ABC of Ocular Pharmacology for Optometrists in Nigeria 2-Drugs terminologies commonly encountered in our practices and their what they mean!

A primary eye care Optometrist, in the rural or urban setting, is faced with the tasks of prescribing ocular medications from time to time. The professional should also be able to read through the drug history of patients as passed on by a former colleague or another medical professional without much hassles.
In our continuing bid to empower the primary eye care Optometrist in Nigeria, Africa and beyond; this blog has decided to put down most of the latinized terminologies on how to write drug prescriptions. It cannot be over emphasized, the importance of such primary knowledge to Optometric practice in Nigeria and beyond.
Excerpt:

Abbreviation	Latin	Meaning
aa	ana	of each
ad	ad	up to
a.c.	ante cibum	before meals
a.d.	aurio dextra	right ear
ad lib.	ad libitum	use as much as one desires; freely
admov.	admove	apply
agit	agita	stir/shake
alt. h.	alternis horis	every other hour
a.m.	ante meridiem	morning, before noon
amp		ampule
amt		amount
aq	aqua	water
a.l., a.s.	aurio laeva, aurio sinister	left ear
A.T.C.		around the clock
a.u.	auris utrae	both ears
bis	bis	twice
b.i.d.	bis in die	twice daily
B.M.		bowel movement
bol.	bolus	as a large single dose (usually intravenously)
B.S.		blood sugar
B.S.A		body surface areas
cap., caps.	capsula	capsule
c	cum	with (usually written with a bar on top of the "c")
c	cibos	food
cc	cum cibos	with food, (but also cubic centimetre)
cf		with food
comp.		compound
cr., crm		cream
D5W		dextrose 5% solution (sometimes written as D5W)
D5NS		dextrose 5% in normal saline (0.9%)
D.A.W.		dispense as written
dc, D/C, disc		discontinue
dieb. alt.	diebus alternis	every other day
dil.		dilute
disp.		dispense
div.		divide
d.t.d.	dentur tales doses	give of such doses
D.W.		distilled water
elix.		elixir
e.m.p.	ex modo prescripto	as directed
emuls.	emulsum	emulsion
et	et	and
ex aq	ex aqua	in water
fl., fld.		fluid
ft.	fiat	make; let it be made
g		gram
gr		grain
gtt(s)	gutta(e)	drop(s)
H		hypodermic
h, hr	hora	hour
h.s.	hora somni	at bedtime
ID		intradermal
IM		intramuscular (with respect to injections)
inj.	injectio	injection
IP		intraperitoneal
IV		intravenous
IVP		intravenous push
IVPB		intravenous piggyback
L.A.S.		label as such
LCD		coal tar solution
lin	linimentum	liniment
liq	liquor	solution
lot.		lotion
M.	misce	mix
m, min	minimum	a minimum
mcg		microgram
mEq		milliequivalent
mg		milligram
mist.	mistura	mix
mitte	mitte	send
mL		millilitre
nebul	nebula	a spray
N.M.T.		not more than
noct.	nocte	at night
non rep.	non repetatur	no repeats
NS		normal saline (0.9%)
1/2NS		half normal saline (0.45%)
N.T.E.		not to exceed
o_2		both eyes, sometimes written as o2
o.d.	oculus dexter	right eye
o.s.	oculus sinister	left eye
o.u.	oculus uterque	both eyes
oz		ounce
per	per	by or through
p.c.	post cibum	after meals
p.m.	post meridiem	evening or afternoon
prn	pro re nata	as needed
p.o.	per os	by mouth or orally
p.r.		by rectum
pulv.	pulvis	powder
q	quaque	every
q.a.d.	quoque alternis die	every other day
q.a.m.	quaque die ante meridiem	every day before noon
q.h.	quaque hora	every hour
q.1h	quaque 1 hora	every 1 hour; (can replace "1" with other numbers)
q.d.	quaque die	every day
q.i.d.	quater in die	four times a day
q.o.d.		every other day
qqh	quater quaque hora	every four hours
q.s.	quantum sufficiat	a sufficient quantity
R		rectal
rep., rept.	repetatur	repeats
RL, R/L		Ringer's lactate
s	sine	without (usually written with a bar on top of the "s")
s.a.	secundum artum	use your judgement
SC, subc, subq, subcut		subcutaneous
sig		write on label
SL		sublingually, under the tongue
sol	solutio	solution
s.o.s., si op. sit	si opus sit	if there is a need
ss	semis	one half
stat	statim	immediately
supp	suppositorium	suppository
susp		suspension
syr	syrupus	syrup
tab	tabella	tablet
tal., t	talus	such
tbsp		tablespoon
troche	trochiscus	lozenge
tsp		teaspoon
t.i.d.	ter in die	three times a day
t.d.s.	ter die sumendum	three times a day
t.i.w.		three times a week
top.		topical
T.P.N.		total parenteral nutrition
tr, tinc., tinct.		tincture
u.d., ut. dict.	ut dictum	as directed
ung.	unguentum	ointment
U.S.P.		United States Pharmacopoeia
vag		vaginally
w		with
w/o		without
X		times
Y.O.		years old

