US Pharm. 2018;43(3):8-12.
Common ophthalmic conditions account for up to 3% of all primary care and emergency department visits.1 However, a recent study found that most of these encounters were for the treatment of nonurgent ocular conditions.2 Pharmacists play a valuable role in assisting patients who may present to the pharmacy with such conditions, helping decrease the inappropriate use of emergency care for nonurgent eye problems.
As patients become more empowered to address their own health concerns, the pharmacist is increasingly becoming the first healthcare professional they encounter. Patients may come to the pharmacy seeking advice for ocular conditions that may be minor and self-limiting. A wide range of nonprescription products are available to treat and provide relief from self-treatable ocular conditions. These conditions, such as blepharitis, usually affect the eyelids and surrounding areas, and some disorders affect the ocular surface, including dry eye and conjunctivitis.3 In some instances, however, relatively minor symptoms can signal a more serious condition.
In order to provide optimal patient care, pharmacists need to understand common ocular conditions that may be encountered. Careful assessment is necessary to rule out more complicated conditions that will require a referral to an eye-care specialist. Most importantly, pharmacists are key in promoting the safe and effective use of medications, as well as patient understanding, to optimize the treatment of ocular conditions.
Dry eye is among the most common ophthalmic conditions, affecting almost 7% of the U.S. adult population.4 Female sex and age are significant risk factors; dry eye is almost two times more prevalent in women and more than three times more prevalent in individuals aged >50 years.4 Additional risk factors that are associated with the development of dry eye include hormonal changes, presence of systemic diseases such as diabetes and Parkinson’s disease, post eye surgery, vitamin A deficiency, contact lens wear, and low humidity.5,6 Patients taking antihistamines, antidepressants, decongestants, diuretics, beta-blockers, retinoids, or phenothiazines are also considered more prone to developing dry eye.5,6
Patients with dry eye will typically experience ocular discomfort described as irritation, grittiness or sandy feeling, burning, itching, or pain and redness, which may be accompanied by ocular fatigue. Patients may also complain about blurred vision, photosensitivity, and mucous discharge. Initially, excessive tearing is common; this is due to corneal irritation, which causes reflex tearing.7,8
Educating the patient about avoiding environmental factors can help improve the symptoms of dry eye. Applying warm compresses, avoiding dry or dusty areas, using humidifiers, avoiding prolonged computer use, wearing sunglasses or goggles in windy, cold environments, and maintaining good eye hygiene are recommendations to alleviate symptoms.8 Dietary supplements, such as omega-3 fatty acids and flaxseed oil, have anti-inflammatory properties that may improve lid function by reducing inflammation and altering the composition of meibomian lipids.8
The mainstay of treatment is to lubricate the eye with artificial-tear supplements. Dry eye is often a chronic condition that requires long-term treatment with ophthalmic lubricants in the form of artificial-tear solutions, nonmedicated ointments, or nonmedicated gels. A number of OTC products are available, with different formulations.
Some formulations contain electrolytes that help treat the surface of the eye; potassium and bicarbonate have been noted to be the most important electrolytes.8 Artificial-tear products contain a variety of ingredients to increase viscosity, which will increase tear-retention time and help protect the ocular surface.8 Carboxymethylcellulose, polyethylene glycol, hydroxypropyl methylcellulose, glycerin, and polyvinyl alcohol are examples of such agents. Higher viscosity agents such as Refresh Celluvisc or Systane Ultra preservative-free should be reserved for more severe cases; they are associated with more visual blurring.8,9 Ophthalmic gels and ointments also have a higher viscosity compared with liquids and are generally reserved for overnight use.
