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Eye care Pharmacist CPD Facts Behind the Fact Card

Eye care
By Katie Hayes This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Patients with eye conditions often


present to the pharmacy seeking
treatment advice. Pharmacists
therefore, have an important role in
the management of eye conditions
including identification of causes,
advice on management, and referral
to other health professionals.
Many eye conditions have
similar presentations. Pharmacists
must differentiate between the
conditions to ensure the patient
receives the most appropriate
management to achieve optimal
patient outcomes.

Learning Objectives
After reading this article, pharmacists
should be able to:
Eileen, an elderly lady presents to the The mechanisms involved in dry eye
Describe common eye
conditions seen in the pharmacy
pharmacy with red, gritty tired eyes. Eileen development are complex and
explains the signs and symptoms started multifactorial. Tear hyperosmolarity leads
Discuss pharmacological and to release of inflammatory mediators and
non- pharmacological treatment around 2 weeks ago. She asks you, the
subsequent inflammation. This causes
options of common eye pharmacist, what she can do to alleviate her
epithelial cell damage, goblet cell loss,
conditions signs and symptoms. and mucin loss resulting in tear film
Recognise when to refer a instability, which further intensifies tear
patient to another health
professional
Dry eye 7
hyperosmolarity. In addition, there are
Dry eye is also known as dry eye syndrome and conditions which directly cause tear film
Discuss the role of the 7
keratoconjunctivitis sicca. It is a chronic and instability. The ocular surface sensory
pharmacist in the management
common condition that affects more women than nerves can be activated in this
of common eye conditions
including counselling for the
men, and can affect physical, social, and environment leading to symptoms such
correct use of various psychological functions, activities of daily living, as discomfort and burning, and possible
treatments. workplace productivity, and quality of life. 1-3 The increased tear secretion as a
Competencies addressed (2014): 01.5, prevalence of dry eye is difficult to estimate but it 4, 7
has been reported in 530% of people who are 50 compensatory response. This can be
02.1, 03.5
4 further exacerbated by friction that occurs
years of age and older. as a result of mucin disturbance in the tear
5,6 7
There are two main types of dry eye : film.

1 .Aqueous tear-deficient dry eye due to


inadequate tear volume, most commonly arising
as an isolated idiopathic condition in
This activity has been postmenopausal women.
accredited by ENHANCE for one hour
of CE. (1 group 1point which may be
converted to 2 group2 points 2. Evaporative dry eye as a result of the
following the successful completion loss of the tear film. This occurs due to
of the associated assessment.) The abnormally rapid evaporation caused by
programme is provided by Self Care, a an inadequate oil layer on the surface of
the aqueous layer of tears.
business unit of the Pharmaceutical
Society of NZ Inc.
Eye care Pharmacist CPD Facts Behind the Fact Card

trauma (e.g. surgery, radiation therapy, symptoms to dry eye (e.g. ocular irritation).4
burns) A blocked lacrimal duct can cause watering
dehydration (e.g. secondary to type 2 of the eye.9 Other causes of acute red eye
diabetes mellitus). include9:

The following can lead to increased tear keratitis (inflammation of the cornea
,
evaporation7 9: caused by infection, trauma, or allergy)

allergic conjunctivitis iritis (inflammation of the iris)

adverse effects of medicines (e.g. episcleritis (inflammation of the sclera)