(source: Wikipedia)

The above prescription codes should help during co-management of disease conditions with other health care providers, objectifying our respect in the medical world and developing Optometry in Nigeria into a truly medical eye care profession in line with the dreams of our founding fathers...
I am all for the 21st century trend of Optometry, but I believe we have to earn it; we have to expand, grow and redefine our place in the medical world!
Long live Nigerian Optometrists,
Long live Optometry!
Compliments of the season!

A discussion session in Pan-OJ Clinic and Diagnostic services limited... My presentation!

Below is the original copy of my presentation during one of the clinic's health education meetings. Read on:

Topic: Clinical Optometry Practice in Eye care

Discussion:

·         Introduction- an Optometrist is an eye care professional who specializes in using refraction and other form of eye tests within the scope of their practice to diagnose, treat & manage conditions of the eye as a functional part of the human system.

 

·         Brief History- The profession Optometry became popular in the early 19^th century. Prior to this time, it was unregulated and was made up of mainly opticians (one who fits glasses) for the commercial purpose of providing spectacles for their clients. Today, the profession has gradually evolved into a medical eye care provider. [In some states in the USA, Optometrists are trained to perform laser surgeries and other invasive procedures on the eyes.]

 

 

·         The Organogram of eye care- The eye care is a sub-sector of the health care sector. There are three different types of care in eye care sub-sector, viz primary, secondary and tertiary eye care.

Primary eye care involves preventive eye care procedures like ocular hygiene, vision screening, education etc.

 Secondary eye care involves treating eye conditions with glasses, drugs or surgery. 

 Tertiary eye care involves using low vision aids to improve vision, post surgical care, glass prescription follow-up for children below 9 years, managing chronic eye conditions e.g. glaucoma.

There are three different types of eye care providers:

1) The optician (those who fix glasses prescribed by a refractionist.),

2) The Optometrist (those who use refraction and other eye tests to non-invasively diagnose and treat/manage/refer patients with eye medical conditions.) and

3) The Ophthalmologist (Eye care specialists who use various invasive procedures to manage eye medical conditions).   

 

The practice of Optometry- The practice of Optometry today has evolved beyond managing ocular conditions with glasses alone into a medical eye care profession as is been witnessed in our clinic. There are currently six sub-units represented in Pan-OJ Clinic and Diagnostic Services Limited.  The practice of optometry in the clinic been able to touch various units in the clinic as highlighted by the following illustrations:

a)    The drug dispensing/nurses unit-

 *The nurses provide the optometrist with auxiliary services in the form of taking Blood pressure(B.P.) , Visual acuity (V.A.), dilating of the eyes with mydriatics etc 

* They educate patients on how to apply their eye drops/ointments.

* The nurses help patients in making choices for frames in the clinic.

