2024 PHARM 129 Lecture - Eye Care (PDF)

PHARM 129 Conjunctivitis S. MacIver OD, FAAO Associate Clinical Professor University of Waterloo, School of Optometry and Vision Science  Learning objectives After this lecture you will be able to: § Identify the ocular anatomy pe...

PHARM 129 Conjunctivitis S. MacIver OD, FAAO Associate Clinical Professor University of Waterloo, School of Optometry and Vision Science  Learning objectives After this lecture you will be able to: § Identify the ocular anatomy pertinent to conjunctivitis § Define conjunctivitis and list the main types of conjunctivitis § Identify the cardinal clinical signs and symptoms of the main types of conjunctivitis § Recognize appropriate drugs and self care strategies to treat and help prevent the spread of conjunctivitis when necessary What is Optometry? Optometry is the profession that provides primary eye care to the community. The Three O’s Optometry, Ophthalmology, Optician…What’s the difference?! Optometry (Doctor of Optometry (OD) degree) § Examine, diagnose and manage eye diseases and disorders of the vision system. Treatment includes corrective lenses, medication or referral to another specialist. Doctors of Optometry provide primary eye care. Ophthalmology (Medical degree and ophthalmology residency) § Physicians who diagnose diseases and disorders of the vision system. Treatment may include corrective lenses, medication, laser, surgery or referral to another specialist Optician (College degree) § Technicians qualified to fit and supply glasses and contact lenses Becoming a Doctor of Optometry § Optometrists require seven to eight years of post-secondary education to obtain their professional designation, Doctor of Optometry § Educational requirements include: § Minimum of three year undergrad degree in science § 4 year University program in optometry § Board Examinations: § Satisfy provincial board requirements § Pass a national examination administered by Canadian Examiners in Optometry § Optional § Residency Training  Case “Help me! My eye has been red and irritated for two days and I’m wondering if you can help me with some eye drops?” PRESENTATION TITLE PAGE 9 BASIC ANATOMY OF THE EYE PRESENTATION TITLE PAGE 10 PRESENTATION TITLE PAGE 11 PRESENTATION TITLE PAGE 12 Differentiating the red eye: Acute vs Chronic § Acute: § Short-term episode of illness § More likely to be conjunctivitis § Review red flag list prior to assuming conjunctivitis and identify urgency of treatment/referral § Chronic: § Long term, pre-existing concern § Less likely to be conjunctivitis § Potential for self-care Teasing out the ocular emergencies § Red Flags: Red Flag Possible diagnosis Pain Trauma, infection, ulceration, uveitis Purulent Discharge Ocular infection Sudden onset (or preceded by a triggering Trauma, infection, ulceration, angle closure event such as trauma glaucoma, uveitis Reduced vision – not improved with Corneal infection, uveitis, angle closure blinking glaucoma, etc. Contact lens wear Requires specific management strategies Presence of fever and swollen eyelid Cellulitis Conjunctivitis § Conjunctivitis is the inflammation of the conjunctival layers (clear membranes lining the eyeball) only § The whites of the eye become red because the blood vessels in the conjunctiva are inflamed § Conjunctivitis is not the only cause for inflammation of the blood vessels PRESENTATION TITLE PAGE 19 Conjunctivitis § Viral conjunctivitis is the most common cause; it can also be caused by bacteria or allergy § It is often accompanied by discharge § It may be irritating but it does not cause any threat to the vision § Common symptoms: § Redness AND discharge § Crusty and sticky eyes in the morning § Foreign body sensation/scratchy/burning § Eyes may feel ”full” (usually from accompanying eyelid swelling, this should not be mistaken for dull/deep boring pain) PRESENTATION TITLE PAGE 20 Common signs of conjunctivitis Slit lamp view: inflammation of palpebral conjunctiva with follicles/papillae Mucopurulent Discharge (seen on slit lamp) Discharge + eyelid swelling PRESENTATION TITLE PAGE 21 Conjunctivitis Differential Bacterial Viral (usually adenoviral) Allergic Symptoms Redness Itching, burning Ithing FBS FBS Watering Superficially sore Recent URTI History of allergies (usually) Often bilateral One eye first, than other (within 2 days) Discharge Purulent Watery-Mucus Watering Signs Chemosis Conjunctival follicles Chemosis Conjunctival papillae Palpable preauricular nodes Red eye red edematous eye Self-care and other Topical Antibiotics Lubricants, cold compresses, Cold compresses, Topical allergy medication, Treatment Lid hygiene CONTAGIOUS! lubrication, removal of pathogens CONTAGIOUS! Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis  Infection Control Protocols § Assume conjunctivitis is infectious until proven otherwise § Do not want to infect others! § DO: § Keep patient away from waiting room if possible § Separate room? § Wash hands § Wear GLOVES § Disinfect everything patient TOUCHES (door knobs, exam chair, computer, all equipment) Bacterial conjunctivitis – Adults Most common pathogen in adults is S. Aureus Most cases of infectious conjunctivitis in adults are viral and do not require antibiotics Usually unilateral but can be bilateral A diagnosis of bacterial conjunctivitis should only be made in patients with thick purulent discharge that continues throughout the day (not just present when wakes up in the morning) More common in adults with children or who live in community homes May occur secondary to exposure to Strep A without other systemic symptoms The discharge can generally be seen at the lid margins and at the corner of the eye when you look at the person Note: All cases of conjunctivitis can cause eyes to be shut in the morning – this is not a differentiator for bacterial conjunctivitis Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Bacterial conjunctivitis -adults PRESENTATION TITLE PAGE 26 https://www-uptodate- com.proxy.lib.uwaterloo.ca/contents/conjunctivitis?search=bacterial%20conjunctivitis%20treatment&source=search_result&selectedTitle=1~4 PRESENTATION TITLE PAGE 27 4&usage_type=default&display_rank=1#H2482188623 Bacterial conjunctivitis – Children Most common pathogens in children: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis Same presentation as adults Bacterial conjunctivitis more common in children then adults Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis CARDINAL PICTURE OF BACTERIAL CONJUNCTIVITIS TIhttps://www.allaboutvision.com/conditions/conjunctivitis-types.htm PAGE 29 Treatment of bacterial conjunctivitis Non-pharmacologic – Self limiting condition – Prevent spread – avoid hand-to-eye contact, wash hands, avoid sharing towels, etc. – Warm/cold compresses in the morning – Avoid contact lens use* (if conjunctivitis is occurring in a contact lens wearer it is better to have them seen by an eye care provider) Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Treatment of bacterial conjunctivitis § Antibiotic eye drops/ointment: Antibiotic drops are only required in true bacterial conjunctivitis In children, ointment may be preferred because it stays on the lids longer Because ointments blur vision for 20 minutes after the dose is administered, drops are preferable for most adults who need to read, drive, and perform other tasks that require clear vision immediately after dosing. Signs and symptoms should improve 24-48 hours after starting treatment, if not then patient should be assessed by eye care provider Empiric approach Also: Erythromycin 5 mg/gram ophthalmic ointment 0.5 inch (1.25 cm) 4 times daily for 5 to 7 days OTC Polysporin eye drops 4x/day (sting) OR Trimethoprim-polymyxin B 0.1%-10,000 units/mL 1 to 2 drops 4 times daily for 5 to 7 days Tobramycin 0.3% ophthalmic drops ophthalmic solution Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Viral Conjunctivitis Typically caused by the adenovirus The conjunctivitis may be part of a viral prodrome followed by upper respiratory tract infection, or the eye infection may be the only manifestation of the disease Typical presentation: Injection; watery or mucoserous discharge and a burning, sandy, or gritty feeling in one eye Patients may report "pus" in the eye, but on further questioning they have morning crusting followed by watery discharge, May have some scanty mucus throughout the day Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Viral Conjunctivitis § Other classic signs and symptoms: May only see mucoid injection if you pull down the eyelid Profuse tearing is more evident compared to mucus discharge May report “pus” in eye but on further questioning it is just in the morning +/- swollen/tender preauricular nodes Other eye often becomes effected in 24-48 hours Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Viral conjunctivitis PRESENTATION TITLE PAGE 34 Cardinal Picture of viral conjunctivitis +/- swollen eyelid https://www.allaboutvision.com/conditions/conjunctivitis-types.htm PAGE 35 Viral Conjunctivitis § Self-Care Treatment Viral conjunctivitis is usually self limiting Copious lubrication with artificial tears Cold Compresses for relief OTC or Rx topical antibiotics will not help A note about Epidemic Keratoconjunctivitis (EKC) In some strains of adenovirus a more aggressive form of viral conjunctivitis can form Causes a keratitis (swelling in the cornea) in addition to conjunctivitis This usually forms 8 days after the conjunctivitis and results in severe foreign body sensation and decreased visual acuity Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Viral Conjunctivitis § In eye care settings: § Use of providone-iodine rinse (after drop of alcaine) in affected eyes within 3 days of infection onset helps to: § Reduce viral load, faster heal time § Decrease amount of time they are contagious § Often prescribe a mild steroid for symptom relief of viral infection and following treatment § COVID related eye infections: PRESENTATION TITLE PAGE 37 COVID eye infections All had been on prior course of topical antibiotics with little improvement/worsening of symptoms. No other COVID symptoms PRESENTATION TITLE PAGE 38 § Case Consideration: “Do I need to stay home from work” Return to school/work § Return