antihistamines) acute glaucoma.
inability to completely cover eyes when These conditions usually present with
closing eyes (i.e. lagophthalmos) significant redness, and require immediate
low blink rate or wide lid aperture medical attention.
Symptoms environmental factors (e.g. low humidity,
high wind velocity) Referral
Dry eye is usually bilateral in presentation.
There are a number of symptoms associated vitamin A deficiency. Refer immediately to emergency care
with dry eye (see Table 1). patients suspected of having keratitis,
Medicines can have a number of effects that
iritis, or acute glaucoma.9 General
Other non-ocular symptoms may assist with can cause or contribute to dry eyes. See
practitioner (GP) or optometrist referral is
identification of the cause. For example, if Practice point 1.
necessary if there is no improvement in
the patient has a dry mouth, dry eyes may
signs and symptoms despite hourly use
be caused by medicine, or autoimmune Assessment of ocular lubricants and for those who
conditions such as Sjgrens syndrome.
It is important to determine signs and have had signs and symptoms despite
symptoms, and their onset and duration, appropriate treatment for 4 weeks and
Risk factors not been reviewed.8,12 Referral is required
as well as non-ocular symptoms (e.g.
General risk factors for dry eye include2,4,7,8: dry mouth, recent illness). Medical for patients who have dry eye signs and
conditions and medicines should be symptoms associated with systemic
increasing age disease (e.g. rheumatoid arthritis) and have
established as these can contribute to dry
female gender eye development and may be important not been examined for their concurrent
medicines considerations in management choice. The ocular symptoms.2 Urgent referral to an
patients environment and lifestyle should ophthalmologist is required for patients
medical conditions
also be assessed to see if changes can be with ongoing or significant vision loss,
decreased corneal sensation diplopia (double vision), and those who
made to improve signs and symptoms. Self-
nutritional deficiencies. management strategies already undertaken have systemic ill health (e.g. weight loss,
by the patient should also be noted. fever).3
Causes
The following can result in decreased tear Diagnosis Management
production7, 9: There is no single test for dry eye diagnosis In the management of dry eye, improving
allergic conjunctivitis and it is generally diagnosed according patient comfort and quality of life are
to subjective reports.4, 10 Optometrists important, as is returning the dry eye to its
blepharitis
or ophthalmologists can diagnose and normal homeostatic state.13 Reducing the
adverse effects of medicines (e.g. risk of complications such as conjunctivitis
monitor dry eye syndrome, and may be able
antihistamines) to differentiate the cause of dry eye with the and keratitis is imperative.9
Sjgrens syndrome following tests5,11: Ocular lubricants (artificial tears) are used
Schirmer test used to determine tear to4,9,14:
Table 1. Symptoms of dry eye production and aqueous tear-deficient supplement or increase tears
dry eye syndrome. With evaporative dry
Dryness slow the rate of tear evaporation
eye syndrome, the Schirmer test is usually
Irritation reduce resorption of tears
normal.
Discomfort
The tear film break-up time test is the dilute inflammatory substances
Itch
time to initial breakup the tear film reduce tear film osmolarity.
Burning following a blink. An accelerated rate
Grittiness Eye drops do not tend to blur vision, but
of intact tear film breakup (<10 sec) is
may require frequent administration (i.e.
Blurred vision characteristic of evaporative dry eye
up to hourly) in severe cases. Gels provide
Foreign body sensation syndrome.
longer relief than eye drops, but gels can
Photosensitivity It is important to rule out other conditions blur vision although less so than ointments. 8
Ocular fatigue through differential diagnosis. Viral Ointments may be used during the day
References: Roat5;McGinnigle6;AMH8 conjunctivitis can produce similar for severe dry eye symptoms, but can blur
Eye care Pharmacist CPD Facts Behind the Fact Card

as to whether this medicine can be ceased.