 

b)   The administrative unit-  [The receptionist and the PRO]

* The Receptionist registers our patients and directs them to the eye examination room.

 * She informs the patients about their glasses and ensures that the patients pay up before final dispensing of glasses and drugs.

* She communicates follow-up information to the patients.

* She assists the patients in choosing their frames in absence of the nurses.

* Sorts out patient’s folders when needed in the eye care unit.

* The public relation officer (the P.R.O.) helps in creating eye care awareness and set seminars/workshops in schools, hospitals, churches etc

* The PRO can assist patients in choosing glasses.

 

The following three clinical co-managed cases highlight the relationship between Optometry practice and general health care practice in Pan-OJ Clinic and Diagnostic Services Limited.

Case History (By the Head Laboratorist) 1:

 Px, 29, A complained of poor and deteriorating vision for the past 5 years especially on the right eye.

 Her visual acuity (V.A.) @ 6 meters was

 

RE: 6/4

LE: 1/60

Refraction was

RE: +0.50 DS (Dioptre Sphere) [6/4]

LE: +0.50 DS (Dioptre Sphere) [1/60]

Both eyes were dilated using Gutt: Mydriacyl 1% one drop every 5 minutes until maximum dilation was achieved.

Ocular fundus examination with the slit lamp and the Ophthalmoscope revealed a macular scar on the Left eye and a coeco-central choroido-retinal scar on the right eye. A laboratory test was requested to rule out toxoplasma gondii as a causative agent.

A laboratory microbial analysis of the blood collected around 12.00 noon for ova/egg of Toxoplasma gondii was carried out which showed the presence of the parasitic egg.

Case History 2 (By Doctor Giwa):

Px B, 33, presents to the clinic with a painful vesicobullous dermatitis on patient’s left side of the face. He complained of photophobia, epiphora, chronic redness and loss of vision on the ipsilateral eye. Patient has variously used over the counter eye drops without much improvement.

His visual acuity @ 6 meters was

RE: 6/5

LE: LP

External examination revealed a neovascularized cornea, corneal ulcer, anterior synechia and associated blepheritis. There is no corneal sensitivity on the left eye.   RVS test was requested and it came out positive. Clinical observation of the red eye with the RVS result confirmed the presence of Herpes Zoaster Ophthalmicus (HZO). He has since been co-managed with a general practitioner. On his last visit, prognosis has improved drastically.

His visual acuity on the Left eye has improved to 6/60!

Case history 3 (By Mr Moses):

Px C, 38, is a known chronic hyperglycaemic patient who presented with sudden reduced vision even with her habitual prescribed glasses. Her presenting visual acuity 6 meters [with her glasses] was

RE: 6/18

LE: 6/12

Her visual acuity @25 cm was N8.

Refraction was

RE:-1.50-1.00 x 30 [6/9]

LE:-1.25-1.00 x 150 [6/9]

     Add 2.25 [N5]

She was given the glasses. 3 months later she returned to the clinic with same complaint that her glasses do not allow her see. Her presenting Fasting Blood Sugar (FBS) was 20 mmol/l. Her visual acuity was

RE: 6/12

LE: 6/12

Refraction was:

RE: +1.00-1.00 x 30 [6/5]

LE: +1.25-1.00 x 150 [6/5]

Add 2.00 [N5]

She was given the new glasses but was told to that her blood sugar level change will affect this new refractive status. Last week, she reported back to the clinic with improved blood sugar value of 9mmol/l. She cannot see with her last glass prescription. Her visual acuity was

RE: Plano-0.75 x 30 [6/4]

LE: -0.25-0.75 x 150 [6/4]

Add 2.00 [N5].

This is a typical case of fluctuating refractive errors in adults associated with DM. the new glasses has since been given to her while a General practitioner manages her hyperglycemia.

 

In conclusion of our session, it cannot be over-emphasised the role of clinical optometry in health care practice. It is no longer the practice of lens prescription. It involves using both topical and non-topical drug agents to treat/manage the condition of the eyes.

