US Pharm. 2009;34(6):12-17.
The pharmacist answers numerous questions about the eyes, many posed by elderly patients. They range from conditions that are relatively minor in nature (e.g., dry eye, allergic conjunctivitis, foreign material in the eye, minor redness, corneal edema) to those that involve serious underlying medical problems (e.g., fading vision, eye pain, cataracts). It is critical to understand the few self-treatable conditions, in order to know when to recommend professional care.
Dry eye is one of the most common ophthalmic conditions affecting the elderly, with a prevalence of 20% in those aged 45 years and above.1 The link to age is strong, with the condition being four times more common in those over the age of 65.1 It is also more prevalent in women. The most common cause is partial or complete deficiency of tears (tear-deficient dry eye). However, another common cause is evaporation of tears from the eye, known as evaporative dry eye.2,3
Patients with dry eye complain that the eyes itch, burn, or sting.4 They may also notice ocular discomfort, blurred vision that worsens as the day passes, a discharge, unusual awareness of the eyes, a feeling that one has to rub or scratch the eyes, a feeling that sand or dirt is in the eyes, redness, light sensitivity, and a desire to cease ongoing activity to close the eyes.1
Dry eye may be caused by the elderly patient’s medications or medical treatments, such as diuretics, antihistamines, anticholinergics, phenothiazines, tricyclic antidepressants, hormones, and radiation.1 It may be caused by smoking or secondary exposure to tobacco smoke, dry air (e.g., cold winter air, air-conditioned air), vitamin A deficiency, wearing contact lenses, or sun exposure.1,4 Dry eye is also experienced in the severe abnormality of tear film known as keratoconjunctivitis sicca or dry eye syndrome.1,2,5 It is a major manifestation of primary Sjögren’s syndrome, along with dry mouth, upper airway dryness, vaginal dryness, and rheumatoid polyarthritis.1,6
The pharmacist can recommend several nonprescription dry eye products. Tear replacement solutions (tear substitutes) are suitable for use during the day, while ophthalmic ointments are better for use during the night.1 Patients should use 1 to 2 drops as needed for up to 72 hours only. They should be cautioned not to overuse the product, as using it six times daily or more can cause a rippled corneal surface. Tear substitutes may contain celluloses (e.g., hypromellose [formerly known as hydroxypropyl methylcellulose], carboxymethylcellulose), polyvinyl alcohol, glycerin, propylene glycol, polyethylene glycols, polysorbate 80, povidone, dextran, and/or gelatin. Celluloses may have a longer duration due to their viscosity. They leave a residue on the eyelashes as the solution evaporates, but it is easily wiped away. Products containing celluloses include Refresh Tears, Refresh Liquigel, Refresh Celluvisc, GenTeal Gel, and TheraTears Drops. Patients should avoid products claiming to treat dry eye or eye fatigue that do not contain any of these ingredients. They may be homeopathic, containing diluted ingredients that have not been proven effective in treating dry eye (e.g., Similasan Eye Drops #3, Optique 1).1
For nighttime use, patients with dry eye may opt to use ocular emollients, which are ointments containing lanolin, mineral oil, paraffin, petrolatum, white ointment, white wax, or yellow wax.1 Patients should pull down the lower eyelid, applying 0.25 inch to the inside of the eyelid, for no longer than 72 hours. These products form an occlusive film on the eye surface that softens tissue, giving a longer-lasting effect. The slight blurring of vision they cause relegates them to use at bedtime, when blurred vision is not as severe a problem. Products include Refresh P.M., Tears Naturale P.M., and Bausch & Lomb Advanced Eye Relief Night Time.
If the problem worsens markedly when the patient is in dry air, it may be due to evaporative causes. Patients can be advised to run a vaporizer or humidifier during the dry winter days when the relative humidity of household air is so low that it dries the eyes, skin, and respiratory tract.1,4 It may be helpful to add humidity during the hottest summer days when the air conditioner runs almost continuously, as this also dries the air.