Management of commonly associated
eye conditions (i.e. treatment of allergic
conjunctivitis, blepharitis, or rosacea) will
Preservatives in topical eye medicine improve ocular irritation.3
products, as well as some other topically Where symptoms cannot be controlled with
applied eye products (e.g. contact the use of ocular lubricants and lifestyle
lenses), can cause a toxic response on measures, specialist referral is necessary.
the eye surface.7, 9 This can initiate the Management for these patients may include
cycle of inflammation, epithelial damage, surgery and use of topical anti-
goblet cell and mucin loss resulting inflammatories (e.g. corticosteroid).4,8
in tear film instability and further tear
hyperosmolarity.
Counselling for dry eye
It is important that patients understand
vision and are often recommended for that dry eye is not always curable. Dry eye
night- or bed-time use.3,8 Ointments do not can however often be managed with a
increase evaporation of tears.7 There contain preservatives but some contain a combination of lifestyle/environmental
are several medicines that decrease mixture of paraffin and lanolin, which may factors and ocular lubricants.
tear production due to impairment be irritant.8 Sprays contain ingredients that
in the delivery of lacrimal fluid to the stabilise the tear film, such as lecithin.2 It Patients should blink frequently, especially
conjunctival sac.7 These medicines may take trialling a number of products while using the computer or reading (i.e.
include2,7,9: to find the products most suitable for the visually attentive tasks).4 Exposure to
anticholinergics (e.g. tricyclic patient.3 heating, hair dryers, air-conditioning, and
antidepressants, antihistamines) windy conditions should be minimised. In
The effectiveness of over-the-counter patients who wear contact lenses, these
selective serotonin re-uptake (OTC) artificial tears for dry eye syndrome should be removed for the day when dry
inhibitors has recently been evaluated in a Cochrane eye symptoms appear.3 See Practice point 3.
review. Due to a lack of robust study
techniques and reporting, firm conclusions A humidified environment can reduce tear
diuretics evaporation and is particularly important
from these studies cannot be drawn.14
However, ocular lubricants are reported to in dry climates.5,13 Patients with dry eye
be safe and have similar effectiveness.14 should not smoke and avoid second-hand
cigarette smoke to reduce ocular irritation.5
The products available for management of Wrap-around glasses can reduce tear
hormone replacement therapy dry eye may contain a range of ingredients evaporation.8
(especially oestrogen alone). with the following actions: emollient,
Note: Antimuscarinic drugs (e.g. film-forming, wetting, viscosity-enhancing, Patients should be adequately hydrated to
anxiolytics, antipsychotics, alcohol) are tear film stabilisation, and promotion of prevent exacerbating dry eye.5 Omega-3
inconclusive, and only plausible if they spreading to prevent evaporation.2,4 See fatty acids have provided benefit in some
cause dehydration. Table 2 for ingredients of ocular lubricant studies of dry eye.5 Patients with dry eye can
products. be encouraged to ensure their diet contains
When assessing a patient with dry eye, sufficient omega-3 fatty acids.5
it is important to consider all medicines For patients with mild-to-moderate
they are taking to identify drug-related dry eye, cellulose derivatives such as
causes. The pharmacist can then refer the hypromellose (0.20.5%) and carmellose Conjunctivitis
patient to the general practitioner (GP) (0.5 or 1%) can be trialled but may require
Conjunctivitis (inflammation of the
or contact the GP to discuss alternative frequent administration.2, 9 Less frequent
conjunctiva) is characterised by varying
medicines if available, to reduce the administration is necessary for polyvinyl
degrees of eye erythema, irritation,
symptoms of dry eye. alcohol and carbomers, but these are
itchiness and discharge.2 Conjunctivitis may
more likely to blur vision than cellulose
be infective (bacterial or viral) or allergic.
derivatives.2,9 Sodium hyaluronate
Bacterial and viral infection are the most
Related Fact Card remains on the ocular surface longer than
common causes of infectious conjunctivitis,
Eye care and Conjunctivitis several other ocular lubricants and may
and numerous allergens can cause allergic
be suitable for some patients.15 Ocular
conjunctivitis.19
lubricants are safe to use in pregnancy and
breastfeeding.2,8 Preservatives in lubricant
products can irritate and damage the eye. Assessment
See Practice point 2. Patients using eye To ensure correct diagnosis and
products more frequently than 3-hourly management plan for patients presenting
should use preservative-free products.8,18 with conjunctivitis-like symptoms, it is
Where medicine is causing or contributing important to establish the history of the
to dry eye, consideration should be made
Eye care Pharmacist CPD Facts Behind the Fact Card

presenting condition as indicated below 2: suggest more serious conditions (e.g.


Duration of symptoms redness concentrated around iris may
suggest uveitis)
Presence of discharge and description
Presence of co-existing symptoms
Preservatives
Vision changes (e.g. vision loss, haloes (e.g. cold symptoms suggest viral Consider preservatives when
around objects) conjunctivitis, or nausea/vomiting recommending a treatment for
Pain location (superficial versus deep), suggest glaucoma. eye conditions. Preservatives are a
and description (e.g. foreign-body Patient history to determine possible necessary part of multi-dose eye
sensation) contributors, assist with management products. However, they can lead to
Location of redness generalised and choice and determine if referral is irritation and damage, particularly
towards corners of the eyes suggests necessary. where inflammation is already present
conjunctivitis, other presentations may and also when there is an inadequate
production of tears to dilute the
preservatives.8, 41 Adverse effects of
preservatives can include inflammation,
44
Table 2. Ingredients in ocular lubricant products Reference allergic reactions, stinging, burning,
dryness, conjunctivitis, and even corneal
Ingredient Action damage.41 Benzalkonium chloride is the
most frequently used preservative and
Macrogol (polyethylene glycol) 400 Viscosity agent, spreading agent
is also the most irritant preservative.8, 12
Cellulose derivatives This may not be problematic in patients
Carmellose Emollient, film-forming, maintaining viscosity using the product infrequently and

