US Pharm. 2011;36(4):12-15.
Pharmacists often encounter patients with minor eye conditions who seek assistance in locating a nonprescription product. Fortunately, there are OTC products that are safe and effective for treating several eye problems, as long as patients read and follow all label directions.1
Although dryness of the eye can occur at any age, it is extremely common in elderly patients, affecting as many as 5 million Americans 50 years of age and older.1,2 The prevalence is estimated at 20% of those aged 45 years or more.1 It is four times more common in patients aged 65 years and above.1 Women are at greater risk, with 3 million of those aged 50 years and above affected, compared to 2 million men in the same age group.2 Many millions do not report the condition but experience less severe ophthalmic dryness.
The most common cause of dry eye is tear-deficient dry eye, a relatively uncomplicated partial or complete reduction in the quantity of tears.1 Patients also complain of dry eye in the winter when ambient air is extremely dry, a condition known as evaporative dry eye. Patients can be advised to minimize evaporation from the eye by keeping a vaporizer or humidifier running during the winter, as well as wearing sunglasses or glasses that fit close to the face or have shields on the sides (e.g., wraparounds).2
Dry eye is caused by a host of prescription and nonprescription drugs, including anticholinergics, antihistamines, diuretics, hormones, nasal decongestants, oral contraceptives, Parkinson’s medications, phenothiazines, and tricyclic and other antidepressants.1,2 Patients who take these medications should be advised to contact their physician rather than adjusting their dose themselves. Dry eye can also be caused by periorbital skin diseases, pregnancy, LASIK surgery, allergies, long-term wearing of contacts, failure to blink while staring at computer or video screens, chronic conjunctivitis (perhaps due to tobacco smoke, infection, or drafts), and by medical conditions (e.g., lupus, Sjögren’s syndrome, rheumatoid arthritis).1,3
Patients with dry eye complain of a burning, scratching, or stinging feeling in the eyes.4 The eyes may also feel tired or strained after reading, even for a short period. Those wearing contacts experience discomfort.
The National Eye Institute and other authoritative sources recommend nonprescription products as initial, first-line therapy for dry eye.2,5 Two approaches provide 24-hour coverage: tear replacement solutions (tear substitutes) during the day and ophthalmic ointments during the night.1 Tear substitutes may contain celluloses (e.g., hypromellose, carboxymethylcellulose), polyvinyl alcohol, glycerin, propylene glycol, polyethylene glycols, polysorbate 80, povidone, dextran, and/or gelatin. Celluloses are common ingredients because they increase the viscosity of the eye drop, which extends the useful duration of activity. They leave a small residue on the eyelashes as they evaporate, but it is easily removed or washed away. Similarly, if tears run down the cheek, a trail of cellulose is visible, but it is also easily removed.
Patients should place 1 to 2 drops of tear substitutes in the affected eye(s) as needed for up to 72 hours. If the symptoms persist beyond this time, they should stop using the product and see a physician.1 They should also stop using them if the condition worsens, or if they experience eye pain, changes in vision, or continued redness or irritation of the eye. Patients should be advised that temporary blurring of vision may occur due to the product’s viscosity, but it should only last a few minutes. Patients should be cautioned not to overuse the product, as using it six or more times daily can cause a rippled corneal surface.1 Products containing celluloses include Clear Eyes Tears, GenTeal Gel Drops, Refresh Plus, and Bion Tears. Dry-eye products with effective formulas that do not include celluloses include Systane Long Lasting Lubricant Eye Drops and Bausch & Lomb Advanced Eye Relief Dry Eye Rejuvenation Drops. For nighttime use, patients can use ocular emollients containing mineral oil or petrolatum (e.g., Refresh Lacri-Lube, Refresh PM).
Redness of the eye is caused by inflammation or dilation of blood vessels.1,6,7 This gives the eye an uncharacteristically red or bloodshot look, producing pain, photophobia, pruritus, and visual changes.7 The cause may be a serious problem, such as acute glaucoma, a foreign body, corneal abrasion or ulceration, excessive warfarin dosing, uveitis, blepharitis, or bacterial/viral conjunctivitis.6 Redness may also be due to less serious causes such as a subconjunctival hemorrhage from straining or coughing, the common cold, or allergic rhinitis.
