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Clinical Medicine in Optometric Practice_Muchnick_2007

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362 APPENDIX 2

GENERIC NAME	BRAND NAME
OR DRUG CLASS	(EXAMPLE)	INDICATION	OCULAR SYMPTOMS	OCULAR SIGNS

Anticonvulsants	Dilantin	Epilepsy	Vision changes	Nystagmus
Antidepressants	MAO inhibitors	Mental depression	Photophobia, blurred	Dilated pupil
	such as Nardil		vision
Antidepressants	Tricyclics like	Mental depression	Blurred vision, eye	Mydriasis
	Elavil		pain, photophobia
Antidiabetic agents	Amaryl	Type 2 diabetes	Blurred vision
Antidyskinetics	Cogentin	Parkinson’s disease	Eye pain, visual blur
Antihistamines	Allegra	Allergy	Contact lens intoler-	Dry eye, mydriasis
			ance, blurred vision
Antimyasthenics	Neostigmine	Myasthenia gravis	Blur, watery eyes	Miosis
Atorvastatin	Lipitor	Cholesterol		Conjunctivitis, swollen
		regulation		eyelids
Baclofen	Lioresal	Multiple sclerosis	Blur, diplopia	Nystagmus, strabismus,
				miosis, mydriasis
Barbiturates	Nembutal	Anxiety	Blurred vision	Swollen eyelids, abnormal
				eye movements
Belladonna alka-	Donnatal	Cramps	Blurred vision,	Dry eyes, reduced accom-
loids			photophobia	modation, mydriasis
Beta-adrenergic	Inderal	High blood		Yellow conjunctiva
blocking agents		pressure
Botulinum toxin	Botox	Blepharospasm,		Dry eye, corneal irritation,
		strabismus		ptosis
Carbamazepine	Tegretol	Epilepsy	Blur, diplopia	Nystagmus, yellow con-
				junctiva, oculomotor
				disturbance, scattered
				punctate, lens opacities
Carbonic anhy-	Diamox	Glaucoma	Photophobia	Increased accommoda-
drase inhibitors				tion, yellow conjunctiva
Cevimeline hydro-	Evoxac	Sjögren’s syndrome	Itchy eyes, blur, vision	Corneal changes
chloride			loss, night vision
			problems
Chloroquine	Aralen	Malaria	Blur, vision loss, halos,	Whorl-like epithelial
			photophobia	opacities of the cornea,
				reduced accommoda-
				tion, retinopathy
				(narrowing arterioles,
				optic disc pallor, optic
				atrophy, macular
				lesions)
Cisapride	Propulsid	Heartburn	Blur
Citalopram	Celexa	Depression	Blur
Clomiphene	Clomid	Fertility	Blur, ﬂashes of light,	Yellow conjunctiva, one
			diplopia,	case of posterior corti-
			photophobia	cal cataract
Clonidine	Catapres	High blood	Burning	Miosis
		pressure
Corticosteroids	Nasonex nasal	Allergy		Glaucoma, cataract, re-
	spray			duced wound healing,
				exophthalmos
Decongestants	Sudafed	Allergy	Contact lens	Dry eye
			intolerance
Delavirdine	Rescriptor	HIV/AIDS	Blurred vision,	Conjunctivitis, nystagmus
			diplopia, dry eyes,
			photophobia

