Eye care Pharmacist CPD Facts Behind the Fact Card

Eye care
By Katie Hayes This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed.

Patients with eye conditions often

present to the pharmacy seeking
treatment advice. Pharmacists
therefore, have an important role in
the management of eye conditions
including identification of causes,
advice on management, and referral
to other health professionals.
Many eye conditions have
similar presentations. Pharmacists
must differentiate between the
conditions to ensure the patient
receives the most appropriate
management to achieve optimal
patient outcomes.

Learning Objectives
After reading this article, pharmacists
should be able to:
Describe common eye
conditions seen in the pharmacy
Discuss pharmacological and
non- pharmacological treatment
options of common eye
conditions
Recognise when to refer a
patient to another health
professional
Discuss the role of the
pharmacist in the management
of common eye conditions
including counselling for the
correct use of various
treatments.
Competencies addressed (2014): 01.5,
02.1, 03.5
Eileen, an elderly lady presents to the
pharmacy with red, gritty tired eyes. Eileen
explains the signs and symptoms started
around 2 weeks ago. She asks you, the
pharmacist, what she can do to alleviate her
signs and symptoms.
Dry eye
Dry eye is also known as dry eye syndrome and
keratoconjunctivitis sicca. It is a chronic and
common condition that affects more women than
men, and can affect physical, social, and
psychological functions, activities of daily living,
workplace productivity, and quality of life. 1-3 The
prevalence of dry eye is difficult to estimate but it
has been reported in 530% of people who are 50
4 further exacerbated by friction that occurs
years of age and older.
5,6
There are two main types of dry eye : film.
The mechanisms involved in dry eye
development are complex and
multifactorial. Tear hyperosmolarity leads
to release of inflammatory mediators and
subsequent inflammation. This causes
epithelial cell damage, goblet cell loss,
and mucin loss resulting in tear film
instability, which further intensifies tear
7
hyperosmolarity. In addition, there are
conditions which directly cause tear film
7
instability. The ocular surface sensory
nerves can be activated in this
environment leading to symptoms such
as discomfort and burning, and possible
increased tear secretion as a
4, 7
compensatory response. This can be
as a result of mucin disturbance in the tear
7