Nonprescription products such as Visine contain vasoconstrictors that are safe and effective for patients 6 years of age and older when used for short-term (no longer than 72 hours) relief of red eye caused by minor irritation. Use beyond the time limit can cause rebound conjunctivitis, a condition in which the eyedrop itself promotes an extended redness.1 Patients with acute glaucoma should not use these products, as they can produce mydriasis, which may bring about an attack.1
Allergic conjunctivitis is an inflammation of the conjunctiva, causing such symptoms as red eye, dilated blood vessels, pruritus, burning, swollen eyelids (worse in the morning), tearing, and possibly a discharge from the eyes that is thick and stringy.1,8 Itching can be so intense that the patient repeatedly rubs the eyes to relieve it. Unfortunately, eye rubbing worsens the condition.
Allergic conjunctivitis is caused by exposure to an allergen, with subsequent release of histamine. To confirm that the problem is allergic in origin, the pharmacist can ask if the patient has other symptoms indicative of allergic rhinitis (e.g., rhinorrhea, nasal congestion, nasal itching, repeated bouts of sneezing).1 The pharmacist can also attempt to discover whether the problem occurs only at certain seasons of the year (e.g., heavy pollen periods), or when a specific environmental condition is present (e.g., room vacuuming, proximity to a cat, spraying of window cleaners, being close to a smoker).
The first line of defense is avoidance and environmental control. However, this is difficult, as families may be financially unable to comply (e.g., removal of all carpets), unwilling to face the consequences (e.g., being forced to give a beloved pet away), or unwilling to sacrifice for the good of the family (e.g., refusal to stop smoking in the house). Patients may find that a cool compress over the eyes provides some relief. Nonprescription oral antihistamines (e.g., Claritin, Zyrtec, Allegra Allergy) may also provide some relief.
Ophthalmic products specifically indicated for allergic conjunctivitis most often contain an antihistamine combined with a vasoconstrictor. They include Naphcon-A, Opcon-A, and Visine-A. The products are safe and effective in patients over the age of 6 years, in a dose of 1 to 2 drops in the affected eye(s) up to four times daily. Patients should stop using the product and see a physician if they experience eye pain, changes in vision, or continued redness or irritation of the eye, or if the condition persists for more than 72 hours. The drops can also cause rebound conjunctivitis if used too often or for too long a period.1,8 They should not be used by patients with heart disease, hypertension, difficulty in urination due to an enlarged prostate, or narrow-angle glaucoma, unless directed to do so by a physician.
Zaditor and Alaway typify another approach to allergic conjunctivitis—a product containing only an antihistamine, ketotifen. Ketotifen has concrete advantages when compared to the antihistamine-decongestant combinations. First, the decongestant contraindications (e.g., hypertension) do not apply to ketotifen. Second, ketotifen is also able to stabilize mast cells and inhibit eosinophils, enhancing its efficacy. Further, one drop provides relief for 8 to 12 hours, whereas the older combination products must be dosed every 4 to 6 hours. This decreased frequency of dosing enhances compliance. Finally, absence of a decongestant in the formula frees patients from the risk of rebound. Patients aged 3 years and above are directed to place one drop in the affected eye(s) twice daily, every 8 to 12 hours. If eye pain, changes in vision, redness of the eyes, or itching that worsens or lasts for more than 72 hours occurs, the patient should discontinue the product and see a physician.
Loose Foreign Material in the Eye
Patients occasionally ask the pharmacist about conditions that fall in the realm of first-aid interventions, such as loose foreign material in the eye. Common symptoms include discomfort, burning, stinging, smarting, tearing, itching, irritation, inflammation, redness, and uncontrollable blinking.1
First, it is vital to ensure that the patient did not engage in hammering, grinding, or any other activity in which a metal shaving or wood chip might have struck the eye at high velocity, causing the piece to become embedded in the eye. Those patients must always seek emergency physician care. Self-care is limited to loose material, such as an eyelash that cannot be easily removed or a bit of sand or dirt that blew into the eye.1 Patients should be advised to first wash their hands and examine the eye in good light, looking up and down and from side to side to locate the object.9 If this is not successful, they may grasp the lower eyelid, gently pulling it down to examine the area beneath. They may also place a cotton swab on the outside of the upper lid, gently flipping the lid over the swab to examine the area beneath. If the patient can see the object on the lid or the eye, he or she may flush the eye with water or a sterile nonprescription rinsing solution to facilitate removal. If the material is on the lid, the patient may also attempt removal with a cotton swab, although patients should be advised not to touch the eye itself with a swab.
