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Nonprescription Ophthalmic and Otic Disorders

• Objectives include recalling exclusions for self-care, distinguishing patients for referral vs. self-care, understanding medication indications/dosing, evaluating patient complaints, and selecting appropriate drug therapy.
• Drugs to know: antazoline phosphate, artificial tears, carbamide peroxide, non-medicated ointments, isopropyl alcohol/anhydrous glycerin, ketotifen fumarate, hyperosmotic solutions (sodium chloride), naphazoline, oxymetazoline, pheniramine maleate, phenylephrine, tetrahydrozoline, and olopatadine

Eye Anatomy

• The lacrimal sac is highly vascularized, leading to potential systemic effects from topical medications
• The sclera makes up the external white portion of the eye and is a tough, collagenous layer
• The cornea contains vascular tissue and protects the eye
• The cornea comprises of three layers which are the epithelium, stromal, and endothelial layers
• Located behind the cornea, the anterior chamber regulates intraocular pressure (IOP)

Ophthalmic Disorders

• Common ophthalmic disorders are dry eye disease, allergic conjunctivitis, corneal edema, foreign substance in the eye, chemical burns, and contact dermatitis and contact dermatitis

Overall Exclusions to Self-Care

• Self-care is not appropriate with eye pain, light sensitivity, blurred vision from ophthalmic ointments, trauma, chemical/heat exposure, symptoms of infection, history of contact lens use, symptoms over 72 hours, macular degeneration, or head lice.

Dry Eye Disease

• Dry eye disease is a common anterior eye disorder characterized by deficient tear production and increased tear evaporation, which leads to irritation and potential tissue damage
• Allergens and dry or dusty conditions may exacerbate
• A white or mildly red sclera, sandy or gritty feeling, burning, stinging, and watery eyes are signs and symptoms
• Antihistamines, antidepressants, decongestants, and diuretics are all drugs that exacerbate dry eye disease

Treatment Goals of Dry Eye

• Treatment Goals: Alleviate dryness, relieve irritation symptoms, and prevent possible tissue damage.

Treatments for Dry Eye

• Treatment includes avoiding triggers like dusty environments, rubbing eyes, and prolonged computer screen use
• Elimination of offending medications and usage of warm compress
• The use of ocular lubricants like artificial tears, non-medicated ointments, and non-medicated gels

Artificial Tears

• Artificial tears act as "lubricating drops" and administered 2–4 times daily depending on severity; can be given hourly if needed
• Vary in preservatives, electrolytes, buffering agents, and pH, use oil based eye drops that will stay in the eye longer
• Artificial tears without preservatives are less likely to irritate the ocular surface

Choosing Artificial Tears

• Demulcents soothe mucous membranes and provide lubrication in the form of a mucoprotective film that include cellulose derivatives (carboxymethylcellulose), dextran 70, gelatin, liquid polyols, polyvinyl alcohol (PVA) such as PEG or glycerin and povidone
• Emollients (fats or oils) increase the lipid layer thickness of the tear film, stabilize the tear film, and reduce evaporation.
• Examples of emollients are mineral oil, castor oil, and flaxseed oil

Ophthalmic Preservatives

• Preservatives are incorporated into multi-dose products to inhibit/minimize growth of microorganisms
• Benzalkonium chloride (BAK) is a preservative where long-term use in the eye can lead to damage
• Chlorhexidine is not as toxic to the eye as BAK
• Mercury-based preservatives contain thimerosal can cause toxicity and are rapidly disappearing from the market

Administration of Eye Drops

• Wash hands and remove contact lenses, then shake well if required
• Then tilt head back, gently pull lower eyelid to create a pouch
• Look up and release eyelid and close eyes for just 1-3 minutes
• Blot excess solutions from around the eye
• Wait at least 5 minutes between drops and instill ointment at least 10 minutes after drops

Non-medicated Ointments/Gels

• Non-medicated Ointments/Gels have a longer retention time and administered twice daily (can be up to 4x/day)
• Many patients prefer administer at bedtime to prevent morning symptoms as can often cause blurred vision
• Primary ingredients are white petrolatum for lubricant, mineral oil to help melt the ointment at body temperature and lanolin to prevent evaporation

Administration of Ointments

• Wash hands and remove contact lenses, then tilt head back
• Place 1/4 - 1/2 inch of ointment inside lower lid in a sweeping motion, followed by releasing lid and closing eyes for 1-2 minutes
• Blot excess solution from around the eye, administered at bedtime
• Administer at least 10 minutes after eye drops

Dry Eye Disease Treatment Algorithm

• First line treatment includes artificial tears and ensuring patients understand they are single use products if using preservative free agent
• Second line of treatment includes non-medicated gels or ointments, and nutritional supplements (omega-3 oils which have anti-inflammatory properties and improve lid function