1 .Aqueous tear-deficient dry eye due to

This activity has been
accredited by ENHANCE for one hour
of CE. (1 group 1point which may be
converted to 2 group2 points
following the successful completion
of the associated assessment.) The
programme is provided by Self Care, a
business unit of the Pharmaceutical
Society of NZ Inc.
inadequate tear volume, most commonly arising
as an isolated idiopathic condition in
postmenopausal women.
2. Evaporative dry eye as a result of the
loss of the tear film. This occurs due to
abnormally rapid evaporation caused by
an inadequate oil layer on the surface of
the aqueous layer of tears.
 Eye care Pharmacist CPD
trauma (e.g. surgery, radiation therapy,
burns)
dehydration (e.g. secondary to type 2
diabetes mellitus).
The following can lead to increased tear
,
evaporation7 9:
allergic conjunctivitis
adverse effects of medicines (e.g.
antihistamines)
inability to completely cover eyes when
closing eyes (i.e. lagophthalmos)
low blink rate or wide lid aperture
Symptoms environmental factors (e.g. low humidity,
high wind velocity)
Dry eye is usually bilateral in presentation.
There are a number of symptoms associated vitamin A deficiency.
with dry eye (see Table 1).
Medicines can have a number of effects that
Other non-ocular symptoms may assist with can cause or contribute to dry eyes. See
identification of the cause. For example, if Practice point 1.
the patient has a dry mouth, dry eyes may
be caused by medicine, or autoimmune Assessment
conditions such as Sjgrens syndrome.
It is important to determine signs and
symptoms, and their onset and duration,
Risk factors
as well as non-ocular symptoms (e.g.
General risk factors for dry eye include2,4,7,8: dry mouth, recent illness). Medical
conditions and medicines should be
increasing age
established as these can contribute to dry
female gender eye development and may be important
medicines considerations in management choice. The
patients environment and lifestyle should
medical conditions
also be assessed to see if changes can be
decreased corneal sensation
made to improve signs and symptoms. Self-
nutritional deficiencies. management strategies already undertaken
by the patient should also be noted.
Causes
The following can result in decreased tear Diagnosis
production7, 9: There is no single test for dry eye diagnosis
allergic conjunctivitis and it is generally diagnosed according
to subjective reports.4, 10 Optometrists
blepharitis
or ophthalmologists can diagnose and
adverse effects of medicines (e.g.
monitor dry eye syndrome, and may be able
antihistamines) to differentiate the cause of dry eye with the
Sjgrens syndrome following tests5,11:
Schirmer test used to determine tear
Table 1. Symptoms of dry eye production and aqueous tear-deficient
dry eye syndrome. With evaporative dry
Dryness
eye syndrome, the Schirmer test is usually
Irritation
normal.
Discomfort
The tear film break-up time test is the
Itch
time to initial breakup the tear film
Burning following a blink. An accelerated rate
Grittiness
of intact tear film breakup (<10 sec) is
Blurred vision characteristic of evaporative dry eye
Foreign body sensation syndrome.
Photosensitivity It is important to rule out other conditions
Ocular fatigue through differential diagnosis. Viral
References: Roat5;McGinnigle6;AMH8 conjunctivitis can produce similar
Facts Behind the Fact Card
symptoms to dry eye (e.g. ocular irritation).4
A blocked lacrimal duct can cause watering
of the eye.9 Other causes of acute red eye
include9:
keratitis (inflammation of the cornea
caused by infection, trauma, or allergy)
iritis (inflammation of the iris)
episcleritis (inflammation of the sclera)
acute glaucoma.
These conditions usually present with
significant redness, and require immediate
medical attention.
Referral
Refer immediately to emergency care
patients suspected of having keratitis,
iritis, or acute glaucoma.9 General
practitioner (GP) or optometrist referral is
necessary if there is no improvement in
signs and symptoms despite hourly use
of ocular lubricants and for those who
have had signs and symptoms despite
appropriate treatment for 4 weeks and
not been reviewed.8,12 Referral is required
for patients who have dry eye signs and
symptoms associated with systemic
disease (e.g. rheumatoid arthritis) and have
not been examined for their concurrent
ocular symptoms.2 Urgent referral to an
ophthalmologist is required for patients
with ongoing or significant vision loss,
diplopia (double vision), and those who
have systemic ill health (e.g. weight loss,
fever).3
Management
In the management of dry eye, improving
patient comfort and quality of life are
important, as is returning the dry eye to its
normal homeostatic state.13 Reducing the
risk of complications such as conjunctivitis
and keratitis is imperative.9
Ocular lubricants (artificial tears) are used
to4,9,14:
supplement or increase tears
slow the rate of tear evaporation
reduce resorption of tears
dilute inflammatory substances
reduce tear film osmolarity.
Eye drops do not tend to blur vision, but
may require frequent administration (i.e.
up to hourly) in severe cases. Gels provide
longer relief than eye drops, but gels can
blur vision although less so than ointments. 8
Ointments may be used during the day
for severe dry eye symptoms, but can blur
 Eye care Pharmacist CPD
Preservatives in topical eye medicine
products, as well as some other topically
applied eye products (e.g. contact
lenses), can cause a toxic response on
the eye surface.7, 9 This can initiate the
cycle of inflammation, epithelial damage,
goblet cell and mucin loss resulting
in tear film instability and further tear
hyperosmolarity.
increase evaporation of tears.7 There
are several medicines that decrease
tear production due to impairment
in the delivery of lacrimal fluid to the
conjunctival sac.7 These medicines
include2,7,9:
anticholinergics (e.g. tricyclic
antidepressants, antihistamines)
selective serotonin re-uptake
inhibitors
diuretics
hormone replacement therapy
(especially oestrogen alone).
Note: Antimuscarinic drugs (e.g.
anxiolytics, antipsychotics, alcohol) are
inconclusive, and only plausible if they
cause dehydration.
When assessing a patient with dry eye,
it is important to consider all medicines
they are taking to identify drug-related
causes. The pharmacist can then refer the
patient to the general practitioner (GP)
or contact the GP to discuss alternative
medicines if available, to reduce the
symptoms of dry eye.
Related Fact Card
Eye care and Conjunctivitis
vision and are often recommended for
night- or bed-time use.3,8 Ointments do not
contain preservatives but some contain a
mixture of paraffin and lanolin, which may
be irritant.8 Sprays contain ingredients that
stabilise the tear film, such as lecithin.2 It
may take trialling a number of products
to find the products most suitable for the
patient.3
The effectiveness of over-the-counter
(OTC) artificial tears for dry eye syndrome
has recently been evaluated in a Cochrane
review. Due to a lack of robust study
techniques and reporting, firm conclusions
from these studies cannot be drawn.14
However, ocular lubricants are reported to
be safe and have similar effectiveness.14
The products available for management of
dry eye may contain a range of ingredients
with the following actions: emollient,
film-forming, wetting, viscosity-enhancing,
tear film stabilisation, and promotion of
spreading to prevent evaporation.2,4 See
Table 2 for ingredients of ocular lubricant
products.
For patients with mild-to-moderate
dry eye, cellulose derivatives such as
hypromellose (0.20.5%) and carmellose
(0.5 or 1%) can be trialled but may require
frequent administration.2, 9 Less frequent
administration is necessary for polyvinyl
alcohol and carbomers, but these are
more likely to blur vision than cellulose
derivatives.2,9 Sodium hyaluronate
remains on the ocular surface longer than
several other ocular lubricants and may
be suitable for some patients.15 Ocular
lubricants are safe to use in pregnancy and
breastfeeding.2,8 Preservatives in lubricant
products can irritate and damage the eye.
See Practice point 2. Patients using eye
products more frequently than 3-hourly
should use preservative-free products.8,18
Where medicine is causing or contributing
to dry eye, consideration should be made
Facts Behind the Fact Card
as to whether this medicine can be ceased.
Management of commonly associated
eye conditions (i.e. treatment of allergic
conjunctivitis, blepharitis, or rosacea) will
improve ocular irritation.3
Where symptoms cannot be controlled with
the use of ocular lubricants and lifestyle
measures, specialist referral is necessary.
Management for these patients may include
surgery and use of topical anti-
inflammatories (e.g. corticosteroid).4,8
Counselling for dry eye
It is important that patients understand
that dry eye is not always curable. Dry eye
can however often be managed with a
combination of lifestyle/environmental
factors and ocular lubricants.
Patients should blink frequently, especially
while using the computer or reading (i.e.
visually attentive tasks).4 Exposure to
heating, hair dryers, air-conditioning, and
windy conditions should be minimised. In
patients who wear contact lenses, these
should be removed for the day when dry
eye symptoms appear.3 See Practice point 3.
A humidified environment can reduce tear
evaporation and is particularly important
in dry climates.5,13 Patients with dry eye
should not smoke and avoid second-hand
cigarette smoke to reduce ocular irritation.5
Wrap-around glasses can reduce tear
evaporation.8
Patients should be adequately hydrated to
prevent exacerbating dry eye.5 Omega-3
fatty acids have provided benefit in some
studies of dry eye.5 Patients with dry eye can
be encouraged to ensure their diet contains
sufficient omega-3 fatty acids.5
Conjunctivitis
Conjunctivitis (inflammation of the
conjunctiva) is characterised by varying
degrees of eye erythema, irritation,
itchiness and discharge.2 Conjunctivitis may
be infective (bacterial or viral) or allergic.
Bacterial and viral infection are the most
common causes of infectious conjunctivitis,
and numerous allergens can cause allergic
conjunctivitis.19
Assessment
To ensure correct diagnosis and
management plan for patients presenting
with conjunctivitis-like symptoms, it is
important to establish the history of the
 Eye care Pharmacist CPD Facts Behind the Fact Card