May require very regular (i.e. up to hourly) administration due to


non-ideal wetting characteristics

Hypromellose Emollient, film-forming, maintaining viscosity

May require very regular administration due to poor wetting character-


in ocular tissues.8
istics
Polyols
Glycerin Lubricant
Polysorbate 80 Lubricant
Propylene glycol Emollient
Hydroxypropyl guar Viscosity agent, liquid turns into a gel when instilled in the eye and
mimics mucin layer of tear film
Sodium hyaluronate Viscosity agent, remains in eye significantly longer than other ocular
lubricants (i.e. hypromellose, polyvinyl alcohol) and greater symptomatic
benefit in more severe cases of dry eye
the tear film.2
Polyvinyl alcohol At 1.4% is a viscosity enhancer, wetting, prevents evaporation
Of interest is that some preservatives
Povidone Tear stabiliser, mimics mucin layer of tears leading to increased adhesion to break down when used. For example,
eye surface and usually used in combination with a viscosity-enhancer sodium perborate becomes water
Dextran 70 Polysaccharide, only capable of enhancing lubricating properties when and oxygen on contact with the eye.2
used in combination with other ocular lubricants, e.g. hypromellose Oxychloro complex (also known as
Carbomer974, Carbomer 980 Visco-elastic lubricant, binds moisture to eye surface purite) breaks down to sodium chloride
and water when exposed to ultraviolet
Paraffin High-viscosity polymer, a superior long-lasting effect compared with
light.2
aqueous-based ocular lubricants
For those patients who have adverse
Can blur vision, irritate the eye, and potentially delay wound healing reactions to preservatives, or it is
Lanolin Lubricant with enhanced retention time as it forms an ointment anticipated that they may have reactions,
consideration should be given to the use
Can be irritating to the eye of single-dose preparations, as these do
Retinol palmitate Vitamin A derivative, required for many functions of the eye including not contain preservatives.
epithelial cell differentiation and reverses squamous metaplasia (e.g. loss
of goblet cells and keratinisation)

Avoid in evaporative dry eye due to detrimental effect on meibomian


glands

Lecithin Contains phospholipid liposomes

Thought to stabilise lipid layers in tear film, reducing evaporation


Eye care Pharmacist CPD Facts Behind the Fact Card

Patients who present with the following withhold chloramphenicol initially to allow
require immediate referral to an emergency time for healing without treatment.23,24
department or ophthalmologist2,2022:
For patients who have not used treatment,
eye pain (note: differentiate from if improvement has not occurred within
discomfort at the ocular surface) 48 hours, treatment should be initiated. For
vision loss/reduction/distortion those patients who have used treatment,
if there is no improvement within 48 hours
photophobia
or symptoms deteriorate, they should seek
eye movement restriction medical advice (i.e. GP or optometrist).20
symptoms suggestive of acute angle-
Chloramphenicol is available as drops
closure glaucoma severe, throbbing
and ointment. Eye drops (0.5%) should be
pain, haloes around lights
administered as 12 drops 2-hourly initially
distorted/irregular pupil or abnormal and as infection improves, administration
pupil reaction (e.g. not reactive to light) frequency should be reduced to 6-hourly
suspected traumatic eye injury/possible for up to 57 days, or for at least 2 days
to have infective (viral or bacterial) penetrating foreign body after clearing of infection, whichever occurs
