10-Chapter-The-Eye-and-Ear-docpdf

The Eye and Ear
10
The Eye and Ear
Questions Alerts!
Common questions in pharmacy exam is to ask!
1) Photoreceptors rods are sensitive for dim light and cones cells sensitivity to daylight and colors.
2) Cornea is upper layer of eye is rate determine step in ophthalmic drops.
4) Eye disorders like conjunctivitis (red or pink eye), blepharitis, and sty (hordeolum), Age related macular
degeneration, Cataract, and glaucoma.
5. External and middle ear problems. Who should be referred? Red flags
Copyright © 2000-2022 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to re-
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produce without permission. This manual is being used during review sessions conducted by
PharmacyPrep.
The Eye and Ear
Optic nerve from both eyes merge at the optic chiasm and becomes the optic tract. This optic tract
connects to the thalamus then and goes to the right and left brain. Primary visual area in occipital lobes
of the cerebral cortex.
• Cornea: In the front of the eyeball is a transparent opening known as the cornea. Rate limiting step
for ophthalmic drops.
• Pupil: After light passes through the cornea, a portion of it passes through an opening known as the
pupil.
• Iris: Pupil opening can be adjusted by the dilation of the iris.
• Ciliary muscles: The lens is attached to the ciliary muscles.
• Q.Ciliary gland: secrete aqeous humor.
• Retina: The inner surface of the eye is known as the retina.
• Q.Macula: Small central area of retina lining. Related to Age-Related Macular Degeneration
(AMD) conditions and leads to central vision loss.
• Optic nerve: The network of nerve cells is bundled together to form the optic nerve on the very
back of the eyeball.
• Q.Optic disk (blind spot): The nerve cells bundled at the very back of the eyeball is also known as
the blind spot. Rods and cones are NOT present on the optic disk, therefore is a blind spot.
• Q.Myopia: If the incoming light from a faraway object focuses before it gets to the back of the eye,
that eye’s refractive error is called “myopia” (nearsightedness).
• Hyperopia: If incoming light from something far away has not focused by the time it reaches the
back of the eye, that eye’s refractive error is “hyperopia” (farsightedness).
• Vitreous humor: In the posterior chamber Gel like fluid-filled between the retina and lens.
• Q. Aqueous humor: Fluid Filled between cornea and lens. Aqueous humor flow from the ciliary
body into the anterior chamber out through a spongy tissue at from the eye called trabecular
meshwork and into the drainage canal. Glaucoma is characterized by high intraocular pressure in
aqueous humor.
• Retinal detachment: Occurs due to inflammation, vascular abnormalities or injury, diabetes or in
cataract surgery.
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PharmacyPrep.
The Eye and Ear
• Optic nerve: A cranial nerve II, is paired cranial nerve that transmits visual information from the
retina to the brain. Optic nerve is composed of retinal ganglion cell axons and glial cells.
Dioptre
Q.A diopter is a unit of measurement of the power of lens. The total optical power of the relaxed eye is
approximately 60 diopters. Diopter lenses are prescribed for reading.
Retina
Retina has 3 cell types, photoreceptor cells (rods & cones), bipolar cells, and ganglion cells.
Retinal bipolar cells: Bipolar cells exist between photoreceptor and ganglionic cells. They act directly
or indirectly to transmit signals from the photoreceptors to ganglionic cells.
Retina cell signalling
Dark: Photoreceptor are depolarized and release glutamate, which activates bipolar cells (inhibitory cells) thus
bipolar cells inhibit ganglion cells.
Light: Light cause photoreceptor to hyperpolarize which inhibits bipolar cells thus activate ganglion cell.
Photoreceptors
The retina contains two types of photoreceptors, rods and cones. The rods are responsible for night vi-
sion, our most sensitive motion detection, and our peripheral vision. The rods are more numerous, some
120 million, and are more sensitive than the cones. However, they are not sensitive to color. The 6 to 7
million cones provide the eye's color sensitivity and they are much more concentrated in the central yel-
low spot known as the macula. The image forms in eye at retina.
RODS CONE
Rhod”opsin” (retinal) Iod”opsin”
Q. Rhodopsin is rod cells pigmenta- Iodopsin is retinal cone cells responsible for
tion. Responsible for dim light vi- day light vision color vision
sion.
More sensitive in dark Less sensitive in dark. Sensitive to colors.
Higher in number Less in number
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PharmacyPrep.
The Eye and Ear
Q. Rods: Light on the retina converts 11-cis retinal to all 11-Trans

