Clinical Pharmacy I - Eye Conditions PDF

University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 1 The red eye Conjunctivitis is a common condition resulting in red eyes, caused by infection, allergy or irritation. It is characterized by varying degrees of ocular redness,...

University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 1 The red eye Conjunctivitis is a common condition resulting in red eyes, caused by infection, allergy or irritation. It is characterized by varying degrees of ocular redness, irritation, itching, pain, discharge, and loss of visual acuity. Conjunctivitis seems to affect sexes equally and may present in any age of patient, although bacterial conjunctivitis is more common in children and viral conjunctivitis more common in adults. All three types of conjunctivitis are essentially self-limiting, although viral conjunctivitis can be recurrent and persist for many weeks. Causes of red eye Incidence Cause Most likely Bacterial, viral or allergic conjunctivitis Likely Subconjunctival hemorrhage Unlikely Episcleritis, scleritis, keratitis, uveitis (iritis), neonatal conjunctivitis Very unlikely Acute closed-angle glaucoma Allergic conjunctivitis Pollen usually causes seasonal allergic conjunctivitis. Itching is the symptom most strongly related to allergic conjunctivitis. The discharge is watery. Management: In addition to removing and/or avoiding exposure to the offending allergen, applying cold compresses to the eyes 3-4 times per day will help reduce redness and itching. In allergic conjunctivitis due to hay fever, if there are other symptoms related to allergic rhinitis, oral antihistamines and nasal corticosteroids will treat most of them and may relieve eye symptoms. The first-line treatment of allergic conjunctivitis is to instill artificial tears as needed. University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 2 For predominant or significant eye symptoms, antihistamine drops (e.g., antazoline, pheniramine and ketotifen) can be helpful. They are very safe and can be used in individuals ages 3 years and older. Ketotifen is considered as the safest and most effective product for the treatment of allergic conjunctivitis. Some preparations are also combined with sympathomimetic decongestant (e.g., naphazoline, tetrahydrozoline, xylometazoline and phenylephrine). They are not recommended in children below 12 years. They should not be used for more than 7 days to avoid rebound effects (especially with phenylephrine or oxymetazoline). If there is prolonged exposure to allergens in allergic conjunctivitis, it may be better to recommend eye drops containing a mast cell stabilizer: Sodium cromoglicate 2% It should not be used in children under 1 year of age. Lodoxamide It should not be used in children under 4 years of age. Ketotifen It is an antihistamine and mast cell stabilizer Nedocromil sodium Only available on prescription Bacterial conjunctivitis The main symptoms of conjunctivitis, apart from redness or ‘pinkness’, are an uncomfortable gritty sensation and a discharge. It is not a painful condition. The discharge is sticky, purulent and mucous. Eyelids stuck together on awakening Only one eye may be affected initially, but symptoms usually affect both eyes within a few hours. If symptoms of conjunctivitis are confined to one eye, this suggests the possible presence of a foreign body or another condition accounting for the red eye. Pathogens that cause bacterial conjunctivitis vary between adults and children. In adults, Staphylococcus species are most common (>50% of cases), followed by Streptococcus pneumoniae (20%), Moraxella species (5%) and Haemophilus influenzae (5%). In children, Streptococcus, Moraxella and Haemophilus are most common. University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 3 Chlamydial conjunctivitis is rare type of ocular infections. It is characterized by watery or mucous discharge, ocular discomfort, low-grade fever, possible blurred vision. Scarring is possible complication. If infection with Chlamydia spp. is known or suspected, or if symptoms are too vague to rule out viral or allergic conjunctivitis, medical referral is mandatory. Management: Acute bacterial conjunctivitis is frequently self-limiting. Most cases of bacterial conjunctivitis resolve anyway within 2–5 days when treated with placebo. If there is a sticky discharge, gentle cleansing of the outside of affected eyes with cotton wool soaked in water can be recommended regardless of whether treatment is being suggested. Chloramphenicol eye drops 0.5% every 2 hours for the first 24 hours and then four times daily or chloramphenicol eye ointment 1% can be used (OTC) for the treatment of acute bacterial conjunctivitis in adults and children aged 2 years or over. Symptoms usually settle in a few days. Five days treatment is usually adequate, but treatment should be continued for 48 hours after resolution of symptoms. Propamidine eye drops (four times daily) and dibromopropamidine isethionate eye ointments (twice daily) can be used in patients older than 12 years. Viral conjunctivitis Viral conjunctivitis is often accompanied by other signs of viral respiratory tract infection, such as cough and cold. The discharge is watery. Symptoms of reddened eyes with watery discharge, ocular discomfort, and hyperemia are noticed. The adenovirus is most commonly implicated in viral conjunctivitis. Typically it is self- limiting and symptoms resolve in 2 or 3 weeks. Management: ‘Watchful waiting’ is a reasonable option for most cases