presenting condition as indicated below 2: suggest more serious conditions (e.g.

Duration of symptoms redness concentrated around iris may
suggest uveitis)
Presence of discharge and description
Presence of co-existing symptoms
Preservatives
Vision changes (e.g. vision loss, haloes (e.g. cold symptoms suggest viral Consider preservatives when
around objects) conjunctivitis, or nausea/vomiting recommending a treatment for
Pain location (superficial versus deep), suggest glaucoma. eye conditions. Preservatives are a
and description (e.g. foreign-body Patient history to determine possible necessary part of multi-dose eye
sensation) contributors, assist with management products. However, they can lead to
Location of redness generalised and choice and determine if referral is irritation and damage, particularly
towards corners of the eyes suggests necessary. where inflammation is already present
conjunctivitis, other presentations may and also when there is an inadequate
production of tears to dilute the
preservatives.8, 41 Adverse effects of
preservatives can include inflammation,
44
Table 2. Ingredients in ocular lubricant products Reference allergic reactions, stinging, burning,
dryness, conjunctivitis, and even corneal
Ingredient Action damage.41 Benzalkonium chloride is the
most frequently used preservative and
Macrogol (polyethylene glycol) 400 Viscosity agent, spreading agent
is also the most irritant preservative.8, 12
Cellulose derivatives This may not be problematic in patients
Carmellose Emollient, film-forming, maintaining viscosity using the product infrequently and

May require very regular (i.e. up to hourly) administration due to

non-ideal wetting characteristics

Hypromellose Emollient, film-forming, maintaining viscosity

May require very regular administration due to poor wetting character-

in ocular tissues.8
istics
Polyols
Glycerin Lubricant
Polysorbate 80 Lubricant
Propylene glycol Emollient
Hydroxypropyl guar Viscosity agent, liquid turns into a gel when instilled in the eye and
mimics mucin layer of tear film
Sodium hyaluronate Viscosity agent, remains in eye significantly longer than other ocular
lubricants (i.e. hypromellose, polyvinyl alcohol) and greater symptomatic
benefit in more severe cases of dry eye
the tear film.2
Polyvinyl alcohol At 1.4% is a viscosity enhancer, wetting, prevents evaporation
Of interest is that some preservatives
Povidone Tear stabiliser, mimics mucin layer of tears leading to increased adhesion to break down when used. For example,
eye surface and usually used in combination with a viscosity-enhancer sodium perborate becomes water
Dextran 70 Polysaccharide, only capable of enhancing lubricating properties when and oxygen on contact with the eye.2
used in combination with other ocular lubricants, e.g. hypromellose Oxychloro complex (also known as
Carbomer974, Carbomer 980 Visco-elastic lubricant, binds moisture to eye surface purite) breaks down to sodium chloride
and water when exposed to ultraviolet
Paraffin High-viscosity polymer, a superior long-lasting effect compared with
light.2
aqueous-based ocular lubricants
For those patients who have adverse
Can blur vision, irritate the eye, and potentially delay wound healing reactions to preservatives, or it is
Lanolin Lubricant with enhanced retention time as it forms an ointment anticipated that they may have reactions,
consideration should be given to the use
Can be irritating to the eye of single-dose preparations, as these do
Retinol palmitate Vitamin A derivative, required for many functions of the eye including not contain preservatives.
epithelial cell differentiation and reverses squamous metaplasia (e.g. loss
of goblet cells and keratinisation)

