Ophthalmic Drops 101

American Academy of Ophthalmology Web Site: www.aao.orgOriginal URL: http://www.aao.org/yo/newsletter/2013-print/article07.cfm

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“Numb the patient, dilate, start IOP-lowering drops … make sure they’re not allergic, thencall me back,” said my senior resident. It was July, and my pockets were filled with a rainbowof eyedrops. Which one was I to avoid in babies? Why did I need to check sickle cell prep?And as my patients always asked, “What are the side effects? Why are my eyes still dilated?”

To help you get a quicker start to understanding the eyedrops you need while on call, here isa list of the most common drops and some clinical pearls. This is not a comprehensive list,nor should these descriptions substitute for medical advice or training. Eyedrops havemultiple indications and side effects beyond what is listed here. This is an introduction to themost common drops encountered while in your first few months of residency.

In the charts below, the brand name is listed in parenthesis if it has not yet become generic.

Anesthetic Drops

Drug LidColor

Duration Indication Cautions

Proparicaine(Alcaine)

Tetracaine(Pontocaine)

White 10–30 min Topical anesthesia

Breaks down cornealepithelium ulcers

Speeds absorption ofsubsequent drops

Long-term use causescorneal ulcers

Check cornealsensation before usein setting of ulcers

Fluress(Benoxinate +fluorescein)

n/awhitedropper

10–20 min Applanation tonometry

Stains defects oncorneal/conjunctivalsurface

Topical anesthesia

Not for Seidel tests(use fluoresceinpaper strips)

Patients may seeyellow when theyblow their nose

Dilation Drops

Drug LidColor

Duration Indication Cautions

Phenylephrine2.5%, 10%(Neosynephrine)

Red 3 hours Use with tropicamidefor adult dilation

Avoid 10% in hypertensivecrisis, pediatrics and theelderly

Tropicamide1%(Mydriacil)

Red 4–6 hours Use with phenylephrinefor adult dilation

Cyclopentolate1%, 2%(Cyclogyl)

Red 24 hours Cycloplegic refractions

Homatropine2%

Red 1–2 days No longermanufactured

Atropine 1% Red 7–10days

Break posteriorsynechiae

Decrease ache fromocular inflammation

Fogging for amblyopiatreatment

Avoid in angle-closureglaucoma

Glaucoma Drops

Drug LidColor

Dosing Class Cautions

Timolol 0.5%(Timoptic)

Yellow BID Beta blocker Avoid in patients with asthma,COPD, CHF and bradycardia

Brimonidine0.1%, 0.15%,0.25%(Alphagan)

Purple TID Alpha agonist Avoid in patients under age of 3

Avoid in nursing women (onlyclass B med)

Dorzolamide(Trusopt)

Orange TID Carbonicanhydraseinhibitor

Avoid in sulfa allergy

Avoid in sickle cell patients withhyphema (can induce sickling in

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anterior chamber)

Patients may complain of bitteror metallic taste

Bimatoprost0.01%, 0.03%(Lumigan)

Travoprost0.004%(Travatan Z)

Latanoprost0.005%(Xalatan)

Tealgreen

Qhs Prostaglandinagonist

May reactivate herpes simplexvirus keratitis

Darkens hazel irides

Conjunctival hyperemiacommon

Avoid in uveitic glaucoma andpregnancy

Cosopt White orDarkblue

BID Combo ofDark bluetimolol +dorzolamide

Combigan Darkblue

BID Combo oftimolol +brimonidine

Acetazolamide250mg tabs,500 mg sequel(caps)slow release(Diamox)

n/a POBID

Carbonicanhydraseinhibitor

Avoid in sulfa allergy

Avoid in sickle cell patients withhyphema (can induce sickling inanterior chamber)

Beware with potassium-losingdiuretics or digitalis

Common side effects:peripheral limbtingling/weakness; bad tastewith carbonated beverages;diarrhea

Methazolamide25mg tabs(Neptazane)

n/a POBID – TID

Carbonicanhydraseinhibitor

Same as above but less severe

Steroid Drops

Drug LidColor

Indication Cautions

Prednisoloneacetate1% (PredForte)

White orPink

Postoperativeinflammation

Iritis

Can cause elevated IOP andcataracts

Fluorometholone0.1% (FML)

White Ocular surfaceinflammation/dry eye

Can cause elevated IOP andcataracts, but to a much lesserextent than above

Antibiotic Drops

Drug LidColor

Indication Cautions

Moxifloxacin(Vigamox)

Gatifloxacin(Zymaxid)

Tan 4th generationfluoroquinolone

Postoperative

Corneal ulcers

Ofloxacin(Ocuflox)

