Misc. Eye Topics 2024 - Students PDF

PHAR 1051 MISCELLANEOUS EYE TOPICS Sarah Larose, BSc Pharm Instructor, Dalhousie College of Pharmacy Some slides courtesy of Dr. Emily Black Miscellaneous Topics Covered...

PHAR 1051 MISCELLANEOUS EYE TOPICS Sarah Larose, BSc Pharm Instructor, Dalhousie College of Pharmacy Some slides courtesy of Dr. Emily Black Miscellaneous Topics Covered Dry Eye Eyelid Conditions Ocular Surgery Learning Objectives By the end of this lecture, students should be able to: Recognize common signs, symptoms, potential predisposing factors, and patient populations that experience the following conditions: dry eyes, blepharitis, hordeolum, chalazion Provide appropriate non-prescription product recommendation for the various conditions (assumes knowledge of treatment options, adverse effects, and contraindications for/precautions with their use): dry eyes, blepharitis Recognize prescription drugs used for blepharitis, be able to explain their role and purposes, know when it is appropriate to choose these agents over nonprescription drugs, be able to discuss adverse effects, contraindications, and precautions for their use. Provide advice on nonpharmacologic treatment/prevention of the following: dry eyes, blepharitis, hordeolum, chalazion Be able to discuss and identify red flags or warning signs/symptoms that would require referral to physicians for a patient presenting with signs/symptoms of the following: dry eyes, blepharitis, hordeolum, chalazion, post ocular surgery Recognize the prescription drugs used adjunctively following procedures for cataract surgery, be able to explain their roles and purpose DRY EYE DISEASE Part 1 of 3 Dry Eye Disease (DED) Dry eye is defined as: “A multifactorial disease of the ocular surface, characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” - International Dry Eye Workshop II (2017) Symptomatic dry eye may be classified as: Aqueous-deficient dry eye Evaporative dry eye *Note: there is overlap and DED may involve multiple mechanisms www.tearfilm.org/dewsreport/index.html Common/Minor Ailment Prescribing Consider that you may be using your prescribing authority for these patients and what that means for your knowledge base on this topic  Anatomy of Tear Film: “Traditional Description” Composed of 3 layers: The Mucous Layer is produced by goblet cells. It acts as a lubricant between the eyelids and the globe. It also traps and removes waste materials (shed epithelial cells, debris and microorganisms). The Aqueous Layer is produced by the lacrimal glands. This layer hydrates the mucous layer, supplies oxygen and electrolytes to the ocular surface, and provides antibacterial defense and wound healing. The Lipid Layer is primarily secreted by the meibomian glands. It enhances tear film spreading, provides a smooth optical surface, and plays a significant role in stabilizing the tear film. CPS Minor Ailments Chapter: Dry Eye  Anatomy of Tear Film: “Updated Description” Composed of 2 layers: Mucoaqueous Layer ↓ friction ↑hydration of ocular surface Lipid Layer ↓surface tension ↓ evaporation of tears ↓ tear film instability CPS Minor Ailments Chapter: Dry Eye Pathophysiology of DED TFOS DEWS II Report - Pathophysiology Pathophysiology of DED TFOS DEWS II Report - Pathophysiology Risk Factors Associated with aging and higher Systemic drugs risk in females Anticholinergic agents or anticholinergic side effects Decreased blinking Amiodarone Ex. Computer use, medical conditions Antiandrogen agents (Parkinson’s disease, hyperthyroidism) Frequent use of eye drops containing Contact lens wearers preservatives (ie. benzalkonium chloride) Environmental factors Low humidity Surgery High temperatures History of surgery on the eye (ex. Wind and air pollution cataract surgery, laser eye surgery, etc.) CPS Minor Ailments Chapter: Dry Eye Dry Eye Disease – Clinical Presentation Common Presentation When to Refer Foreign body sensation Ocular pain, trauma to the eye, patient may say “sandy” or “scratchy” chemical or heat exposure feeling Foreign body present Itchy, burning, or “tired” eyes Protrusion of eye Change in vision Bilateral eye involvement Contact lens wearer Other symptoms include: Lack of response to treatment photophobia, blurred vision, redness, discomfort, difficulty in moving the lids CPS Minor Ailments Chapter: Dry Eye  Ruling out RED FLAGS Contact Lens Use Chemical Exposure, Injury or Trauma to the Eye Recent surgery, fingernail, mascara wand, branch, etc. Visual Disturbance: Anything that impacts the ability to see clearly Double vision, halos & glare, blurred or wavy vision, blindness, flashes, etc. Photophobia All RED FLAGS from our Conjunctivitis Pain (As a prominent symptom, Moderate - Severe) Lecture would be applicable as well Note Mild: Hordeolum, conjunctivitis, blepharitis, episcleritis Prior