Avoid in evaporative dry eye due to detrimental effect on meibomian

glands

Lecithin Contains phospholipid liposomes

Thought to stabilise lipid layers in tear film, reducing evaporation

 Eye care Pharmacist CPD
to have infective (viral or bacterial)
conjunctivitis wear contact lenses,
refer them to their GP or optometrist.18
When suffering from infective (bacterial)
conjunctivitis, use of contact lenses
should be avoided until 24 hours after
completing the course of treatment.42
Patients who wear contact lenses and are
suffering from dry eye should remove
contact lenses (e.g. remove for the day
when symptoms of dry eye appear).
3
eye symptoms.
Consideration of contact lenses is
also important when patients are
recommended topical eye treatments.
Preservatives in eye drops can damage
soft contact lenses. It is recommended
patients wearing soft contact lenses and
using eye drops with preservatives avoid
wearing contact lenses during treatment
and for 48 hours post-treatment.2 If
possible, preservative-free eye drops
should be used in patients who wear
contact lenses.9 Ointments should never
be used while contact lenses are worn.9
Patients who present with the following
require immediate referral to an emergency
department or ophthalmologist2,2022:
eye pain (note: differentiate from
discomfort at the ocular surface)
vision loss/reduction/distortion
photophobia
eye movement restriction
symptoms suggestive of acute angle-
closure glaucoma severe, throbbing
pain, haloes around lights
distorted/irregular pupil or abnormal
pupil reaction (e.g. not reactive to light)
suspected traumatic eye injury/possible
penetrating foreign body
corneal involvement, e.g. cloudy,
ulcerated
associated nausea/vomiting
history of welding without eye protection
immediately prior to symptom onset
eye surgery or laser treatment within the
last 6 months
if symptoms do not resolve within
710 days.
GP or optometrist referral are required in
the following circumstances2,20:
suspected superficial foreign body in the
eye
contact lens wear (keratitis risk)
nflammaition of the cornea > permanent damage to eyes
copious yellow-green purulent discharge,
which accumulates after being wiped
away
infection not confined to conjunctiva.
Bacterial conjunctivitis
Bacterial conjunctivitis generally begins
as an unilateral red eye with purulent
discharge. The other eye may become
infected after 1 or 2 days.22 It can be a
primary infection or secondary to a viral
infection or blepharitis.22 Patients often
experience discomfort such as stinging or a
gritty sensation and eye erythema is diffuse
and generalised.2,21
Management
Bacterial conjunctivitis is self-limiting and
without treatment, has cleared within
5 days in approximately two-thirds of
patients. However chloramphenicol is
considered clinically desirable as it can lead
to faster resolution and reduce relapse.2,23
It is therefore reasonable to either treat
with chloramphenicol immediately, or to
Facts Behind the Fact Card
withhold chloramphenicol initially to allow
time for healing without treatment.23,24
For patients who have not used treatment,
if improvement has not occurred within
48 hours, treatment should be initiated. For
those patients who have used treatment,
if there is no improvement within 48 hours
or symptoms deteriorate, they should seek
medical advice (i.e. GP or optometrist).20
Chloramphenicol is available as drops
and ointment. Eye drops (0.5%) should be
administered as 12 drops 2-hourly initially
and as infection improves, administration
frequency should be reduced to 6-hourly
for up to 57 days, or for at least 2 days
after clearing of infection, whichever occurs
first.2,20 Chloramphenicol eye ointment
1% can be used as an adjunct to drops
(administered at night) or as monotherapy
(ointment is applied 3 times daily and
continued until 2 days after the infection
has resolved).2 The ointment should
be applied inside the lower eyelid with
approximately 11.5 cm applied.2, 8, 20
While generally well-tolerated,
chloramphenicol application can cause
stinging, burning, or itching. 25 Rarely,
patients may experience allergy as
indicated by local reactions, dermatitis,
angioedema, and anaphylaxis, requiring
immediate cessation, referral to and
follow-up with a medical professional. The
urgency should be determined by reaction
severity.8, 25
Chloramphenicol use is contraindicated
in patients with hypersensitivity history to
any of the excipients in chloramphenicol
eye products and/or toxic reaction
to chloramphenicol.25 The use of
chloramphenicol products should also be
avoided in patients with an individual or
family history of blood dyscrasias (i.e. bone
marrow problems), and GP or optometrist
referral is necessary if treatment is
required.25
Viral conjunctivitis
Viral conjunctivitis tends to be unilateral
at initiation, with a red eye and serous
discharge. Transfer to the other eye may
occur after 23 days but with reduced
intensity.22 The most common cause of