Tan 3rd generationfluoroquinolone

Postoperative

Erythromycin ointment(Emycin)

n/atube

Bacterial conjunctivitis

Sterile cornea defectsto prevent infection

Prevent ophthalmianeonatorum

Bacitracin ointment(Bacitracin)

n/atube

Methicillin-resistantStaphylococcus aureus

Tobramycin Dexamethasoneointment (Tobradex)

n/atube

Gram negatives(Pseudomonas)


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Neomycin, PolymyxinDexamethasone ointment(Maxitrol)

n/atube

Postoperative

Common grampositives

Neomycin is the mostcommon cause ofcontact dermatitis

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About the author: Janice C. Law, MD, is an assistant professor at theVanderbilt Eye Institute in Nashville. She received her ophthalmologytraining at the Kresge Eye Institute in Detroit, where she also served aschief resident. After a two-year medical and surgical retina fellowship atthe Vanderbilt Eye Institute, Dr. Law joined the retina faculty as assistantprofessor in vitreoretinal diseases and surgery. Dr. Law is also theassociate program director for residency education in ophthalmology andplays a very active role in developing curricula and assessing teaching andlearning within ophthalmic education.


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How to Conduct an Eight-PointOphthalmology Exam



Getting called to the ER in the middle of the night, you will be working in lessthan ideal environments more times than not. The key is to remember thatyou are there for the patient and to address their issues efficiently. Here aresome pointers for the standard eight-point exam, with tips for when you areon call.

1. Visual acuity

Make sure that the patient is wearing his or her correction if possible,and use pinhole to determine best acuity.If you are checking vision at near, make sure the patient uses +2.75 or+3.00 readers.

Tip: Have a near card, +2.50 loose lens and pinhole occluder with you. Moretimes than not, patients will not have their glasses in the emergent setting.

2. Pupils

Observe pupil size and shape in the dark, using an indirect light source.Check the reactivity of each pupil separately with a muscle light orpenlight, and then perform the swinging-flashlight test to evaluate foran afferent pupillary defect.If an anisocoria exists in dark lighting, check pupil shape and size in thelight as well.

Tip: You must check for a relative afferent pupillary defect. Remember thatyou can check for it by reverse.

3. Extraocular motility and alignment

Check corneal light reflexes to assess alignment. If not centered inpupils, perform cover testing.Have the patient follow an object in the six cardinal directions to assessversions (ductions are tested monocularly).Document muscle under action with a minus (–), over action with a plus(+) on a scale of 1 to 4, with 0 being normal motility.

Tip: Make sure to check all nine cardinal positions of gaze. The ER staff’s“blessing” of motility with a four-point exam is not adequate.

4. Tonometry

Try to record applanation tonometry if possible; however, a Tono-Penmay be easier to use in ED.Remember to record the time of pressure measurements.

Tip: Applanation is ideal, but Tono-Pen is acceptable in most cases.Sometimes palpation is all that you have.

5. Visual field

Document visual-field defects from the patient’s perspective.Make sure you assess all four visual-field quadrants.Use a small object, like a cotton tip applicator or eye drop bottle, tomore accurately document a scotoma.If the patient has poor acuity (i.e., worse than count fingers), you canassess field with hand motion or light.

Tip: Using dilation drop caps or small red balls also allows determination ofsubtle color desaturation. An Amsler grid can be very helpful when assessingmacular issues.

6. External examination

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Assess structures like lymph nodes and temporal arteries as indicatedby the history.Assess lid position by measuring marginal reflex distance from pupillarylight refl ex and the edge of the upper or lower lid.Assess skin for any suspicious lesions that may need biopsy.Use an exophthalmometer to measure the degree of proptosis inmillimeters.Test CNII-VIII if patient has sudden onset of diplopia or otherneurologic symptoms.

Tip: Look for facial asymmetry, ptosis and proptosis.

7. Slit-lamp examination

The exam should document the lids/lashes/lacrimal system,conjunctiva/sclera, cornea, anterior chamber, iris and lens.The length and width of any infiltrates, scars or epithelial defects shouldby measured so that they can be followed.

Tip: Sometimes a slit lamp is not available or not practical due to trauma. Apenlight/muscle light exam is better than nothing in these situations.

8. Fundoscopy

Perform slit-lamp biomicroscopy to evaluate the optic nerve, maculaand vessels.Make note of the cup-to-disc ratio, asymmetry between the opticnerves and any focal thinning.Use an indirect ophthalmoscope to assess the retina periphery fortears/defects.The slit lamp can be used to visualize the anterior vitreous and identifyheme and pigmented or white cells.Any fundus pathology should be accurately drawn and the sizedocumented in units such as disc diameters or disc areas.