Thank You.

Dr Victor Ezebuiroh Okwudiri (OD)

 

Hope you enjoyed it... Compliments of the season!

Hypertension and the Eye... What the Primary Eye care Optometrist Should Know.

Hypertension is a chronic cardiovascular condition characterized by elevated blood pressure.
The normal blood pressure is a function of two measurements: the diastolic and the systolic blood pressure measurements. The diastolic is measured in between two systolic beats, when the heart muscles are relaxed. The normal diastolic value ranges from 60-90mmHg. The systolic is measured when the heart muscle contracts followed by a beat. The normal systolic value ranges from 100-140 mmHg. A ratio=

Systolic/Diastolic (mmHg) defines the arbitrary blood pressure.

An indivudual is said to be hypertensive when his systolic is consistently equal to and/or above 140 mmHg with a consistent diastolic reading of 90 mmHg and above.
Like other cardiovascular conditions, hypertension has strong affinity for blood vessels especially the capillaries. Arterisclerosis and arteriolosclerosis are major cardiovascular changes that is associated with chronically elevated blood pressure.
The eye is surrounded by end blood vessels, i.e. blood vessel with terminal roots in the eye. The retina, the uvea and the optic nerve areas are vascularized areas of the posterior eyeball. They are made-up of tiny arterioles susceptible to chronic hypertension. The chronicity and management of systemic hypertension determines how most ocular symptoms of the disease manifest. And the vascularized parts of the eyes are frequently affected more often than the non-vascular portions of the eyes. For instance, the retina is more affected in systemic hypertension than by the non-vascularized cornea.
The retina and the choroid are the earliest to start showing signs of systemic hypertension. Thinning of retinal vasculature, nicking of retinal vessels, deep seated choroidal vascular changes and oftentimes background hypertensive retinopathies. This patient complains of reduced visual acuity both far and near especially in the adult population. The resulting refractive error is often a hyperopic shift. One will expect increased crystalline lens sclerosis in adult hypertensive patients.
Poorly managed or unmanaged systemic hypertension causes more dramatic ocular complications. The retina, the choroid, the optic nerve and the surrounding vitreous body casts varying signs and symptoms that complicates visual acuity. The retinal sensitivity is severely reduced in cases of proliferative hypertensive rethinopathy. Retinal haemorrahge is not uncommon in very poorly managed systemic hypertension. Chronic and unmanaged hypertension could cause serious choroidal vascular complications which often results in low vision or even blindness.
As a primary health care specialist, it is required of us to always place emphasis on the rouine BP check for our patients even without complementary ocular symptoms.Every patient with hypertension should be periodially visually examined to rule out potentially blinding signs associated with long standing hypertension. Refer every hypertention patient you come in contact with to the nearest medical centre while encouraging healthy living viz exercises, dieting and periodic medical check-ups etc...

Optometry and where the future of eye care lies...

Optometry has evolved from mere provision of optical glasses for reading to primary and secondary eye care providers in the 21st Century.
About 1000 years ago, production and sales of optical reading glasses were reported to be going on in ancient China by Venetian Marco Polo and by a British historian, Sir John Needham . Dr Gross (OD, PhD) of the school of Optometry Indiana in the United States noted that by 1300s Italy, Netherland and Germany were documented to have started manufacturing optical spectacles for commercial purpose.
Between 1850-1900 the first school of Optometry was established.
In 1901, Minnesota state became the first to regulate Optometry practice with the use of "License to practice". Viz:

"Over 110 years ago, on April 13, 1901, Minnesota Senate Bill 188 was signed into law establishing the first optometry practice Act. That first scope of practice was defined as:

“An act to regulate the practice of optometry.