viral conjunctivitis is adenovirus. Viral
conjunctivitis frequently occurs when
patients also have upper respiratory tract
infection.22
Management
There are no specific products for treatment
of viral conjunctivitis and products for
symptomatic relief are recommended
where necessary.2, 22 Ocular lubricants
can be used as with dry eye, and topical
vasoconstrictors (e.g. phenylephrine), can
be used if considered necessary.22 Cold
compresses used several times daily may
also provide relief. Viral conjunctivitis
is particularly contagious and patients
should be counselled on hygiene self-care
measures that will minimise the spread of
the condition (e.g. washing hands frequently
and not sharing towels).2 The patient
is infectious until the weeping and eye
erythema resolves, usually 1012 days.2
Allergic conjunctivitis
Allergic conjunctivitis is caused by an ocular
response to an airborne allergen, and may
be seasonal or perennial. It may also occur
as a contact hypersensitivity reaction (e.g.
preservatives in eye drops).22, 26 It can be
difficult to distinguish from infective (i.e.
bacterial or viral) causes of conjunctivitis.22
Seasonal allergic conjunctivitis is commonly
caused by pollens from trees, and grasses
and usually occurs in spring, late summer,
and early autumn.26 Perennial conjunctivitis
is caused by non-seasonal allergens (e.g.
dust mites and animal dander).26 Allergic
conjunctivitis generally presents as itchy
eyes with a watery or stringy discharge, and
is usually bilateral.22, 26 Eyelid oedema may
occur and patients often have rhinitis.26
Management
Patients who are treating rhinitis with
intranasal corticosteroids may find that
they have some relief of eye symptoms.
For mild eye symptoms, irrigation with
sodium chloride 0.9% solution twice daily,
together with ocular lubricants (48 times
daily) and cold compresses as needed may
be sufficient to control symptoms.8 For
moderate symptoms, recommend a topical
antihistamine (e.g. azelastine, levocabastine)
or a topical antihistamine mast cell
stabiliser, which also inhibit inflammatory
mediator release from mast cells (e.g.
olopatadine, ketotifen).8 These products
are safe in pregnancy and may be used
Eye care Pharmacist CPD Facts Behind the Fact Card
in breastfeeding.8 See Table 3 for allergic
conjunctivitis medicines.
Sodium cromoglycate and lodoxamide are
mast cell stabilisers but can take time to
be effective and should be commenced 2
4 weeks prior to likely onset of
symptoms.8 Ocular decongestants (e.g.
phenylephrine, a sympathomimetic) may
be used to reduce erythema, but should be
limited to short-term use (i.e. 5 days) due to
the risk of rebound redness.2 Patients with Shake any product before use where
more severe disease or whose symptoms directed.
are not controlled with aforementioned Pull down the lower eyelid to form a
management should be referred to their pouch.
doctor. Place one drop in pouch without
touching the dropper to the eye or
Self-care strategies eyelashes and close eye.
Self-care strategies for allergic conjunctivis27: Apply gentle pressure for a few
minutes with a finger to the bridge of
Avoidance of symptom triggers (e.g.
pollens, dust mites, and animal dander). the nose to prevent/reduce drainage
of medicine from the eye.
Monitor pollen count (e.g. smartphone
applications) and if count is high, try to Wipe away excess drops or drainage
from eyelid and lashes with a clean
avoid going outside.
tissue.
Stay indoors in spring, on windy days or
If instilling further drops, wait several
after thunderstorms.
minutes between instillation of each
Select garden plants that require drop to maximise efficacy.
pollination by birds or insects and avoid
those that release seeds into the air.
Wear wrap-around sunglasses (note these
can also reduce tear evaporation in dry eye).
Stye
Pull down the lower eyelid to form a
A stye (hordeolum) is an acute infection pouch.
of the sebaceous gland associated with
an eyelash follicle. The infection is usually
caused by staphylococci and may be
internal or external.8, 22 The eyelid of the
affected area becomes swollen, and
painful and sensitive to touch.2 The abscess To spread the ointment, blink several
will develop over time into a pus-filled times.
lesion, then either spontaneously shrink Wipe away excess ointment or
and resolve or burst over a few days. drainage from eyelid and lashes with a
Management may lead to faster symptom clean tissue.
resolution.2 Management includes applying Vision may be temporarily blurred.
warm compresses to encourage pointing
(yellow or white pus at top of stye)
34 times daily for 510 minutes, and often
the stye will spontaneously discharge. 8
Removing the affected eyelash may hasten Before first use of product, prime
resolution.22 It is important to note that product by pushing down nozzle
application of antibiotics is generally 34 times.
unnecessary, and does not result in faster
Hold bottle 10 cm away from eye.
symptom resolution.2
Close eyes.
Blepharitis
Blepharitis is inflammation of the lid
margins and is usually bilateral in

