Age-Related Macular Degeneration (AMD) Overview
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Questions and Answers

What is the most common form of blindness caused by Age-Related Macular Degeneration (AMD)?

  • Wet AMD (correct)
  • Metamorphopsia
  • Dry AMD
  • Blurred vision

    • What percentage of individuals in the US aged 65 to 75 have Age-Related Macular Degeneration (AMD)?

  • 5%
  • 10% (correct)
  • 20%
  • 30%

    • Which of the following antioxidant components was not included in the AREDS study formulation?

  • Zinc (80mg with 2mg copper)
  • 15mg beta-carotene
  • Eicosapentaenoic acid (EPA) (correct)
  • 500mg vitamin C

    • What was the reported reduction in progression for patients with moderate AMD as a result of the AREDS formulation?

    <p>30%</p> Signup and view all the answers

    In the AREDS2 study, what was the result of substituting beta-carotene with lutein and zeaxanthene?

    <p>Reduced progression to wet AMD in certain patients</p> Signup and view all the answers

    What is a primary characteristic of the advanced stage of Dry AMD?

    <p>Mild vision loss to legal blindness</p> Signup and view all the answers

    What percentage of AMD-related blindness is associated with Dry AMD?

    <p>14%</p> Signup and view all the answers

    What significant risk does Age-Related Macular Degeneration (AMD) pose to the fellow eye?

    <p>Significant risk of damage</p> Signup and view all the answers

    What should be done if irritation from foreign material in the eye is severe or persistent?

    <p>Refer for treatment immediately.</p> Signup and view all the answers

    Which of the following is NOT a recommended isotonic solution for self-treatment of foreign material in the eye?

    <p>Antibacterial eye drops</p> Signup and view all the answers

    Which symptom would primarily indicate a bacterial conjunctivitis condition?

    <p>Very red eye with grayish, yellowish mucous discharge</p> Signup and view all the answers

    What is the recommended position for flushing the eye when using an irrigating solution?

    <p>Leaning forward with the affected eye down</p> Signup and view all the answers

    Which symptom is associated with viral conjunctivitis, commonly known as 'Pink Eye'?

    <p>Copious watery discharge</p> Signup and view all the answers

    What is a common feature of allergic conjunctivitis?

    <p>Pinkish eye with itching and some watering</p> Signup and view all the answers

    What is the primary risk associated with using eye cups for treatment?

    <p>Contamination</p> Signup and view all the answers

    What immediate action is advised if foreign material in the eye is suspected to be related to chemical exposure?

    <p>Refer for medical treatment without delay.</p> Signup and view all the answers

    What is one common characteristic of artificial tears that use preservatives?

    <p>They should generally not be used more than four times a day due to irritation.</p> Signup and view all the answers

    Which of the following ingredients is NOT commonly found in artificial tears?

    <p>Fluorescein sodium</p> Signup and view all the answers

    Which preservative is considered 'mild' and breaks down to inert ingredients upon contact with the eye?

    <p>Sodium perborate</p> Signup and view all the answers

    What is a key difference between Lumify and Visine in terms of their active ingredients?

    <p>Lumify contains brimonidine tartrate, while Visine contains tetrahydrozoline HCl.</p> Signup and view all the answers

    Which active ingredient in artificial tears is known for reducing redness caused by minor irritations?

    <p>Brimonidine tartrate</p> Signup and view all the answers

    What should be done after applying eye drops before administering an ointment?

    <p>Wait at least 10 minutes.</p> Signup and view all the answers

    What is a potential drawback of using artificial tears with preservatives?

    <p>They may cause discomfort and irritation with frequent application.</p> Signup and view all the answers

    Which of the following treatments is best for patients who have trouble using eye drops?

    <p>Ocular inserts</p> Signup and view all the answers

    How can patients mitigate the discomfort from high-viscosity artificial tears?

    <p>Switch to a lower-viscosity agent.</p> Signup and view all the answers

    When is it recommended to use preservative-free artificial tears?

    <p>When more frequent application is needed.</p> Signup and view all the answers

    What is the general dosing guideline for artificial tears?

    <p>1-2 drops in the affected eye 1-4 times per day.</p> Signup and view all the answers

    What type of artificial tears is known for providing long-lasting relief and is suitable for lipid-deficient dry eye?

    <p>Oil-containing drops</p> Signup and view all the answers

    Which of the following is an example of a preservative-free artificial tear product?

    <p>Tears Again</p> Signup and view all the answers

    What does the AREDS study indicate about the effect of antioxidants on patients with moderate AMD?

