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OPTOMETRIC PHYSICIAN SYMPOSIUM January 26Th, 2019

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OPTOMETRIC PHYSICIAN SYMPOSIUM January 26Th, 2019 30TH Annual OPTOMETRIC PHYSICIAN SYMPOSIUM January 26th, 2019 Anterior Segment Grand Rounds Blair Lonsberry, O.D., FAAO 1/25/2019 Dendritic Ulcers Case • 20 year old male presents with a red painful eye – Started that morning when he woke up – reports a watery discharge, no itching, and is not a contact lens wearer • SLE: – See attached image with NaFl stain 3 Herpes Simplex Keratitis: Clinical Features • Characterized by primary outbreak and subsequent reactivation • Primary outbreak is typically mild or subclinical • After primary infection, the virus becomes latent in the trigeminal ganglion or cornea • Stress, UV radiation, and hormonal changes can reactivate the virus • Lesions are common in the immunocompromised (i.e. recent organ transplant or HIV patients) 1 1/25/2019 Anti‐Viral Medication Pediatric HSV Keratitis Drug Mechanism of Action Bioavailability Dosing Side Effects Acyclovir Acyclovir interferes 10‐30% gets Simplex: Overall very safe • pediatric herpes simplex keratitis has an 80% risk with DNA synthesis absorbed 400 mg Nausea, of recurrence, a 75% risk of stromal disease, and inhibiting viral Short ½ life 5x/day vomiting, a 30% rate of misdiagnosis replication *Metabolized in Zoster: headaches, kidneys 800 mg dizziness, • 80% of children with herpes simplex keratitis 5x/day confusion develop scarring, mostly in the central cornea Valacyclovir Acyclovir pro‐drug 95% converted Simplex: Same as acyclovir – results in the development of astigmatism Equivalent to acyclovir to acyclovir* 500 mg tid but better for pain Better Zoster: – 25% of children have more than 2 D of astigmatism, management bioavailability 1 g tid most of which is irregular and longer 1/2 • consider pediatric HSV when a patient has life unilateral recurrent disease in the anterior Famciclovir Inhibits DNA chain Superior to Simplex: Same as acyclovir segment (Famvir) elongation acyclovir* 250 mgTID It is metabolized to Zoster: penciclovir where it is 500 mg TID active 10‐20x as long as acyclovir Herpes Simplex Keratitis Management HSV Stromal Disease • Topical: – Viroptic (trifluridine) q 2h until epi healed then • HSV Stromal disease is an immune‐mediated disease taper down for 10-14 days. • Increased risk of scarring and high risk of poor visual • Viroptic is toxic to the cornea. prognosis – Zirgan (ganciclovir) available, use 5 times a • Requires corticosteroids (HEDS: corticosteroid reduced risk of day until epi healed then 3 times for a week progression by 68%) (US only) – Without epithelial defect: corticosteroids and prophylactic anti‐viral dosage – With epithelial defect: active infection anti‐viral dosage with judicious corticosteroids 2 1/25/2019 How much to dose steroid? Herpes Simplex Keratitis • HEDS used QID of prednisolone phosphate • Prophylactic Treatment: – Reduces the rate of recurrence of epithelial and stromal • Current Recommendations: keratitis by ≈ 50% – Mod –severe (especially with neo): 1% • Acyclovir 400 mg BID Prednisolone or Lotemax QID to 6x/day • Valtrex 500 mg QD • Famvir 250 mg QD – Want the lowest dose needed to control the inflammation • L‐lysine 1 gram/day: – AAO EBM Treatment Guideline 2014 – Proven to “slow down” and retard the growth of • Topical steroid for 10 weeks (this is based on HEDS results) with oral the herpes virus and inhibit viral replication antiviral • Frequent debilitating recurrences, bilateral involvement, or HSV infection in a monocular patient Herpes Simplex Epithelial Keratitis Prophylaxis?? • Treatment Regimen: : – Zirgan 5x/day until the ulcer heals, then 3x/day for one week • Pitfalls to Prophylaxis – Oral Valtrex 500 mg 3x/day for 7‐10 days – Reduction of recurrence does not persist once drug – Artificial tears stopped – Resistance???? – L‐Lysine 2 grams daily? • van Velzen, et. al., (2013) demonstrated that long‐ • Proven to “slow down” and retard the growth of the herpes virus and term ACV prophylaxis predisposes to ACV‐refractory inhibit viral replication – Debride the ulcer? disease due to the emergence of corneal ACVR HSV‐1. • Prior to topical antiviral therapy debridement was treatment of choice • Generally try to avoid use of sharp instruments and use of cotton swab and anesthetic • RTC 1 day, 4 days, 7 days 3 1/25/2019 Consider Combining APAP with NSAID’s for Mild to Pain Management: Oral Analgesics Moderate Pain Relief • Conditions potentially requiring us of oral 1:00 pm: Two 325mg Tylenol analgesics: – Corneal ulcers 3:00 pm: Two 200mg Ibuprofen – Herpes simplex/zoster 5:00 pm: Two 325mg Tylenol – Post‐surgical 7:00 pm: Two 200mg Ibuprofen – Trauma – Thermal burns Alternated every 2 hours while awake – Each medication is q 4 hours. Acetaminophen Ibuprofen • Adult analgesic dose: 