P ROTOCOLS I N
EYE CONDITIONS
PROTOCOL BOOKLET
BIANCA MARIA S
TIVALA
This booklet was compiled by Bianca Maria Stivala as part of an undergraduate
project entitled “Protocols in Eye Conditions” carried out for the partial
fulfilment of the requirements of the course leading to the Degree of Bachelor
of Pharmacy (Honours).
The study was carried out under the supervision of Professor Lilian
M. Azzopardi, Head of Department, Department of Pharmacy, University of
Malta.
The validation panel:
 Dr. Joseph Farrugia, M.D., M.M.C.F.D.
 Mr. Demis Fsadni, B.Pharm. (Hons.)
 Dr. Marco Grech, M.D., Cert. Diab. (ICGP), M.M.C.F.D.
 Dr. Jan Janula, M.D., Ph.D., S.D.S.Oph. (Prague)
 Mr. Franco Mercieca, M.D., F.R.C.Ophth. (UK)
 Mr. Mark Mercieca, B.Pharm. (Hons.)
Sponsored by: Actavis Malta Ltd.
Printed by: FiveStar Printing Ltd.
The author makes no representation, expressed or implied, with regards to the
accuracy of the information contained in this booklet and cannot accept any
legal responsibility or liability for any errors or omissions that may be made.
Bianca Maria Stivala
Department of Pharmacy
Faculty of Medicine and Surgery
University of Malta
Msida, Malta
Published in August 2011
PROTOCOLS IN EYE
CONDITIONS
BIANCA MARIA S
2011
TIVALA
PREFACE
Pharmacists are commonly consulted about the management of
signs and symptoms of common eye conditions. Pharmacists are in
a position to identify signs and symptoms that require immediate
referral. They are in a position to support patients in selfmanagement of dryness, conjunctivitis and external segment and
eyelid conditions. In the management of eye conditions patients
need to be educated about the proper use of ophthalmic
medications.
The protocols presented in this handbook have been developed by
Bianca Maria Stivala, a pharmacy student as part of her project.
This project is part of a research study being undertaken at the
Department of Pharmacy with the aim of developing and
disseminating protocols for the local scenario that are evidencebased.
Professor Lilian M.Azzopardi
Head, Department of Pharmacy
CONTENTS
How to use this booklet
2
Interpretation of shapes
3
Protocol for External Segment & Eyelid Conditions
4
Protocol for Conjunctivitis
10
Protocol for Dry Eye Disease
15
References
21
HOW TO USE THIS BOOKLET
This booklet contains three flow chart protocols whose aim is to
guide pharmacists in diagnosing and managing ocular conditions
and recognising conditions which warrant referral. The protocols
are guidelines compiled using evidence-based medicine, which
when coupled with the pharmacist’s experience provide the best
pharmaceutical care to the patient.
This booklet is to be used with a companion explanatory text
handbook which contains explanations and references for each
protocol step. The text which corresponds with treatment and
management steps provides more detail about pharmacological
and non-pharmacological patient advice, which is of practical
significance.
The handbook is available online as a downloadable and printable
A4 size document entitled “Protocols in Eye Conditions Handbook”
at URL http://www.um.edu.mt/ms/pharmacy/research/protocols
2
INTERPRETATION OF SHAPES
Data box
Known information about the
patient
Action box
Pharmacist is required to
perform an action
Yes
Decision box
Pharmacist is required to make a
decision which leads to
different paths
No
Connector box
Directs pharmacist to another
step on another page
Terminator box
Pharmacist is required to perform
an action and exit the protocol
3
Step number label
3
EXTERNAL SEGMENT & EYELID CONDITIONS
1
Patient presents with inflammation
of the eyelid and/or eyelid margin
2
Pharmacist greets patient
4
3
Is pharmacist
familiar with
patient?
No
Pharmacist asks questions
to know identity of patient.
Go to box 5.
Yes
5
Does patient
wear contact
lenses?
6
Yes
Refer
No
7
Yes
Go to box 8
4
Is there any
lump or localised
swelling present?
No
Go to box 25
From box 7
8
9
Is there any
redness on the
lump?
No
There is no redness
on the lump
Yes
10
Go to box 12
Patient reports tenderness
to touch
12
11
Is the lump
painful?