retinal. The retinal is a vitamin A is essential for the regeneration
of 11-cis retinal. Deficiency of vitamin A causes night blindness.
Q. Beta carotene --> Retinol (vitamin A) --> 11-Cis retinal-> op-

sin
Carotenoids
QAlerts!
1) More sensitive photoreceptors for dim light in eye? Rods
2) Color sensitive photoreceptors are? cones
3) Rhodopsin is red photosensitive pigment in the retinal "rods" important vision in dim light.
4) Iodopsin is pigment present in the retinal “cones” important in daylight.
5) What arteries supply blood to eye? External carotid arteries.
6. Vitamin A deficiency cause? Night blindness
7. What is precursor of vitamin A? carotenoids
GLAUCOMA
Glaucoma is a chronic condition that occurs due to high intraocular pressure, and can lead to blindness.
Normal range intraocular pressure or ocular hypertension 12 to 22 mm Hg (>22 mm Hg  risk of dam-

age to optic fiber). Due to angle closure increasing intraocular pressure (IOP) cause glaucoma. This is
due to;
• Increase in aqueous humor production cause increased IOP.
• Decrease aqueous humor secretion (outflow) from shlemn canal.
• Q. Aqueous humor is present in the anterior eye chamber. Aqueous humor is secreted from ciliary
tissue (ciliary gland).
• Q. Vitreous humor is present in the posterior eye chamber.
OPEN ANGLE GLOUCOMA CLOSED ANGLE GLOUCOMA

CUASED BY SLOW BLOCKADE OF SCHLEM Caused BY SLOW BLOCKADE OF SCHLEM
CANAL CANAL
Q. WIDE AND OPEN ANGLE BETWEEN IRIS Closure angle glaucoma between iris and cornea.
AND cornea.
MOST COMMON 90% OR MORE Less common
FIRST LINE: PG ANALOGUES, BBs FIRST LINE: PG ANALOGUES, BBs
Glaucoma is a disease of the eye characterized by increased intraocular pressure resulting in damage to
the optic nerve and the retina. It can lead to blindness if left untreated.
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PharmacyPrep.
The Eye and Ear
Q. Glaucoma investigations: Automated perimetry, Optic disc photography, Evaluation of central corne-
al thickness, Optic disc and retinal imaging.
Treatment of glaucoma
There are 5 classes of medications beta blockers, prostaglandin analogs, carbonic anhydrase inhibitors,
alpha2 agonist and cholinergic agonist.
Glaucoma treatment Mechanism Tips