presentation.2, 28 Contributors to blepharitis
include microorganisms, abnormal
secretions from the lid margin, and an
abnormal tear film.22
Posterior blepharitis is caused by meibomian
gland dysfunction. Signs and symptoms are
often worse in the morning,2 and include
erythema of the lid margin, burning, itching,
sticky discharge, and greasy scales that are
easily removable.8, 22 Posterior blepharitis
is generally associated with seborrhoeic
dermatitis or rosacea.22
Anterior blepharitis is caused by
staphylococcus leading to inflammation
of the anterior lid margin with hair follicle
involement.22 Patients present with crusts
that adhere to the eyelid and small abscess
or shallow ulceration of the eyelash base.8, 22
Initial therapy for blepharitis involves
application of warm compresses (to closed
eyes) twice daily for 510 minutes and lid
scrubs.5, 8 Lids should be scrubbed twice
daily while blepharitis is active and once
daily for prevention of recurrence.8 Scrubs
choices include: bicarbonate solution (1
teaspoon in 500 mL cooled boiled water),
baby shampoo solution (5 drops in 100 mL
cooled boiled water), and propriety lid
solutions/wipes.8, 22 The scrub solution
should be used to soak a gauze, cotton
bud or similar and then applied to the
eyelid(s).8 A downward motion is used for
the upper eyelid and an upward motion
for the lower eyelid.2 If symptoms of
anterior (staphylococcal) blepharitis are not
controlled with lid hygiene, chloramphenicol
ointment 1% can be applied once or twice
daily for 13 weeks.8, 22 It is important that
patients understand the ongoing need to
use compresses and scrubs to prevent active
blepharitis episodes.
Table 3. Allergic conjunctivitis medicines
Drug Mode of action
Levocabas- Antihistamine
tine
Ketotifen Antihistamine-mast cell
stabiliser
Olopatadine Antihistamine-mast cell
stabiliser
Cromoglycate Mast cell stabiliser
Lodoxamide Mast cell stabiliser
References: Rutter2;AMH8
Eye care Pharmacist CPD
Glaucoma
Glaucoma is an optic nerve neuropathy
most commonly associated with elevated
intraocular pressure (IOP).29 It is the
second most common cause of blindness
worldwide.30 Glaucoma is primarily classified
as open-angle glaucoma (OAG) and closed-
angle glaucoma (CAG). The classification is
based on the angle at the junction of the iris
and the cornea at the edge of the anterior
chamber.30 See Figure 1.
CAG occurs where there is a narrowing of
the anterior chamber angle.29 It is due to
increased IOP resulting from inadequate
aqueous drainage from the anterior
chamber causing optic nerve damage.2 CAG
may be primary or secondary. In primary
CAG, there is no identifiable secondary
cause and the patient has an anatomical
predisposition.29 Secondary CAG is due
to a co-existing condition that leads to a
narrowing or closure of the angle at the
anterior chamber.31
Patients with acute CAG present with eye
erythema and pain and must be referred to
the GP or emergency department.2 If not
treated within 24 hours, the patient is at risk
of permanent blindness.31
Optic nerve damage in OAG leading to
loss of retinal ganglion cell axons, causes
progressive peripheral visual field loss,
and then central field vision loss.31 Under
examination, the optic nerve (or disc)
appears hollowed out, termed cupping.31
If the condition is not treated, irreversible
blindness will result. As OAG is generally
asymptomatic, it is important that people
have regular eye examinations. Eye health
and eye examination may form part of a
health promotion activity in community
pharmacy.
Strength Directions
0.05% eye drops Initially 1 drop twice daily, increasing
to 1 drop three to four times daily if
necessary
0.025% eye 1 drop twice daily
drops
0.1% eye drops 1 drop twice daily
Note: Prescription Only medicine
2% eye drops 1 drop four to six times daily
0.1% eye drops 1 drop four times daily
Facts Behind the Fact Card
Management
Diagnosis and early treatment are vital
in glaucoma management. IOP can be
reduced with the use of medicine, laser, and
surgery. Treatment choice is dependent on
glaucoma type.30
Medicine is first-line management for most
patients with OAG.8 The medicines used in
open-angle glaucoma management reduce
production of aqueous humour and/or
increase aqueous humour outflow.8 As OAG
is generally asymptomatic, adherence to
treatment is a major problem. Up to 50% of
people do not use their medicine correctly,
therefore it is imperative for pharmacists to
explain the importance of medicine during
patient counselling.8 Medicines available for
the management of OAG are described in
Table 4.
Prostaglandin analogues increase aqueous
humour outflow and are first line in OAG
management.33 This group of medicines
can cause iris hyperpigmentation, and
thickening, lengthening, and darkening of
the eyelashes.8 If response to an agent in this
group is poor, another agent from this class
may be trialled due to structural differences.
However, the use of two prostaglandin
analogues together must be avoided due to
potential for paradoxical IOP increase.8
Beta-blockers decrease aqueous humour
production and are first-line agents.8, 33
Timolol blocks beta1 and beta2 receptors and
should be avoided in patients with asthma.
Betaxolol is beta1 selective and may be
used with caution in patients with asthma.8
Due to the potential for systemic adverse
effects such as bradycardia, it is important
that patients understand appropriate
administration including the need to
occlude the tear duct. See Practice point 4.
Alpha2 agonists reduce production, and
increase outflow, of aqueous humour.33
There is a decline in the effect of
apraclonidine after 1 month and increasing
ocular adverse effects after 3 months of
treatment.8 It is therefore recommended for
use up to a maximum of 3 months.8 These
agents are second-line in the management
of OAG.8
Carbonic anhydrase inhibitors reduce
aqueous humour formation and are second-
line agents.8, 33 Allergy risk to these agents
may be increased in patients who have a
sulfonamide allergy.8 Acetazolamide (oral
carbonic anhydrase inhibitor) is reserved for
use where other treatments have failed.8 It is
not tolerated by up to 50% of people.8
 Eye care Pharmacist CPD Facts Behind the Fact Card

Pilocarpine increases aqueous outflow, but is
rarely used for OAG management due to
poor tolerance and frequent administration
requirements.8
Figure 1. Open-angle and closed-angle glaucoma
Sjgrens syndrome
While the cause of Sjgrens syndrome is
unknown, the condition is associated with
rheumatoid arthritis.2 Exocrine glands,
especially the salivary and lacrimal glands,
become infiltrated with inflammatory
mediators leading to damage and
dysfunction, often resulting in severe sicca
symptoms (dry eyes and/or dry mouth).34, 35
The treatment of dry eyes associated with
Sjgrens syndrome is as for other causes of
dry eye with decreased tear production, that
is, the use of ocular lubricants.35

Macular degeneration
(age-related)
Age-related macular degeneration (AMD)
is caused by ageing. There are two forms of
AMD: dry or wet. All AMD begins as dry and
approximately 15% of people progress to the
wet form.36 Dry AMD, while painless, causes
progressive central vision loss, whereas wet
AMD can cause rapid (e.g. days-to-weeks)
central vision loss/distortion.36, 37 See Figure 2.
Risk factors for AMD development include
older age, smoking, and family history.38
As loss of vision is not likely to be noticeable
Table 4. Open angle glaucoma medicines until significant progression of AMD has
occurred, it is important that patients have
Drug Strength Directions regular eye examinations where AMD
can be identified early and management
Prostaglandin analogues
undertaken. Pharmacists should encourage
Bimatoprost 0.03% 1 drop at night patients to undertake regular eye
examinations.
Latanoprost 0.005% 1 drop at night

