years should be started on 2.5 mg daily. Individuals aged 6 years and older may receive 5 to 10 mg daily.
Your patient has a confirmed Dx of bacterial blepharitis and doesn't want an ointment. Name an option:
fluoroquinolone- ex. moxifloxacin; or azithromycin ophth.
Main culprit of blepharitis -bacterial origin is:
stapylococcus
Underlying etiology or causes of blepharitis include:
Inflammation, hypersecretion of the sebaceous glands (seborrheic dermatitis), or meibomian gland dysfunction
Name a vasoconstrictor (decongestant) eye gtt:
naphazoline, tetrahydrozoline
Name 3 allergen(s) that can cause perennial allergic rhinitis.
Individuals with perennial allergic rhinitis experience symptoms throughout the year
indoor mold, shellfish, dust, animal dander
individuals with seasonal allergies experience symptoms that correspond to seasonal peaks in tree, grass, and weed pollens
leaf mold and weeds are causes of seasonal rhinitis.
Name the conjunctivitis etiology: watery dc, tearing, itching, chemosis, bilateral presentation.
ALLERGIC
Common organisms seen in acute bacterial conjunctivitis (name two):
Staphylococcus, Streptococcus, Moraxella, and Haemophilus
Less common: GC
Patients with ocular sx 2/2 allergic rhinitis, respond well to which class of drugs- name the patho:
Mast cell stabilizers: cromolyn, lodoxamide, bepotastine, nedocromil
Or combo Antihistamine/Mast cell stabilizer: azelastine, epinastrine, ketotifen, and olpatidine
First-line treatment for MILD DED:
artificial tears QID
moderate to severe, artificial tears QHourly + lubricating ung at bedtime.
A 29-year-old patient who is employed as a bus driver presents in follow-up for allergic rhinitis. The patient has been taking fluticasone, 2 sprays per nostril daily for 1 month. The patient notes minimal symptomatic improvement. The patient has no other health issues and takes no other medication. What is the most appropriate next step?
The patient should initiate a trial of oral fexofenadine, loratadine, cetirizine (Allegra or an Rx of the like), a second-generation antihistamine, for the continued symptoms of allergic rhinitis.
Use of intranasal corticosteroids, such as fluticasone, should not continue beyond 3 weeks if there is no symptomatic improvement.
Diphenhydramine, a first-generation antihistamine, would not be the best choice for this patient due to its sedating effects and the patient’s need to maintain alertness to effectively perform driving.
Intranasal cromolyn is only helpful in preventing symptoms of allergic rhinitis, not treating the acute disease.
Immunotherapy should be considered if treatment failure on other agents occurs.
What is the first step in treating allergic rhinitis?
- think allergen
The first step in treating allergic rhinitis is to remove the allergen, if possible, as most allergic reactions resolve within a few days once the cause is removed. If pharmacologic treatment is necessary, intranasal corticosteroids are first-line agents, antihistamines are second-line agents, and intranasal cromolyn is a third-line agent that works only prophylactically
Which is an example of a type IV hypersensitivity reaction?
Contact Dermatitis; GVHD
These reactions are termed delayed hypersensitivity reactions because they typically occur from 2 days to 1 week after exposure. Type IV reactions are cell-mediated responses to T lymphocytes making contact with an antigen.
Types I to III hypersensitivity reactions are mediated by antibodies. Transfusion reactions are type II reactions, anaphylaxis is a type I reaction, and systemic lupus erythematosus is a type III reaction.
Name the conjunctivitis etiology: watery dc, usually starts in one eye, peripheral injection, foreign body sensation
VIRAL
Which antihistamine is the least sedating?
Fexofenadine or loratadine are second-generation antihistamines and are the least sedating of the agents listed.
Second-generation antihistamines do not cross the blood–brain barrier to the same extent as older first-generation antihistamines, so they produce less sedation.
While cetirizine is also a second-generation antihistamine, it is reported to have a higher incidence of sedation than other agents in this group.