    <p>Antioxidants significantly reduced progression by 30%.</p> Signup and view all the answers

    What is a common symptom associated with early-stage Age-Related Macular Degeneration (AMD)?

    <p>Blurred vision.</p> Signup and view all the answers

    In the AREDS2 study, which change did NOT affect the progression of AMD?

    <p>Adding omega-3 fatty acids.</p> Signup and view all the answers

    What percentage of AMD-related blindness is accounted for by 'Wet' AMD?

    <p>86%</p> Signup and view all the answers

    What is the age range monitored in the AREDS study?

    <p>55 to 80 years.</p> Signup and view all the answers

    What is the expected percentage of individuals over 75 years in the US with a visual impairment related to AMD?

    <p>30%</p> Signup and view all the answers

    What does the intermediate stage of AMD imply about progression to advanced stages?

    <p>Moderate progression expected in 18% of cases.</p> Signup and view all the answers

    What is the overall expectation for visual impairment in developed countries regarding AMD by 2020?

    <p>It is expected to double.</p> Signup and view all the answers

    What condition may allow for self-treatment of foreign material in the eye?

    <p>Loose foreign material with minor irritation</p> Signup and view all the answers

    Which of the following is NOT a suitable solution for flushing the eye?

    <p>Hydrogen peroxide</p> Signup and view all the answers

    Which symptom is characteristic of bacterial conjunctivitis?

    <p>Very red eye with grayish, yellowish mucous discharge</p> Signup and view all the answers

    What is a proper technique for using an irrigating eye wash?

    <p>Tilt head with the ear next to the affected eye down</p> Signup and view all the answers

    What distinguishes allergic conjunctivitis from viral conjunctivitis?

    <p>Watery eyes with itching and little discharge</p> Signup and view all the answers

    What is the recommended action if self-treatment for foreign material in the eye is unsuccessful?

    <p>Refer the patient for treatment</p> Signup and view all the answers

    Which type of discharge is associated with viral conjunctivitis?

    <p>Copious watery discharge</p> Signup and view all the answers

    What precaution should be taken when using eye cups to flush the eye?

    <p>There is a risk of contamination</p> Signup and view all the answers

    What is a key component of the AREDS2 formulation that helps in AMD prevention?

    <p>10mg lutein</p> Signup and view all the answers

    Which statement about the new formulations available after AREDS2 is accurate?

    <p>They fall under the category of nutraceuticals.</p> Signup and view all the answers

    Which of the following combinations is contraindicated for smokers in vitamin formulations?

    <p>Vitamin A included in the formulation</p> Signup and view all the answers

    What has been noted about ocular vitamins that are not part of the AREDS formulation?

    <p>They often lack large controlled studies.</p> Signup and view all the answers

    What is a claimed benefit of Ocuvite regarding eye health?

    <p>Provides protection against blue light.</p> Signup and view all the answers

    What does the presence of multiple vitamins without clinically demonstrated effectiveness imply for AMD?

    <p>They may not offer any real benefit for AMD.</p> Signup and view all the answers

    How does the AREDS2 formulation potentially benefit former smokers specifically?

    <p>By reducing the risk of lung cancer.</p> Signup and view all the answers

    What common misconception about ocular vitamins can lead to ineffective treatment choices?

    <p>All formulations can treat AMD.</p> Signup and view all the answers

    What is a common contributor to dry eye syndrome?

    <p>Sjögren syndrome</p> Signup and view all the answers

    Which sign indicates that a referral to an eye doctor is necessary?

    <p>Discharge from the eye</p> Signup and view all the answers

    What is the best method for administering eye drops?

    <p>Tilt head back and pull lower eyelid away to form a pouch</p> Signup and view all the answers

    Which of the following treatments is often recommended for dry eye?

    <p>Topical lubricants like artificial tears</p> Signup and view all the answers

    What is a significant risk of using Visine compared to Lumify?

    <p>Increased likelihood of rebound redness</p> Signup and view all the answers

    What is the purpose of the lipid layer in the tear film?

    <p>To prevent evaporation of tears</p> Signup and view all the answers

    What should be done if the first artificial tears do not relieve dry eye symptoms?

    <p>Switch to a different drop with different ingredients</p> Signup and view all the answers

    Which type of artificial tears can be used more frequently without irritation?

    <p>Preservative-free artificial tears</p> Signup and view all the answers

    What component of artificial tears may prevent them from working effectively?

    <p>Overuse or reliance on high-viscosity drops</p> Signup and view all the answers

    Which method can help to increase the effectiveness of eye drops after application?