conjunctivitis wear contact lenses, corneal involvement, e.g. cloudy, first.2,20 Chloramphenicol eye ointment
refer them to their GP or optometrist.18 ulcerated 1% can be used as an adjunct to drops
When suffering from infective (bacterial) (administered at night) or as monotherapy
associated nausea/vomiting
conjunctivitis, use of contact lenses (ointment is applied 3 times daily and
history of welding without eye protection continued until 2 days after the infection
should be avoided until 24 hours after
immediately prior to symptom onset has resolved).2 The ointment should
completing the course of treatment.42
eye surgery or laser treatment within the be applied inside the lower eyelid with
Patients who wear contact lenses and are last 6 months approximately 11.5 cm applied.2, 8, 20
suffering from dry eye should remove
if symptoms do not resolve within While generally well-tolerated,
contact lenses (e.g. remove for the day
710 days. chloramphenicol application can cause
when symptoms of dry eye appear).
GP or optometrist referral are required in stinging, burning, or itching. 25 Rarely,
the following circumstances2,20: patients may experience allergy as
indicated by local reactions, dermatitis,
suspected superficial foreign body in the angioedema, and anaphylaxis, requiring
eye immediate cessation, referral to and
3
eye symptoms.
contact lens wear (keratitis risk) follow-up with a medical professional. The
nflammaition of the cornea > permanent damage to eyes
Consideration of contact lenses is copious yellow-green purulent discharge, urgency should be determined by reaction
also important when patients are which accumulates after being wiped severity.8, 25
recommended topical eye treatments. away
Preservatives in eye drops can damage Chloramphenicol use is contraindicated
infection not confined to conjunctiva. in patients with hypersensitivity history to
soft contact lenses. It is recommended
patients wearing soft contact lenses and any of the excipients in chloramphenicol
using eye drops with preservatives avoid Bacterial conjunctivitis eye products and/or toxic reaction
wearing contact lenses during treatment to chloramphenicol.25 The use of
Bacterial conjunctivitis generally begins chloramphenicol products should also be
and for 48 hours post-treatment.2 If
as an unilateral red eye with purulent avoided in patients with an individual or
possible, preservative-free eye drops
discharge. The other eye may become family history of blood dyscrasias (i.e. bone
should be used in patients who wear
infected after 1 or 2 days.22 It can be a marrow problems), and GP or optometrist
contact lenses.9 Ointments should never
primary infection or secondary to a viral referral is necessary if treatment is
be used while contact lenses are worn.9
infection or blepharitis.22 Patients often required.25
experience discomfort such as stinging or a
gritty sensation and eye erythema is diffuse
and generalised.2,21
Viral conjunctivitis
Viral conjunctivitis tends to be unilateral
Management at initiation, with a red eye and serous
discharge. Transfer to the other eye may
Bacterial conjunctivitis is self-limiting and
occur after 23 days but with reduced
without treatment, has cleared within
intensity.22 The most common cause of
5 days in approximately two-thirds of
patients. However chloramphenicol is
considered clinically desirable as it can lead
to faster resolution and reduce relapse.2,23
It is therefore reasonable to either treat
with chloramphenicol immediately, or to
Eye care Pharmacist CPD Facts Behind the Fact Card