Beta blockers Q. ↓ IOP by inhibiting the 1st line
Timolol, formation of aqueous humor.
Betaxolol,
Levobunolol
Prostaglandin analogues "prost" ↓IOP by increasing the out- 1st line
PGF2 α flow of aqueous humor
latanoprost, through the uveoscleral path-
bimatoprost, way.
latanoprostene,
travoprost
Carbonic anhydrase (CA) inhib- ↓IOP by inhibiting enzymes
itors that are involved in the for-
Acetazolamide (po, iv), mation of aqueous humor.
Dorzolamide,
Brinzolamide
Alpha2 agonist Dual action reduces intraocular
Brimonidine pressure inhibiting the pro-
apraclonidine duction and increasing uveo-
scleral outflow.
Alpha2 agonist: (Brimonidine, apraclonidine): Dual action reduces intraocular pressure inhibiting the
production and increasing uveoscleral outflow. It has a peak ocular hypotensive effect occurs 2 hours
after post-dosing. The topical gel reduced erythema through direct vasoconstriction.
Cholinergic agonists (Pilocarpine, carbachol): Directly stimulate muscarinic receptors to contract the
ciliary muscle and increase trabecular outflow.
QAlerts!
A pregnant diagnosed with open-angle glaucoma. Which of the following medication is NOT rec-
ommended for the treatment of glaucoma? Prostaglandin analog
Which drugs promote uterus contraction and should be avoided in pregnancy? Prostaglandin analog
A 45-year-old with asthma for the past 5 years and currently using salbutamol, and fluticasone
inhalers. Now diagnosed with open-angle glaucoma. Which of the following is the first-line thera-
py of OAG? “Prost”
The above causes drug-drug interactions and drug-disease interaction.
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PharmacyPrep.
The Eye and Ear
Choose a drug which increases trabecular outflow and decreases intraocular pressure in glau-
coma
A) Brimonidine
B) Pilocarpine
C) Acetazolamide
D) Latanoprost
E) Timolol
Age related macular degeneration (AMD)
It is chronic disease is due to gradual Q. deterioration of macular in a central vision leading to progres-
sive vision loss. The macula is in center of retina.
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PharmacyPrep.
The Eye and Ear
It is two types;
Dry AMD: This is characterized by drusen means white to yellow spots in the central retina. It may or
may not cause vision loss.
Wet AMD: Caused by the presence of choroidal neovascular membrane (CNM). This is a common
cause of severe central vision loss.
The Amsler grid or chart is useful for detecting vision changes in patients. This chart consists of a grid
with straight lines and even lines. If the patient sees a dark spot in the center of the grid or lines appear
wavy, should see the ophthalmologist.
Q. Multivitamins without carotenoids are used prophylaxis for AMD (avoid carotenoids in AMD).
Q. Lutein & Zeaxanthin are two types of carotenoid analogs, which are yellow to red pigments found
widely in vegetables. Lutein is the precursor of zeaxanthin. Lutein 5 mg content yields zeaxanthin 250
mcg.
Carotenoid analogs may contain in a multivitamin that is used for AMD prophylaxis (VITALUX-S).
Smoking is the major risk factor for AMD.
Wet AMD treatment

VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITOR: Bevacizumab, ranibi-
zumab, and Pegaptanib. Used for the treatment of AMD.
QAlerts!
Patient with dry and wet Age-related macular disorder will receive prophylaxis of? Multivitamins
Multivitamin containing carotenoids can increase risk of? cancer
Cataract
Cloudy or opaque cataracts on the lens of the eye are generally caused by a major lens Q.protein crystalline dena-
turisation. In cataracts less light reaches the retina and thus impairs vision.
Preventing Cataract:
• Avoid using corticosteroids for a long duration.
• Quit smoking
• Q.Use sunglasses.
Post cataract complications include infection, glaucoma and inflammation.
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PharmacyPrep.
The Eye and Ear
When the eye lens becomes cloudy, decreases acuity, and has no pain, this obstructs the vision and is referred to
as a cataract. The most common cause of cataract is aging, diabetes, trauma, and congenital disease. Long term
use of corticosteroids and cataract may progress even after stopping steroids.
Cataract surgery postoperative care antibiotics, dilators and anti-inflammatory drugs.
Antibiotics: Fluoroquinolones 7-10 d (besifloxacin, ciprofloxacin, gatifloxacin, moxifloxacin and oflox-

acin). Aminoglycosides 7-10 d. Gentamicin, neomycin, tobramycin
If lens capsule broken during cataract surgery, use oral ciprofloxacin or ofloxacin.
Dilators and cycloplegic: used to keep iris away from the implant during the early healing period and
improve comfort by decrease ciliary muscle spasm.
Cyclopentolate, phenylephrine, tropicamide.
Anti-inflammatory 3-4 wks: Dexamethasone, prednisolone, diclofenac, and ketorolac.
Combination eye drops: Tobradex (tobramycin+ dexamethasone) ointment and suspension eye drops.
Instilling Eye drops