APPENDIX 2

363

GENERIC NAME	BRAND NAME
OR DRUG CLASS	(EXAMPLE)	INDICATION	OCULAR SYMPTOMS	OCULAR SIGNS

Dexmethylpheni-	Focalin	ADHD, obesity	Blur	Accommodative changes,
date (amphet-				mydriasis
amine cogener)
Difenoxin with	Motofen	Diarrhea	Blur	Reduced accommodation
atropine
Digitalis	Lanoxin	Increases heart	Blur, yellow vision
		strength
Disopyramide	Norpace	Abnormal heart	Blur	Dry eyes, contact lens
phosphate		rhythm		intolerance
Disulﬁram	Antabuse	Alcoholism	Blur, eye pain, dry eyes	Yellow conjunctiva, optic
				neuritis
Diuretics (loop)	Lasix, Furosemide	High blood	Blur	Yellow vision with
		pressure		furosemide
Donepezil	Aricept	Alzheimer’s		Sunken-appearing eyes,
				conjunctivitis
Doxepin	Zonalon, Sinequan	Eczema	Blur	Mydriasis
Enalapril maleate	Enalapril	High blood pres-	Dry eyes	Yellow conjunctiva
		sure (ACE
		inhibitor)
Encainide	Enkaid	Antiarrhythmic	Blur, diplopia	Periorbital edema
Epoetin	Epogen, Procrit	Antianemia	Visual disturbances	Conjunctivitis
Ergoloid mesylates	Gerimal	Mood behavior	Blur
Estrogens	Premarin, clomi-	Menopause, osteo-	Change or loss of vision
	phene	porosis, breast	(rare), diplopia
		cancer
Etanercept	Enbrel	Rheumatoid	Blur	Blue-yellow color blind-
		arthritis		ness, optic neuritis,
				uveitis
Ethambutol	Myambutol	Tuberculosis	Blur, eye pain, loss of	Red-green color blind-
			vision	ness, optic neuritis,
				visual ﬁeld loss
Ethchlorvynol	Placidyl	Insomnia	Diplopia, blur	Yellow conjunctiva
Felbamate	Felbatol	Seizure control in	Blurred vision, diplopia	Miosis, visual ﬁeld defect
		epilepsy
Fentanyl	Actiq	Narcotic analgesic	Vision change
		to reduce pain
Flecainide	Tambocor	Antiarrhythmics	Blurred vision, photo-	Yellow conjunctiva,
			phobia, diplopia	“spots” in vision,
				nystagmus, decreased
				accommodation
Fludarabine	Fludara	Antimetabolite to	Blindness	Yellow conjunctiva, visual
		treat chronic		disturbances
		lymphocytic
		leukemia
Fludrocortisone	Florinef	Corticosteroid	Blindness, blurred	Proptosis, yellow conjunc-
			vision	tiva, posterior subcap-
				sular cataract, exoph-
				thalmos, increased
				intraocular pressure
Fluoroquinolones	Cipro	Antibiotic	Blurred vision	Yellow conjunctiva
Fluticasone	Flovent	Corticosteroid in-	Blindness, blurred	Conjunctivitis
		haler for asthma	vision, eye pain
Gabapentin	Neurontin	Seizure control in	Diplopia, blurred	Nystagmus, cataract, con-
		epilepsy	vision, pain,	junctivitis, dry eyes, vi-
			photophobia	sual ﬁeld defect, ptosis