Allergic Conjunctivitis

• Allergic Conjunctivitis occurs when exposures to allergens like pollen, animal dander, or dust leads to red, itchy, or watery eyes
• Blurred vision can also occur from excessive tears
• Treatment goals include limit/reduce severity of allergic reaction protect the ocular surface and remove/avoid allergens and provide symptomatic relief
• Normal eyes have sclera that is essentially white, with adequate tear film and no significant discharge or watering
• Bacterial contains red eyes, with sticky, yellow or yellow/green that may be stuck together upon waking
• Viral Conjunctivitis is most commonly known as pink eye that is red, itchy, watery, and highly contagious
• Allergic conjunctivitis is very similar in appearance to viral conjunctivitis, but accompanied by nasal congestion, sneezing, eyelid swelling and sensitivity to light

Allergic Conjunctivitis: Treatment

• Non-pharmacologic treatments include avoiding triggers, apply cold eye compresses, keep windows closed, and use air filters.
• Pharmacologic treatments include artificial tears (1st line), ophthalmic antihistamines/ mast cell stabilizers, or decongestants

Allergic Treatment Algorithm

• First line is to avoid the allergen and instill artificial tears as needed
• Can use ophthalmic antihistamines + mast cell stabilizers such as Ketotifen fumarate (Zadiator) or Olopatadine (Pataday)
• Additional options are decongestants like antihistamines, and oral antihistamines

Ophthalmic Antihistamines and Mast Cell Stabilizers

• Ketotifen fumarate (Zadiator) is an ophthalmic antihistamine + mast cell stabilizer, a potent H-1 receptor antagonist, that inhibits mast cell degranulation and is does not contain a decongestant allowing for longer use
• Instill 1 drop into affect eye(s) 2–3 times daily but is it contraindicated in patients with angle-closure glaucoma
• Remove contacts before use, and wait 10 minutes after use to re-insert, and approved for patients greater > 3 years old

Pataday

• Pataday (Olopatadine) is an ophthalmic antihistamine + mast cell stabilizer that is a Potent H-1 receptor antagonist and inhibits mast cell degranulation
• Does not contain decongestant and is instilled 1 drop into affected eye(s) 1-2x times daily
• It is approved for patients greater than 2 years old.

Ophthalmic Antihistamines

• OTC antihistamine products are combined with a decongestant with Pheniramine maleate + naphazoline
• Antazoline phosphate + naphazoline is not availible in US
• Act as specific histamine-1 (H1) receptor antagonist and provides rapid relief of symptoms
• Instill 1-2 drops in affected eye(s) up to 4 times is a contradication for patients with or with a risk for angle-closure glaucoma
• Side effects are burning or stinging due to anticholinergic activity that can cause pupillary dilation

Ophthalmic Decongestants

• Ophthalmic Decongestants reduce ocular redness and act as local vasoconstrictors by acting on alpha-adrenergic receptors of the ophthalmic vasculature to constrict eye vessels and reduce redness and have no effect on the allergic response
• OTC agents available for topical eye application is phenylephrine, naphazoline, tetrahydrozoline, oxymetazoline and brimonidine and dont use for over 72 hour to rebound rednedd

Ophthalmic Decongestants

• Usage greater than 72 hours can cause rebound conjunctival hyperemia (rebound congestion), but is less likely with naphazoline and tetrahydrozoline
• If use as directed will not induce ocular or systemic adverse
• Caution with patients with hypertension, cardiovascular disease, diabetes, hyperthyroidism, or pregnancy
• Contraindicated in patients with angle-closure glaucoma

Product Selection Guidelines

• Consider the patient when selecting the correct product which includes trying articial tears first
• Use Ketotifen if safe for 3+ years old and Olopatadine is safe for 2+ years old
• Can occur rebound hyperemia

Corneal Edema

• Corneal Edema must be diagnosed by an eye care provider prior to self-treatment initiation
• Occurs from over-wear of contact lenses, surgical damage, or inherited corneal dystrophies
• Patients may subjectively see halos or starbursts around lights and the provider MUST diagnose and recommend self-care treatment

Corneal Edema: Treatment

• Only sodium chloride is available without a prescription, topical hyperosmotic formulations
• Can be 2% and 5% solutions, and ointments (5%), follow with adding 5% nighttime ointment if continuous symptoms and switch to using 5% solutions when adding if no improvement. medical referral must be sought out if symptoms after 1-2 weeks

Hyperosmotics

• Hyperosmotics increase the tonicity of the tear film, which which promotes movement of fluid from the cornea to tear film which eleminates excessive fluid.
• Administer 1-2 drops very 3-4 hours although they are not frequently used because of burred vision.
• Burning may be a common but is contradindication in trauma to a corneal epithelium

