Evan Williams, PharmD, BCPS, BCACP Assistant Professor of Pharmacy Practice Husson University School...

Basic Ophthalmologic Assessment for Community

PharmacistsEvan Williams, PharmD, BCPS, BCACP

Assistant Professor of Pharmacy PracticeHusson University School of Pharmacy

Conjunctivitis ◦ Bacterial, Viral, Allergic◦ The role of the pharmacist

Things that can be confused with conjunctivitis◦ What is an emergency◦ When to refer to where

Review administration of eye medications

Overview

Differentiate between serious and less serious causes of red eye

Identify what symptomatology warrant referral to an eye care professional or an emergency department

List important findings that would necessitate a referral to a higher level of care

Describe proper eye drop/ointment application technique

Objectives

I have no actual or potential conflicts of interest in relation to this presentation

Disclosure

Basic Anatomy of the Eye – Orbit

http://www.southbayophthalmology.com/wp-content/uploads/2010/05/eyelidanatomybandw.jpg

Basic Anatomy of the Eye – Globe

http://www.southbayophthalmology.com/wp-content/uploads/2010/04/G021.jpg

Basic Anatomy of the Eye – Conjunctivae

http://media.mansmed.com/data/media/4/conjunctiva_01_anatomy.jpg

Basic Anatomy of the Eye – Conjunctivae

http://www.anatomyatlases.org/firstaid/images/eyeB.jpg

Basic Anatomy of the Eye - Cornea

http://www.lab.anhb.uwa.edu.au/mb140/corepages/eye/images/cor20he.jpg

Very thin!

Avascular but well supplied with nerves

Apgar, D. Ophthalmology: Selected Topics. 2/2/10

Inflammation of the conjunctivae◦ Typically bacterial/viral or allergic

May need to rule out other conditions

If any doubt, patient should be referred

Conjunctivitis

Conjunctivitis

http://www.firstvieweyecare.com/wp-content/uploads/2011/04/conjunctivitis.png

Injection of vessels

Conjunctivitis - Hyperemia

http://upload.wikimedia.org/wikipedia/commons/thumb/5/58/Hyperemia_conjunctiva.jpg/1024px-Hyperemia_conjunctiva.jpg

More severe, intense conjunctival hyperemia

Corneal involvement = keratitis

Keratoconjunctivitis

Conjunctival edema

Chemosis

http://web.uni-plovdiv.bg/stu1104541018/docs/res/emergency_medicine_atlas/Ch.2.htm

Usual presentation of conjunctivitis ◦ And many other eye problems◦ There are many causes for red eye

You need to be able to differentiate cases that can be managed in a community pharmacy setting from those that need referral◦ Secondarily, you need to recognize the possibility

of those serious disorders that need urgent or emergent ophthalmologic care

Red Eye

Basic 7◦ Location◦ Quality◦ Severity◦ Timing◦ Context◦ Associated Symptoms◦ Modifying Factors

What do you think caused this?

Evaluation of “Red Eye”

How does the eye feel? How is your vision compared to before this

started? When did this start?

◦ How often has this happened before?◦ How long after surgery?

How did this start? What else is wrong or different?

◦ Associated symptoms? What makes it better/worse?

Subjective Evaluation

General Other URI Manifestations Lids Conjunctivae Cornea Objective foreign body sensation Photophobia Obvious trauma Hypopyon Hyphema

Objective Evaluation

Less Serious Causes of Red Eye Conjunctivitis

◦ Bacterial◦ Allergic◦ Viral◦ Non-specific

Lid Problems◦ Hordeolum◦ Chalazion◦ Blepharitis

Subconjunctivial Hemorrhage

Dry Eye Syndromes

Entropion

Irritative Causes◦ Pterygium

Degenerative Causes◦ Pigueculum

Reactive Causes◦ Phlyctenular

keratoconjunctivitis (PKC)


You can recommend an OTC product for initial management of some conditions

For conditions that cannot be managed with an OTC product, you can direct the patient to the appropriate level of care in the appropriate timeframe

You can recognize most conditions that need referral

Your Role as a Pharmacist

Any red eye in a contact lens wearer◦ Even if it seems uncomplicated

Corneal Abrasion/Ulcer Autoimmune Causes

◦ Scleritis◦ Episcleritis

Infectious Keratitis◦ Infectious inflammation of the cornea

Lacrimal System Disorders Iritis Periorbital Cellulitis Orbital Cellulitis

Potentially Serious Causes of Red Eye


Acute Angle-Closure Glaucoma Penetrating Trauma

◦ To the globe or the orbit Endophthalmitis

◦ Infection within the posterior chamber◦ Associated with trauma, including surgery