CONTINUED

364 APPENDIX 2

GENERIC NAME	BRAND NAME
OR DRUG CLASS	(EXAMPLE)	INDICATION	OCULAR SYMPTOMS	OCULAR SIGNS

Guanabenz	Wytensin	Antihypertensives		Miosis
Haloperidol	Haldol	Mental conditions	Blurred vision	Unexplained reduced
				visual acuity, cataracts,
				retinopathy, ﬁxed stare
Hydrocodone	Vicoprofen	Pain relief	Blurred vision
Hydroxychloro-	Plaquenil	Antiprotozoals (ma-	Blurred vision	Pigmentation of corneal
quine		larial prevention),		endothelium and Des-
		antirheumatoid		cemet’s membrane,
		arthritis, lupus		reduced accommoda-
		erythematosus		tion, retinopathy, optic
				nerve pallor, macular
				lesions
Inamrinone	Inamrinone	Heart failure		Yellow conjunctiva
Inﬂiximab	Remicade	Crohn’s disease and		Yellow conjunctiva, optic
		rheumatoid		neuritis
		arthritis
Isoniazid	Laniazid	Tuberculosis	Blurred vision	Yellow conjunctiva, optic
				neuritis, optic atrophy
Isotretinoin	Accutane	Acne, psoriasis	Blurred vision, reduced	Conjunctivitis, corneal
			night vision, dry eye,	opacities and neovascu-
			diplopia	larization, cataracts,
				color vision alteration
Ketorolac trometh-	Toradol	Pain relief	Blurred vision
amine
Lamotrigine	Lamictal	Seizure control in	Blurred vision, diplopia,	Nystagmus, strabismus,
		epilepsy	photophobia	ptosis
Leﬂunomide	Arava	Rheumatoid	Blurred vision	Yellow conjunctiva, cata-
		arthritis		ract, conjunctivitis
Levodopa	Sinemet	Parkinson’s disease	Blurred vision, diplopia,	Mydriasis, ophthalmople-
			eyelid spasms	gia, miosis, lid
				retraction
Lithium	Lithobid	Bipolar disorder	Blurred vision	Pseudotumor cerebri,
				papilledema
Maprotiline hydro-	Ludiomil	Mental depression	Blurred vision
chloride
Mecamylamine	Inversine	Antihypertensive	Blurred vision	Mydriasis
Meclizine	Antivert	Motion sickness	Blurred vision, diplopia
		and vertigo
Metformin	Glucophage	Type 2 diabetes	Blurred vision
Methotrexate		Antimetabolite for	Blurred vision	Yellow conjunctiva,
		cancer, psoriasis,		conjunctivitis
		rheumatoid
		arthritis
Methyldopa	Aldomet	Antihypertensive	Blurred vision	Yellow conjunctiva
Methysergide	Sansert	Migraine	Vision changes
maleate
Midodrine	ProAmatine	Treats low blood	Blurred vision
		pressure	(common)
Minoxidil topical	Rogaine	Scalp hair growth	Blurred vision	Conjunctivitis
Modaﬁnil	Provigil	Narcolepsy	Blurred vision
Molindone	Moban	Mental depression	Blurred vision	Ophthalmoplegia
Moricizine	Ethmozine	Antiarrhythmic	Blurred vision
Naratriptan	Amerge	Migraine	Blurred vision
Narcotic analge-	Tylenol with co-	Pain relief	Blurred vision, diplopia	Miosis, yellow
sics with acet-	deine			conjunctiva
aminophen

APPENDIX 2

365

GENERIC NAME	BRAND NAME
OR DRUG CLASS	(EXAMPLE)	INDICATION	OCULAR SYMPTOMS	OCULAR SIGNS

Nateglinide	Starlix	Type 2 diabetes	Blurred vision
Nefazodone hydro-	Serzone	Mental depression	Blurred vision, eye	Mydriasis
chloride			pain, diplopia
Nevirapine	Viramune	HIV/AIDS		Injected conjunctiva,
				yellow conjunctiva
Niacin (vitamin B3)	Niacor	Nutrition supple-		Yellow conjunctiva
		mentation
Nitrates	Nitrolingual	Angina	Blurred vision
Nonsteroidal anti-	Voltaren, Indo-	Arthritis, analgesia,	Photophobia	Eyelid swelling, corneal
inﬂammatory	methacin	antipyretic		toxicity with
drugs (NSAIDs)				keratopathy
Octreotide	Sandostatin	Severe diarrhea	Blurred vision	Bell’s palsy
Olanzapine	Zyprexa	Psychosis	Diplopia
Olmesartan	Benicar	Antihypertensive	Blurred vision, eye pain
medoxomil
Olsalazine	Dipentum	Ulcerative colitis		Yellow conjunctiva
Omeprazole	Prilosec	GERD, gastric	Blurred vision
		ulcers
Oxcarbazepine	Trileptal	Epilepsy	Change in vision, diplo-
			pia, blurred vision
Pantoprazole	Protonix	GERD	Sudden loss of vision,	Lid swelling, yellow
sodium			blurred vision	conjunctiva
Paroxetine hydro-	Paxil	Mental depression,	Blurred vision	Ophthalmoplegia,
chloride		panic disorder,		mydriasis
		anxiety disorder
Pergolide mesylate	Permax	Parkinson’s disease	Blurred vision, tempo-	Reduced accommodation,
			rary blindness,	conjunctivitis, ocular
			diplopia	pain, mydriasis, kerati-
				tis, cataract, glaucoma
Phenothiazines	Thorazine, Mel-	Mental and	Changes in color	Ophthalmoplegia, pigmen-
(chlorpromazine)	laril, Stelazine,	emotional	vision, night	tation of corneal endo-
	Chlorpromazine	disorders	blindness	thelium and Descemet’s
				membrane, anterior
				subcapsular (stellate-
				shaped) cataract, scleral
				discoloration, pigmented
				retinopathy
Phenoxy-	Dibenzyline	Antihypertensive		Miosis
benzamine
Primidone	Mysoline	Anticonvulsant	Diplopia	Nystagmus, eyelid edema
Propafenone	Rythmol	Antiarrhythmic	Blurred vision
hydrochloride
Quinine sulfate	Quinine	Malaria	Blurred vision, diplopia,	Distorted color vision,
			photophobia, night	optic atrophy
			blindness
Raloxifene hydro-	Evista	Osteoporosis in	Loss of vision
chloride		postmenopausal
		women
Rifampicin	Rifadin	Tuberculosis	Visual disturbances	Yellow conjunctiva,
				injected conjunctiva
Rizatriptan	Maxalt	Migraine	Blurred vision, dry eyes	Toxicity of melanin-rich
benzoate			with irritation	ocular tissues (potential)
Salicylates	Anacin, aspirin,	Pain relief and fever		Eyelid swelling
	Ecotrin	reduction

