Eye Problems: Symptoms and Treatments

• The text is about exclusions to self-treatment of eye problems, signs and symptoms of dry eye and allergic conjunctivitis, recommended treatments for these conditions, classifications of active ingredients in medications, self-care advice, stye treatment, allergic rhinitis, colds, and constipation

Eye Problems - Exclusions to Self-Treatment

• Eye pain is an exclusion for self-treatment
• Blurred vision not associated with ophthalmic ointments necessitates professional evaluation
• Sensitivity to light requires medical attention
• Contact lens wearers should seek professional advice for eye issues
• Blunt trauma to the eye warrants immediate medical assessment
• Chemical exposure to the eye requires professional intervention
• Exposure to heat, including sun exposure, is an exclusion
• Symptoms persisting for more than 72 hours need evaluation
• Eyelid disorders should be assessed by a healthcare provider
• Signs of infection necessitate medical intervention
• Macular degeneration requires professional monitoring and treatment
• Blepharitis, hordeolum, and chalazion often need professional management
• Head lice require specific treatment

Dry Eye

• Common in postmenopausal women
• Bell's palsy, Sjogren's syndrome, thyroid disorders, and rheumatoid arthritis all increase likelihood
• Certain medications like antihistamines, antidepressants, decongestants, beta-blockers, and diuretics can cause it
• Onset is typically gradual
• The sclera may appear normal or slightly red
• Patients often describe a gritty or sandy sensation in the eye

Allergic Conjunctivitis

• Associated with allergies
• Itching is a primary symptom (if absent, this diagnosis is less likely)
• Other symptoms include watering, redness, and swelling

Dry Eye - Treatment

Drug

• Topical cyclosporine (Restasis®, Cequa®)
• Topical lifitegrast (Xiidra®) acts as an integrin antagonist
• Intranasal varenicline (Tyrvaya®) works as a nicotinic acetylcholine receptor agonist
• Topical corticosteroids can provide relief
• Systemic pilocarpine (cholinergic agent) may be considered

Non-Drug

• Avoid dusty and dry environments, and stay away from vents
• Use a humidifier to add moisture to the air
• Limit prolonged computer screen use
• Wear protective eyewear
• Artificial tears provide lubrication (e.g., Soothe, Systane, Refresh)
• Ointments offer longer-lasting relief but can cause blurry vision

Artificial Tears Considerations

• Preservative-free or disappearing preservative formulations are suitable for sensitivities or compromised corneas
• Preservative-free options may be more expensive and prone to contamination (discard after use)
• Disappearing preservative options include GenTeal, Systane, Refresh
• Preservative-free options include Blink tears, FreeRefresh, Soothe

Allergic Conjunctivitis - Treatment

Drug

• Artificial tears can be used as needed for symptom relief
• Ketotifen eye drops (Alaway®, Zaditor®) are effective
• Olopatadine hydrochloride (Pataday®) is another option
• Oral antihistamines are considered if needed

Non-Drug

• Avoid or remove the offending allergen
• Apply cool compresses 3-4 times a day

Classifying Active Ingredients

Ketotifen

• Antihistamine/mast cell stabilizer
• Suitable for ages 3 years and older
• Use twice a day
• Remove contact lenses before use and wait 10 minutes before re-inserting
• Offers relief within minutes and is safe for long-term use with no rebound risk

Olopatadine hydrochloride (Pataday®)

• Antihistamine/mast cell stabilizer
• Suitable for ages 2 years and older
• Dosing: 0.1% - 1 drop twice a day; 0.2% - 1 drop once a day
• Remove contact lenses before use, waiting 10 minutes before re-inserting
• Provides relief within minutes
• Burning, stinging, headache, and blurred vision can occur

Ophthalmic Decongestants

• Not generally recommended because of potential rebound issues

Ocular Vasoconstrictors

• Phenylephrine
• Naphazoline
• Tetrahydrozoline
• Oxymetazoline
• Toxic if ingested by children
• Limit use to less than 72 hours
• Contraindicated in angle-closure glaucoma
• May worsen dry eye

Ophthalmic Antihistamines

• Pheniramine
• Antazoline
• Only found in combination with vasoconstrictors

Self-Care Counseling Points

Dry Eyes

• Start with twice-daily application, increasing to 3-4 times a day as needed, or even hourly
• Consider switching to more viscous drops, gels, or ointments if side effects occur or results are insufficient
• Utilize preservative-free options for sensitivities, and can be used indefinitely if effective
• Consult an eye care provider if symptoms persist after 72 hours

Allergic Conjunctivitis

• Treats itching, redness, and watering
• Review proper eye drop administration techniques
• May initially cause burning, stinging, or discomfort
• Relief should begin within minutes
• Seek professional help if symptoms worsen or do not improve after 3 days