Be it enacted by the Legislature of the State of Minnesota:

Section I. The practice of optometry is defined as follows, namely: The employment of subjective and objective mechanical means to determine the accommodative and refractive states of the eye and the scope of its functions in general.”" [1]

Ever since then Optometry has been evolving into a medical practice. This could be observed in the trend of Optometry advancement in the USA. DPA (Diagnostic Pharmaceutical Agent) was allowed to be part of the Optometry scope of practice in Rhodes Island in 1971. Prior to that time legistative fisticuff in Indiana saw the Optometric practice recieve approval for DPA in 1935 but was fully affirmed by the Attorney General of the state by July 17th 1946. Today all Optometry practice in the USA are allowed to use DPAs in their practice, the state of Maryland became the last state to approve DPA into Optometric practice by January 13th 1989.
 Nigerian Optometrists are allowed to use DPA in practice inferentially:

"Optometry” means a health-care profession specialising in the art and science of

vision care and whose scope of practice includes—

(a) eye examinations to determine refractive errors and other departures

from the optimally healthy and visually efficient eye;

(b) correction of refractive errors using spectacles, contact lenses, low

vision aids and other devices;

(c) correction of errors of binocularity by means of vision training

(orthoptics);

(d) diagnosis and management of minor occular infections which do not

pose a threat to the integrity of the occular or visual system; and
(e) occular first aid;[2]
[See the part (d) above to throw more light on DPA approval for Nigerian Optometrists].

But it remains to be fully introduced into the main stream Optometry practice in Nigeria especially in Public hospitals. Rumor mills making rounds have it that most Optometrists in our government facilities are restricted to refraction, depriving them of the flexibility of the 21st Century Optometry practice. DPA includes topical anesthesias, mydriatric/cycloplegic agents and ocular dyes.
Optometry practice in Europe is not as harmonized as it is in North America, Canada and in Australia. For example, in 1938 the first drug for diagnosis in Optometry was inserted into Worshipful Company of Spectacle Makers (SMC)- one of the two bodies of Optometry in the UK. It was not till 1968 that it became a legal requirement as passed by law for the optometrist to use Diagnostic agents in the UK.
In other European countries like in Italy, Optometry is not legally recognised as a profession. Norway has been regulating Optometry practice since 1988 and was legally allowed to use DPA medications in a regulated framework since 2004. In Ireland, Optometry has been regulated since 1953, but was legally allowed to use cycloplegia as a DPA in their amended Act of 2003.
In Asia, Optometry practice is evolving into a model eye care profession. In Philipines for instance, the first refraction centre was opened in 1902 and Optometry came under a body known as the Board of Optical examiners in 1913. Optometry became regulated by law in 1917 and in 1919 it was amended. Professional Optometry in Philipines had an upward review of their regulation and came up with Ethical codes for Optometry in 1957 Amendment Act.
The Revised Optometry Law in the Philipines of 1995 updated and modernized many aspects of optometry including the use of diagnostic pharmaceuticals (DPA).
In Japan Optometry is yet to be fully recognized by the government and hence no proper regulation is been in place. China does not recognise Optometry as a profession either.
On the flip side, Malaysia has a body of Optometry formed in February 1984 known as Association of Malaysian Optometrist. In 1985, Malaysian Association of Practicing Opticians was formed but it was in 1991 that a legislation to regulate Optometry was put forward.
It defined Optometry as,"
The employment of methods for the measurement of the powers of vision, or the adaptation of ophthalmic lenses or prisms for the aid of the powers of vision, or both." [3]
The Act allows the use of Diagnostic Drugs for refraction.

Most states in the USA have the approval to use Therapeutic Pharmaceutical Agents (TPA) and the first state with TPA approval was in West Virginia, 1976. In 1977, North Carolina became first state to pass a law that requires the Optometrists to use injectable and oral medication for therapeutic purposes. In 1998 the District of Columbia became the last state in the USA to enforce Optometrist right to TPA for treatment and management of  ocular diseases.