CONTINUED

366 APPENDIX 2

GENERIC NAME	BRAND NAME
OR DRUG CLASS	(EXAMPLE)	INDICATION	OCULAR SYMPTOMS	OCULAR SIGNS

Sertraline hydro-	Zoloft	Mental depression	Blurred vision, diplopia	Mydriasis, reduced
chloride				accommodation, con-
				junctivitis, ocular pain,
				anisocoria, exophthal-
				mos, hyphema, optic
				neuritis
Sildenaﬁl citrate	Viagra	Erectile dysfunction	Abnormal vision,	Mydriasis, blue-green
			blurred vision, color	vision, conjunctivitis,
			vision changes, pho-	cataract, dry eyes,
			tophobia, diplopia,	blindness secondary to
			vision loss	anterior ischemic optic
				neuropathy
Sumatriptan	Imitrex	Migraine	Vision changes	Swollen eyelids, lacrima-
				tion, reduced accom-
				modation, conjunctivi-
				tis, extraocular muscle
				disorder, keratitis,
				miosis, low vision, my-
				driasis, retinal vein and
				artery occlusions, isch-
				emic optic neuropathy
Tamoxifen citrate	Nolvadex	Breast cancer treat-	Blurred vision	Yellow conjunctiva,
		ment in women		cataract development,
		and men		crystal deposit in retinal
				blood vessels, color
				vision changes, optic
				neuritis, retinal vein
				occlusion
Terazosin hydro-	Hytrin	Antihypertensive	Blurred vision	Conjunctivitis
chloride
Terbinaﬁne hydro-	Lamisil	Antifungal		Yellow conjunctiva
chloride
Tolterodine tartrate	Detrol	Bladder problems	Blurred vision	Reduced facility of ac-
				commodation, xeroph-
				thalmia
Topiramate	Topamax	Epilepsy	Vision problems,	Nystagmus, superciliary
			blurred vision, diplo-	effusions leading to
			pia, eye pain, vision	shallow anterior cham-
			loss	ber with angle-closure
				glaucoma and sudden
				myopia (caused by
				forward displacement of
				lens from effusions)
Venlafaxine	Effexor	Mental depression	Vision changes, blurred
			vision
Zaleplon	Sonata	CNS depressant	Blurred vision, diplopia
Zolmitriptan	Zomig	Migraine		Swollen eyelids, potential
				toxicity from accumula-
				tions within melanin-
				rich ocular tissues
Zolpidem tartrate	Ambien	Insomnia	Diplopia, abnormal	Eye irritation, ocular pain,
			vision	scleritis, reduced
				accommodation, cor-
				neal ulcers, glaucoma

ACE, Angiotensin-converting enzyme; MAO, monoamine oxidase; GERD, gastroesophageal reﬂux disease; ADHD, attention deﬁcit hyperactivity disorder, CNS, central nervous system.

A P P E N D I X 3

Injection Techniques Speciﬁcally Tailored for the Optometrist

Bruce Muchnick and Janice Glass

Injectable drugs can be administered in several ways. The two routes that are emphasized here are the subcutaneous (SQ) route and the intramuscular (IM) route. The time for an injectable medication to take effect can vary from seconds to longer than 30 minutes depending on the purposeful choice of the drug, dosage, and route of administration. Although this control is a distinct advantage of the parenteral technique, injections are the most hazardous way to administer a drug. Exercising caution and maintaining proper technique prevent infection and avoid damage to the pa-

tient’s nerves, blood vessels, tissues, and bones.