History of ocular disease (see box for some examples) Visually assess for: Irregular Pupils, Visible Corneal Opacity/Haze, Focal Redness, Rash ± Vesicles on eyelid or around eye, Ciliary Flush, Hyper-purulent Discharge Severe Systemic Symptoms Nausea, headache Always refer if you are unable to confirm the diagnosis and/or self-care is not appropriate MedSask Minor Ailments: Conjunctivitis CPS Minor Ailments Chapter: Conjunctivitis Approach to Red Eye for Primary Care Practitioners 2015 Nonpharmacologic Management What are some approaches that you could consider to reduce dry eyes and ocular irritation? Smoking cessation and avoidance of smoke exposure Limit screen time or take more breaks Cool compresses applied to eye lids Humidifier Goggles Ski/swim goggles with moist gauze inside Moisture chamber spectacles Tear duct occlusion Punctal plugs inserted CPS Minor Ailments Chapter: Dry Eye Pharmacologic Management Tear replacement with ocular lubricants is traditionally considered a “mainstay” (1st line) of DED therapy OTC products are often termed “Artificial tears” due to their attempt to replace or supplement the natural tear film These products DO NOT target the underlying pathophysiology of DED = Symptomatic treatment CPS Minor Ailments Chapter: Dry Eye  Ocular Lubricants / “Artificial Tears” Available as liquid, gel, or ointments Ideal lubricant 1-2 week trial of products to determine Preservative free efficacy Especially in moderate to severe disease Largely regarded as safe Contain potassium, bicarbonate, other ADR include: blurred vision, “ocular electrolytes and have a polymetric system discomfort” and foreign body sensation that increases retention time Neutral or slightly alkaline pH Contain volume enhancing agents or Lower Osmolarity ocular lubricants Active ingredients unclear, proprietary Efficacy difficult to compare, lacking large head-to-head trials Test your knowledge: Ointments and gels have increased retention time but contribute to the adverse effect of _________ www.tearfilm.org/dewsreport/index.html Preservatives Purpose: Protect from contamination Less toxic preservatives include: Polyquad Typically required in multidose products Sodium chlorite Sodium perborate Benzalkonium chloride is most frequently used and most toxic Toxicity related to: concentration and frequency of dosing, severity of disease, amount of tear secretion Mild disease can be used 4-6 times per day www.tearfilm.org/dewsreport/index.html  Ideal Characteristics Electrolytes Osmolarity Potassium and bicarbonate are most critical Hypo-osmolar tear substitutes may Potassium: maintains corneal thickness counteract the increased tear osmolarity Bicarbonate: promotes recovery of found in DED which causes: epithelial barrier function Corneal changes Pro-inflammatory Ex. Calcium chloride, Magnesium chloride, Ocular lubricants with osmolarity 40 Accounts for ~50% of visual impairment in those >40 Numerous risk factors: Including history of uveitis, diabetes, ocular trauma, vitrectomy May be acquired by underlying genetic conditions May develop as a result of radiation or glucocorticoid use Treated by removing the lens 95% of procedures are successful Cataract in the Adult Eye Preferred Practice Pattern 2016 Postoperative Management “Postoperative regimens of topically applied antibiotics, corticosteroids, NSAIDs, and oral analgesic agents vary among practitioners. There are no controlled investigations that establish optimal regimens for the use of topical agents. Therefore, it is the decision of the operating surgeon to use any or all of these products singly or in combination.” – PPP 2016, Cataract in the Adult Eye Postoperative Recovery – When to Refer Patient should be comfortable with a possible mild foreign body sensation CPS Therapeutic Choices Chapter: Cataract Surgery Postoperative Care  Postoperative Pharmacotherapy Purpose Medication Examples Duration of use Prevent endophthalmitis Ophthalmic Fluoroquinolone or 7-10 days Antibacterials Aminoglycoside Control IOP and prevent Ophthalmic Beta-blocker, Alpha- Up to a week spike Glaucoma medications agonist, Carbonic (occasionally longer) anhydrase inhibitor, Prostaglandin analogue Prevent Cystoid Macular Ophthalmic NSAIDs, 3-4 weeks Edema Anti-inflammatory Corticosteroids Decrease ciliary muscle Ophthalmic Cyclopentolate, 2-3 weeks spasms & keep iris off Dilators and cycloplegics Phenylephrine, implant Tropicamide Soreness Oral Analgesic Acetaminophen PRN CPS Therapeutic Choices Chapter: Cataract Surgery Postoperative Care Postoperative Monitoring Cataract in the Adult Eye Preferred Practice Pattern 2016 Selected References CPS/RxTx Olson RJ, Braga-Mele R, Chen SH, Miller KM, Pineda R 2nd, Tweeten JP, Musch DC. Cataract in the Adult Eye Preferred Practice Pattern®. Ophthalmology. 2017 Feb;124(2):P1-P119. PMID: 27745902.