    <p>Closing the eyes and minimizing blinking</p> Signup and view all the answers

    What is the recommended action if using drops and ointment together?

    <p>Apply drops first and wait 10 minutes before ointment</p> Signup and view all the answers

    Which of the following conditions is commonly treated with over-the-counter products?

    <p>Subconjunctival hemorrhage</p> Signup and view all the answers

    What active ingredient in Lumify is responsible for reducing redness in the eyes?

    <p>Brimonidine tartrate</p> Signup and view all the answers

    What is the primary recommended treatment for bacterial conjunctivitis?

    <p>Topical antibacterial drops</p> Signup and view all the answers

    Which of the following medications is used for viral conjunctivitis caused by herpes simplex virus?

    <p>Trifluridine eye drops</p> Signup and view all the answers

    What is the key advice for patients suffering from allergic conjunctivitis?

    <p>Do not rub or scratch the eyes</p> Signup and view all the answers

    Which class of medication is NOT typically associated with treating allergic conjunctivitis?

    <p>Oral corticosteroids</p> Signup and view all the answers

    What is a common characteristic of a hordeolum?

    <p>Palpable nodule and swelling</p> Signup and view all the answers

    Which treatment is typically recommended for managing chalazion?

    <p>Hot compresses with message</p> Signup and view all the answers

    What condition is associated with increased fluid accumulation in the cornea?

    <p>Corneal edema</p> Signup and view all the answers

    What is a potential side effect of topical antihistamines in treating eye conditions?

    <p>Rebound congestion</p> Signup and view all the answers

    Which of the following is a common symptom of blepharitis?

    <p>Red, scaly, thickened eyelids</p> Signup and view all the answers

    Which of the following treatments is NOT recommended for hiccuping issues related to subconjunctival hemorrhage?

    <p>Topical antibiotics</p> Signup and view all the answers

    What is a recommended dosage interval for Muro 128 5% ointment?

    <p>1 to 2 drops every 3 to 4 hours</p> Signup and view all the answers

    Which condition is characterized by itching and redness, often confused with allergies?

    <p>Blepharitis</p> Signup and view all the answers

    What side effect is commonly associated with prolonged use of topical antihistamines for eye relief?

    <p>Dryness and stinging</p> Signup and view all the answers

    What is the proper treatment for asymptomatic pinguecula?

    <p>Artificial tears and sunglasses</p> Signup and view all the answers

    Study Notes

    • AMD is a degeneration of the macula that commonly begins after the age of 55.
    • AMD progresses and early signs include blurred vision, metamorphopsia, and loss of brightness.
    • It was responsible for 8.7% of all blindness worldwide in 2007, and this figure is expected to double by 2020.
    • It is the most common cause of blindness in developed countries.
    • 10% of individuals in the US between 65 and 75 years old have AMD.
    • 30% of individuals in the US over 75 years old have a visual impairment related to AMD.

    AMD Progression

    • The progression of AMD differs depending on the stage.
    • In the early stage, the progression to an advanced stage is slow or nonexistent in 5 years (~1%).
    • In the intermediate stage, moderate progression to an advanced stage occurs in 5 years (18%). It can be treated with over-the-counter (OTC) medication.
    • The advanced stage of AMD can be categorized into "Dry" and "Wet" AMD.
      • Dry AMD is associated with mild vision loss to legal blindness and accounts for 14% of AMD-related blindness.
      • Wet AMD presents with moderate vision loss to legal blindness and accounts for 86% of AMD-related blindness.
    • There's a significant chance of further AMD damage affecting the other eye.

    AREDS Study

    • The Age-Related Eye Disease Study (AREDS) group monitored 4,757 participants aged 55 to 80 years old.
    • Participants received a placebo or antioxidants: 15 mg beta-carotene, 500 mg vitamin C, 400 IU vitamin E, and zinc (80 mg with 2 mg copper).
    • These antioxidants significantly reduced the progression (30%) in patients with moderate AMD.
    • This specific combination of supplements is marketed as AREDS vitamins.

    AREDS 2 Study

    • This study focused on 4,023 participants aged 55 to 80 years old.
    • Lowering the zinc concentration and eliminating beta-carotene from the original AREDS formulation had no noticeable impact on progression.
    • Switching beta-carotene for lutein plus zeaxanthin reduced progression to wet AMD but not overall progression.
      • For patients in the lowest quintile of lutein and zeaxanthin dietary intake, lutein plus zeaxanthin decreased overall progression.
    • Adding docosahexaenoic acid (DHA) plus eicosapentaenoic acid (EPA) (omega-3 fatty acids), or both, to the AREDS formulation (original or variant) had no effect on overall progression for the entire group.

