Pharmacy OT Lecture 2024 PDF

Ophthalmic Conditions Michael R. Kozlowski, O.D., Ph.D., FAAO, DABO October 22, 2024 1  Outline / Learning Objectives Signs and symptoms of some common ocular disorders treated with OTC therapeutic agents OTC therapeuti...

Ophthalmic Conditions Michael R. Kozlowski, O.D., Ph.D., FAAO, DABO October 22, 2024 1  Outline / Learning Objectives Signs and symptoms of some common ocular disorders treated with OTC therapeutic agents OTC therapeutic agents and contraindications for their use Referring out Prescription medication for common ocular disorders Correctly administering eye drops, eye ointments, and eye washes Ocular vitamins 2  Healthy Eye Cornea (Epithelium) Pupil Iris Limbus Punctum Conjunctiva Eyelid Margin https://www.zeiss.com/vision-care/us/eye-health-and-care/health-prevention/a-workout-for-your-eyes.html 3 Conditions treated with OTC products 1.Dry eye 5.Corneal edema 2.Foreign material in eye 6.Eyelid problems 3.Conjunctivitis: allergic or Hordeolum viral Chalazion 4.Red eyes from other causes Blepharitis Subconjunctival hemorrhage Demodex Pinguecula 7.Macular Degeneration Pterygium 4  Signs that Referral is Necessary Eye pain (other than irritation or transient shooting pains) Discharge from eye (other than tearing) Vision changes (e.g., blur, diplopia, metamorphopsia) Sensitivity to light Blunt trauma or chemical/heat exposure Symptoms lasting longer than 3 days Flashes, new floaters, “curtain” or “cloud” in vision Problems in contact lens wearer (except dryness) 5  Condition 1: Dry Eye Caused by abnormalities in tear film production, availability, and stability Contributors 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-responding cases should be referred 6  The Tear Film Lipid layer Secreted by meibomian glands (and glands of Zeiss and Moll) Prevents evaporation Aqueous layer Secreted by lacrimal glands (and glands of Krause and Wolfring) Mucin layer Secreted by goblet cells Attaches and spreads tear film over ocular surface (From: Novartis 2012) 7  Signs and Symptoms Reddish conjunctiva Sandy, gritty feeling Reflex tearing Sharp pains of short duration 8 Appearance Aging-related Changes in Lid Margin 9  Treatment Goals Improve tear quantity and quality Relieve signs and symptoms Prevent or reverse corneal damage (superior punctate keratitis → exposure keratopathy) 10  Treatment Approach Non-Pharmaceutical Avoidance of environmental irritants Insertion plugs into puncta (prevents tear drainage) Surgery - Eyelid and adnexa 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 11  Artificial Tears Think of ATs as “hand cream for the eyes” Regular use improves ocular surface, decreases dry eye symptoms Use only when eyes hurt provides only brief relief Frequency of use can be limited by preservative No proven difference between most ATs in effectiveness for treating dry eye Different ATs claim ancillary advantages 12  Artificial Tears Many types Many types Different active Different active Ingredients Ingredients Different preservatives Different preservatives (or non-preserved) (or non-preserved) Other ingredients Other ingredients 13  Artificial Tear Preservatives Conventional Benzalkonium chloride (BAK) Polyquad (PQ) Do not use more than QID or irritation may occur Mild GenAqua – sodium perborate Purite , OcuPure® - stabilized oxychloro complex SofZia® - ionic-buffered solution Breakdown to inert ingredients upon contact with eye; can use more often than QID Preservative-free (PF) No limitation on frequency of use 14  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) 15  Artificial Tear Active Ingredients Glycerine – mostly BAK preserved Oasys Tears Plus (non preserved) Moisture Eyes (with propylene glycol) Soothe Lubricating Eye Drops (with propylene glycol; mild preservative) Polyvinyl alcohol (PVA) – mostly BAK preserved Tears Again (PF) FreshKote (PQ) With polyvinyl pyrrolidone Amisol CLEAR: phospholipids, polysorbate-80, glycerin 16 Artificial Tear Inactive Ingredients Surfactant, mucin mimic and in-bottle thinner for it, active ingredients 17 “Digital” and “Contact” AT’s 18  Administration General dosing: 1 – 2 drops in affected eye 1 – 4 times/day Can use preservative-free products more often Administration Tilt head back and gently grasp lower eyelid and pull it away from eye to form a pouch https://www.invisioneyecare.com/blog/eye-conditions-made-better- with-artificial-tears-invision-eye-care-specialists Look up