Hypopyon Hyphema

Emergency Causes of Red Eye


REFER ALL potentially serious or emergency causes of red eye

You can differentiate between emergency problems that need to go the ED and those that can go immediately to the patient’s eye care professional◦ Optometrist vs Ophthalmologist

Your Role as a Pharmacist

Two Important Findings

REFER THESE PATIENTS REFER THESE PATIENTS

Objective foreign body sensation◦ Described as PAIN, not

just a scratchy feeling◦ Objective in that the

patient cannot keep eye open for more than a few seconds Permanent squint

◦ If lights are dimmed to rule out photophobia, the eye STILL cannot be kept open

Photophobia◦ Extreme sensitivity to

light◦ Patients may wear

sunglasses and avoid bright light

◦ Cannot tolerate exam light shone into eye

◦ However, in a darkened room, the eye can be held open Differential feature

compared to ‘objective foreign body’ sensation

Any change in vision in the timeframe of the red eye symptoms that is different from the patient’s baseline◦ Does not include obstructed vision due to

discharge that can be cleared from the eye to restore normal vision

Significant pain that can be localized to the eyeball (globe) itself

Additional Warning Symptoms

Characterized by purulent drainage at the corners of the eye and the border of the eyelid◦ Eyelids crusted shut in the morning

This is not a reliable differential feature◦ Will continue purulent discharge throughout the day◦ More discharge will appear within minutes of wiping it

away◦ Usually begins unilaterally but often becomes bilateral

within a few days Lacks

◦ Pain, photophobia, visual changes (aside from discharge), corneal lesions, or limbal flush

Highly contagious

Bacterial Conjunctivitis

http://www.uptodate.com.ezproxy2.library.arizona.edu/contents/conjunctivitis?source=machineLearning&search=pink+eye&selectedTitle=1~150&sectionRank=1&anchor=H19#H6


http://web.uni-plovdiv.bg/stu1104541018/docs/res/emergency_medicine_atlas/Ch.2.htm

Common organisms include◦ S. pneumoniae, Haemophilus sp., M. catarrhalis in

kids◦ Add S. aureus in adults

Hyperactue = hyperpurulent due to N. gonorrheae◦ Can be vision threatening – needs emergent

referral




Bacterial Conjunctivitis – GC

http://optometrist.com.au/wp-content/uploads/2012/07/conjunctivitis-gonoccocal.jpg

Bacterial conjunctivitis is self-limiting in most cases◦ Topical antibiotics probably shorten the course of

the infection if given before day 6 If treatment is deemed necessary

◦ Erythromycin ointment Can have therapeutic effect with “close” application

◦ Polymyxin/Trimethoprim drops or Bacitracin ointment

◦ Avoid fluoroquinolone drops due to resistance ◦ Avoid aminoglycosides due to toxicity



Characterized by watery discharge and scratchy feeling◦ Eyelids may be crusted shut in the morning

Less commonly than with bacterial◦ Often there are other viral URI manifestations◦ Usually begins unilaterally but often becomes

bilateral within a few days Lacks


Highly contagious

Viral Conjunctivitis


Commonly caused by adenovirus◦ Can also be caused by other “cold” viruses

Rhinovirus, coronavirus, coxsackievirus, VZV◦ Most potentially serious cause is HSV

Know how to tell the difference Self-limiting

◦ 1-3 weeks◦ Some patients will benefit from topical OTC

products recommended for allergic conjunctivitis◦ HSV is treated with antivirals

We will not cover this



Adenoviral


http://webeye.ophth.uiowa.edu/eyeforum/cases/cases-i/case28/Adenovirus3_01192005.jpg


HSV Blepharoconjunctivitis

Viral Conjunctivitis - HSV

http://s3-media1.ak.yelpcdn.com/bphoto/3V3c9HeHD7JmP2KzefkWJg/l.jpg

http://www.herpes.com/images/herpes-in-the-eye.jpg

Viral Conjunctivitis - VZV

http://www.aao.org/publications/eyenet/201204/images/CUcomp02_1.jpg

Characterized by watery discharge and scratchy feeling◦ Eyelids may be crusted shut in the morning