Instilling Tilt head backward, place a drop in conjunctiva sac; Q. put gentle pressure on inner
Technique cantus (to prevent systemic absorption of eye drops).
Terms: OD = right eye OS = left eye OU =both eyes
QAlerts!
What is incorrect about instilling eye drops? Tilt head forward
To improve of absorption eye drops? After instilling eyedrops close your eyes for 2-3 min
To prevent systemic side effects of eye drops? Put gentle pressure on the inner cantus.
How much time to wait for the second drop of different eye drops? Separate 5-10 minutes between
2 eyedrops
If the patient instills ointment and drops, which goes first and why? drops first
If antibiotic eyedrops and anti-inflammatory eyedrops are instilled. Which one should instill first
and at what time interval? Antibiotic
What is an incorrect statement about cataract prevention? Using steroids helps
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PharmacyPrep.
The Eye and Ear
Ear Conditions
Outer ear, middle ear and inner ear
OTITIS EXTERNA (outer ear) OTITIS MEDIA (middle ear) Inner ear
Two common problems associated Infection of the middle ear cavity and the Noise, drug exposure,
with outer ear swimmers’ ear (otitis most infection in childhood. such as ASA, ototoxic
externa) and earwax build-up. Symptoms include acute ear pain often 1
ear and developing over a few hours, fever drug, vestibular
Swimmers Ears and reduced hearing. toxicities and Q.
Q. Self-treated by non-prescription. Vertigo, Meniere’s
Q. Require referral to a physician.
Symptoms should be significantly re- disease.
duced by day 3 of therapy.
The common cause of middle ear infection
is S. pneumonia, M. catarrhalis, H. influen-
Q. Refer if fever & severe pain and are
za.
not diminished by OTC pain medica-
tions.
First-line antibiotics amoxicillin, azithro-
The most common cause of external ear
mycin
infection is P. aeruginosa.
Ciprofolaxacin.
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PharmacyPrep.
The Eye and Ear
Q. Ear wax Fluid is an indicator of infection of ear

When to refer? Wax buildup with hear- bones or tympanic membrane (fever,
ing loss, or with pain, foreign objects in pain in the ear, redness and swelling,
the ear canal. drainage).
Child presents with fever and ear pain?
Q. 1) Ceremonious gland produc- The drug of choice for otitis media?
es? earwax Amoxicillin or azithromy-
Q. 2) Earwax is removed by car- cin/clarithromycin
bamide peroxide and mineral oil.
Otitis externa (outer ear)

Swimmer’s ear
Eczematous otitis externa: Drainage resulting from mild otitis externa may be self-treated. Q. Ear pain
associated with ear drainage; the patient should be referred to a physician.
Otitis media
Q. Otitis media with perforation of the tympanic membrane or drainage from the middle ear, the patient
should be referred to a physician.
Drugs that cause ototoxicity: Aminoglycosides (can cause permanent hearing loss), furosemide, Acetyl-
salicylic acid, ibuprofen, acetaminophen, cisplatin and carboplatin.
QAlerts!
A 3 years old has ear discharge, what is the correct step you have to do?
A-wait and watch
B. refer to doctor
C. give wax removal
Instilling ear drops

Instilling Ear Technique:
drops For infants and toddlers pull ear down and back.
For adults and older children pull ear up and back
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PharmacyPrep.
The Eye and Ear
Lie on unaffected side

Stay on side for 5-10 min after drops instilled.
Can put cotton moistened with medication in the ear to keep drops in place.
Terms: AD = AS = AU =
QAlerts!
How to instill ear drops in 8 years old child? Pull ear up and back
Dental anatomy and physiology