of viral conjunctivitis. Symptoms may be eased by bathing the eyelids to remove any discharge and using lubricant eye drops. Viral causes are highly contagious, and the pharmacist should University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 4 instruct the patient to follow strict hygiene measures (e.g., not sharing towels, washing hands frequently). A patient will remain infectious until the redness and weeping resolve (usually in 10–12 days). Currently, an exclusion period from school is not recommended for patient with viral conjunctivitis. Subconjunctival hemorrhage A subconjunctival hemorrhage is a very common cause of a red eye. It can look very alarming, but it causes no discomfort and is usually harmless. The redness usually clears within 1–2 weeks. It is most commonly a spontaneous, unexplained occurrence, and patients can usually simply be reassured. Patient is referred to the doctor if high blood pressure was suspected or if they had unexplained bleeding or bruising elsewhere. Referral points: Painful eye conditions Symptoms persist for longer than 1 week photophobia (discomfort to light) Marked redness Vision is affected University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 5 Painful eye conditions All the following conditions (including uveitis) are better to be referred to the physician: Corneal ulcers Corneal ulcers may be due to an infection or a traumatic abrasion. The main symptom is that of pain as the cornea is exquisitely sensitive. There may be surrounding scleral inflammation. An abrasion can be caused by contact lenses, but wearers may not get as much pain as constant contact reduces the pain sensation. Keratitis Keratitis is inflammation of the cornea, often with infection. It often presents with a unilateral, acutely painful red eye, and the patient complains of discomfort from bright light (photophobia). Sometimes it is caused by ultraviolet light damage from a welding torch or from sunbeds. It may be caused by herpes simplex virus or, occasionally, a bacterial infection. If herpes virus is the cause, there is usually an associated history of cold sores. Acanthamoeba keratitis is sometimes seen in soft contact lens wearers and is associated with poor lens hygiene, extended wear and swimming while wearing lenses. Uveitis Uveitis, sometimes known as iritis, is inflammation of the iris and surrounding cilia body. It may occur in association with some forms of arthritis, sarcoidosis or tuberculosis. It sometimes occurs as an isolated event with no obvious cause. Glaucoma Glaucoma occurs when the pressure of the fluid within the eye becomes abnormally high. University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 6 Eyelid disorders A number of disorders can afflict the eyelids, ranging from mild dermatitis to malignant tumors. In the context of community pharmacy consultations, the most common presenting conditions will be blepharitis, hordeola (styes), and chalazion. Stye (Hordeolum) Styes typically present as acute, painful, localized eye swelling that develops over a few days. External stye presents as a swollen upper or lower lid, which will be painful and sensitive to touch. A small yellow pus-filled lesion may be visible. The lesion will then spontaneously shrink and resolve or burst over the next few days. Symptoms of internal styes are similar to those of an external stye, with pain, redness, and swelling being present, although pain is often more severe, and pus- filled lesions are not obvious due to inward growth. If the eyelid is everted, localized swelling should be visible. Management Although styes are caused by bacterial pathogens, the use of antibiotic therapy is not usually needed. OTC medication is generally not required. It can respond well to conservative treatment. A warm compress applied for 5–10 minutes three or four times a day can bring an external stye to a head and, once it bursts, the pain will subside, and the symptoms will resolve. The use of dibromopropamidine has been advocated in the treatment of styes but is of unproven benefit. Blepharitis Blepharitis describes inflammation of the margin of the eyelids. Characteristic symptoms are itchy, stinging and sticky eyes. The symptoms and appearance are like conjunctivitis and the conditions are often confused. It include loss of lashes and corneal irritation. It tends to be a chronic condition, and often there is an underlying chronic infection. University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 7 Signs and symptoms Blepharitis is bilateral with symptoms ranging from irritation, itching, and burning of the lid margins. Lid margins may appear red and raw, accompanied by excessive tearing and crusty debris or skin flakes around the eyelashes. Symptoms also tend to be worse in the mornings, and patients might complain of eyelids being stuck together. Symptoms are often intermittent, with exacerbations and remissions occurring over long periods. The mean age of occurrence is 50 years of age. In chronic cases, madarosis (missing lashes) and trichiasis (inturned lash) can occur. This latter symptom can lead to further local irritation and result in conjunctivitis. Etiology Blepharitis has staphylococcal, seborrheic, or meibomian gland dysfunction etiologies. Anterior blepharitis refers to staphylococcal and seborrheic causes because they primarily affect the bases of the eyelashes. Posterior blepharitis refers to meibomian gland dysfunction Management Management of blepharitis involves advice on good eyelid hygiene, including advice to