Tip: Always be systematic in your exam.


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About the author: Edward Hu, MD, PhD, is a cataractspecialist practicing in Iowa’s Quad Cities. After graduatingfrom the Massachusetts Institute of Technology, hereceived both his MD and a PhD in retinal electrophysiologyfrom the New York University School of Medicine. Hecompleted his residency at the University of Iowa Hospitalsand Clinics, perennially ranked one of the top three trainingprograms in the country.


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Management Outline for CommonOphthalmic Conditions



Learning the ophthalmic exam while being immediately thrust into a clinicsetting is stressful. Many questions need to be asked and answered. Onething I devised in those first few weeks was this “When should I have themreturn?” cheat sheet that I shrunk to 8-point font and stuck in my pocket. Ithelped me memorize some of the details and minimize my questions. I hopeyou find it helpful. (See the abbreviation key at the end of the article.)

DM

1. No DR — DFE q1yr

2. Mild NPDR (DBH, HE, MAs 1–2 quads) — DFE q1yr

3. Mod NPDR (mild + CWS, venous beading) — DFE q6mo

4. Severe NPDR: a, b OR c — DFE q4mo

a. 4 quadrants w/MAs, DBHs

b. 2 areas of venous beading

c. 1 IRMA

5. PDR

a. NVD >1/3 disc area

b. VH w/any NVD

c. VH w/NVE >1/2 disc area

d. Any NVI

1. Get staff approval for PRP

2. PRP

3. RTC 6–8wks after PRP

4. RTC based on regression — if PDR inactive, RTC 6mo

6. CSME

1. RT w/i 500?m of fovea

2. HE's w/i 500?m of fovea if assoc w/adjacent RT

3. RT >1 disc area w/i 1 disc diameter of fovea

Rx: focal or grid argon laser and RTC 3mo

POAG/suspect (non-adv)

TA q4mo for POAG, q6mo for POAG-S, q1yr if stable VF x3

VF q1yr

DFE q1yr

-Monocular — 1/2 of above intervals & safety specs (polycarb)

-Monocular trial needed when initiating new anti-glaucoma gtts; RTC 2wks forresponse

s/p LPI

PF1% QID x4–5d, RTC 1wk — D/C PF1% if no cell; no taper





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needed; DFE after

LPI (breaks PS)

s/p YAG

RTC 1wk for MR, TA, SLE to ensure no capsular fragments invisual axis

s/p CE/IOL

POD#1 — VA, TA, SLE; Rx: PF1% q2h to QID, abx QID; NSAID ifavailable

POD#7 — VA, TA, SLE; Rx: continue NSAID x1mo, taper PF1%QID x7d, TID x7d,

BID x7d, QD x7d, then stop; d/c abx

POD#30 — VA, MR, TA, SLE, DFE

AMD

1. VA, Amsler grid, DFE — if all is stable, f/u 6mo

2. If VA decreases, Amsler abnormal or SRF/SRH on DFE, to Retina w/i 1wk

The following are definitions of the above abbreviations in order of appearancein text. Note: Once the definition of an abbreviation has been given, it is notrepeated.

DM: Diabetes mellitusDR: Diabetic retinopathyDFE: Dilated fundoscopic examNPDR: Nonproliferative diabetic retinopathyDBH: Dot-blot hemorrhageHE: Hard exudatesMA: MicroaneurysmCWS: Cotton-wool spotIRMA: Intraretinal microvascular abnormalityPDR: Proliferative diabetic retinopathyNVD: Neovascularization of the discVH: Vitreous hemorrhageNVE: Neovascularization elsewhereNVI: Neovascularization of the irisPRP: Panretinal photocoagulationRTC: Return to clinicCSME: Clinically significant macular edemaRT: Retinal thickeningPOAG: Primary open-angle glaucomaTA: Tonometry by applanationPOAG-S: Primary open-angle glaucoma suspectVF: Visual fieldLPI: Laser peripheral iridotomyPF1%: Pred Forte 1%PS: Posterior synechiaeYAG: Yttrium aluminum garnet (laser for posterior capsular opacification[PCO])MR: Manifest refractionSLE: Slit-lamp examCE/IOL: Cataract extraction/intraocular lens implantPOD: Postoperative dayVA: Visual acuityRx: TreatmentAMD: Age-related macular degenerationSRF: Subretinal fluidSRH: Subretinal heme


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About the author: Natasha L. Herz, MD, is a cataract,corneal and refractive surgeon who works as a solopractitioner at Kensington Eye Center in the Washington,D.C., metropolitan area. She completed her residency andfellowship at the Cullen Eye Institute at Baylor College ofMedicine in Houston. Local peers selected her to appear inWashingtonian magazine’s Top Doctors of 2012. She alsoserves on the Academy’s Young OphthalmologistCommittee and is the chair of the young physiciancommittee for her local medical society. She has served asa member of the YO Info editorial board since 2008 andbecame the chair in August 2011.