    Healthy Eye

    • The cornea, iris, pupil, limbus, punctum, and conjunctiva are all vital components of a healthy eye.
    • The eyelid margin plays a crucial role in protecting the eye.

    Conditions Treatable with OTC Products

    • Dry eye
    • Foreign material in the eye
    • Conjunctivitis (allergic or viral)
    • Red eye from other causes:
      • Subconjunctival hemorrhage
      • Pinguecula
      • Pterygium
    • Corneal edema
    • Eyelid problems:
      • Hordeolum
      • Chalazion
      • Blepharitis
      • Demodex
    • Macular Degeneration

    Referral Signs

    • Eye pain beyond irritation or temporary shooting pains
    • Eye discharge other than tearing
    • Vision changes, including blur, diplopia, or metamorphopsia
    • Light sensitivity
    • Blunt trauma, chemical or heat exposure
    • Symptoms persisting for more than 3 days
    • Flashes, new floaters, or a "curtain" or "cloud" in vision
    • Problems in contact lens wearers (excluding dryness)

    Dry Eye

    • Dry eye is caused by abnormalities in tear film production, availability, and stability.
    • Factors contributing to dry eye:
      • Environmental exposures: allergens, reduced humidity, dry, dusty air.
      • Medical conditions: lid or corneal defects, Sjögren syndrome, rheumatoid arthritis, Bell palsy.
      • Medications: antihistamines, diuretics, anticholinergic effects.
      • Aging: dermatochalasis, aponeurotic, ectropion.
    • Moderate to severe or non-responsive cases should be referred.

    The Tear Film

    • Tear film consists of three layers:
      • Lipid layer: secreted by meibomian glands, glands of Zeiss and Moll, prevents evaporation.
      • Aqueous layer: secreted by lacrimal glands, glands of Krause and Wolfring.
      • Mucin layer: secreted by goblet cells, attaches and spreads tear film over the ocular surface.

    Dry Eye Signs and Symptoms

    • Reddish conjunctiva
    • Sandy, gritty sensation
    • Reflex tearing
    • Sharp pains of short duration

    Dry Eye Treatment Goals

    • Improve tear quantity and quality.
    • Relieve signs and symptoms.
    • Prevent or reverse corneal damage (superior punctate keratitis → exposure keratopathy).

    Dry Eye Treatment Approach

    • Non-pharmaceutical:
      • Avoidance of environmental irritants.
      • Insertion plugs into puncta (prevents tear drainage).
      • Surgery - Eyelid and adnexa.
    • Prescription (Rx):
      • Topical perflurorhexyloctane (Meibo).
      • Topical cyclosporine (Restasis, Cequa).
      • Topical lifitegrast (Xiidra).
      • Intranasal varenicline (Tyrvaya).
    • OTC
      • Topical lubricants (artificial tears, non-medicated ointment, etc.).
      • Ocular inserts and sprays.
      • Topical brimonidine tartrate 0.025% (Lumify) for redness.

    Artificial Tears

    • Artificial tears (ATs) are like "hand cream for the eyes".
    • Regular use improves the ocular surface and reduces dry eye symptoms.
    • Use only when eyes hurt provides only brief relief.
    • Frequency of use can be limited due to preservatives.
    • Most ATs haven't shown a significant difference in their effectiveness for treating dry eye.
    • ATs claim to offer additional benefits.

    Artificial Tear Preservatives

    • Conventional: benzalkonium chloride (BAK), polyquad (PQ), do not use more than QID (4 times a day) to avoid irritation.
    • Mild: GenAqua (sodium perborate), Purite, OcuPure (stabilized oxychloro complex), SofZia (ionic-buffered solution), break down into inert ingredients upon contact with the eye, can be used more often than QID.
    • Preservative-free (PF): no limitation on frequency of use.

    Artificial Tear Active Ingredients

    • Carboxymethyl cellulose: Optive (compatible solutes, mild preservative), Refresh Tears (combined with glycerol; mild preservative and PF), Thera Tears (hypotonic, PF).
    • Polyethylene glycol / Propylene glycol: Systane, Systane Ultra (hydroxypropyl guar; PQ or PF), Systane Balance (LipiTech system; PQ), Blink Tears (hyaluronic acid, mild preservative).
    • Hydroxypropyl methylcellulose (HPMC): Genteal (mild preservative), Tears brand (with dextran, some with glycerin; PQ or PF), Visine Tears (with glycerin and PEG; BAK).
    • Glycerine: Oasys Tears Plus (non-preserved), Moisture Eyes (with propylene glycol), Soothe Lubricating Eye Drops (with propylene glycol; mild preservative).
    • Polyvinyl alcohol (PVA): Tears Again (PF), FreshKote (PQ), Amisol CLEAR (phospholipids, polysorbate-80, glycerin).