viral conjunctivitis is adenovirus. Viral in breastfeeding.8 See Table 3 for allergic


conjunctivitis frequently occurs when conjunctivitis medicines.
patients also have upper respiratory tract
Sodium cromoglycate and lodoxamide are
infection.22
mast cell stabilisers but can take time to
be effective and should be commenced 2
Management 4 weeks prior to likely onset of
There are no specific products for treatment symptoms.8 Ocular decongestants (e.g.
of viral conjunctivitis and products for phenylephrine, a sympathomimetic) may
symptomatic relief are recommended be used to reduce erythema, but should be
where necessary.2, 22 Ocular lubricants limited to short-term use (i.e. 5 days) due to
the risk of rebound redness.2 Patients with Shake any product before use where
can be used as with dry eye, and topical
more severe disease or whose symptoms directed.
vasoconstrictors (e.g. phenylephrine), can
be used if considered necessary.22 Cold are not controlled with aforementioned Pull down the lower eyelid to form a
compresses used several times daily may management should be referred to their pouch.
also provide relief. Viral conjunctivitis doctor. Place one drop in pouch without
is particularly contagious and patients touching the dropper to the eye or
should be counselled on hygiene self-care Self-care strategies eyelashes and close eye.
measures that will minimise the spread of Self-care strategies for allergic conjunctivis27: Apply gentle pressure for a few
the condition (e.g. washing hands frequently minutes with a finger to the bridge of
and not sharing towels).2 The patient Avoidance of symptom triggers (e.g.
pollens, dust mites, and animal dander). the nose to prevent/reduce drainage
is infectious until the weeping and eye of medicine from the eye.
erythema resolves, usually 1012 days.2 Monitor pollen count (e.g. smartphone
applications) and if count is high, try to Wipe away excess drops or drainage
from eyelid and lashes with a clean
avoid going outside.
Allergic conjunctivitis tissue.
Stay indoors in spring, on windy days or
Allergic conjunctivitis is caused by an ocular If instilling further drops, wait several
after thunderstorms.
response to an airborne allergen, and may minutes between instillation of each
Select garden plants that require drop to maximise efficacy.
be seasonal or perennial. It may also occur pollination by birds or insects and avoid
as a contact hypersensitivity reaction (e.g. those that release seeds into the air.
preservatives in eye drops).22, 26 It can be
difficult to distinguish from infective (i.e. Wear wrap-around sunglasses (note these
bacterial or viral) causes of conjunctivitis.22 can also reduce tear evaporation in dry eye).
Seasonal allergic conjunctivitis is commonly
caused by pollens from trees, and grasses Stye
and usually occurs in spring, late summer, Pull down the lower eyelid to form a
and early autumn.26 Perennial conjunctivitis A stye (hordeolum) is an acute infection pouch.
is caused by non-seasonal allergens (e.g. of the sebaceous gland associated with
dust mites and animal dander).26 Allergic an eyelash follicle. The infection is usually
conjunctivitis generally presents as itchy caused by staphylococci and may be
eyes with a watery or stringy discharge, and internal or external.8, 22 The eyelid of the
is usually bilateral.22, 26 Eyelid oedema may affected area becomes swollen, and
painful and sensitive to touch.2 The abscess To spread the ointment, blink several
occur and patients often have rhinitis.26
will develop over time into a pus-filled times.
lesion, then either spontaneously shrink Wipe away excess ointment or
Management and resolve or burst over a few days. drainage from eyelid and lashes with a
Patients who are treating rhinitis with Management may lead to faster symptom clean tissue.
intranasal corticosteroids may find that resolution.2 Management includes applying Vision may be temporarily blurred.
they have some relief of eye symptoms. warm compresses to encourage pointing
For mild eye symptoms, irrigation with (yellow or white pus at top of stye)
sodium chloride 0.9% solution twice daily, 34 times daily for 510 minutes, and often
together with ocular lubricants (48 times the stye will spontaneously discharge. 8
daily) and cold compresses as needed may Removing the affected eyelash may hasten Before first use of product, prime
be sufficient to control symptoms.8 For resolution.22 It is important to note that product by pushing down nozzle
moderate symptoms, recommend a topical application of antibiotics is generally 34 times.
antihistamine (e.g. azelastine, levocabastine) unnecessary, and does not result in faster
Hold bottle 10 cm away from eye.
or a topical antihistamine mast cell symptom resolution.2
stabiliser, which also inhibit inflammatory Close eyes.
mediator release from mast cells (e.g. Blepharitis
olopatadine, ketotifen).8 These products
are safe in pregnancy and may be used Blepharitis is inflammation of the lid
margins and is usually bilateral in
Eye care Pharmacist CPD Facts Behind the Fact Card

