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By J. Pranck. Southern Nazarene University. 2019.

Drug-induced glaucoma is a form of secondary glaucoma induced by topical and systemic medications cordarone 100 mg line. The differential diagnosis buy cordarone 200 mg on-line, prognosis and several future directions for research will be discussed purchase 100 mg cordarone with mastercard. Ophthalmologists should be aware of these types of glaucoma, which to my opinion are becoming more common in a busy glaucoma clinic. These studies have also shown that these12 numbers are directly related to the frequency of the administration and duration of usage of this medication. At higher risk are patients with primary open-angle glaucoma, their first-degree relatives, diabetic patients, highly myopic individuals, and patients with connective tissue disease, specifically rheumatoid arthritis. In addition, patients with angle recession glaucoma are more susceptible to corticosteroid-induced glaucoma. The risk factors include preexisting primary open-angle glaucoma, a family history of glaucoma, high myopia, diabetes mellitus and young age. These drugs will incite an attack in individuals with very narrow anterior chamber angles that are prone to occlusion, especially when the pupils are dilated. The classes of medications that have the potential to induce angle-closure are topical anticholinergic or sympathomimetic pupil dilating drops, tricyclic antidepressants, monoamine oxidase inhibitors, antihistamines, anti-Parkinson drugs, antipsychotic medications and antispasmolytic agents. Patients with narrow or wide open angles are potentially susceptible to this rare and idiosyncratic reaction. Other evidence suggests that the corticosteroid-induced cytoskeletal changes could inhibit pinocytosis of aqueous humour or inhibit the clearing of glycosaminoglycans, resulting in the accumulation of this substance and blockage of the aqueous outflow. Medications have a direct or indirect effect, either in stimulating sympathetic or inhibiting parasympathetic activation causing pupillary dilation, which can precipitate an acute angle-closure in patients with occludable anterior chamber angles. Histamine H1receptor antagonists (antihistamines) and histamine H2 receptor antagonists (e. Antidepressants such as fluoxetine, paroxetine, fluvoxamine and venlafaxine also have been associated with acute angle-closures, which is believed to be induced by either the anticholinergic adverse effects or the increased level of serotonin that cause mydriasis. Sulfa-containing medications may result in acute angle-closures by a different mechanism. This involves the anterior rotation of the ciliary body with or without choroidal effusions, resulting in a shallow anterior chamber and blockage of the trabecular meshwork by the iris. Pupillary dilation and a preexisting shallow anterior chamber angle are not necessary. The exact reason for ciliary body swelling is unknown but it occurs in susceptible individuals. However, a pilot study was conducted in the Hong Kong Eye Hospital and the Prince of Wales Hospital recently, which showed that short-term use of topiramate, did not induce an asymptomatic angle narrowing. Therefore, it was suggested that topiramate induced secondary angle-closure glaucoma may be an all- or-none phenomenon. Anterior Chamber Iris Lens Pupil Cornea Iris Fluid Forms Here Angle Fluid Exits Here Fig. Aqueous humor flow Carbamazepine is also an anticonvulsive medication and a mood stabilizer and is primarily used in treating of epilepsy, bipolar disorders and trigeminal neuralgia. The anterior chamber depth measured by Scheimpflug imaging (Pentacam , Oculus Optikgerate GmbH, Wetzlar,® Germany) was 1. Both eyes had edematous cornea, very shallow anterior chamber, iris bombe and mid-dilated pupil that were not reacting to light. The anterior chambers’ depth was deepened and patent iridotomies, mild-dilated pupil, clear lens and posterior pole with normal optic discs were observed. Non-steroidal agents associated with glaucoma Unlike corticosteroid agents, the list of non-steroidal agents associated with glaucoma is wide and diverse (Table 1). The largest single cause of glaucoma in these patients appears to be an atropine-like effect, eliciting pupillary dilatation. The pupillary dilatation seen in these cases may be enough to precipitate an attack of angle- closure glaucoma in patients with narrow angles. As an alternative, some agents have been documented to produce an idiopathic swelling of the lens, associated with angle closure glaucoma. Some agents directly obstruct the trabecular meshwork, such as the viscoelastic agents and silicone oil. These episodes were felt to reflect the anticholinergic effect of these agents on the eyes. Of the non-tricyclic drugs, fluoxetine (Prozac ) and mianserin hydrochloride (Bolvidon )® ® 15 have been documented to be associated with attacks of angle-closure glaucoma. These episodes do not involve the pupil and are not responding to cycloplegic agents. This observation has been confirmed by A-scan measurements of the eye during such an attack. It has always been difficult to separate the various risk factors to the patient undergoing general anesthesia. This effect is felt to be due to an increased extra-ocular muscle tone from these agents. The H1 antihistamines block the action of histamine on capillary permeability and vascular, bronchial, and other smooth muscles. Although the anticholinergic action is