Less commonly than with bacterial◦ Often there are other allergic manifestations◦ Usually initially bilateral◦ Can be unilateral if due to eye medication applied

only to one eye Lacks


Allergic Conjunctivitis



http://dxline.info/img/new_ail/conjunctivitis-allergic.JPG

Conjunctival follicles


http://www.intechopen.com/source/html/44041/media/image3.jpeg

Some patients will benefit from OTC topical lubricants◦ Multiple artificial tear products

Can also use or add a decongestant (alone or + antihistamine)◦ Oxymetazoline 0.025% soln◦ Tetrahydrozoline 0.05% soln

Also available with zinc sulfate◦ Naphazoline 0.025% and 0.05% soln◦ Ketotifen 0.05% soln

Also has mast cell stabilizing properties



The following slides briefly describe things that can be confused with simple conjunctivitis

Many need to be referred, although some can be treated initially with OTC products

Other Selected Eye Problems

Blepharitis◦ Can be bacterial, viral, or allergic◦ May occur alone or with conjunctivitis

Hordeolum◦ Acute infectious process of one of 3 glands in the

eyelid◦ Fast onset and painful

Chalazion◦ Chronic inflammation due to blockage of

meibomian glands of eyelid◦ Take a long time to form, non-painful

Lid Problems


Staph Blepharitis

http://www.intechopen.com/source/html/44009/media/image5_w.jpg

Allergic Blepharitis

http://webeye.ophth.uiowa.edu/eyeforum/atlas/photos/allergic-blepharitis1.jpg

Hordeolum

Chalazion

Bleeding from conjunctival capillaries Usually asymptomatic

◦ Someone else points it out to patient or they look in a mirror

Usually due to trauma◦ Rubbing eyes◦ Sneezing/Coughing

Rarely associated with extreme BP Resolves spontaneously over several days

Subconjunctival Hemorrhage


Subconjunctival Hemorrhage

http://dxline.info/img/new_ail/subconjunctival-hemorrhage_4.jpg

Chronic disorder

Hx will reveal chronic nature if acute exacerbation

Often, patients will already be on a lubricant product and possibly ophthalmic cyclosporine

Dry Eye Syndromes


Entropion

Pterygium◦ Benign, fibrous, wedge shaped growth of tissue

that may grow into the cornea◦ Common in people from hot, dry climates◦ Requires surgical removal

Irritative Conjunctivitis


https://www.eyecancer.com/content/images/cms/pterygium.jpg

http://upload.wikimedia.org/wikipedia/commons/6/6a/Pterygium_%28from_Michigan_Uni_site%2C_CC-BY%29.jpg

Pingueculae◦ Common, benign, usually asymptomatic yellow or

white deposit on the conjunctiva near the medial or lateral limbus

◦ Can become inflamed short term (pingueculitis)

Degenerative Conjunctivitis


http://upload.wikimedia.org/wikipedia/commons/5/53/PRE-OPERATIVE_PINGUECULA.JPG

At risk for corneal damage◦ Corneal abrasions/ulcers◦ Infectious Keratitis

Usually bacterial Often Pseudomonal Fluoroquinolone use reserved for such patients

This is why we refer virtually all “red eye” problems in these patients

Contact Lens Wearers


Corneal Ulcer

http://bestpractice.bmj.com/best-practice/images/bp/en-gb/561-3_default.jpg

Red eye associated with limbal (or ciliary) flush◦ Increased injection around limbus

A lesion may be visible in the cornea Discharge may be visible if infectious

◦ Purulent if bacterial Hypopyon may be present

◦ Watery if viral Symptoms include photophobia and

objective foreign body sensation

Keratitis


Bacterial Keratitis

http://www.cmej.org.za/index.php/cmej/article/viewFile/2673/2903/15652

Viral Keratitis

http://www.artisanoptics.com/Documents%20and%20Settings/27/Site%20Documents/Condition%20Images/Herpes%20Simplex%20Keratitis.jpg

Viral Keratitis

http://siklusair.com/wp-content/uploads/2013/08/herpes-zoster-keratitis.jpg

Presents with a sudden onset of severe unilateral frontal and/or temporal headache

Often associated with pupil fixed in mid dilation, red eye, “steamy” cornea, limbal flush, and decreased vision