Preservatives are used in many ophthalmic formulations to decrease the chance of bacterial contamination in multidose containers and to increase the shelf life of the product. Preservatives can exacerbate ocular inflammation of dry eye; it is recommended not to use preserved tears more than four to six times a day. If a patient has moderate-to-severe dry eye and requires more frequent application of an ocular lubricant, the absence of a preservative is a more important consideration than the active lubricating agent.10
Because the osmolarity of tears in dry-eye patients is increased, hypoosmotic products have been created to help counteract the proinflammatory nature of hyperosmolar tears. Products with higher colloidal osmolality may help restore appropriate water transport across ocular membranes.10
A stye, also known as an external hordeolum, is an acute bacterial infection caused by Staphylococcus aureus in up to 95% of cases, with Staphylococcus epidermis being the second most common causative bacterium.11,12 The name hordeolum is derived from “hordeum,” which means “barley” in Latin, because it resembles barley. Styes can occur in anyone, but they are more likely to affect adults because of the higher levels of androgen and incidence of rosacea; they can also occur in children, however.11 Additional risk factors include seborrheic dermatitis, chronic blepharitis (eyelid inflammation), meibomian-gland dysfunction, ocular rosacea, selective immunoglobulin M deficiency, and high serum lipid levels.11,13
Patients with a stye often present with complaints of burning, tenderness, and swelling on one eyelid.12 It is usually characterized by a small, erythematous abscess that may become yellow and pus-filled.12 Styes usually resolve on their own in 1 to 2 weeks.11 If left untreated, a stye can potentially develop into cellulitis around the eyelid, which spreads rapidly.12 Nonpharmacologic recommendations include applying warm compresses and massaging the abscess for 15 minutes at least four times per day, and plucking the lash (if the stye is on a lash follicle) to drain the pus.11,12 If it does not resolve within 2 weeks, the patient should be referred to a physician, who may prescribe topical or systemic antibiotics.11,14
Allergic conjunctivitis is estimated to affect up to 30% of the general population.15 Most patients with ocular allergies also have seasonal allergic rhinitis. Seasonal and perennial conjunctivitis are the most common forms of ocular allergies. Grass pollen, animal fur, and topical eye preparations are among the many possible causes. Patients typically present with bilateral eye symptoms, including red, itchy, and watery eyes; pruritus is considered the hallmark sign.
When treating patients suffering from allergic conjunctivitis, goals of therapy include avoidance of allergens, reduction in severity and symptoms, and protection of the eye surface. Patients should be asked questions in order to identify ocular allergens and should receive education on how to avoid them. Avoidance measures include checking the pollen count and staying inside enclosed environments when it is high, keeping windows closed, turning on the air conditioning, wearing sunglasses outdoors, and using air filters. Application of cold compresses to the eyes three to four times per day may also alleviate symptoms of redness and itchiness.16
In addition to allergen avoidance, artificial tears may also be recommended. These agents help dilute ocular allergens and prevent them from interacting with the ocular surface.17 If symptoms persist, an OTC antihistamine/mast-cell stabilizer, ketotifen, should be recommended. Ketotifen provides relief from ocular itching when used twice daily and is safe in patients aged 3 years and older. In patients who suffer from allergic rhinitis and allergic conjunctivitis, consideration should be given to intranasal corticosteroid sprays. These agents appear to have beneficial effects on ocular symptoms, including itching, tearing, redness, and puffiness.18,19
Decongestant eye drops containing phenylephrine, naphazoline, tetrahydrozoline, or oxymetazoline either alone or with antihistamines offer another treatment option for patients with allergic conjunctivitis. These agents cause vasoconstriction, alleviating only hyperemia and having no effect on ocular itching.20 Their duration of action is short, requiring frequent administration, and their use is associated with tachyphylaxis; patients should be advised not to use decongestants for more than 72 hours and to self-monitor for rebound congestion.20
Viral conjunctivitis represents up to 80% of all acute-conjunctivitis cases.21 Adenovirus is the most common cause, and it is highly contagious.21,22 Patients will typically present with redness and excessive watery discharge in one eye. Other symptoms include photophobia, itching, and foreign-body sensation. Crusting of the eyelids may be present, most commonly in the morning. In most cases, the second eye becomes infected within days. The patient is considered contagious for up to 2 weeks after the second eye becomes infected; good hygiene practices need to be maintained in order to decrease the spread, including frequent hand washing and avoiding shared personal items.23 Treatment is mainly supportive, including cold compresses, antihistamine drops if pruritus is present, and artificial tears.21 If symptoms persist beyond 2 weeks, the patient should be referred to an ophthalmologist.