Older patients may have minor redness of the eye for which they wish relief. Such products as Visine contain vasoconstrictors that are safe and effective when used for short-term relief of red eye caused by minor irritation.1 They should not be used longer than 72 hours to prevent rebound conjunctivitis, a condition in which the product causes further ophthalmic irritation, prompting the patient to continue to use the product far longer than the 72-hour self-use limit. These products should not be used by patients with narrow-angle glaucoma, since they can produce mydriasis, which can trigger an attack of glaucoma.
Elderly patients may ask for assistance with such symptoms as bilateral ophthalmic itching, redness, tearing, and burning. The patient could have allergic conjunctivitis, and the pharmacist can further identify the condition by asking if the patient has a history of allergic rhinitis (e.g., hay fever).1 If the patient has not yet been diagnosed with the condition, the pharmacist may ask if the patient also has runny nose, nasal congestion, episodes of sneezing, or itching of the nose.7-9 It may also be helpful to ask whether the patient notices a seasonal occurrence, as when certain grasses, trees, or weeds are flowering, or occurrence only in certain circumstances, such as spraying window cleaner, vacuuming, or being in close proximity to an animal such as a cat or horse. If allergic conjunctivitis is possible, the pharmacist can recommend antihistamine and vasoconstrictor combinations such as Opcon-A, Naphcon-A, or Visine-A. These combinations should not be used by patients with heart disease, hypertension, difficulty in urination due to an enlarged prostate, or narrow-angle glaucoma. If they are used for more than 72 hours, they can cause rebound conjunctivitis.
The pharmacist can also suggest ketotifen for allergic rhinitis. It is a single-entity ophthalmic antihistamine available as Zaditor or Alaway.10 It possesses several significant advantages when compared to the combinations. Their contraindications do not apply to Zaditor and Alaway. Further, ketotifen acts as a mast cell stabilizer and also inhibits eosinophils, in addition to its antihistamine action. Further, one drop lasts for 12 hours, whereas the combinations must be dosed every 4 to 6 hours, a significant advantage in the elderly patient. Finally, the formula is decongestant free, which spares the patient from the risk of rebound conjunctivitis. However, it should not be used longer than 72 hours without seeking a physician’s care.
Loose Foreign Material in the Eye
Elderly patients occasionally ask for help with loose foreign material in the eye. It may be an eyelash or dirt in the eye that they are unable to remove due to limited mobility. It can cause discomfort, burning, stinging, smarting, tearing, itching, irritation, inflammation, redness, and uncontrollable blinking.1 Foreign material may cause ocular infection and should be removed. The pharmacist can recommend a sterile eyewash that is used to gently irrigate the eye, with the hope that the inrushing fluid will dislodge the object and flood it from the eye. Products include Collyrium for Fresh Eyes and Bausch & Lomb Advanced Eye Relief Eye Wash. Patients should be told to discard the eyecups that are usually packaged with these products, as they are not sterile at the point of use and could allow environmental contaminants to enter the eye.
Conditions That Must Be Referred
The FDA requires general warnings on ophthalmic products. For instance, if patients experience eye pain, changes in vision, or continued redness and irritation, nonprescription product use should be halted and a physician consulted. If the condition worsens or persists (for more than 72 hours in the case of ophthalmic vasoconstrictors, emollients, demulcents, antihistamines, and astringents), the patient must also stop using the product and seek professional care.1
Patients may ask about cataract treatment or prevention. The Internet offers numerous irresponsible and dangerous alternatives to legitimate medical therapy, such as herbal mixtures, ayurveda (e.g., placing homemade teas into the eye), imagery (e.g., imagining cleaning the lens), reflexology, juice therapy, vitamins and minerals, Chinese medicine, and homeopathy (e.g., Similasan Cataract Care).11-14 Patients who are concerned about cataracts must be referred to a physician for legitimate medical care.
Older patients may request assistance in choosing new eyeglasses. If the patient simply wishes visual magnification with otherwise normal vision, many pharmacies sell reading glasses that the patient can self-fit until a good match is found. If, on the other hand, the patient complains of visual loss that has occurred recently, a physician visit is the wisest option. The problem may be glaucoma, with gradual visual loss that can never be regained.