DPA approval has been in force since 1987 in Canada and recently most Provinces in that country allows the Optometrists to use TPA in practice. Alberta was the first province to grant optometrists with TPA legislation in October 22, 1996. In December 1997 the Optometry Professional Act of New Brunswick was expanded to "the use of pharmaceutical agents" [6], which includes classes of TPAs and all topical pharmaceuticals. The province of Saskatchewan was next in January 2, 1998. Limited use of TPA was incoporated into the legislation. In 1999, Yukon province became next to adopt a TPA legislation similar to Alberta and New Brunswick. In May 2000, Nova Scotia province amended its Optometric legislation to start using TPA in practice with an upward review in 2006 and in 2007. In June 2000, Quebec province made a law to allow Optometrists to use TPAs and it was approved in 2003.

In Columbia Optometry practice enjoys the right to prescribe therapeutic agents (Decree No. 1340, passed on July 14, 1998.). No other country in Latin America or the Caribbean has a law allowing optometrists to use or prescribe pharmaceuticals of any type. Argentina, Brazil and Chile have been struggling to gain recognision while Venezuela and Maxico does not recognise Optometry as a profession. Ecuador remains the second country after Columbia to recieve a legal framework for Optometrist. The first law was passed in 1979 [Decree 3601]. Another legislation in 1994 saw the passage of Law 65 Article 174, which officially recognized the profession of optometry.

 In Europe, the use of therapeutic pharmaceutical agents (TPA) is still evolving especially with the formation of a strong unifying body headed by the Association of European Schools and Colleges of Optometry (AESCO), the UK GOC (General Optical Council) and the World Council of Optometry(WCO). In 2000, the GOC rules were reviewed to allow Optometrists enforce their professional jubgements and to use limited TPA for curative/management purposes even though the Medicines Act of 1968 provided the UK Optometrists {Opticians} the opportunity to use DPA and mild prophylactic antibacterial agent for contact lens wearers.

In 2005, another review saw the expansion of therapeutic role for the UK Optometrists, (Titcomb and Lawrenson 2006):
● Update to the list of POMs available to all registered optometrists
● Removal of the 'emergency' requirement for the sale and supply of Pharmacy (P) and General Sales List (GSL) medicines.[4]

In 2008 another review in the Medicines Act allowed the UK Optometrists to prescribe most TPAs. The unification of the European Union and the independent prescribing right won by the UK Optometrists in 2007, it remains to be seen the destination of Optometry in Europe. But for sure the future of Optometry in Europe looks very promising.
In Asia, TPAs are more often than not left for the Ophthalmologists because Optometry is studied as pure Optical science. You can get your degree from a Polythecnic e.g in Singapore, in Hong Kong; or even in Technical colleges e.g. in Korea.

A pattern is emerging from all these. The profession is taking a turn towards inclusive medical eye care as the evolution continues. For instance a law in Kentucky in 2011 authorized the use of surgery and therapeutic lasers by state Optometrists. Before then Optometrists in Oklahoma have been providing laser and non-laser surgical procedures since 1998 (Senate Bill 1192). 
As the profession keeps advancing the following steps should be patternized for posterity sake:
1) Becoming organized,
2) Seeking government regulation through education, research and advancement in technology,
3) Developing competence in use of DPA/TPA
4) Developing evolutionary medical eye care that will address secondary and tetiary eye care gaps in the world today.

The trend is progressive. The scope of Practice is expanding. The development, advancement and improvement of professional practice in Optometry globally has become the default. No wonder the world Council of Optometry expanded the frontier of Optometry thus:

"Optometry is a healthcare profession that is autonomous, educated, and regulated

(licensed/registered), and optometrists are the primary healthcare practitioners of the

eye and visual system who provide comprehensive eye and vision care, which includes

refraction and dispensing, detection/diagnosis and management of disease in the eye,

and the rehabilitation of conditions of the visual system."[5]

Nigerian Optometrists should not be left behind because the onus of proof lies with us to make a paradgm shift towards medical eye care with a view to tackling the burden of blindness locally and globally!
 Thank you,
Dr Ezebuiroh Victor Okwudiri

N/B: This is intended for educative purpose and to inform the members of the public and it does not attract any financial obligation