    Artificial Tear Inactive Ingredients

    • Surfactants, mucin mimics, and in-bottle thinners for active ingredients.

    “Digital” and “Contact” Artificial Tears

    • These are specifically designed for those who spend a lot of time in front of screens or who wear contact lenses.

    Artificial Tear Administration

    • General dosing: 1-2 drops into the affected eye 1-4 times a day.
      • Use PF products more often.
    • Administration:
      • Tilt head back and gently grasp lower eyelid, pulling it away from the eye to form a pouch.
      • Look up and apply a drop. Release eyelid.
      • Close the eye and minimize blinking.
      • Use a finger to apply gentle pressure over the tear duct (punctum).
      • Wait at least 5 minutes before instilling the next drop.

    Failure of Artificial Tears to Provide Relief

    • Change to AT with different active (and inactive) ingredients (different polymer and/or preservative system).
    • Increase the frequency of use (check preservative).
    • Switch to an oil, ointment, or gel, or add thicker viscosity drops at bedtime to ATs during the day.
    • Discuss compliance.
    • Refer to an eye doctor.

    Oils, Gels, Ointments

    • Oil-containing drops: Refresh Endura (castor oil, polysorbate 80, carbomer 1342, glycerin; PF), SootheXP (light mineral oil, mineral oil, polysorbate 80; PQ).
    • Ointments and gels: Refresh PM ointment (white petrolatum, mineral oil; PF), Tear Naturale PM ointment (white petrolatum, mineral oil; PF), Genteal Gel (HPMC, carbopol 980; mild preservative), Tear Again Night and Day Gel (carboxymethyl cellulose, mild preservative), Liposic gel (phospholipid liposomes, PF).

    Ointment Administration

    • Gently pull the lower lid away from the eye and apply ¼ - ½ inch ribbon.
    • Avoid contact between the applicator and the eye.
    • Wait 10 minutes after applying drops before using ointment if both are used (using ointment first would prevent drops from penetrating the tear film or cornea).

    Inserts and Sprays

    • Inserts: Lacriserts (hydroxypropyl cellulose, non-preserved).
    • Tear Again Advanced Liposomal Spray (mild preservative)
      • Contains liposomes and vitamins (A,C,E).
      • Especially beneficial for lipid-deficient dry eye.
      • Helpful for patients who have trouble with eye drops.

    Lumify

    • Brimonidine 0.025% (Bausch and Lomb).
    • Alpha-2 adrenergic agonist.
    • For ocular redness due to minor eye irritations.
    • Fast-acting (1 minute) and long-lasting efficacy.
    • OTC for those 5 years and older.
    • 1 drop every 6-8 hours.

    Lumify Comparison to Visine

    • Visine:
      • Active ingredient is tetrahydrozoline HCI, 0.05%.
      • Alpha-2 agonist.
      • Tolerance develops with repeated use.
      • Rebound redness occurs when discontinued after tolerance has developed.
    • Lumify:
      • Active ingredient is brimonidine tartrate, 0.025%.
      • Also an alpha-2 agonist.
      • Low risk of tachyphylaxis or rebound hyperemia when used as directed.

    Which Dry Eye Treatment to Recommend

    • Milder preservatives are less likely to cause eye irritation.
      • Use PF products if frequent application is recommended.
    • Time on the eye (acute period of relief) depends on viscosity and certain ingredients, such as guar.
    • Oils and lipid/liposomal formulations are good for cases with eyelid problems.

    Foreign Material

    • Irritation and tearing caused by foreign material in the eye.
    • Self-treatment is only acceptable if the foreign material is loose, irritation is minor, and it's not related to chemical exposure or penetrating injury.
      • Refer if self-treatment is unsuccessful.
    • Otherwise, or if in doubt, refer for treatment.

    Foreign Material Referral

    • Refer all instances of potential penetration, chemical exposure, embedded objects, or suspected corneal abrasion.

    Loose Foreign Body – May Self-Treat

    • If a loose foreign body is present, self-treatment can be attempted.

    Loose Foreign Body Self-Treatment

    • Use an isotonic, buffered solution intended to flush the eye.
    • Examples:
      • Accu-Wash (irrigating solution).
      • Eye Stream Eye Wash.
      • Sterile saline solution.
      • Contact lens rinsing solution (if available).