and apply a drop; release the eyelid Close the eye and minimize blinking Use a finger to put gentle pressure over the tear duct (punctum) Wait at least 5 minutes before instilling the next drop, if indicated 19  Failure of ATs 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 Some patients don’t like the “gummy” or sticky consistency of high- viscosity drops - may need to use lower-viscosity agents more frequently instead Refer to eye doctor 20  Oils, Gels, Ointments Oil-containing drops Refresh Endura (Castor oil, polysorbate 80, carbomer 1342, glycerin; PF) SootheXP (light mineral oil, mineral oil, poysorbate 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) 21  Administration of Ointments Gently pull lower lid away from eye and apply ¼ - ½ inch ribbon Avoid contact between the applicator and eye If drops and ointment are used, wait 10 minutes after applying the drops prior to using ointment Using ointment first would prevent drops from penetrating the tear film or cornea 22  Inserts and Sprays Inserts Lacriserts (hydroxypropyl cellulose, non-preserved) Tear Again Advanced Liposomal Spray (mild preservative) Contains liposomes and vitamins (A,C,E) Especially good for lipid deficient dry eye Useful in patients who have trouble with eye drops 23  Lumify Brimonidine 0.025% (Bausch and Lomb) Alpha-2 adrenergic agonist For ocular redness d/t minor eye irritations Fast acting (1 min) and long-lasting efficacy OTC ≥ 5 y/o 1gtt q6-8h Figures without attribution are from corporate marketing materials 24  Comparison with Visine Visine Active ingredient in 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 for tachyphylaxis or rebound hyperemia when used as directed 25  Which DE Tx to Recommend Milder preservatives are less likely to cause irritation to the eye themselves Use preservative-free if frequent application is recommended Time on the eye (i.e., 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 26  Condition 2. Foreign Material Irritation and tearing caused by foreign material in the eye May be self-treated ONLY if foreign material is loose, irritation is minor, and it is not related to chemical exposure or penetrating injury Refer if not successful Otherwise, or if in doubt, refer for treatment 27 Foreign Material – Referral 28 Loose Foreign Body – May Self-Treat 29  Self Treatment 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 that is all patient has available 30  Irrigating Eye Wash Use Bend over sink or towel and tilt 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 use of eye cups due to risk of contamination 31  Condition 3: Conjunctivitis Viral (“Pink Eye”) Bacterial (“Red Eye”) Allergic 32  Conjunctivitis Classifications Viral Bacterial Allergic Pinkish-red eye with Very red eye with Pinkish eye with copious watery grayish, yellowish itching discharge mucous discharge Watering but little or Slow onset Rapid onset no discharge Mild pain: sensation of Moderate to severe pain May be chronic or foreign object in eye Possible related to recent onset Often associate with upper respiratory Bilateral history of exposure to infection Chronic, red eyes viral respiratory infection Tearing/blurring May be associated with Papillae inside of lids fever Bilateral CONTAGIOUS! 33  Viral conjunctivitis Most commonly EKC or HSV EKC can be self-resolving AT’s Hygiene Trifluridine eye drops (Viroptic®) – Rx only Ganciclovir eye drops (Zirgan®) – Rx only Should always be referred to eye doctor 34  Bacterial Conjunctivitis Topical antibacterial drop Some common types: Polytrim Moxifloxacin Ofloxacin Erythromycin (educate) Tobradex (unsure Dx) Should always be referred to eye doctor 35 Allergic conjunctivitis 36  Treatment Artificial tears (chilled) Topical antihistamines and/or mast cell stabilizers (Rx or OTC) Oral antihistamines Counsel patients to avoid rubbing or scratching eyes to decrease risk of injury Recommend professional care if condition persists 37  Rx Topical Mast Cell Stabilizers Lodoxamide tromethamine 0.1% drops (Alomide ) 1gtt, qid, ≥ 2yo Cromolyn sodium 4% drops (Crolom ) 1gtt, qid, ≥ 4yo Nedocromil sodium 2% drops (Alocril ) 1gtt, bid, ≥ 3yo Pemirolast potassium drops (Alamast ) 1gtt, qid, ≥ 3yo Take 7 to 14 days to work – best if given before allergic response starts 38  Rx Topical Antihistamines Emedastine difumarate 0.05% drops (Emadine ) 1gtt, qid, ≥ 3yo Cetirizine ophthalmic solution, 0.24% (Zerviate ) 1gtt BID, ≥ 2yo Hydrella vehicle (contains glycerin and hydroxypropyl methylcellulose) for added comfort No comparison made to other ocular anti-histamine/mast cell stabilizers Significantly reduced itching at 15m and 8h compared to placebo 39  Rx Topical Antihistamine/Mast Cell Stabilizer Combinations Azelastine hydrochloride 0.05% (Optivar ) 1gtt, bid, ≥ 3yo Bepotastine besilate 1.5% drops (Bepreve ) 1gtt, bid, ≥ 2yo Epinastine hydrochloride 0.05% (Elestat ) 1gtt, bid, ≥ 3yo 40  OTC Oral Antihistamines Diphenhydramine (Benadryl ) 25-50mg, q4-6h, no children’s formulation Cetirizine hydrochloride (Zyrtec ) 10mg, qd, ≥ 2yo Fexofenadine hydrochloride (Allegra ) Up to 180mg daily, ≥ 6yo Loratadine (Claritin ) 10mg, qd, ≥ 2yo Chlorpheniramine (Chlor-Trimeton ) 4mg, q4-6h, ≥ 6yo 41  OTC Topical Antihistamine/Mast Cell Stabilizer Combinations Ketotifen fumarate 0.025% > 3y/o Many brand names: Zaditor , Alaway , TheraTears Eye Itch Relief Olopatadine hydrochloride > 2y Pataday Twice Daily Relief Pataday Once Daily Relief Pataday Once Daily Relief Extra Strength Alcaftadine 0.25% Lastacaft 1gtt QD, ≥ 2yo Reduces itching in 3 minutes, lasts for 16 hours 42  Side Effects and Cautions for OTC Topical Antihistamine/Mast Cell Stabilizer Rebound congestion of conjunctiva Duration: no longer than 72 hours Systemic side effects (rare if good technique used) Common local effects include eye dryness, stinging Contraindicated in narrow angle glaucoma (may cause dilation Use with caution in diabetes and heart disease Be aware of drug interactions (TCA’s, MOAI’s, etc.) 43  Condition 4: Other Red Eyes Subconjunctival Hemorrhage 44 Pinguecula 45 Pterygium 46 Contact Lens Related 47  Treatment Refer symptomatic complaints For asymptomatic subconjunctival hemorrhage (first occurrence), recommend ATs For asymptomatic pingueculae, or pterygia, recommend ATs and sunglasses For all others, especially in CL wearers – REFER Educate all CL wearers Regular case replacement Use of re-wetting drops for dryness Compliance with replacement schedule and wear instructions 48  Condition 5: Corneal Edema Loss of transparency due to increased fluid accumulation within the cornea Caused by prolonged contact lens wearing, surgical damage to cornea, exposure to bright lights (welding, reflection off snow), corneal disease (e.g., Fuch endothelial dystrophy) Symptoms include foggy vision E0070k1b And halos or starbursts around lights; with or without reduced vision Must be referred for diagnosis and treatment 49  Treatment Hypertonic sodium chloride Muro 128 solution and ointment 2%, 5% Many others – need to be sterile Increase tonicity of tear film promotes movement of fluid from cornea to increased osmotic tear film Normal tear flow eliminates excess fluid Directions for Muro 128 1 to 2 drops every 3 to 4 hours and/or administration of ointment at night 2% -- better tolerated for long term therapy 5% -- associated with more stinging and burning 50  Condition 6: Eyelid Problems Hordeolum (hor-DEE-oh-lem) Chalazion (cha-LAY-zee-ahn) Blepharitis Demodex infestation 51  Hordeolum Infection (usually staphylococcus species) of glands of eyelid Presents as a palpable nodule and swelling of eyelid Tender to the touch 52  Chalazion May be located on or near the eyelid Noninfectious granuloma Non-tender to gentle touch Can cause blurry vision 53  Treatment Hordeolum Hot compresses with message 3 to 4 times/day for 5 to 10 minutes Topical or oral antibiotic cover → refer Chalazion Hot compresses with message 3 to 4 times/day for 5 to 10 minutes Should clear up within 1 week If not, antibiotic or surgery may be required → refer Decrease future occurrences with an eyelid scrub Diluted baby shampoo and q-tips Commercially available lid scrubs 54  Blepharitis Common chronic inflammatory condition of eyelid margins Associated with: Staphylococcus epidermis, Staphylococcus aureus, seborrheic dermatitis (dandruff/cradle cap) Symptoms include red, scaly, thickened eyelids; itching; burning; excess blinking 55 Appearance 56  Treatment Warm compresses for 15 to 20 minutes – 2 to 4 times/day Bruder Mask , or equivalent Lid scrub Mix ¼ tsp “no more tears” formula baby shampoo in 1 cup water tepid warm water (poor compliance) Wash hands thoroughly Apply to margin of lids; avoid eyes Rinse with warm water Use commercial preparation; Eye Scrub; Lid-Wipes; Ocusoft Plus Lid Scrub pads 57  Demodex Mites Live in hair follicles Diagnosed by epilation and microscopic examination Treated