Travoprost 0.004% 1 drop at night Management

Beta-blockers A 2014 Cochrane review concludes there
is no high-quality evidence to support the
Betaxolol 0.25% (suspension), 0.5% (solution) 1 drop twice daily
benefits of nutritional supplementation for
equally effective
primary prevention of AMD.39 While reversal
Timolol of damage is not possible, supplements may
0.5% 1 drop once or twice daily
reduce the risk of progression to advanced
0.25%, 0.5% (extended-release) 1 drop once daily disease. The Age-Related Eye Disease
0.1% (gel) 1 drop once daily Study (AREDS) found a beneficial effect of
antioxidants (vitamins C and E, and beta-
Alpha2 agonists carotene) and zinc supplementation for
slowing the progression to advanced AMD.39
Brimonidine 0.15%, 0.2% similarly effective 1 drop twice daily
If recommending these products, caution
Carbonic anhydrase inhibitors should be exercised as people taking high-
dose zinc were at increased risk of hospital
Brinzolamide 1% 1 drop twice daily
admission due to genitourinary diseases. 39
Dorzolamide 2% 1 drop three times daily (monotherapy), Omega-3 fatty acids have not been shown
1 drop twice daily (adjunct to beta-blocker) to be of benefit in preventing AMD or for
slowing progression to advanced AMD. 39 It
Acetazolamide 250 mg tablets Half a tablet twice daily to 1 tablet four times daily
is important that patients with AMD who
Cholinergics also smoke are advised to cease smoking
to prevent progression to advanced AMD.40
Pilocarpine 1%, 2%, 3%, 4% Initially 1 drop of 1% three to four times daily, slowly In addition to supplements, wet AMD
increasing as according to response and tolerability treatment includes the use of intravitreal
vascular endothelial growth factor (VEGF)
inhibitors such as ranibizumab, and
aflibercept.8, 40
Reference: AMH8
 Eye care Pharmacist CPD Facts Behind the Fact Card

Figure 2. Vision loss associated with AMD

Case study
To ensure that you make the correct diagnosis, explain to Eileen you need to find out more information. Eileen describes feeling generally well
aside from her red, gritty eyes. She has hypertension, asthma, and osteoarthritis, and takes perindopril,
Symbicort 200/6 (eformoterol 6 microgram, budesonide 200 microgram), terbutaline, and paracetamol. She explains that in the last few months
she often doesnt make it to the toilet on time. Her GP prescribed
oxybutynin, which she has been taking for about 3 weeks.
You explain to Eileen that oxybutynin may have caused her symptoms. There are several ways to manage this including possible medicine change
and using eye products to relieve symptoms. You write
a note to remind yourself to write up your clinical intervention.

You invite Eileen to participate in a Medicines Use Review to which she consents. You discover that oxybutynin has reduced Eileens
incontinence; however Eileen has noticed the eye signs and symptoms started around a week ago. She also has a dry mouth.
You listen to Eileen describe the impact that incontinence has on her social activities. You explain to Eileen there are other medicines
that may manage her incontinence, which could be trialled to see if they cause less eye symptoms. These include a patch, which she
may like to discuss with her GP to assess its suitability. You also recommend an ocular lubricant containing carmellose 0.5% to use
when required for her current symptoms.
You provide Eileen with a copy of her medication profile as well as a referral letter for her GP to explain the possible cause of Eileens signs
and symptoms and potential resolutions to the condition. Eileen says she will make a GP appointment on her way home.
 Eye care Pharmacist CPD Facts Behind the Fact Card

References
1. Uchino M, Schaumberg DA. Dry eye disease: impact on quality of life and vision. Curr Ophthalmol Rep 2013;1(2):5157.
2. Rutter P, Newby D. Ophthamology. In: Community pharmacy: symptoms, diagnosis and treatment. 2nd edn. Sydney: Elsevier; 2012.
3. Tong L, Tan J, Thumboo J, et al. Dry eye. BMJ 2012;345:e7533.
4. Shtein RM. Dry eyes. In: UpToDate. 2015. At: www.uptodate. com/contents/dry-eyes
5. Roat MI. Keratoconjunctivitis sicca. In: Merck manual (professional version). 2014. At: www.merckmanuals. com/professional/eye-disorders/corneal-disorders/
keratoconjunctivitis-sicca
6. McGinnigle S, Naroo SA, Eperjesi F. Evaluation of dry eye. Surv Ophthalmol 2012;57(4):293316.
7. The definition and classification of dry eye disease: report of the definition and classification subcommittee of the international dry eye workshop. Ocul Surf
2007;5(2):7592.
8. Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2016.
9. National Institute for Health and Care Excellence. Dry eye syndrome; 2012. At: http://cks.nice.org.uk/dry-eye-syndrome
10. Fraunfelder FT, Sciubba JJ, Mathers WD. The role of medications in causing dry eye. J Ophthalmol 2012;2012:285851.
11. Methodologies to diagnose and monitor dry eye disease: report of the diagnostic methodology subcommittee
of the international dry eye workshop (2007). Ocul Surf 2007;5(2):10852.
12. BMJ. The management of dry eye. BMJ 2016;353:i2333.
13. Management and therapy of dry eye disease: report of the management and therapy subcommittee of the international dry eye workshop (2007). The Ocular
Surface. Ocul Surf 2007;5(2):16378.
14. Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database of Systematic Reviews 2016, Issue 2.
15. Abelson MB, Anderson R. Demystifying demulcents. Review of ophthamology. 2006; At: www.reviewofophthalmology.com/ article/demystifying-dumulcents
16. Evans K, Madden L. Recommending dry eye treatments in community pharmacy. The Pharmaceutical Journal 2016.