    Irrigating Eye Wash Use

    • Bend over a sink or towel and tilt the head with the ear next to the affected eye down.
    • Hold the bottle next to the nose near the corner of the affected eye.
    • Squeeze the bottle and allow the solution to flow across the eye.
    • Repeat for the other eye if affected.
    • Avoid using eye cups due to the risk of contamination.

    Conjunctivitis

    • Conjunctivitis can be viral (“Pink Eye”), bacterial (“Red Eye”), or allergic.

    Conjunctivitis Classifications

    • Viral:
      • Pinkish-red eye with copious watery discharge.
      • Slow onset.
      • Mild pain; sensation of a foreign object in the eye.
      • Often associated with a history of exposure to viral respiratory infection.
      • May be associated with fever.
      • Bilateral.
      • Contagious!
    • Bacterial:
      • Very red eye with grayish, yellowish mucous discharge.
      • Rapid onset.
      • Moderate to severe pain.
      • May relate to an upper respiratory infection.
      • Bilateral.
    • Allergic:
      • Pinkish eye with itching.
      • Watering but little or no discharge.
      • Slow or rapid onset.
      • May be chronic or recent.
      • Bilateral.
      • Chronic red eyes.
      • Tearing/blurring.
      • Papillae inside the lids.

    Ophthalmic Conditions Treated with OTC Products

    • Conditions: Dry eye, foreign material in eye, allergic or viral conjunctivitis, red eyes (subconjunctival hemorrhage, pinguecula, pterygium), corneal edema, eyelid problems (hordeolum, chalazion, blepharitis, Demodex), macular degeneration.
    • Referral Necessary:
      • Eye pain (other than irritation)
      • Discharge from eye
      • Vision changes (blur, double vision, distortions)
      • Light sensitivity
      • Blunt trauma or chemical/heat exposure
      • Symptoms lasting more than 3 days
      • Flashes, floaters, "curtain" or "cloud" in vision
      • Contact lens problems (except dryness)

    Condition 1: Dry Eye

    • Causes: Abnormalities in tear film production, availability, and stability.
    • Contributors:
      • Environmental: Allergens, reduced humidity, dry air
      • Medical: Lid or corneal defects, Sjögren syndrome, rheumatoid arthritis, Bell palsy
      • Medications: Antihistamines, diuretics, anticholinergic medications
      • Aging: Dermatochalasis, aponeurotic, ectropion
    • Moderate to Severe or Non-Responding Cases: Should be referred to an eye doctor.

    The Tear Film

    • Lipid Layer: Secreted by meibomian glands, prevents evaporation.
    • Aqueous Layer: Secreted by lacrimal glands, provides moisture.
    • Mucin Layer: Secreted by goblet cells, attaches and spreads the tear film over the ocular surface.

    Dry Eye Signs and Symptoms

    • Reddish conjunctiva
    • Sandy, gritty feeling
    • Reflex tearing
    • Sharp pains of short duration

    Dry Eye Treatment Goals

    • Improve: Tear quantity and quality
    • Relieve: Signs and symptoms
    • Prevent or Reverse: Corneal damage (superior punctate keratitis → exposure keratopathy)

    Dry Eye Treatment Approach

    • Non-Pharmaceutical: Avoiding irritants, punctal plugs, eyelid surgery
    • Prescription: Topical perfluorhexyloctane (Meibo), topical cyclosporine (Restasis, Cequa), topical lifitegrast (Xiidra), intranasal varenicline (Tyrvaya)
    • OTC: Topical lubricants (artificial tears, ointments), ocular inserts and sprays, topical brimonidine tartrate 0.025% (Lumify) for redness

    Artificial Tears

    • Purpose: Improve ocular surface and decrease dry eye symptoms
    • Use: Use only when eyes hurt; provides brief relief
    • Frequency: Limited by preservatives
    • Effectiveness: No proven difference between most artificial tears
    • Ancillary Advantages: Different brands claim various benefits

    Artificial Tear Preservatives

    • Conventional: Benzalkonium chloride (BAK), Polyquad (PQ) - Use no more than 4 times per day
    • Mild: GenAqua, Purite, OcuPure, SofZia - Can use more often than 4 times per day
    • Preservative-Free (PF): No frequency limitations

    Artificial Tear Active Ingredients

    • Carboxymethyl cellulose: Optive, Refresh Tears, Thera Tears
    • Polyethylene glycol / Propylene glycol: Systane, Systane Ultra, Systane Balance, Blink Tears
    • Hydroxypropyl methylcellulose (HPMC): Genteal, Tears brand, Visine Tears
    • Glycerine: Oasys Tears Plus, Moisture Eyes, Soothe Lubricating Eye Drops
    • Polyvinyl alcohol (PVA): Tears Again, FreshKote, Amisol CLEAR