No discharge No objective foreign body sensation Medical Emergency

Acute Angle-Closure Glaucoma


Acute Angle-Closure Glaucoma

Blood in the anterior chamber – REFER

Hyphema

http://www.ttuhsc.edu/som/ophthalmology/eyeatlas/Anterior%20Chamber/spontaneous_hyphema_with_clot_secondary_to_warfarin.jpg

http://www.varga.org/hyphema.jpg

Proper dose of all eye drops is ONE drop◦ More than that spills out◦ If you need to administer more, wait 5-10 minutes

in between subsequent doses Try to avoid contact between the tip of the

dropper and anything else Nasolacrimal Occlusion

◦ Increases contact with eye structures◦ Probably improves absorption and efficacy◦ Can minimize systemic absorption◦ Recommend routinely for 2-3 minutes

Administration of Eye Drops


Two Handed Technique

http://www.glaucoma.org/uploads/eye-drops-steps.jpg

Optimal method◦ Apply a ribbon/strip of ointment to the inside lower

eyelid Warn patient that vision will be blurry for a few

minutes after application Kids or “difficult” adults

◦ Any successful method◦ Apply ribbon to lashes of upper eyelid and close eye◦ Same thing with closed eye◦ Body temperature usually results in at least some

medication becoming liquefied so that some gets in contact with conjunctivae

Administration of Eye Ointment


Recognize what to refer:◦ All contact lens wearers◦ Chronic problem (Entropion, dry eye)◦ Hx recent eye surgery◦ Localized conjunctival lesion (pterygium, pigueculum)◦ Hx of trauma to the eye or soft tissue around the eye◦ Any question of corneal abnormality (presence of limbal

flush, abrasion, ulcer, infxn)◦ Hypopyon (pus in anterior chamber)◦ Hyphema (bleeding in anterior chamber)◦ Prominent HA (acute angle – closure glaucoma)◦ Photophobia◦ Objective foreign body sensation

Summary

Recognize the red flags:◦ Objective foreign body sensation◦ Photophobia◦ Change in vision◦ Eyeball Pain

These all require REFERRAL!

Summary

Bacterial Conjunctivitis◦ Most are self–limited and not sight threatening◦ Kids may not be allowed back to school – refer?◦ Highly contagious – refer?◦ Refer hyperpurulent (GC) and newborn conjunctivitis

Viral Conjunctivitis◦ Most are self-limited and not sight threatening◦ OTC topical lubricants, vasoconstrictors,

antihistamines◦ Refer any suspicion of HSV or VZV

Allergic Conjunctivitis◦ Most are recurrent◦ If inadequate response to OTC tx, refer for Rx tx

Summary

Apgar, D. Ophthalmology: Selected Topics. 2/2/10Vire

Post-Test Questions A patient presents to your counter with what she believes is

pink eye. She states that she has a little bit of crusted discharge in the mornings and her eyes feel scratchy and produce a lot of watery discharge throughout the day. Her eyes appear puffy and red, with clear, watery discharge and significant chemosis. Her right eye is more injected than the left. Upon further questioning, she states that she and her husband got a pet cat 3 days ago. Which of the following is the best treatment option for this patient?

a) Emergent referral to the hospitalb) Urgent referral to her eye care professionalc) Cyclosporine Ophthalmic Emulsiond) Oxymetazoline 0.025% soln eye drops and remove offending agente) Erythromycin Ophthalmic Ointment and remove offending agent

Which of the following are warning signs that require EMERGENT referral to the ED?

I. Objective Foreign Body SensationII. Any Red Eye in Contact Lens WearersIII. Photophobia

a) I onlyb) II onlyc) I and II onlyd) I and III onlye) I, II, and III

Post-Test Questions

A patient presents to your counter to ask about a small spot on her right eye. It is very small, off-white to yellowish in color, and is at about 7 o’ clock on her iris. She reports no pain, foreign body sensation, photophobia, or changes in vision. Her eye appears normal otherwise with no redness. She states she noticed the spot 2 days ago when she was removing her contact lenses. She wants to know if there is an OTC product she should be taking. Which of the following is the likely cause of this spot and the correct method of dealing with this issue?

a) HSV Conjunctivitis – use an OTC lubricating eye drop and seek

further tx if it doesn’t resolve within 2 daysb) Corneal Lesion – Refer to her eye care professional as soon as

possiblec) Hypopyon – Refer emergently to the ED d) Hordeolum – suggest an OTC antihistamine/lubricating combo

product and refer to her eye care professional as soon as possiblee) Corneal Lesion – Refer emergently to the ED

Post-Test Questions

Thank you!

Questions

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