Dry Eye and Allergic Conjunctivitis - Key Points

• Commonly self-treatable
• Refer if signs suggest a more severe condition or OTC treatments are ineffective after 72 hours
• Recognize when preservative-free tear products are needed
• Ketotifen or olopatadine are recommended for allergic conjunctivitis
• Ophthalmic decongestants/vasoconstrictors should be avoided

Stye Treatment Recommendations

• Apply warm compresses 3-4 times a day
• If it lasts more than 3 days, see an eye care professional

Allergic Rhinitis - Characteristic Features

• Intermittent allergic rhinitis (IAR): Symptoms occur less than 4 days/week or less than 4 weeks/year
• Persistent allergic rhinitis (PAR): Symptoms occur more than 4 days/week or more than 4 weeks/year
• Episodic: occurs only upon exposure to allergen
• Common allergens include pollen, mold, dust mites, and occupational substances like wood dust and chemicals
• Histamine leads to vasodilation and sneezing
• Kinins, prostaglandins, and leukotrienes cause itchy throat and congestion
• Symptoms include itchy eyes, nose, palate, sneezing, red eyes, fatigue, and cognitive impairment
• Signs to look for: allergic crease on the nose, Dennie-Morgan lines under eyes, and open-mouth breathing
• Potential complications: Sinusitis, nasal polyps, hyposomnia, and asthma exacerbations

Allergic vs. Non-Allergic Rhinitis

• Allergic rhinitis always involves itching

Allergic Rhinitis - Exclusions to Self-Treatment

• Children under 12 years old
• Pregnant or lactating women
• Symptoms of non-allergic rhinitis
• Signs of infection
• Presence of undiagnosed/untreated asthma, COPD, or other respiratory issues

Allergic Rhinitis - Self-Care Strategies

Non-Drug

• Pollen avoidance involves keeping windows closed
• Dust control requires regular cleaning and avoiding dust-collecting items
• Mold reduction involves maintaining low humidity and repairing leaks
• HEPA filters help remove airborne allergens
• Nasal wetting agents (sprays, gels, irrigation) can alleviate congestion
• Homeopathic remedies may contain allergens, necessitating caution

Drug (See details below)

• Intranasal corticosteroids: fluticasone, budesonide, mometasone
• Oral antihistamines: 1st and 2nd generation
• Azelastine
• Cromolyn sodium

Intranasal Corticosteroids - Details

• Reduces nasal congestion, runny nose, sneezing, and itching
• Dosing: Adults - 2 sprays per nostril once daily; Children (<12 years) - 1 spray
• Administration: Shake well, prime, and aim away from the middle of the nose
• Counseling: Max. benefit in 1-2 weeks; if no relief after 1-4 weeks, or any nosebleeds or vision changes, see PCP
• Common Adverse Effects: Bleeding, sneezing, cough, pharyngitis

Antihistamines - Details

• Blocks histamine/H1 receptor release
• Used for itching, sneezing, rhinorrhea
• Relief begins in 1-3 hours
• First-generation (sedating): Non-selective, lipophilic, and have anticholinergic/serotonin/alpha-adrenergic effects
• Second-generation (non-sedating/peripherally selective): Lipophobic and peripherally selective

Antihistamines - Adverse Effects

• First-generation:
  • CNS: Sedation, impaired performance, anxiety, hallucinations
  • Cholinergic blockage: Dry mouth/eyes, blurred vision, reflex tachycardia
  • Photosensitivity
• Interactions:
  • QT prolongation risk increases with amiodarone and loratadine
  • Antacids reduce fexofenadine absorption
  • CNS depressants enhance side effects
• Contraindications:
  • Sedating: Newborns, lactation, BPH, bladder obstruction
  • Cetirizine: Hypersensitivity to hydroxyzine

Azelastine - Details

• Steroid-free nasal antihistamine for congestion, itching, runny nose, and sneezing
• Suitable for ages 6+
• Use 1-2 sprays once or twice daily as needed for 3-14 days
• Adverse effects: Drowsiness, sneezing, discomfort

Intranasal Cromolyn - Details

• Stabilizes mast cells, preventing mediator release
• No systemic action or interactions
• For allergic rhinitis in patients 2+
• Dosing: 1 spray 3-6 times per day for 3-7 days initially, with 2-4 weeks for maximum improvement
• Adverse effects: Sneezing, burning, stinging

Allergic Rhinitis - Product Selection & Counseling

• INCS are generally the best choice
• AH are best for episodic allergies, using the least sedating option first
• For special populations:
  • Pregnant: INCS compatible. Decongestants should be avoided.
  • Lactation: Cromolyn is suitable.
  • Kids: Refer if <12. Loratadine or intranasal cromolyn. Avoid sedating AH.
  • Elderly: Avoid sedating AH. Use loratadine/cromolyn.