    Artificial Tear Inactive Ingredients

    • Surfactants, mucin mimics, and in-bottle thinners for active ingredients

    “Digital” and “Contact” Artificial Tears

    • Digital: For users of digital devices
    • Contact: Solutions designed for contact lens wearers

    Artificial Tear Administration

    • Dosing: 1-2 drops in affected eye 1-4 times per day; use preservative-free products more often.
    • Procedure:
      • Tilt head back
      • Gently pull lower eyelid down to create a pouch
      • Look up and apply a drop
      • Close eye and minimize blinking
      • Put gentle pressure over tear duct (punctum)
      • Wait at least 5 minutes before instilling another drop

    Failure of Artificial Tears to Provide Relief

    • Change: The active (and inactive) ingredients
    • Increase: Frequency of use (check preservative)
    • Switch: To an oil, ointment, or gel; thicken viscosity drops at bedtime
    • Discuss: Compliance; some patients dislike thick drops and may need to use thinner agents more frequently
    • Refer: To an eye doctor

    Oils, Gels, and Ointments

    • Oils: Refresh Endura, SootheXP
    • Ointments: Refresh PM ointment, Tear Naturale PM ointment, Genteal Gel, Tear Again Night and Day Gel, Liposic gel
    • Gels: Liposic gel

    Ointment Administration

    • Procedure:
      • Gently pull lower eyelid away from eye and apply ¼ - ½ inch ribbon.
      • Avoid contact between applicator and eye.
      • Wait 10 minutes after applying drops before using ointment.

    Inserts and Sprays

    • Inserts: Lacriserts
    • Sprays: Tear Again Advanced Liposomal Spray (contains liposomes and vitamins A, C, E)

    Lumify

    • Active Ingredient: Brimonidine 0.025% (Bausch and Lomb)
    • Purpose: For ocular redness due to minor eye irritations
    • Action: Alpha-2 adrenergic agonist; fast acting (1 minute) and long-lasting
    • OTC: Available over the counter
    • Age: For individuals 5 years or older
    • Dosing: 1 drop every 6-8 hours

    Comparison with Visine

    • Visine:
      • Active ingredient: Tetrahydrozoline HCI, 0.05% (alpha-2 agonist)
      • Tolerance develops with repeated use
      • Rebound redness occurs after discontinuation
    • Lumify:
      • Active ingredient: Brimonidine tartrate, 0.025% (alpha-2 agonist)
      • Low risk of tachyphylaxis or rebound hyperemia when used as directed

    Which Dry Eye Treatment to Recommend

    • Milder Preservatives: Less likely to cause irritation
    • Preservative-Free: Use if frequent application is recommended
    • Time on the Eye: Viscosity and ingredients (like guar) influence the duration of relief
    • Oils and Lipid/Liposomal Formulations: Good for cases with eyelid problems

    Foreign Material in the Eye

    • Refer patients if foreign material is deeply embedded, irritation is severe, or if chemical exposure or penetrating injury is suspected.
    • For loose foreign bodies, recommend irrigating the eye with an isotonic, buffered solution.
    • Avoid using eye cups due to the risk of contamination.

    Conjunctivitis

    • Viral conjunctivitis (Pink eye) is often associated with viral respiratory infections and is contagious.
    • Bacterial conjunctivitis (Red eye) presents with rapid onset and moderate to severe pain.
    • Allergic conjunctivitis is characterized by itching, watering, and possible chronic or recent onset.

    Treatment for Conjunctivitis

    • Viral conjunctivitis: Refer to an eye doctor and consider topical antiviral treatments such as Trifluridine (Viroptic®) or Ganciclovir (Zirgan®).
    • Bacterial conjunctivitis: Refer to an eye doctor and consider topical antibacterial drops such as Polytrim, Moxifloxacin, Ofloxacin, Erythromycin, or Tobradex (if diagnosis is uncertain).
    • Allergic conjunctivitis: Recommend artificial tears (chilled), topical antihistamines and/or mast cell stabilizers (Rx or OTC), oral antihistamines. Counsel patients to avoid rubbing or scratching eyes. Refer if condition persists.

    Topical Mast Cell Stabilizers

    • Many topical mast cell stabilizers are available for allergic conjunctivitis, including Lodoxamide (Alomide), Cromolyn (Crolom), Nedocromil (Alocril), and Pemirolast (Alamast).
    • These medications take 7 to 14 days to work and are most effective when administered before the allergic response begins.