mild, orphenadrine citrate (Norgesic ), an H1® antihistamine, has been documented to precipitate an attack of angle-closure glaucoma. These agents exert only a weak response but should be approached with caution in the patient at risk for glaucoma. Salbutamol and ipratropium (used in combination for chronic obstructive airway) have also been documented to precipitate attacks of angle-closure glaucoma due to the anticholinergic effect of ipratropium in combination with the effect of salbutamol (a β2 adreno receptor agonist) on increrasing aqueous humor production. Therefore, these agents should be used with caution in21 patients at risk for such an attack of glaucoma. However, disopyramide phosphate (Norpace ) does appear to have some® anticholinergic activity and has indeed been documented to produce an attack of angle- closure glaucoma. It is not clear why this occurs, nor have any risk factors for this adverse effect, such as family history of glaucoma, been identified. In case of topical corticosteroid drops, using a lower potency steroid medication, such as the phosphate forms of prednisolone and dexamethasone, loteprednol etabonate or fluorometholone should be considered.

Patients with co-morbid conditions such as type 2 diabetes order cordarone 200mg mastercard, hypertension buy cordarone 200mg without prescription, dyslipidaemia etc cheap cordarone 200 mg. To this end a good history should be taken and physical examination should be done at each visit to identify problems that are likely to have an adverse effect on the pregnancy. High risk pregnancies (pregnancies that are likely to have one or more risk factors) should be referred to a hospital or obstetrician for management. Health education involving healthy behaviours, diet, exercise, danger signs in pregnancy, emergency preparedness and preparations for safe delivery is useful for all mothers. Assessment of the mother at each ante natal visit: • Does the mother look well or ill? Often, no cause for the vomiting is found; however, it may also be associated with multiple pregnancy or molar pregnancy. It usually occurs in the second half of pregnancy and it is characterized by hypertension and proteinuria. The presence of pedal oedema or excessive weight gain may also be a feature of pre-eclampsia. Blood pressure monitoring every 4 hours together with daily weighing of the patient are essential in the management of pre-eclampsia alongside the recommended investigations. These cases are best managed in hospital under the supervision of an obstetrician. While blood pressure reduction is essential, lowering the blood pressure below 140/90mmHg may cause foetal distress and should be avoided. When the “obstetrician” considers that the foetus is immature, the patient should be transferred to a hospital capable of looking after the immature baby. The diastolic pressure should not go below 90 mmHg as placental perfusion may be impaired with resultant foetal distress. Note Toxicity to Magnesium sulphate presents as slowing or arrest of the heart beat and the respiration and loss of the deep tendon reflexes. Before giving a dose ensure that the following parameters are normal: • Respiratory rate >12-16 per minute. Note Do not give furosemide (frusemide) as part of the treatment for the hypertension unless there is pulmonary oedema present. It is associated with increased rate of miscarriage, preterm delivery, fetal growth restriction, fetal demise and increased perinatal loss. Pharmacological treatment (Evidence rating: C) • Ferrous sulphate, oral, 200 mg 8 hourly (This may be increased to 400 mg 8 hourly in severe cases if no gastric symptoms occur) • Folic acid, oral, 5 mg daily • Multivitamin, oral, One tablet 8 hourly • Parenteral Iron: For those with iron deficiency anaemia who are unable to tolerate oral iron, parenteral iron may be given. This should be given under careful observation and a small test dose should first be given (check product leaflet for test dose). Treatment for severe anaemia (Hb < 7g/dL) is best given in health facilities with blood transfusion capability 101. A fasting blood glucose test and 2-hour post-prandial blood glucose test must be done on all pregnant women at booking and also at 28-32 weeks (see section onAntenatal Care). The management of diabetes mellitus in pregnancy involves a multi- disciplinary approach comprising a team of obstetricians, midwives, nurses, dieticians, physicians, anaesthetists and paediatricians. For those who can afford a glucose meter, it would be prudent to do a glucose profile every 2-4 weeks. This involves the recording of fasting blood glucose, pre- breakfast, pre-lunch, post-lunch, pre-dinner and post-dinner levels. However, some patients would need to be admitted to hospital for short periods to ensure good glycaemic control. If complications exist then earlier delivery may be indicated • Indications for Caesarean section include severe pre-eclampsia, previous caesarean section, advanced maternal age, malpresentation or foetal macrosomia • If elective preterm delivery is necessary, confirm pulmonary maturity with amniocentesis (if facilities are available). There may be the need to mature the foetal lungs with corticosteroidsunder specialist care. For the convenience of patients shared care between specialist and medical officer may be appropriate. Cardiac disease may be present before the pregnancy or develop during the pregnancy or puerperium (peripartum cardiomyopathy). Examples are the increasing pulse