with Xdemvy – Lotaliner ophthalmic solution 0.25% Gutierrex, M. Tea Tree Oil shampoo (25%) or Ocusoft Oust Demodex cleanser (QD) Ocusoft Plus lid scrubs (QD) Wash pillowcases, discard used cosmetics, etc. 58  Condition 7: Age-Related Macular Degeneration (AMD) Description Degeneration of the macula generally beginning after the age of 55y Progressive Early symptoms are blur, metamorphopsia, loss of brightness Responsible for 8.7% of all blindness worldwide in 2007, figure expected to double by 2020 Most common cause of blindness in developed countries 10% of individuals in the US between 65y and 75y have AMD 30% of individuals in the US >75y have a visual impairment related to AMD 59  AMD Progression Early stage Slow, or no, progression to advanced stage in 5 years (~1%) Intermediate stage Moderate progression to advanced stage in 5 years (18%) Treatable with OTC medication Advanced stage “Dry” AMD Mild vision loss to legal blindness 14% of AMD-related blindness “Wet” AMD Moderate vision loss to legal blindness 86% of AMD-related blindness Significant risk of AMD damage to fellow eye 60  AREDS Study The Age-Related Eye Disease Study (AREDS) group monitored 4757 people aged 55 to 80y Participants were treated with placebo or antioxidants: 15mg beta-carotene 500mg vitamin C 400IU vitamin E Zinc (80mg with 2mg copper) The antioxidants significantly reduced progression (30%) in patients with moderate AMD This cocktail is marketed as AREDS vitamins 61  AREDS Results Data are from patients with moderate AMD Risk is for progress from to advanced stage ~ 30% decrease AREDS 2010 62  AREDS2 Study 4023 participants aged 55 to 80 Lowering the Zn concentration and eliminating beta carotene from the original AREDS formulation had no effect on progression Substituting beta carotene with lutein plus zeaxanthene reduced progression to wet AMD but not overall progression For patients in the lowest quintile of lutein and zeaxanthene dietary intake, lutein plus zeaxanthene reduced overall progression Adding docosahexaenoic acid (DHA) plus eicosapentaenoic acid (EPA) (omega-3 fatty acids), or both to the AREDS formulation (the original or one or its variants) had no effect on overall progression of entire group Genetic testing first? (Awh et al.) – Debatable 63  AREDS 2 Vitamins New, “AREDS2” formulation should look like this: 10mg lutein 2mg zeaxanthine 500mg vitamin C 400IU vitamin E 25mg zinc oxide (still usually 80mg) / 2mg cupric oxide Advantages: Reduced lung cancer risk in former smokers (no vitamin A) At least as effective in prevention AMD progression More effective in prevention progression to wet AMD, the most damaging stage 64 PreserVision 65  Read the Label In the aftermath of AREDS2, there will probably be many new or altered formulations of vitamins available for AMD These are classified as “nutraceuticals” as long as they don’t claim to treat any disease (see below) Nutraceuticals are not regulated by the FDA like drugs 66  Read the Back of the Label too This formulation not only contains lutein and zeaxanthine, but ALSO contains vitamin A There is no demonstrated benefit for this combination The presence of vitamin A is a contraindication for smokers Many other vitamins with no clinically demonstrated effect on AMD are also included 67  Ocular Vitamins (NOT AREDS) Many formulations are NOT for AMD – e.g., Ocuvite , ICaps. Proposed indications: Dry eye Cataract Diabetic retinopathy Decreased vision Blue light protection Anecdotal evidence, but no large, controlled studies Probably not beneficial for people who eat a healthy diet Active area of commercial development and research 68  Ocuvite Blue Light 25 mg Lutein, 5 mg Zeaxanthin Isomers; Bausch and Lomb Protection against blue light One soft gel daily, in the morning with a full glass of water during a meal “Helps eyes shield and filter blue light” “Helps replenish the macular pigment layer that helps filter blue light” “These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease” 69  Summary of Conditions treated with OTC Products 1.Dry eye 4.Other causes of red eyes AT’s, gels, ointments, insert, Refer CL-related spray Palliative: AT’s, gels, 2.Loose foreign material in ointments eye 5.Corneal edema Eye wash Hypertonic Saline 3.Conjunctivitis: allergic, 6.Eyelid problems bacterial, or viral Lid scrubs Antihistamines/mast cell Warm compresses stabilizers Palliative: AT’s, gels, 7.Macular degeneration ointments ARED2 Vitamins 70