Loose Foreign Substance in the Eye

• Self-treatment is appropriate if there is only minor irritation and no abrasion of the eye surface
• Foreign substances can sometimes contact the ocular surface
• Reflexing tearing may need irrigants will help remove the foreign substance as well as non-medicated ophthalmic petrolatum ointment at bedtime

Foreign Substance in the Eye

• The symptoms are paint and tearing. reflexing of tears, Non-medicated ophthalmic petrolatum ointment is fine

Ocular Irrigants

• Ocular Irrigants cleanse ocular tissues and maintain moisture with balance of pH and osmolality to clear unwanted material
• Should not be used for open wounds in or near the eyes

Chemical Burns

• Chemical burns can exposure to alkalis (oven cleaners), acids (battery acid, vinegar), solvents and irritants (Mace, tear gas)
• Considered an ophthalmic emergency where emergency treatment will be sterile for irrigants

Contact Dermatitis

• Contact Dermatitis is swelling scaling reddening and may occur because to the usage of cosmetics, eye medications, and foreign objects
• Discontinue the suspected offending substance in mild cased while swelling is treated with oral antihistamines or by going to the provider

Key Ophthalmic Points

• Many ophthalmic products are available to manage symptoms of minor disorders of the eye and eyelid
• Nonprescription ophthalmic products should be used in cases of minor discomfort, and the pharmacist should refer the patient to seek medical care if in doubt.
• Patients with narrow-angle glaucoma should not use topical ocular decongestants
• Educate patients about overuse of topical ocular decongestants
• Properly counsel patients on appropriate eye drop/ointment applications

Ear Pathophysiology

• The External Ear: Includes the auricle (pinna) and the External Ear Canal (EAC)
• The Middle Ear: Includes tympanic membrane, ossicles, and middle ear space
• The Inner Ear: Incudes cochlea, auditory canals, and Eustachian tubes,
• Children are more prone to ear infections due to a shorter and flatter Eustachian tube

Cerumen (ear wax)

• Cerumen (ear wax) is a Mix of oily and fatty fluids excreted in the outer portion of the EAC that lubricates the surface, trapping barrier to pathogens and foreign particles
• Many factors can cause disruption of the flow of cerumen to the outer ear, a narrow/irregular shape of the EAC
• Excessive hair and irritation from foreign objects (hearing aids, ear plugs) also causes disruptions

Ear Disorders

• Ear Disorders:
• Typically more common in the pediatric and geriatric population
• The Most common cause of hearing loss in all groups
• Self-treatment with OTC medications should be limited to external ear disorders, not in < age of of 12

Ear Disorder Exclusions to Self-Care

• Ear Disorder Exclusions to Self-Care include; <12 year old (impacted cerumen)
• Signs of infection include; pain with ear discharge.
• Presence of ruptured tympanic membrane, presence of bleeding, ear surgery within 6 weeks, and tympanostomy tubes present

Excessive or Impacted Cerumen: Clical/Treatment

• Clical Presentation of ear infection includes; Dull/itching, hearing loss/Tinnitus, dizziness/ear fullness, vertigo, and severe pain must be referral
• Prevent adverse and ear-soft agents with irrigation

Pharmacologic Therapy

• Pharmacologic Therapy is Debrox (Carbamide peroxide 6.5% in anhydrous glycerin) that can be used alone or in combination with warm water irrigation
• Only used in patients > 12 years old, < 12 must be done under advice of a physician

Administration of Ear Drops

• Wash hands with soup and water before and after for cleaning while preforming procedure with no water
• Then position drop near opening to not have to insert in ear but to be inserted enough
• To enter drops use finger to enter in the ear canal opening and hold still to work
• Use cotton to absorb extra fluids, repeat if needed

Other agents: Not Recommended

• Docusate sodium and Hydrogen peroxide has conflictive data.
• With off-label used of olive, it not very recommended due to lack of studies

Water-Clogged Ears

• Excessive moisture in the ear canal can be caused by: Excessive hair/Narrowing, over production, excessive sweating
• There symptoms is a localized pain that leads hear loss

Treatment of Water-Clogged Ears

• Ear treatment include turning ear down to manipulated it for the water to come
• As well as ear plugs

Pharmacologic Treatment

• Include isopropyl alcohol, and acetic alcohol, to reduce irritation, and to refer to medical provider of symptoms.

Isoprpyl Alcholo

FDA approved minimum use, avoid lightining, in heat can cause the it to sting with the Glycerin

Acetic acid 5% and isopropyl

• In order to make the formula acidy patients must use with white vinegar only, and discard after.
• With minor burning due to the open skin the properties will help kill bacteria.

Key Otic Points

• Limit self-treatment of otic disorders for minor symptom, to use it until symptoms relief
• Evaluate patients with symtpoms bleeding with the doctor if the ear do not improve.