Suitable nonprescription rinsing products include Collyrium for Fresh Eyes and Bausch & Lomb Advanced Relief Eye Wash.1 These sterile, nonmedicated eye washes can be used to flush the eye gently after removal of contacts. The degree of pressure placed on the squeeze bottle controls the force with which the fluid rushes into the eye. These products include an eyecup in the package, but patients should be cautioned not to use these devices, as they cannot be considered sterile at the point of use due to environmental contamination and an inability to sterilize the cup before or after use. The products also claim to help in eyes affected by air pollutants (smoke or pollen) and chlorinated water. Like other nonprescription ophthalmics, they should not be used if the patient has eye pain, changes in vision, or continued redness or irritation of the eye, or if any condition seems to worsen or persist. These products also should not be used for any wound in or near the eyes.
Generally, you will need to seek professional care from an optometrist or ophthalmologist when you have pain in the eyes, when your vision changes, or when your eye continues to be red or feel irritated. Many nonprescription eye products also caution you to discontinue using them and seek professional care if the condition persists for more than 72 hours.
Dry eye is common, and many OTC products are available to treat it. They include drops and gels for daytime use and small tubes of ointment for nighttime use. Examples include Refresh, GenTeal, and TheraTears (daytime) and Refresh PM and Refresh Lacri-Lube (nighttime).
You may have redness of the eye from the common cold and allergies. Products such as Visine can remove minor redness, although you should not use them if you have narrow-angle glaucoma, and you must stop using them after 3 days to prevent a condition in which the product actually causes the redness, known as rebound conjunctivitis.
You may have an allergic condition of the eyes, caused by the same sources that produce hay fever (e.g., pollen, spray cleaners, cat dander). Your eyes itch, water, and burn. Products such as Opcon-A, Naphcon-A, and Zaditor can provide relief. Be sure not to administer any products to children below the lowest ages specified on the label.
You may have a loose foreign material in the eye, such as dirt or an eyelash. Collyrium for Fresh Eyes and Bausch & Lomb Advanced Relief Eye Wash are products that can gently cleanse the eye.
Infections of the eye or surrounding skin should always be seen by an eye care professional. This includes pinkeye, styes, infections of the eyelids, and other suspected infections.
Physicians may need to prescribe antibiotics or other safe and effective products.
Objects Lodged in the Eye
If you believe an object has become lodged in your eye from working with wood or metal or from any other activity, visit an emergency room if a physician cannot see you immediately. You should not wait, as your eye may not register the discomfort after a short period, making you think the object is gone.
Home remedies for the eye can be extremely dangerous, as they will not be sterile and may cause pain and permanent loss of vision. For example, boric acid is an old home remedy for eye infections, but its use can be hazardous, especially for infants. This substance may be included in very small amounts in legitimate eye products, but making your own boric acid eye treatments at home can cause serious harm.
As always, read and follow all directions on any label. If you need further information, ask your pharmacist for assistance.
1. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
2. Facts about dry eye. National Eye Institute. www.nei.nih.gov/health/dryeye/
3. Dry eye syndrome. MedlinePlus. www.nlm.nih.gov/medlineplus/
4. Dry eyes. MedlinePlus. www.nlm.nih.gov/medlineplus/
5. Dry eye syndrome. National Guideline Clearing House. Agency for Healthcare Research and Quality. www.guideline.gov/content.
6. Eye redness. MedlinePlus. www.nlm.nih.gov/medlineplus/
7. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81:137-145.
8. Allergic conjunctivitis. MedlinePlus. www.nlm.nih.gov/medlineplus/
9. Eye—foreign object in. MedlinePlus. www.nlm.nih.gov/medlineplus/
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