presentation.2, 28 Contributors to blepharitis Glaucoma Management


include microorganisms, abnormal
secretions from the lid margin, and an Glaucoma is an optic nerve neuropathy Diagnosis and early treatment are vital
abnormal tear film.22 most commonly associated with elevated in glaucoma management. IOP can be
intraocular pressure (IOP).29 It is the reduced with the use of medicine, laser, and
Posterior blepharitis is caused by meibomian second most common cause of blindness surgery. Treatment choice is dependent on
gland dysfunction. Signs and symptoms are worldwide.30 Glaucoma is primarily classified glaucoma type.30
often worse in the morning,2 and include as open-angle glaucoma (OAG) and closed-
erythema of the lid margin, burning, itching, Medicine is first-line management for most
angle glaucoma (CAG). The classification is patients with OAG.8 The medicines used in
sticky discharge, and greasy scales that are based on the angle at the junction of the iris
easily removable.8, 22 Posterior blepharitis open-angle glaucoma management reduce
and the cornea at the edge of the anterior production of aqueous humour and/or
is generally associated with seborrhoeic chamber.30 See Figure 1.
dermatitis or rosacea.22 increase aqueous humour outflow.8 As OAG
CAG occurs where there is a narrowing of is generally asymptomatic, adherence to
Anterior blepharitis is caused by the anterior chamber angle.29 It is due to treatment is a major problem. Up to 50% of
staphylococcus leading to inflammation increased IOP resulting from inadequate people do not use their medicine correctly,
of the anterior lid margin with hair follicle aqueous drainage from the anterior therefore it is imperative for pharmacists to
involement.22 Patients present with crusts chamber causing optic nerve damage.2 CAG explain the importance of medicine during
that adhere to the eyelid and small abscess may be primary or secondary. In primary patient counselling.8 Medicines available for
or shallow ulceration of the eyelash base.8, 22 CAG, there is no identifiable secondary the management of OAG are described in
cause and the patient has an anatomical Table 4.
Initial therapy for blepharitis involves
application of warm compresses (to closed predisposition.29 Secondary CAG is due Prostaglandin analogues increase aqueous
eyes) twice daily for 510 minutes and lid to a co-existing condition that leads to a humour outflow and are first line in OAG
scrubs.5, 8 Lids should be scrubbed twice narrowing or closure of the angle at the management.33 This group of medicines
daily while blepharitis is active and once anterior chamber.31 can cause iris hyperpigmentation, and
daily for prevention of recurrence.8 Scrubs Patients with acute CAG present with eye thickening, lengthening, and darkening of
choices include: bicarbonate solution (1 erythema and pain and must be referred to the eyelashes.8 If response to an agent in this
teaspoon in 500 mL cooled boiled water), the GP or emergency department.2 If not group is poor, another agent from this class
baby shampoo solution (5 drops in 100 mL treated within 24 hours, the patient is at risk may be trialled due to structural differences.
cooled boiled water), and propriety lid of permanent blindness.31 However, the use of two prostaglandin
solutions/wipes.8, 22 The scrub solution analogues together must be avoided due to
should be used to soak a gauze, cotton Optic nerve damage in OAG leading to potential for paradoxical IOP increase.8
bud or similar and then applied to the loss of retinal ganglion cell axons, causes
eyelid(s).8 A downward motion is used for progressive peripheral visual field loss, Beta-blockers decrease aqueous humour
the upper eyelid and an upward motion and then central field vision loss.31 Under production and are first-line agents.8, 33
for the lower eyelid.2 If symptoms of examination, the optic nerve (or disc) Timolol blocks beta1 and beta2 receptors and
anterior (staphylococcal) blepharitis are not appears hollowed out, termed cupping.31 should be avoided in patients with asthma.
controlled with lid hygiene, chloramphenicol If the condition is not treated, irreversible Betaxolol is beta1 selective and may be
ointment 1% can be applied once or twice blindness will result. As OAG is generally used with caution in patients with asthma.8
daily for 13 weeks.8, 22 It is important that asymptomatic, it is important that people Due to the potential for systemic adverse
patients understand the ongoing need to have regular eye examinations. Eye health effects such as bradycardia, it is important
use compresses and scrubs to prevent active and eye examination may form part of a that patients understand appropriate
blepharitis episodes. health promotion activity in community administration including the need to
pharmacy. occlude the tear duct. See Practice point 4.

Table 3. Allergic conjunctivitis medicines Alpha2 agonists reduce production, and


increase outflow, of aqueous humour.33
Drug Mode of action Strength Directions There is a decline in the effect of
apraclonidine after 1 month and increasing
Levocabas- Antihistamine 0.05% eye drops Initially 1 drop twice daily, increasing
tine to 1 drop three to four times daily if ocular adverse effects after 3 months of
necessary treatment.8 It is therefore recommended for
use up to a maximum of 3 months.8 These
Ketotifen Antihistamine-mast cell 0.025% eye 1 drop twice daily agents are second-line in the management
stabiliser drops
of OAG.8
Olopatadine Antihistamine-mast cell 0.1% eye drops 1 drop twice daily
Carbonic anhydrase inhibitors reduce
stabiliser Note: Prescription Only medicine
aqueous humour formation and are second-
Cromoglycate Mast cell stabiliser 2% eye drops 1 drop four to six times daily line agents.8, 33 Allergy risk to these agents
may be increased in patients who have a
Lodoxamide Mast cell stabiliser 0.1% eye drops 1 drop four times daily
sulfonamide allergy.8 Acetazolamide (oral
carbonic anhydrase inhibitor) is reserved for
use where other treatments have failed.8 It is
not tolerated by up to 50% of people.8
References: Rutter2;AMH8
Eye care Pharmacist CPD Facts Behind the Fact Card

Pilocarpine increases aqueous outflow, but is Sjgrens syndrome especially the salivary and lacrimal glands,
rarely used for OAG management due to become infiltrated with inflammatory
poor tolerance and frequent administration While the cause of Sjgrens syndrome is mediators leading to damage and
requirements.8 unknown, the condition is associated with dysfunction, often resulting in severe sicca
rheumatoid arthritis.2 Exocrine glands, symptoms (dry eyes and/or dry mouth).34, 35
The treatment of dry eyes associated with
Sjgrens syndrome is as for other causes of
dry eye with decreased tear production, that
Figure 1. Open-angle and closed-angle glaucoma is, the use of ocular lubricants.35