Elderly patients may ask about an object that has become lodged in the eye. Perhaps they were engaging in a post-retirement hobby or craft that involved grinding or working with metal, wood, glass, or other materials. These activities can cause foreign materials to move toward the face and into the eye with a great deal of force.15 If the patient has not taken the protective step of wearing eye goggles, the object can lodge in the eye. The conjunctival surfaces have the capability of accommodating a certain degree of discomfort, so the irritation may eventually decrease, even though the object remains imbedded in the eye.1 Even if patients feel little discomfort at the time of counseling, they should be referred for an examination.
Elderly patients with eye infections should always be referred. Ophthalmic infections are usually either bacterial or viral in origin, such as conjunctivitis or bleph aritis. Nonprescription products are ineffective for both. This includes products for red eyes (e.g., Visine), as well as commercial or homemade boric acid solutions.
As you age, your eyes may become more vulnerable to a variety of problems. Serious conditions such as cataracts or glaucoma must be treated by an eye care professional, but relatively minor eye irritations like those described below can be self-treated with proper care.
You can treat dry eye for up to 3 days without seeing a physician or optometrist. During the day, you may find artificial tear drops (e.g., Refresh Tears, Refresh Celluvisc, GenTeal, TheraTears, Tears Naturale Forte) to be effective. The usual dose is 1 to 2 drops as needed, although you do not usually need to use the drops more than six times daily. During the night, you may choose ophthalmic ointments, which you use by carefully applying 0.25 inch of product to the inside of the lower eyelid. These products (e.g., Tears Naturale P.M., Bausch & Lomb Advanced Eye Relief Night Time, Refresh P.M.) can blur the vision if used during the day, but at night they are ideal for keeping the eyes from drying out.
Redness of the Eye
You may also self-treat redness of the eye due to minor irritation for up to 3 days with such products as Visine, Bausch & Lomb Advanced Eye Relief Redness, and Clear Eyes. However, if you have narrow-angle glaucoma, you should not use these products. In addition, using them beyond 72 hours can actually cause a condition of increased redness. Instead of continuing to use them, you should stop use completely so the eyes can recover.
Foreign Material in the Eye
You may be bothered by loose foreign material in the eye, such as an eyelash or dirt blown into the eye. If you cannot easily remove the irritant, you may try sterile eyewashes such as Bausch & Lomb Advanced Eye Relief Eye Wash or Collyrium for Fresh Eyes. However, the eyecups in those products can allow bacteria to contaminate your eye, so the eyecup should be discarded as soon as you open the package. Instead, gently allow a stream of liquid to pour into the eye, flooding the foreign material out of it.
You may have had hay fever when you were younger. If so, you may have noticed that standard oral antihistamines did not adequately treat the troubling eye problems that occur with allergies, such as tearing, itching, redness, and burning. Several eye drops can help with this annoying problem, such as Bausch & Lomb Opcon-A, Naphcon-A, and Visine-A. Place 1 to 2 drops in the eyes up to four times daily for no more than 3 days. Overuse can cause redness of the eye.
A new product known as Zaditor is dosed at 1 drop every 8 to 12 hours. While the first three products should not be used if you have heart disease, high blood pressure, difficulty in urination due to an enlarged prostate, or narrow-angle glaucoma, Zaditor can be used if you have these problems.
For problems more serious than those listed above, it is advisable to see your physician or optometrist.
Remember, if you have questions, Consult Your Pharmacist.
2. Kaercher T, Bron AJ. Classification and diagnosis of dry eye. Dev Ophthalmol. 2008;41:36-53.
3. King-Smith PE, Nichols JJ, Nichols KK, et al. Contributions of evaporation and other mechanisms to tear film thinning and break-up. Optom Vis Sci. 2008;85:623-630.
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15. Wasfi E, Kendrick B, Yasen T, et al. Penetrating eyelid injury: a case report and review of the literature. Head Face Med. 2009;5:2.
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