200‐400mg q4hours – Maximum Dosage: 2400 mg/day for pain (approved for 3200 • Mechanism of Action is not well understood. mg/day in arthritis treatment) – Possibly some CNS component – Very weak inhibitor of prostaglandin synthesis • OTC: 200 mg tabs • Rx: 300, 400, 600, 800mg tabs • One of the most commonly used analgesics for mild • Peak levels 1‐2 hours to moderate pain. – Equal analgesic properties to ASA unless associated with • Most renal toxic of all the NSAID’s inflammation, where it is less effective. • Brand Names: Motrin, Advil, and Nuprin Take home: Good for pain; Good for fever; No effect on inflammation 4 1/25/2019 Indoleacetic Acids: Indomethacin Oral Analgesics: Guidelines • Adult Dosage: 25‐50 mg TID • Never exceed maximum recommended dosages: • Rx Only: 10mg ‐ 75mg capsules – ASA: 8 grams/day • Mainly used as a short term anti‐inflammatory especially – Acetaminophen: 4 grams/day for conditions that do not respond to less toxic NSAIDS. – Ibuprofen: 1200 mg/day OTC and 2400 mg/day – Indomethacin has a very high level of intolerance compared to other NSAID’s. prescription – Naproxen: 1250 mg/day • Oral NSAID most widely used in Tx of ocular inflammation. – Naproxen Sodium: 1375 mg/day – Codeine: 360 mg/day Cox‐2 Inhibitors Oral Analgesics: Guidelines • Selective agents for only COX‐2 designed to protect the GI system from the • Make the proper diagnosis first (ie. Don’t side effects seen with NSAID’s. prescribe without knowing what you are prescribing for!) • Major agent available on the market is Celecoxib (Celebrex). • Treat the underlying cause for the pain – Other agents Valdecoxib (Bextra) and Rofecoxib (Vioxx) were removed from the market due to increased risk of heart attacks and strokes. • Treat the pain at presentation..don’t wait! – It is approved for the treatment of osteoarthritis and rheumatoid arthritis. • Treat pain continuously over a 24 hour schedule – Dosage: 100 mg BID or 200 mg daily • Non‐prescription drugs should be first choice and tend to be low cost • Treat patients with the simplest and safest means to alleve pain 5 1/25/2019 Scheduled Medications –Most Opioids Opioids Side Effects Schedule Description Optometric Medications I Not commercially available; no approved indication • Side Effects are very hard to predict because opioids can Very addictive medications that Oxycodone = OxyContin, OxyFast cause CNS depression or stimulation. are accepted for medicinal use Oxycodone + APAP = Percocet or Tylox Oxycodone + ASA = Percodan Oxycodone + NSAID = Combunox • CNS Side Effects II Hydromorphone (Dilaudid) Codeine Sulfate = Codeine Generic – Dizziness, lightheadedness, sedation, and drowsiness are Meperidine (Demerol) the most common. Hydrocodone + APAP = Lortab or Vicodin – Mood elevation (euphoria) and disorientation can occur in Hydrocodone + Ibuprofen = Vicoprofen some patients. Significant abuse risk, but less Codeine + APAP = Tylenol 3 and Tylenol 4 III potent than I or II. May still – Exacerbated if used in combination with alcohol, contain narcotics. depression medications such as tricyclic antidepressants, Relatively low abuse potential Propoxyphene (Darvon) anticholinergics, antihistamines, anti‐seizure medications, and limited risk Propoxyphene with APAP = Darvocet or muscle relaxants, etc. IV (Removed from Market in November 2010). – Visual symptoms such as blurry vision, miosis, and diplopia Pentazocine + APAP (Talacen) can occur. Tramadol Very limited abuse potential. Acetaminophen V May be OTC in some states. Opioid Side Effects Schedule III Opioids: Codeine • Usually administered in combination with . – – Respiratory Side Effects: Tylenol 3 = Codeine 30 mg and Acetamenophin 300 mg • Respiratory Depression • Dosage: 1‐2 tablets every 4 hours. – Most serious side effect of the opioids – – Opioids suppress the brainstem respiratory centers Tylenol 4 = Codeine 60 mg and Acetamenophin 300 » Alter tidal volume, respiratory rate, rhythmicity, and mg responsiveness to CO2 • Dosage: 1 tablet every 4 –6 hours – Does not commonly occur at therapeutic doses in healthy patients, – Also available as generic with 15, 30, or 60 mg of but must use caution in patients with pulmonary disease. Codeine with 300 mg of Acet. or elixer of 12 mg codeine + 120 mg Acet. per 5 mL. The FDA• hasElixer mandated can be that used all prescription in children medications for pain havemanagement no more than if >3325 mg of Acetaminophenyears. in each capsule/tablet by January 2014. 6 1/25/2019 Schedule II Opioids: Hydrocodone Schedule II Opioids: Oxycodone • Approximately 6X more potent than codeine. • Approximately 10‐12X more potent than codeine • Milder Side Effects than Codeine: Less – As potent as parenteral morphine when given constipation and sedation. orally. • Clinically believed to cause more euphoria than • Lower level of side effects in comparison to codeine, but
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