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Learning the Lingo: OphthalmicAbbreviations



Given the amount of abbreviations in the ophthalmic lexicon, one might thinkophthalmologists speak purely in code.

To help you avoid the confusion and steer away from the embarrassingmistake, this cheat sheet includes more than 100 basic abbreviations thatyou’ll need to know as you learn the professional lingo.

ACAKAKCALTAPD, RAPDAppARMD, AMD

Anterior chamberAstigmatic keratometryAllergic keratoconjunctivitisArgon laser trabeculoplasty(Relative) Afferent pupillary defectApplanation tonometryAge-related macular degeneration

BDRBRAOBRVO

Background diabetic retinopathyBranch retinal artery occlusionBranch retinal vein occlusion

CACGcCCFCOAGCRAOCRVOCSC, CSR, CSCRCSME

Chronic angle-closure glaucomaWith correctionCount fingersChronic open-angle glaucomaCentral retinal artery occlusionCentral retinal vein occlusionCentral serous (chorio) retinopathyClinically significant macular edema

DRDSEKDVD

Diabetic retinopathyDescemet stripping endothelial keratoplastyDissociated vertical deviation

EECCEEKCERMETE(T)

EsophoriaExtracapsular cataract extractionEpidemic keratoconjunctivitisEpiretinal membraneEsotropiaIntermittent esotropia

FTCFFTHM

Full to count fingersFull to hand motion

HMHSVHVFHZO

Hand motionHerpes simplex virusHumphrey visual fieldHerpes zoster ophthalmicus

ILMIOLIOPIRMA

Internal limiting membraneIntraocular lensIntraocular pressureIntraretinal microvascular abnormality

KCSKPs

Keratoconjunctivitis siccaKeratic precipitates

LASIKLPLPI

Laser in situ keratomileusisLight perceptionLaser peripheral iridotomy

MAMHMR

MicroaneurysmMacular holeManifest refraction

NLPNPDRNSCNVA

No light perceptionNonproliferative diabetic retinopathyNuclear sclerotic cataractNeovascularization of the angle





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NVDNVENVGNVI

Neovascularization at discNeovascularization elsewhereNeovascular glaucomaNeovascularization of iris (rubeosis iridis)

ODOSOU

Oculus dexter (right eye)Oculus sinister (left eye)Oculus uterque (both eyes)

PASPCO, PCFPDRPEE/PEKPERRL(A)PHPK, PKPPOAGPPVPRKPRPPSCPTKPVDPVR

Peripheral anterior synechiaePosterior capsule opacity (fibrosis)Proliferative diabetic retinopathyPunctate epithelial erosion/keratopathyPupils equal, round, reactive to light and accommodationPinholePenetrating keratoplastyPrimary open-angle glaucomaPars plana vitrectomyPhotorefractive keratectomyPanretinal photocoagulationPosterior subcapsular cataractPhototherapeutic keratectomyPosterior vitreous detachmentProliferative vitreoretinopathy

RDRGRRKROPRPER/RRRDRP

Retinal detachmentRuptured globe repairRadial keratotomyRetinopathy of prematurityRetinal pigment epithelium Resection and recessionRhegmatogenous retinal detachmentRetinitis pigmentosa

SB, SBPsCSLESLTSO, SiOSRF

Scleral buckling procedureWithout correctionSlit-lamp examinationSelective laser trabeculoplastySilicone oilSubretinal fluid

TRD Tractional retinal detachment

VAVFVHVKH

Visual acuityVisual fieldVitreous hemorrhageVogt-Koyanagi-Harada syndrome

XXTX(T)

ExophoriaExotropiaIntermittent exotropia


***

About the author: David E. Vollman, MD, MBA, is aclinical instructor in the department of ophthalmology andvisual sciences at the Washington University School ofMedicine and a staff ophthalmologist at the St. Louis VAMedical Center. After completing an MD/MBA dual-degreeprogram at the Ohio State University College of Medicine,he completed his ophthalmology residency at theWashington University/Barnes-Jewish Hospital/St. LouisChildren's Hospital Consortium Program. Subsequently, heserved as chief resident at Washington University, helpingto direct the inpatient consult service and residenteducation.



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Ophthalmic Drops 101