Bacterial conjunctivitis is another common, highly contagious ocular infection. S aureus is the most common cause of bacterial conjunctivitis in adults, whereas children are more commonly affected by Streptococcus pneumoniae and Haemophilus influenzae.21,22 Patients will usually present with a purulent or mucopurulent discharge with a red eye and eyelid edema. Bilateral matting of the eyelids and lack of itching are strong indicators of bacterial conjunctivitis.21 Signs and symptoms typically last up to 10 days but may persist for up to 1 month.21,22 Up to 60% of cases are self-limiting, usually resolving within 2 weeks.21 Topical antibiotics reduce the duration of the disease and decrease transmission. Patients should be referred to an ophthalmologist if they are experiencing any changes in vision or if no improvement is seen after 1 week of treatment.
Role of the Pharmacist
Pharmacists should counsel patients on the proper use of ophthalmic agents, as they are often incorrectly used (TABLE 1). General nonpharmacologic recommendations to patients displaying symptoms of eye conditions should be advised to remove contact lenses, avoid wearing eye makeup, keep from rubbing the eyes, and washing hands before applying self-treatment. Patients who should immediately be referred to a specialist include those who use contact lenses, have experienced trauma to the eye, experience any vision changes including the onset of floaters and diplopia, experience severe ocular pain and/or sensitivity to light, and those who are also experiencing any systematic symptoms along with their ocular complaints.23
Common Eye Disorders
Some eye conditions can be treated with OTC products, whereas others require a prescription. To prevent the condition from worsening, remove contact lenses, avoid wearing eye makeup, keep from rubbing the eyes, and wash hands before applying an OTC product. If you experience pain, redness, changes in vision, or persistent discomfort, see your physician immediately. Stop using OTC products if you continue to experience symptoms.
Dry Eye: You may be bothered by irritation, grittiness or sandy feeling, burning, itching, pain, and redness, which may be accompanied by eye fatigue. You may also experience blurred vision, sensitivity to light, and mucous discharge. Artificial-tear products such as Refresh Optive Advanced Lubricant Eye Drops, Soothe, Systane Lubricant Eye Drops, and Refresh Optive are effective. Before bed, you may choose to use ophthalmic ointments (e.g., Systane Nighttime, Soothe Nighttime, Refresh PM), as they keep eyes lubricated longer; however, they may cause blurred vision.
Styes: You may experience burning, tenderness, and swelling of one eyelid. Styes usually resolve on their own in 1 to 2 weeks. Applying warm compresses and massaging the abscess for 15 minutes at least four times per day and plucking the lash if the stye is on a lash follicle to drain the pus may help relieve the symptoms. If the stye does not go away in 2 weeks, see your physician.
Allergic Eyes: You may experience red, itchy, and watery eyes, usually from grass pollen during allergy season, or your symptoms may be caused by another allergen, such as animal fur, or by another topical eye preparation. In addition to avoiding or minimizing exposure to your allergen, you may try artificial tears. If you still experience symptoms, Zaditor or Alaway may help relieve the itching. If you also experience a stuffy nose or other symptoms of hay fever, you may benefit from an intranasal spray (e.g., Flonase, Nasocort). Naphcon A, Opcon-A, and Visine-A eye drops may be used for up to 3 days to decrease the redness associated with allergic conjunctivitis.
Pink Eye: In addition to redness, burning, discomfort, and blurred vision that clears when you blink, you may experience mucous discharge while you sleep that glues your lashes together. To remove crusting on the eyelids, gently clean them with a cotton swab dipped in sterile saline or boiled, cooled water. See your physician if you experience any of the above symptoms, as you may require antibiotic treatment.
Steps for Applying Eye Drops
• Wash your hands with soap and water; then dry them with a clean towel.
• Tilt your head backward while sitting, standing, or lying down. With your index finger placed on the soft spot just below the lower eyelid, gently pull down to form a pocket.• Look up directly at the dropper. Squeeze one drop into the pocket
of your lower eyelid. Don’t blink, wipe your eye, or touch the tip of the bottle to your eye or face.• Close your eye gently for 1 to 3 minutes without blinking it.
• Use a clean tissue to absorb and wipe away any drops that spill out of your eye and onto your eyelid and face.
• Wait at least 5 minutes before applying the next drop, if needed.
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24. The Mentholatum Company. Before you buy eyedrops: what you need to know. December 2017. www.rohtoeyedrops.com/wp-content/uploads/2017/12/Before-You-Buy-Eye-Drops-What-You-Need-to-Know.pdf. Accessed February 13, 2018.
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