to school/work School: Some daycare centers and schools may require that students with conjunctivitis receive 24 hours of topical therapy before returning to school. Viral/bacterial conjunctivitis is highly contagious and spread by direct contact with secretions or contact with contaminated objects Infected individuals should not share handkerchiefs, tissues, towels, cosmetics, linens, or eating utensils The safest approach to prevent spread to others is to stay home until there is no longer any discharge Jacobs, D., & Gardiner M. (2019). Conjunctivitis. In Givens, Jane(MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/conjunctivitis Allergic Conjunctivitis Allergic conjunctivitis is caused by airborne allergens contacting the eye that, with specific immunoglobulin E (IgE) Causes local mast cell degranulation and the release of chemical mediators including histamine, eosinophil chemotactic factors, and platelet-activating factor, among others Hamrah P, Reza D. (2019). Allergic Conjunctivitis:Managment. In Feldweg A (MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/allergicconjunctivitis Allergic Conjunctivitis Cardinal symptom is: ITCHING Bilateral redness and watering are other tell tale signs Can be associated with lid swelling Often have a history of atopy, seasonal allergy or specific allergy (eg. cats, dogs, dust, etc) Hamrah P, Reza D. (2019). Allergic Conjunctivitis:Managment. In Feldweg A (MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/allergicconjunctivitis Cardinal Picture of viral conjunctivitis +++ ITCHING https://www.allaboutvision.com/conditions/conjunctivitis-types.htm PAGE 43 Treatment of allergic conjunctivitis: Non-pharmacological management/ Self Care Avoid eye rubbing, rubbing can cause mechanical degranulation of mast cells Allergen avoidance – Strategy depends on allergen – Ex. stay indoors, avoid cats Cool compresses can help reduce eyelid and periorbital edema Nasal steroid may work if have rhinitis as well Frequent use of refrigerated artificial tears throughout the day can also help to dilute and remove allergens Reduce contact lens wear Hamrah P, Reza D. (2019). Allergic Conjunctivitis:Managment. In Feldweg A (MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/allergicconjunctivitis Treatment of allergic conjunctivitis: Over the counter (OTC) drugs Topical decongestants – Not first-line for treatment of allergic conjunctivitis and not typically recommended by eye care professionals – Reduce eye redness and conjunctival edema – Do not use more than ~10 days – rebound redness – Examples: Clear Eyes (naphazoline), Visine Original (tetrahydrozoline) Hamrah P, Reza D. (2019). Allergic Conjunctivitis:Managment. In Feldweg A (MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/allergicconjunctivitis Treatment of allergic conjunctivitis: OTC drugs (cont’d) Antihistamine/decongestant combinations (topical) – The antihistamine component competitively and reversibly blocks histamine receptors in the conjunctiva and eyelids, thus inhibiting the actions of the primary mast cell- derived mediator – Decrease itching and tearing, in addition to decongestant – More effective than decongestant alone – Do not use for more than ~10 days – rebound redness – Examples: Naphcon-A, Opcon-A (naphazoline/pheniramine) Hamrah P, Reza D. (2019). Allergic Conjunctivitis:Managment. In Feldweg A (MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/allergicconjunctivitis Treatment of allergic conjunctivitis: OTC drugs (cont’d) Oral antihistamines (2nd gen.) – May provide some symptom relief – Onset of action is slower than topical antihistamines, possibly less effective particularly if symptoms are limited to the eyes – Examples: Claritin (loratadine), Aerius (desloratadine) Mast cell stabilizers (some are OTC, some are rx) – Prevent histamine release – Require regular use, starting before allergy season – Examples: Opticrom (sodium cromoglycate) Ocular lubricants/artificial tears – May provide some relief for irritated eyes – Avoid products with benzalkonium chloride – may irritate eyes Hamrah P, Reza D. (2019). Allergic Conjunctivitis:Managment. In Feldweg A (MD.), UpToDate. Retrieved March 9, 2020, from https://www.uptodate.com/contents/allergicconjunctivitis  Treatment of allergic conjunctivitis: Prescription drugs Dual acting antihistamine/mast cell stabilizer (THE MOST COMMON CLASS PRESCRIBED) – Alleviate itching and some inflammation – Convenient dosing schedule for patients (once a day) – Ex. Olopatadine (Patanol) Topical antihistamines – Not typically used anymore – Ex. Levocabastine (Livostin) – Rapid onset of action – More effective than oral antihistamines and OTC topical antihistamine/decongestant combinations Mast cell stabilizers Prescribed MCS not typically used anymore Full efficacy is reached 5 to 14 days after therapy has been initiated, and therefore, these medicines are not useful for acute symptoms – Ex. nedocromil  Patient case example § Susan, a 47 year old woman, comes in with a self diagnosed ‘pink eye’. She wants to know whether she should use polysporin drops, and if so, how should she use them?