Common Antihistamines

1st Generation (Sedating, Non-Selective)

• Brompheniramine (found in combination products)
• Chlorpheniramine – Chlor-Trimeton®
• Diphenhydramine – Benadryl®

2nd Generation (Nonsedating, Peripherally Selective)

• Cetirizine – Zyrtec® (can cause sedation)
• Fexofenadine – Allegra®
• Levocetirizine – Xyzal® (can cause sedation)
• Loratadine – Claritin®, Alavert®

Colds - Characteristic Features

• Often caused by rhinovirus
• Appear 1-3 days after, and last 7-14 days
• Sore throat followed by nasal congestion/sneezing/coughing/chills/headache/low grade fever
• Potential complications: Middle ear infections, bacterial pneumonia, bronchitis

Colds - Exclusions to Self-Treatment

• Fever
• Chest pain/shortness of breath
• Worsening of symptoms
• Underlying conditions (COPD/heart failure/AIDS/immunosuppressant)
• Advanced age or anyone < 3 months
• Bacterial infection symptoms

Colds - Self-Care Strategies

• Aimed at reducing symptoms and preventing transmission
• Non-drug: Hydration, rest, increased humidification, nasal irrigation, saline gargle, nasal strips
• For rhinitis/nasal congestion: Nasal spray/decongestant
• Prevention: Hand washing, sanitizers, disinfectant sprays

Decongestants - Details

• Adrenergic agonists; constrict vessels and decrease edema
• Used for eustachian tube, nasal congestion, and cough associated with postnasal drip

Systemic

• Phenylephrine: 10 mg every 4 hours (not very effective)
• Pseudoephedrine: 60 mg every 4-6 hours (restricted usage)

Intranasal

• Naphazoline
• Phenylephrine
• Oxymetazoline (long-acting)

Adverse Effects

• Increased heart issues, anxiety, insomnia, burning/stinging, rhinitis medicamentosa (rebound congestion)
• Contraindications: MAOIs and ergot derivatives
• Warnings: Worsening of hypertension, hypothyroidism, diabetes, prostatic hypertrophy

Oral Pseudoephedrine vs. Phenylephrine

• Pseudoephedrine: Kept behind the counter, purchase limits exist, requires a logbook and ID
• Treatment: Slow withdrawal and replace with topical decongestant or saline spray

Other Cold Treatments

• Local anesthetics (benzocaine, dyclonine HCL): For sore throat
• Menthol or camphor: Not useful
• Systemic analgesics: For aches/fever Note: Combination products should be used with caution

Constipation - Signs and Symptoms

• <3 bowel movements/week; straining, dry stools, loss of appetite, headache, lower back pain, bloating
• Primary: Slower GI transit time, pelvic floor dysfunction
• Secondary: Structural abnormalities, psychological factors, medications, dietary factors
• Complications: Hemorrhoids, anal fissures, rectal ulcers, BP surge

Constipation - Drugs That May Cause

• Narcotics, verapamil, diltiazem, anticholinergics

Constipation - Exclusions to Self-Treatment

• Marked abdominal pain, significant distention/cramping, flatulence, fever
• Nausea or vomiting
• Paraplegia or quadriplegia
• Daily laxative use
• Unexplained changes in bowel habits, weight loss, blood in stool, change in stool character
• Symptoms persisting for >2 weeks or recurring over 3 months
• History of inflammatory bowel disease, colostomy, anorexia
• Age <2 years

Constipation - Self-Care Strategy

Non-Drug

• Increase fluid and fiber intake and up activity

Drug

• Bulk-forming agents: psyllium, methylcellulose, polycarbophil
  • Onset: 12-24 hours
  • Adverse effects: Cramping, flatulence, esophageal obstruction
  • Do not use in patients who can't swallow, restricted diet, etc.
• Hyperosmotics: glycerin suppositories, PEG powder
  • Adverse Effects: Rectal irritation, cramps, flatulence, nausea, bloating
• Emollients: docusate
  • Onset: 12-72 hours
  • May cause diarrhea or mild cramping
• Lubricants: mineral oil
  • Onset: 6-8 hours (oral), 5-15 minutes (enema)
• Saline laxatives: Magnesium citrate, Milk of Magnesia, Na Phosphate
  • Onset: 30 min - 6 hours
  • Adverse effects: Dehydration, fluid imbalance
• Stimulants: senna, bisacodyl, castor oil
  • Onset: 6-10 hours (oral), 15-60 minutes (suppository)
  • Adverse effects: Severe cramping

Constipation - Special Populations

Kids

• Diet Changes, MgOH or Glycerin Supp

Elderly

• Lifestyle Mod, Bulk Forming or PEG
• Avoid Mineral/Saline Laxatives

Pregnant

• Lifestyle Mod, Bulk Forming
• Avoid Oils and Saline Laxatives

Constipation - Counseling

• Do not take laxatives longer than a week
• If vomit, nausea, rectal bleed see PCP