    Topical Antihistamines

    • Topical antihistamines are beneficial for allergic conjunctivitis. Examples include Emedastine (Emadine), Cetirizine (Zerviate), Azelastine (Optivar), Bepotastine (Bepreve), and Epinastine (Elestat).

    Oral Antihistamines

    • Various OTC oral antihistamines can be recommended for allergic conjunctivitis, including Diphenhydramine (Benadryl), Cetirizine (Zyrtec), Fexofenadine (Allegra), Loratadine (Claritin), and Chlorpheniramine (Chlor-Trimeton).

    OTC Topical Antihistamine/Mast Cell Stabilizer Combinations

    • Several OTC combination medications are available, including Ketotifen (Zaditor, Alaway, TheraTears Eye Itch Relief), Olopatadine (Pataday, Pataday Twice Daily Relief, Pataday Once Daily Relief Extra Strength), and Alcaftadine (Lastacaft).

    Contraindications and Cautions

    • Avoid OTC topical antihistamines/mast cell stabilizers in narrow angle glaucoma.
    • Use with caution in diabetes and heart disease.
    • Be aware of drug interactions, such as with tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs).

    Subconjunctival Hemorrhage

    • Refer patients with symptomatic complaints.
    • For asymptomatic subconjunctival hemorrhage (first occurrence), suggest artificial tears.

    Pinguecula and Pterygium

    • Refer patients with symptomatic complaints.
    • For asymptomatic pingueculae and pterygia, recommend artificial tears and sunglasses.
    • Refer all contact lens wearers with red eyes, especially if it is related to contact lens wear.
    • Educate contact lens wearers about important maintenance practices: regular case replacement, use of re-wetting drops, and compliance with replacement schedules and wear instructions.

    Corneal Edema

    • Refer patients for diagnosis and treatment.
    • Topical hypertonic sodium chloride solutions such as Muro 128 (2% and 5%) can be used to promote fluid movement from the cornea.
    • 2% Muro 128 is better tolerated long-term, while 5% is associated with more stinging and burning.

    Eyelid Problems

    • Hordeolum (Stye): Apply hot compresses and massage the area 3-4 times daily. Refer for topical or oral antibiotics if needed.
    • Chalazion: Apply hot compresses and massage the area 3-4 times daily. Refer if condition persists.
    • Blepharitis: Regularly apply warm compresses for 15-20 minutes, 2-4 times daily. Use a diluted baby shampoo or commercially available lid scrubs for cleansing.
    • Demodex infestation: Apply Xdemvy (Lotaliner), Ocusoft Oust Demodex cleanser, Ocusoft Plus lid scrubs. Encourage pillowcase washing and discarding used cosmetics.
    • AMD is a progressive degeneration of the macula, typically starting after age 55.
    • Early symptoms include blurred vision, metamorphopsia (distorted vision), and loss of brightness.
    • It is the most common cause of blindness in developed countries.
    • AMD progresses through early, intermediate, and advanced stages.
    • The intermediate stage is treatable with OTC medications.
    • Advanced AMD can be “dry” or “wet”, with wet AMD being more aggressive.

    AREDS Studies

    • The AREDS study revealed that a combination of antioxidants (beta-carotene, vitamin C, vitamin E, zinc, and copper) significantly reduced progression of AMD in patients with moderate AMD.
    • The AREDS2 study indicated that substituting lutein plus zeaxanthin for beta-carotene in the original AREDS formula reduced progression to wet AMD, but not overall progression.

    AREDS2 Vitamins

    • The AREDS2 formulation consists of lutein, zeaxanthin, vitamin C, vitamin E, zinc oxide, and cupric oxide.
    • This formulation is advantageous due to reduced lung cancer risk in former smokers and its effectiveness in preventing AMD progression.

    Ocular Vitamins and Nutraceuticals

    • Many formulations are NOT specifically for AMD, such as Ocuvite and ICaps.
    • These are classified as nutraceuticals and are not regulated by the FDA like drugs.

    Ocuvite Blue Light

    • Ocuvite Blue Light supplements contain lutein and zeaxanthin and aim to protect against blue light.
    • Claims include: helping eyes shield and filter blue light, replenishing the macular pigment layer, and filtering blue light.

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    Pharmacy OT Lecture 2024 PDF

    Description

    Explore the effects and progression of Age-Related Macular Degeneration (AMD). This quiz delves into the causes, early signs, and statistics related to AMD, particularly focusing on its impact on population aged 55 and older. Test your knowledge on the types of AMD and their implications for vision.

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