rate, collapsing pulse and the presence of cardiac murmurs and a slight rise in the jugular venous pressure. Management involves a multi-disciplinary team including the obstetrician, neonatologist and physician. Pharmacological treatment Refer all patients needing treatment to a physician specialist or obstetrician. Primary post- partum haemorrhage refers to bleeding of more than 500 ml from the genital tract within the first twenty-four hours of delivery or any amount of blood loss that result in haemodynamic compromise of the patient. Secondary post-partum haemorrhage is defined as excessive vaginal bleeding occurring from twenty-four hours to six weeks after delivery. The bleeding may occur with the placenta retained or after its expulsion from the uterus. Provided the uterus is curetted gently and no damage is done the blood loss usually ceases soon afterwards and the patient may be discharged • If such a haemorrhage occurs in association with the placenta retained in the uterus, the following should be the course of action: • Rub up a contraction by manual pressure on the uterine fundus • Pass a urethral catheter to empty the bladder • Attempt removal of the placenta by controlled cord traction as soon as a contraction is felt. If not successful await the next contraction and repeat the procedure • If the placenta cannot be expelled in this fashion, manual removal under anaesthesia is indicated • If the facilities for manual removal under anaesthesia are not immediately available refer to hospital. Give at least 2000 ml in first hour • Aim to replace 2-3x the volume of estimated blood loss. Note Avoid dextrans; they interfere with grouping and cross matching as well as with coagulation of blood • If the uterus is poorly contracted (atonic) and the placenta is out and complete, • Misoprostol, oral/sublingual, 600 micrograms • Prostaglandin F2 alpha (if available) should be administered directly into the myometrium. In the first stage of labour the uterine contractions are painful and patients may therefore require analgesia. In the second stage of labour analgesia is required for instrumental delivery and when an episiotomy is given. It is therefore best not to give it when delivery is anticipated within 4 hours i. Inhalational • Nitrous Oxide 50% / Oxygen 50% This is used in the late first stage when delivery is expected within 1 hour. Epidural This procedure administered by an anaesthetist is a very effective way of reducing labour pains. When it is given in the first stage its use extends through the second stage of labour. During the second stage of labour Local Anaesthetics (for episiotomy and pudendal block anaesthesia to facilitate instrumental delivery).

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International cooperation Successful cases of international cooperation reaffirm the importance of sharing expertise and standardizing data collection purchase 100mg cordarone fast delivery. The investigation of specific cases of illegal sales rely on rapid exchange of information and concerted action between States concerned buy cordarone 100mg without a prescription. Guideline 22: Governments with experience in establishing and enforcing effective regulatory measures order 100 mg cordarone with amex, including relevant legislation and admi- nistrative provisions, are requested to make their expertise available to other States by, inter alia, organizing workshops, providing training and disseminating material (e. Guideline 23: Governments with experience in identifying, investigating and prosecuting the illegal sale of preparations containing internationally controlled substances through the Internet are requested to provide training in or organize the training of national competent authorities and law 6 enforcement officers of other countries. Guideline 24: The Board recommends that Governments ensure that their national authorities respond in an appropriate manner to requests for coop- eration from other States in cases involving the illegal sale of preparations containing internationally controlled substances through the Internet. Countries of origin of illegal shipments should, upon receipt of information or request for cooperation, respond in a timely manner by taking measures to stop the illegal activities, initiating criminal proceedings and adequately sanctioning offenders. Guidelines 13 Guideline 25: The Board recommends that Governments introduce adequate standards for investigating cases involving seizures of internatio- nally controlled substances that were sold illegally through the Internet; such standards should include minimum requirements for collecting and reporting data. Data on seizures, whether required for the further investigation of specific cases or for analysis of trends, should be reported to all States concerned and all international organizations working in this field (e. Minimum reporting requirements include information on the quantity seized, the international non-proprietary name of the drug or the name of the preparation, the pharmaceutical form of the preparation seized, the country of origin of the shipment, the country of destination of the shipment, information on the offending website, sources of supply etc. Assessments of psychotropic substances are reported to the International Narcotics Control Board. Bona fide pharmacies: genuine pharmacies that are duly licensed and registered by the national competent authorities of the country where they operate to prepare and dispense