At: www.pharmaceutical-journal.com/learning/learning- article/recommending-dry-eye-treatments-in-community- pharmacy/20201430.article

17. Samarawickrama C, Chew S, Watson S. Retinoic acid and the ocular surface. Surv Ophthalmol 2015;60(3):18395.
18. Foster CS, Ekong AS, Anzaar F, et al. Dry eye syndrome. In: Medscape. 2016. At: http://emedicine.medscape.com/ article/1210417-overview
19. Roat MI. Overview of conjunctivitis. In: Merck manual (professional version). 2016. At: www.msdmanuals.com/en-au/ professional/eye-disorders/conjunctival-and-
scleral-disorders/ overview-of-conjunctivitis
20. Pharmaceutical Society of Australia. Guidance for the provision of a pharmacist only medicine - chloramphenicol for ophthalmic use. Canberra: PSA; 2015.
21. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician 2010;81(2):13744.
22. Eye infections [revised Nov 2014]. In: eTG complete. Melbourne: Therapeutic Guidelines; 2016.
23. Sheikh A, Hurwitz B, van Schayck CP, et al. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews 2012, Issue 9.
24. Azari AA, Barney NP. Conjunctivitis: a systemtatic review of diagnosis and treatment. JAMA 2013;310(16):17219.
25. Aspen Pharma. Chlorsig product information; 2010. At: www. aspenpharma.com.au/product_info/pi/PI_Chlorsig.pdf
26. Roat MI. Allergic conjunctivitis. In: Merck manual (professional version). 2016. At: www.merckmanuals.com/professional/ eye-disorders/conjunctival-and-scleral-
disorders/allergic- conjunctivitis
27. Better Health Channel. Hay fever. 2013. At: www.betterhealth. vic.gov.au/health/conditionsandtreatments/hay-fever
28. Garrity J. Blepharitis. In: Merck manual (professional version). 2016. At: www.merckmanuals.com/professional/eye- disorders/eyelid-and-lacrimal-
disorders/blepharitis
29. Weizer JS. Angle-closure glaucoma. In: UpToDate. 2015. At: www.uptodate.com/contents/angle-closure-glaucoma
30. Rhee DJ. Overview of glaucoma. In: Merck manual (profession version). 2016. At: www.merckmanuals.com/professional/eye- disorders/glaucoma/overview-of-glaucoma
31. Rhee DJ. Angle-closure glaucoma. In: Merck manual (professional version). 2016. At: www.merckmanuals.com/

professional/eye-disorders/glaucoma/angle-closure- glaucoma
32. Jacobs DS. Open-angle glaucoma: epidemiology, clinical presentation, and diagnosis. In: UpToDate. 2016. At: www.uptodate.com/contents/open-
angle-glaucoma- epidemiology-clinical-presentation-and-diagnosis
33. Jacobs DS. Open-angle glaucoma: treatment. UpToDate. 2016. At: www.uptodate.com/contents/open-angle-glaucoma- treatment
34. Hajj-ali RA. Sjgrens syndrome (SS). In: Merck manual (professional version). 2013. At: www.merckmanuals. com/professional/musculoskeletal-
and-connective-tissue- disorders/autoimmune-rheumatic-disorders/sj%C3%B6gren- syndrome-ss
35. Inflammatory connective tissue disease [revised Oct 2015]. In: eTG complete. Melbourne: Therapeutic Guidelines;2016.
36. Garg SJ. Age-related macular degeneration (AMD or ARMD). In: Merck manual (professional version). 2014. At: www.
merckmanuals.com/professional/eye-disorders/retinal- disorders/age-related-macular-degeneration-amd-or-armd
37. Arroyo JG. Age-related macular degeneration: clinical presentation, etiology, and diagnosis. In: UpToDate. 2016. At: www.uptodate.com/contents/age-
related-macular- degeneration-clinical-presentation-etiology-and-diagnosis
38. Guymer RH, Chong EW. Modifiable risk factors for age-related macular degeneration. Med J Aust 2006;184(9):4558.
39. Evans JR, Lawrenson JG. A review of the evidence for dietary interventions in preventing or slowing the progression of age-related macular degeneration.
Ophthalmic Physiol Opt 2014;34(4):3906.
40. Arroyo JG. Age-related macular degeneration: treatment and prevention. In: UpToDate. 2016. At: www.uptodate.com/ contents/age-related-macular-
degeneration-treatment-and- prevention
41. Baudouin C, Labb A, Liang H, et al. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res 2010;29(4):31234.
42. Chlorsig eye drops and eye ointment consumer medicines information. In: eMIMS cloud. Sydney: MIMS Australia; 2016.

43. Optrex actimist 2 in 1 eye spray MIMS abbreviated prescribing information. In: eMIMS cloud. Sydney: MIMS Australia; 2016.
44. Rutter2;Shtein4;Report7;AMH8;Abelson15;Evans16;Samarawickrama17