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Pediatric Pharmacology and Pathology

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7/31/2017 In the next 2 hours……. Pediatric Pharmacology and Pathology . Ocular Medications and Children The content of th is COPE Accredited CE activity was prepared independently by Valerie M. Kattouf O.D. without input from members of the optometric community . Brief review of examination techniques/modifications for children The content and format of this course is presented without commercial bias and does not claim superiority of any commercial product or service . Common Presentations of Pediatric Pathology Valerie M. Kattouf O.D., F.A.A.O. Illinois College of Optometry Chief, Pediatric Binocular Vision Service Associate Professor Ocular Medications & Children Ocular Medications & Children . Pediatric systems differ in: . The rules: – drug excretion – birth 2 years old = 1/2 dose kidney is the main site of drug excretion – 2-3 years old = 2/3 dose diminished 2° renal immaturity – > 3 years old = adult dose – biotransformation liver is organ for drug metabolism Impaired 2° enzyme immaturity . If only 50 % is absorbed may be 10x maximum dosage Punctal Occlusion for 3-4 minutes ↓ systemic absorption by 40% Ocular Medications & Children Ocular Medications & Children . Systemic absorption occurs through….. Ocular Meds with strongest potential for pediatric SE : – Mucous membrane of Nasolacrimal Duct 80% of each gtt passing through NLD system is available for rapid systemic absorption by the nasal mucosa – 10 % Phenylephrine – Conjunctiva – Oropharynx – 2 % Epinephrine – Digestive system (if swallowed) Modified by variation in Gastric pH, delayed gastric emptying & intestinal mobility – 1 % Atropine – Skin (2° overflow from conjunctival sac) Greatest in infants – 2 % Cyclopentalate Blood volume of neonate 1/20 adult Therefore absorbed meds are more concentrated at this age – 1 % Prednisone 1 7/31/2017 Ocular Medications & Children Ocular Medications & Children . Distribution to Site of Action in Pediatric Patients determined by : – Size of body fluid compartment . Package inserts warn – Muscle mass ”safety and efficacy has not been established in children” – Fat storage – Tissue blood flow FDA recognizes that accepted medical practice often includes prescribing medications for use in patient populations that are not included in – Protein binding capabilities approved labeling (PDR ophthalmology) Anterior / Posterior Segment . 20D Lens . MODIFICATION OF AN EYE EXAMINATION Hand Held Slit Lamp FOR THE PEDIATRIC PATIENT . Burton Lamp . BIO . Direct Ophthalmoscope Anterior Segment Examination Guidelines Anterior Segment Norms . Lids / Lid Margins – Observe for : Shape irregularity Corneal Horizontal Diameter in Neonate Discharge on lashes/lid margin 9-10 mm – Evert Lower lids to expose Corneal Horizontal Diameter in a 1 year old Bulbar/ Palpebral conjunctiva, observe for: 11 mm Follicles Corneal Horizontal Diameter in Adult Papillae Discharge 11.5 –12.0 mm Edema Reached by 3-4 years . Cornea / Iris / Lens – Observe clarity / opacities/ irregularity 2 7/31/2017 Anterior Segment Norms Pupils Size Constricted - 1.2 - 2 mm Fully dilated - 7.5 – 8 mm Ocular Pharmaceuticals Resting – 2.5 - 4 mm In infancy pupillary rxn to light less than in childhood Side Effects of Diagnostic Pharmaceutical Agents in Children Often absent in very premature infants (1st response at 28-32 wks) IOP 8-15 mmHg Increases by 1 mmHg/yr from birth to age 5 Medication Class Example Ocular/ Systemic Side Local Side Effect Effect ADMINISTRATION OF CYCLOPLEGIC IN CLINIC Adrenergic Agonist Phenylephrine Conjunctival Hypertension, Blanching tachycardia, arrhythmias . Cycloplegic Spray 0.5% Tropicamide 0.5% Cyclogel Cholinergic Agents Cyclopentalate Ocular irritation, Hyperactivity, 2.5% Phenylephrine Atropine follicular restlessness, Tropicamide conjunctivitis, delirium, seizures, GI cutaneous disturbance, hyperemia temperature elevation, respiratory . O’BRIEN Pharmacy depression 800-627-4360 Side Effects of Diagnostic Pharmaceutical Agents in Children Treatment with Atropine . Proper patient selection… . Phenylephrine risks – Moderate-high hyperopia – Hyperthyroidism and cardiovascular problems may result is tachyarrhythmia – Moderate amblyopia (20/100 or better visual acuity) . Premature / ROP patients =  systemic side effects – Use Cyclomydril 0.2% cyclo / 1 % phenylephrine . Administration schedule no increased blood pressure – 1 gtt 1.0% Atropine sulfate daily vs. weekend only . Cholinergic Agents frequency of installation can be reduced as acuity improvement is – Education: parents may call with dilation concerns not expecting it to last into next day observed – Atropine toxicity more susceptible to minimal installation is one drop of 1% Atropine sulfate two times per Lightly pigmented week Brain damage Down Syndrome . Side Effects / Emergency contact information 3 7/31/2017 The following Atropine instillation program is prescribed: Atropine Instillation for Amblyopia Prescription glasses should be worn for: full time / near activities / distance activities Our evaluation found that ________________________ has amblyopia of the Install 1 Drop Atropine into the RIGHT / LEFT eye on the indicated days: right / left / both eyes. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Amblyopia is reduced vision in an eye that has not received adequate or appropriate use during early childhood, often known as “lazy eye”, and has ***please keep medication out of reach from other family members*** many causes which have been explained by your doctor. If not treated, the amblyopic eye may never develop good vision and may even be functionally Special Instructions: ____________________________________________________________________________ blind. Possible Atropine Ophthalmic Solution Side Effects: Burning/stinging/redness of the eye, eye irritation, or temporary blurred vision may occur. Most people do not experience serious The treatment of amblyopia may require multiple therapy methods in which side effects from using this medication. Tell your doctor immediately if any of these unlikely but serious side effects occur: dizziness, fainting, new or increased eye your doctor may prescribe occlusion therapy with patching or atropine pressure/pain/swelling/discharge, rash, or itching/swelling (especially of the fact/tongue/throat. Rare, but very serious side instillation. Active amblyopia vision therapy may be recommended to effects include: slow/shallow breathing, mental/mood, fast/irregular heartbeat. enhance the effectiveness of occlusion therapy. Glasses are also prescribed Your next appointment is on ______________. If you have any questions, please feel free to contact us at (312) 949-7280 or after in most cases. hours via our EMERGENCY number at (312) 225-6200. Administration of Ocular Meds Ointment vs. Drops . Ointment – blurred vision Ocular Pharmaceuticals – contact dermatitis Commonly Used Ocular Anti-Biotic Medications in Children . Drops – risk of systemic toxicity – contact time with cornea (diluted by tears) Ocular Medications & Children Ocular Medications & Children Anti-biotic Ointments Anti-biotic Ointments Drug Age Approval Drug Dosing Erythromycin > 2 months Erythromycin qid Tobrex > 2 months Tobrex qid Ciloxan > 2 years Ciloxan tid x 2 days, bid x 5 days Polysporin > 2 years Polysporin qid 4 7/31/2017 Ocular Medications & Children Anti-biotic Drops Ocular Medications & Children Drug Age Approval Anti-biotic Drops Polytrim 2 months Fluoroquinolones Besivance 1 yr • Polytrim – Broad spectrum, effective, inexpensive Moxeza > 4 months Ciloxan 1 yr • AzaSite – macrolide anti-biotic (Z-pack) Ocuflox 1 yr • Prolonged ½ life - dosing schedule Quixin 1 yr • 1 gtt q 8-12 hrs (tid) x 2 days Vigamox 1 yr • 1 gtt qd x 5 days Zymaxid 1 yr • Broad spectrum, effective, expensive Iquix 6 yr Other Antibiotics Azasite > 1 yr Gentamycin unknown Sulfacetamide unknown Ocular Medications & Children Ocular Medications & Children Anti-biotic Drops Anti-biotic Drops • Fluoroquinolones (concentration dependent) Drug Dosing • Besivance (0.6%)– new, Advanced A-B Polytrim qid Vehicle: DuraSite mucoadhesive – provides enhanced ocular surface residency time Flouroquinolones Dosing = tid (q 8 hrs) Pediatric schedule: AM → after school → at bed time Besivance tid • Ciloxan (0.3%) Moxeza bid • Ocuflox (0.3%) • Moxeza (0.5%) prolonged contact due to gum base = bid dosing Ciloxan 1gtt q 2hrs x 2days, qid x 5 days • Quixin (0.5%) Ocuflox 1gtt q 2hrs x 2days, qid x 5 days • Vigamox (0.5%) no preservative • Zymar (0.3%) Quixin 1gtt q 2hrs x 2days, qid x 5 days • Zymaxid (0.5%) ↑ concentration may enhance clinical results • Iquix (1.5%) Vigamox tid Zymar 1gtt q 2hrs x 2days, qid x 5 days Zymaxid 1gtt q 2hrs x 2days, qid x 5 days Azasite tid x 2days, qd x 5days Ocular Medications & Children Anti-biotic Drops Drug Dosing Polytrim qid Azasite tid x 2days, qd x 5days Besivance tid Moxeza bid Anterior Segment Pathology Ciloxan qid Ocuflox qid Nasolacrimal Duct Obstruction Quixin qid Vigamox tid Zymar qid Zymaxid qid 5 7/31/2017 Nasolacrimal Duct Obstruction Nasolacrimal Duct Obstruction Etiology and Anatomy . Clinical Characteristics – 5-6% of newborns – 1/3 bilateral . Membranous blockage of valve of Hasner – Unilateral associated with amblyogenic anisometropic refractive error (20%) . Incomplete opening of lower end of the NLD along side of nose between inner – Clinically evident at 3-4 weeks of age canthus of eyelid and inferior turbinate of the nasal cavity – Redness irritation of lids – **With secondary conjunctivitis discharge
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