NOTE: Injections are potentially dangerous techniques that should be attempted by the optometrist only after he or she has received advanced training and appropriate certiﬁcation.

THE SUBCUTANEOUS ROUTE Use

The SQ route is used to deliver a dose of epinephrine to mitigate an allergic reaction; epinephrine is effective in this instance when given by the SQ route. Because of its high potency, epinephrine given IM could cause life-threatening arrhythmias and hypertension.

Contraindications

To prevent damage to subcutaneous tissue, drugs that are irritating, oil-based, or concentrated are given by the IM route. Administration of one of these solutions by the SQ route could cause tissue extravasation, necrosis, abscess, or tissue ischemia.

Subcutaneous Sites

An injection into SQ tissue is usually best done at a site where no blood vessels, bones, or nerve endings are present near the surface. Frequently used sites are the thighs, the hips, the fat pad of the lower abdomen, and the ﬂabby tissue above the elbow of the upper arm, (Figures Al to A4).

FIGURE A1 ■ Flabby tissue above the elbow of the upper arm is a frequently used site for a subcutaneous injection.

367

368 APPENDIX 3

FIGURE A2	■	Twelve SQ sites are found around the fat pad in	FIGURE A4	■	The upper thigh is a commonly used SQ site.

the lower abdomen of this elderly patient.

FIGURE A3 ■ Three sites around each hip are appropriate SQ sites where no signiﬁcant blood vessels, bones, or nerve endings are present.

Subcutaneous Needle

The optometrist should choose a 25to 27-gauge, 5⁄8-inch needle with a 3-ml syringe or a tuberculin syringe. The volume range for SQ injections is 0.1 ml to 1.0 ml.

Onset and Duration of Action

Onset is in minutes (as in the case of epinephrine) to hours (as in some types of insulin and heparin). The duration of action is hours to weeks.

APPENDIX 3

369

Administration by Subcutaneous Injection

Step 1: Obtain equipment and medication. Assemble syringe and needle according to manufacturer’s instructions if necessary. Today, most such instruments are preassembled and sterilized.

Step 2: Withdraw the drug by inverting the vial and pulling back on the plunger to the desired dose at eye level. Withdraw needle from vial and depress plunger to remove air from barrel.

Step 3: Select the site. Pinch at least a 1-inch fat fold. Select whatever angle permits the needle to reach the tissue between the muscle and the fat.

370 APPENDIX 3

Step 4: Cleanse the skin area in a circular, outward motion with an alcohol swab and let it air dry.

Step 5: Insert the needle quickly with a dart-like motion (it is not necessary to aspirate) at a 45to 90-degree angle.

APPENDIX 3

371

Step 6: Inject the drug slowly and withdraw the needle. If bleeding is present, apply gentle pressure with a dry, sterile sponge. Do not massage the site.

THE INTRAMUSCULAR ROUTE

The IM route is used when one is delivering a larger volume of drug than with the SQ route, when giving an irritating drug, or when a more rapid onset is needed. Absorption into the bloodstream is faster than with the SQ route because of the greater blood supply to the muscles.

Complications from IM injections include necrosis, skin sloughing, abscesses, nerve injury, and persistent pain. To safely administer an IM injection, the site chosen should not be near large blood vessels and large nerves.

Intramuscular Sites

The ventrogluteal (gluteus medius and minimus) site has dense muscles and no major blood vessels or nerves.

The dorsogluteal (gluteus maximus) site is the most dangerous. An injection made too close to the buttocks crease could puncture the superior gluteal artery and damage the sciatic nerve permanently. This area is a common site of injection, however. To locate the proper area, one can picture a cross, superimposed on the right gluteus maximus with the intersection of the horizontal and vertical lines located in the center of the right cheek. The only safe area for an IM injection in the dorsogluteal site is in the superior lateral box formed by the cross (Figure A5).

The vastus lateralis (outer midthigh) site has no major arteries or blood vessels. This area is easily located but can be painful because of the large number of nerve endings in the muscle. It is often used in children (Figure A6).

The deltoid site is easily accessible but is a small muscle; therefore no more than 2 ml of medication can be given in one injection. The optometrist can give as much as 2 ml of medication in each arm if necessary (Figure A7).

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