Macular degeneration
(age-related)
Age-related macular degeneration (AMD)
is caused by ageing. There are two forms of
AMD: dry or wet. All AMD begins as dry and
approximately 15% of people progress to the
wet form.36 Dry AMD, while painless, causes
progressive central vision loss, whereas wet
AMD can cause rapid (e.g. days-to-weeks)
central vision loss/distortion.36, 37 See Figure 2.
Risk factors for AMD development include
older age, smoking, and family history.38
As loss of vision is not likely to be noticeable
Table 4. Open angle glaucoma medicines until significant progression of AMD has
occurred, it is important that patients have
Drug Strength Directions regular eye examinations where AMD
can be identified early and management
Prostaglandin analogues
undertaken. Pharmacists should encourage
Bimatoprost 0.03% 1 drop at night patients to undertake regular eye
examinations.
Latanoprost 0.005% 1 drop at night

Travoprost 0.004% 1 drop at night Management


Beta-blockers A 2014 Cochrane review concludes there
is no high-quality evidence to support the
Betaxolol 0.25% (suspension), 0.5% (solution) 1 drop twice daily
benefits of nutritional supplementation for
equally effective
primary prevention of AMD.39 While reversal
Timolol of damage is not possible, supplements may
0.5% 1 drop once or twice daily
reduce the risk of progression to advanced
0.25%, 0.5% (extended-release) 1 drop once daily disease. The Age-Related Eye Disease
0.1% (gel) 1 drop once daily Study (AREDS) found a beneficial effect of
antioxidants (vitamins C and E, and beta-
Alpha2 agonists carotene) and zinc supplementation for
slowing the progression to advanced AMD.39
Brimonidine 0.15%, 0.2% similarly effective 1 drop twice daily
If recommending these products, caution
Carbonic anhydrase inhibitors should be exercised as people taking high-
dose zinc were at increased risk of hospital
Brinzolamide 1% 1 drop twice daily
admission due to genitourinary diseases. 39
Dorzolamide 2% 1 drop three times daily (monotherapy), Omega-3 fatty acids have not been shown
1 drop twice daily (adjunct to beta-blocker) to be of benefit in preventing AMD or for
slowing progression to advanced AMD. 39 It
Acetazolamide 250 mg tablets Half a tablet twice daily to 1 tablet four times daily
is important that patients with AMD who
Cholinergics also smoke are advised to cease smoking
to prevent progression to advanced AMD.40
Pilocarpine 1%, 2%, 3%, 4% Initially 1 drop of 1% three to four times daily, slowly In addition to supplements, wet AMD
increasing as according to response and tolerability treatment includes the use of intravitreal
vascular endothelial growth factor (VEGF)
inhibitors such as ranibizumab, and
aflibercept.8, 40
Reference: AMH8
Eye care Pharmacist CPD Facts Behind the Fact Card

Figure 2. Vision loss associated with AMD

Case study
To ensure that you make the correct diagnosis, explain to Eileen you need to find out more information. Eileen describes feeling generally well
aside from her red, gritty eyes. She has hypertension, asthma, and osteoarthritis, and takes perindopril,
Symbicort 200/6 (eformoterol 6 microgram, budesonide 200 microgram), terbutaline, and paracetamol. She explains that in the last few months
she often doesnt make it to the toilet on time. Her GP prescribed
oxybutynin, which she has been taking for about 3 weeks.
You explain to Eileen that oxybutynin may have caused her symptoms. There are several ways to manage this including possible medicine change
and using eye products to relieve symptoms. You write
a note to remind yourself to write up your clinical intervention.

You invite Eileen to participate in a Medicines Use Review to which she consents. You discover that oxybutynin has reduced Eileens
incontinence; however Eileen has noticed the eye signs and symptoms started around a week ago. She also has a dry mouth.
You listen to Eileen describe the impact that incontinence has on her social activities. You explain to Eileen there are other medicines
that may manage her incontinence, which could be trialled to see if they cause less eye symptoms. These include a patch, which she
may like to discuss with her GP to assess its suitability. You also recommend an ocular lubricant containing carmellose 0.5% to use
when required for her current symptoms.
You provide Eileen with a copy of her medication profile as well as a referral letter for her GP to explain the possible cause of Eileens signs
and symptoms and potential resolutions to the condition. Eileen says she will make a GP appointment on her way home.
Eye care Pharmacist CPD Facts Behind the Fact Card

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