**Hydroxyzine and diphenhydramine are both first-generation antihistamines.
A 49-year-old patient with no prior medical history develops wheezing and pruritus shortly after receiving a vaccine at an outpatient clinic. There is no epinephrine autoinjector available. What amount of epinephrine solution would be appropriate to administer intramuscularly?
0.2-0.5ml of 1mg/ml solution
15-30 kg= 0.15mg x1, repeat after 5min
>30 kg= 0.3mg x1, repeat after 5min
This patient is experiencing anaphylaxis and should be treated with intramuscular epinephrine. The usual dose for adults is 0.2 to 0.5 mL of 1 mg/mL solution
Antiviral therapy for zoster ophthalmicus includes:
PO/IV famciclovir, valacyclovir
adjunctive therapy- cool compress, pain mgt.
Systemic steroids ok- NEVER topical (mgt by ophth)
**Always involve ophthalmology consult- asap
Anaphylaxis is what type of hypersensitivity?
Type I/ IgE
Anaphylaxis occurs when sensitized mast cells and basophils release IgE mediators including histamine and leukotrienes, which sets off a systemic reaction and induces symptoms such as angioedema, flushing, pruritus, urticaria, nausea, vomiting, and wheezing. It is a type I reaction because it involves the interaction between an antigen and a specific immunoglobulin (Ig) E antibody.
PATHO behind glaucoma:
Aqueous humor is produced by the ciliary body and secreted into the posterior chamber of the eye. A pressure gradient in the posterior chamber forces the aqueous humor between the iris and the lens and through the pupil into the anterior chamber.
A patient presents for evaluation of nasal congestion, which has persisted for a few weeks. It is relieved with use of an over-the-counter intranasal medication, but the patient reports needing to gradually increase how often the medication is used to achieve the same effect. Which medication is the patient most likely using?
Afrin, Dristan- oxymetazoline
Use of intranasal sympathomimetic amines, such as oxymetazoline, typically produces a rapid reduction of nasal congestion. However, use beyond 3 to 4 days can lead to rhinitis medicamentosa, or rebound congestion, which is believed to result from ischemia caused by the drug’s intensive local vasoconstriction and local irritation of the agent itself. Such effects may prompt individuals to increase use of these medications, further worsening symptoms. Resolving this problem requires discontinuing use of the offending agent
A 36-year-old patient with no significant past medical history is evaluated for a report of nasal congestion for the past 6 weeks. The patient has been taking loratadine for the past month with limited improvement. The patient uses oxymetazoline nasal spray 5 to 6 days per week, which the patient started following the first week of symptoms. The patient has not been given any steroids or antibiotics. What should the health care provider recommend the patient do first?
The patient is experiencing rhinitis medicamentosa, or rebound congestion, caused by topical decongestants with prolonged use greater than 3 days. It is characterized by severe edema, congestion, and increased discharge due to decreased receptor sensitivity, which interferes with ciliary action and dries out the nasal mucosa. The best solution to this problem is to discontinue the offending agent, which in this case is oxymetazoline. It would be inappropriate to prescribe phenylephrine because this is another topical decongestant that carries the same side effect. Switching antihistamines is unlikely to be effective, and there is no clear indication to prescribe an antibiotic.
Patient education for bacterial conjunctivitis- name 3:
EYE hygiene, warm compress, ABX use if indicated, refrain from wearing contacts, change out mascara and any other old facial products.
Bronchodilators used in the management of asthma and chronic obstructive pulmonary disease (COPD) include which class(es)? Think- relaxing airway smooth muscle and increasing bronchial ciliary activity
Muscarinic antagonists (LAMAs- Spiriva/tiotropium, Trelegy/fluticasonefuroate+)
beta-2 adrenergic agonists (LABAs- Symbicort budesonide/formoterol) ; and
methylxanthines (theophylline) function by relaxing airway smooth muscle and increasing bronchial ciliary activity.