medication and provide other pharmaceutical services to patients. Many pharmacies have expanded their services through the Internet, thus allowing customers to order and purchase over-the-counter and prescrip- tion drugs online. In the case of prescription drugs, patients are usually required to submit a written prescription or provide the name and telephone number of the prescribing physician. Certifying programmes: certifying programmes are used to accredit legitimate Internet pharmacies so that customers can differentiate between accredited (legiti- mate) and non-accredited (illegitimate) pharmacies. Certifying programmes for Internet pharmacies can be carried out, for example, by national professional associations in cooperation with Government offices. Dispensing drugs: dispensing drugs involves the interpretation, evaluation and implementation of a prescription drug order; it includes the preparation of a drug or device and its delivery to a patient in a suitable container appropriately labelled for subsequent administration or use. Estimates for narcotic drugs: the calculated quantities of a specific narcotic drug required by a country for medical and scientific purposes for the period of one year. Such estimates are communicated on a yearly basis to the Board, which must confirm them. Financial services: companies that provide a variety of money and investment- related services. For the purpose of the guidelines, the term “financial services” refers only to services facilitating non-cash payments, for example through debit cards, credit cards and electronic payment services such as CyberCash, PayPal etc. The international drug control conventions: the Single Convention on Narcotic Drugs of 1961 as amended by the 1972 Protocol;a the Convention on Psycho- tropic Substances of 1971;b and the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988. Annex Glossary 15 Internationally controlled substances: the narcotic drugs listed in the schedules of the Single Convention on Narcotic Drugs of 1961 as amended by the 1972 Protocol, the psychotropic substances listed in the schedules of the Convention on Psychotropic Substances of 1971, and the precursors listed in the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988. International mail courier companies: companies that offer parcel delivery or expedited mail services. Such courier services are often supplied by privately owned companies that pick up, transport and deliver letters, parcels and packages, both nationally and internationally. International non-proprietary names: designations that have been adopted by the World Health Organization and that are used to identify pharmaceutical substances or active pharmaceutical ingredients used in medicines. Each inter- national non-proprietary name is unique, globally recognized and considered public property. Internet pharmacies: online businesses through which medicines can be sold, prescriptions dispensed and relevant information provided. Illegal Internet pharmacies operate without licences and without being registered, dispensing prescription medicines without requiring proof of prescription. Internet service providers: companies that provide access to the Internet and related services, such as domains for establishing websites. Internet service providers have the equipment and telecommunication lines necessary to provide clients in a certain geographical area access to the Internet. Large Internet service providers have independent access to high-speed leased lines and are therefore less dependent on local telecommunication service providers. Non-prescription drugs: medicines that can be purchased without a prescription, also known as over-the-counter drugs. Pharmacists: individuals, registered and licensed by Government authorities to prepare and dispense medicinal drugs. Pharmacies: duly licensed establishments where medicinal drugs are dispensed and patients receive pharmaceutical care. Postal and courier services: public postal service providers are State owned and have a monopoly on most types of mail services. Courier services are usually parcel delivery or expedited mail services which may be also supplied by the postal monopolies but are predominantly owned by private companies. Practitioners: individuals who have been licensed, registered or otherwise authorized by the appropriate jurisdiction to prescribe and administer drugs in the course of professional practice. Prescriptions: orders for medication issued by physicians, dentists or other properly licensed health-care practitioners on which the name of the patient, the medical preparations to be used by the patient and their dosage are indi- cated. Prescriptions are part of a professional relationship between prescriber, pharmacist and patient. Prescription drugs: medicines that can only be dispensed upon submission of a prescription. I G f t s P t i t h o t e t i t r S t a t h t h t e t F U b l i c I S * 0 8 5 6 4 2 4 * P S — b r y 2 — U . It provides a standardised method of relating the infant’s dose via breast milk to the maternal dose. Infant factors: The most important infant factors to consider are the age and maturity of the infant. Infants can be categorised as low (age 6-18 months), moderate (full-term infants age 2 weeks – 6 months) or high risk (premature, newborn or infants with medical conditions such as renal impairment) of adverse effects from exposure to medications from breast milk.

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