avoid eye make-up. This involves soaking the closed eyes with a warm cotton wool pad or flannel and subsequently cleaning the eyelids by wetting a cloth or cotton bud with cleanser (for example, baby shampoo diluted 1 : 10 with warm water or bicarbonate solution) and wiping along the lid margins. Blepharitis can cause dry eye, prescribing an ocular lubricant can be tried. Sometimes topical antibiotics are used for flare-ups of the condition, and long-term treatment is often needed (6 weeks or more). University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 8 Chalazion A chalazion (plural chalazia or chalazions) or meibomian cyst is forms when the meibomian gland becomes blocked. It develops over a number of weeks and initially can cause discomfort but becomes painless. A lump should be clearly visible if the eyelid is everted. A chalazion is self-limiting, although it might take a few weeks to resolve completely. No treatment is needed unless the patient complains that it is particularly bothersome and is affecting vision. Chalazion that becomes bothersome to the patient may need surgical intervention. It required assessment from doctor. Entropion Entropion is defined as an inversion of the eyelid margin. It can be unilateral or bilateral, with the lower eyelid more frequently affected. The in-turning of the eyelid causes the eyelashes to be pushed against the cornea, resulting in ocular irritation and conjunctival redness. It is most often seen in older adults due to aging changes making the musculature more lax. Referral is needed for surgical repair to correct the problem. Taping down the lower lid to draw the eyelid margin away from the eye is sometimes employed as a temporary solution. Ectropion Ectropion is the converse of entropion; the eyelid turns outward, exposing the conjunctiva and cornea to the atmosphere. Patients will often present complaining of a continually watering eye. This can lead to dryness of the eye because the eye is not receiving adequate lubrication. Ectropion is seen with advancing age and often is noted in people who suffer from Bell’s palsy. University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 9 Dry eye disease Dry eye disease, dry eye syndrome, dysfunctional tear syndrome or keratoconjunctivitis sicca (KCS) is a frequent cause of eye irritation, causing varying degrees of discomfort. It is a common problem, particularly in older adults. The condition is chronic, with no cure. In dry eyes, the quantity or the composition of tears changes; either not enough salty fluid is produced by the tear glands, or tears may evaporate too quickly, or they may not spread evenly over the cornea (or a mixture of these things). Tear production diminishes with age and is affected by female hormones, so the problem is most common in older women. Signs and symptoms People with dry eyes may report irritated, gritty, scratchy or burning eyes, a feeling of something in their eyes, excess watering and blurred vision. Patients with dry eyes may report experiencing some blurring of vision when they first wake up in the morning. Factors and triggers of dry eye Windy, dry climates increase tear evaporation. Long periods of time spent working at a computer screen are associated with dry eye because blinking tends to be less frequent; thus redistribution of the tear film happens less often. Patients with rheumatoid arthritis, diabetes, Sjögren’s syndrome, thyroid problems, rosacea, Bell’s palsy, etc. Some eyelid conditions such as blepharitis and ectropion Medications including antihistamines, beta-blockers, chemotherapy, diuretics, HRT, oral contraceptives, isotretinoin, SSRIs and TCAs may affect the quantity and composition of tears. Preservatives in ophthalmic topical treatments may also contribute to dry eyes. Individuals who wear contact lenses are more likely to experience dry eyes. University of Anbar - College of Pharmacy Clinical Pharmacy I - Eye conditions 10 Referral points: Suspected medicine-induced dry eye Suspected dry eye induced by medical condition as in the patient complains of a dry mouth or symptoms could be due to an autoimmune disease. Severe dry eye Failed OTC treatment Nonpharmacologic Therapy Patients should avoid dry or dusty places. Using humidifiers or repositioning workstations away from heating and air conditioning. Wearing eye protection (e.g., sunglasses or goggles) in windy, outdoor environments. Opening windows, even for a short time, will also help to refresh and moisten the air. Avoiding tobacco smoke and smoking cessation. Avoiding prolonged use of computer screens. If using a computer for long periods, ensure that the monitor is at or below eye level, avoid staring at the screen, and take frequent breaks to close/blink eyes. Pharmacologic Therapy Dry eyes are managed by the instillation of artificial tears and lubricating ointments. These products contain (but not limited to) the following agents: hypromellose, carmellose, polyvinyl alcohol, carbomers (e.g., carbomer 940 and carbomer 980), polyvinyl alcohol, sodium chloride, hydroxyethyl cellulose, hydroxypropyl methylcellulose, sodium hyaluronate, and wool fats. If a product causes irritation or if soft contact lenses are worn, preservative- free eye drops are to be used. For people with severe symptoms, preservative-free artificial tears are suitable. Adding an ocular lubricant ointment to use at night is advisable. Eye ointments containing paraffin may be uncomfortable and blur vision, so they should usually only be used at night and never with contact lenses.