• There are 20 primary teeth and 28 to 32 permanent teeth. The last 4 is being wisdom teeth.
• In the adult, there are 16 teeth in maxilla and 16 in the jaw.
• Wisdom teeth may or may not grow in.
• Incisors 8, canine 4, premolar 8, molar 8. Q. Wisdom tooth (third molar) 4 of 32 teeth’s.
• Baby teeth start to grow during the intrauterine first trimester (8 weeks).
• Teeth are made of enamel, dentin, and cement. Dentin composes most of the roots.
• Crown is covered by enamel.
• The root embedded inside the maxilla and jaw bones has a bulb canal.
• The bulb canal contains blood supply and nerve terminals.
• The root teeth may be single in number or multiple.
• Gingival or gums consist of mucosal tissue lying over the alveolar bone.
• Plaque is yellow sticky films that form on the teeth and gums.
• Bacteria in plaque release acid that harm the enamel.
• Brushing and flossing daily the teeth will prevent tartar forming.
• Q. Fluorides are a primary protector against dental cavities.
• Fluorides make teeth surface more resistant to acids.
• Drinking water contains enough fluorides.
Tips
• Blind spot is  optic disc
• Age related macular degeneration cause  central vision loss
• Glaucoma occurs due to  abnormal increase IOP in the eyeball
• Drugs that are used to treat glaucoma are  sympathetic blockers (B-blockers), Prostaglandin ana-
logs (Latanoprost), CA diuretics (acetazolamide).
• Photoreceptor sensitive to daylight? cones
• Photoreceptor sensitive to dark or dim light? rods
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PharmacyPrep.
The Eye and Ear
• What are the most sensitive photoreceptors? rods

• Age-related macular degeneration caused due to gradual deterioration of the macula
• Glaucoma occurs due to  Increase IOP
• What is the mechanism of drugs that are used to treat glaucoma are  inhibitor formation of aque-
ous humor or increase the outflow of aqueous humor.
• Meniere's disease is characterized as? Vertigo, hearing loss and tinnitus.
• Vitreous humor is? The clear gel fills the space between the lens and the retina of eyeball of human.
• Wisdom teeth? 3rd molar and there are 4 wisdom teeth.
• When to refer for swimmer’s ear?
• What to do for earwax?
• When to refer for otitis media?
Select True/False Statements

• The retina contains two types of photoreceptors, rods and cones. (True/False)
• These rods are responsible for night vision, our most sensitive motion detection, and our peripheral
vision. (True/False)
• The rods are more numerous, some 120 million, and are more sensitive than the cones. However,
they are NOT sensitive to color. (True/False)
• The 6 to 7 million cones provide the eye's color sensitivity and they are much more concentrated in
the central yellow spot known as the macula. (True/False)
• Cones are sensitive to color vision (True/False)
• Acute otitis media has a high spontaneous recover rate up to 80%. Children experience spontaneous
recovery with placebo or no drug therapy? (True/False)
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PharmacyPrep.

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The Eye and Ear

Q. Rods: Light on the retina converts 11-cis retinal to all 11-Trans

Q. Beta carotene --> Retinol (vitamin A) --> 11-Cis retinal-> op-

Normal range intraocular pressure or ocular hypertension 12 to 22 mm Hg (>22 mm Hg  risk of dam-

OPEN ANGLE GLOUCOMA CLOSED ANGLE GLOUCOMA

Glaucoma treatment Mechanism Tips

The above causes drug-drug interactions and drug-disease interaction.

Age related macular degeneration (AMD)

Wet AMD treatment

Multivitamin containing carotenoids can increase risk of? cancer

Post cataract complications include infection, glaucoma and inflammation.

Antibiotics: Fluoroquinolones 7-10 d (besifloxacin, ciprofloxacin, gatifloxacin, moxifloxacin and oflox-

Cyclopentolate, phenylephrine, tropicamide.

Anti-inflammatory 3-4 wks: Dexamethasone, prednisolone, diclofenac, and ketorolac.

Instilling Eye drops

Terms: OD = right eye OS = left eye OU =both eyes

Q. Ear wax Fluid is an indicator of infection of ear

Otitis externa (outer ear)

A-wait and watch

C. give wax removal

Instilling ear drops

Lie on unaffected side

Dental anatomy and physiology

• What are the most sensitive photoreceptors? rods

Select True/False Statements

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