No
Swelling is tender
but not painful
Yes
13
Check if swelling points towards
lid margin or towards conjunctiva
Go to box 15
Go to box 14
5
EXTERNAL SEGMENT & EYELID CONDITIONS
From box 13
15
14
Does swelling
point towards
lid margin?
No
Chalazion
(meibomian cyst)
Yes
19
Does the redness
have a white/
yellowish core?
No
Evert patient’s eyelid after cl
hands with an appropriate c
agent
Yes
20
External hordeolum
(stye)
No
21
Is there any pus
on the inside of
the eyelid?
Yes
Treatment
Warm compresses applied 3-4 times daily for
10-15 minutes.
Refer to general practitioner as antibiotic therapy is required.
6
Internal hordeolum
16
Did patient ever
manifest these
symptoms before?
17
Yes
Refer
No
22
leaning
cleaning
18
Treatment
Warm compresses applied twice daily for 3-5 minutes. The
lesion should be massaged in the direction of the eyelashes
with clean fingers or cotton tips.
Refer to general practitioner if swelling does not subside or
becomes red.
23
24
7
EXTERNAL SEGMENT & EYELID CONDITIONS
From box 7
25
26
Does patient have
seborrhoeic dermatitis
of scalp and/or
eyebrows?
Yes
Are there gr
scales presen
the eyelid
Yes
No
Seborrhoeic ble
30
Are there dry
scales present on
the eyelid margin?
No
Go to box 26
Yes
31
Are there
greasy scales
also present?
No
Staphylococcal bleph
Yes
Treatment
33
Mixed infection
blepharitis
 Warm compresses applied for seve
 Eyelid hygiene once daily or as oft
effective may be required on a long
Refer to general practitioner for appro
8
reasy
nt on
d?
No
Meibomian gland
dysfunction
(posterior blepharitis)
28
29
Treatment
27
epharitis
 Warm compresses applied for several minutes.
 Eyelid hygiene once daily or as often as required. If
effective may be required on a long-term basis.
 Keep scalp, eyebrows, and other areas affected by
seborrhoeic dermatitis clean by means of soap and water
shampoo.
Refer to general practitioner for appropriate antibiotic therapy.
32
haritis
34
eral minutes.
ten as required. If
g-term basis.
opriate antibiotic therapy.
9
CONJUNCTIVITIS
1
Patient presents with a red eye
2
Pharmacist greets patient
4
3
Is pharmacist
familiar with the
patient?
No
Pharmacist asks
questions to know
identity of patient.
Go to box 5.
No
5
Are the eyes
painful?
6
Yes
Refer
No
7
Does the patient
wear contact
lenses?
No
Go to box 9
10
8
Yes
Refer
From box 7
9
Yes
Does the patient have
physical injury?
10
Refer
14
Refer
No
11
Check if redness is unilateral or
bilateral.
Yes
13
12
Are symptoms
unilateral?
Have symptoms
been unilateral for
more than 2 days?
Yes
No
No
16
15
Were symptoms
initially unilateral?
No
Yes
Infectious conjunctivitis
Go to box 22
Go to box 17
11
CONJUNCTIVITIS
From box 15
17
Symptoms were
always bilateral
18
19
Are the eyes
itchy?
No
Refer
Yes
20
Allergic conjunctivitis
21
Treatment
Non-pharmacological advice:
 Minimise exposure to allergens as much as possible
 Wash clothes and fabric frequently
 Shower/bathe before bedtime
 Cool compresses to alleviate itching and remove any dry crusts
Pharmacological treatment:
 Topical antihistamine/vasoconstrictor agent
 Topical histamine H1-receptor antagonist (levocabastine, emedastine)
 Artificial tears to dilute allergens (carboxymethyl cellulose, hydroxypropyl
methylcellulose)
 For recurrent or persistent cases: mast cell stabilisers (sodium cromoglicate)
12
From box 16
23
22
No
Is there any discharge
present?
Refer
Yes
24
Is the discharge
purulent/
mucopurulent?
No
No
25
Is the discharge
serous (watery)?
Yes
Yes
28
26
Bacterial conjunctivitis
Adenoviral conjunctivitis
27
Go to box 29
Treatment
 Supportive treatment with cool compresses, artificial tears
and/or topical antihistamines.
 Give advice on good hygiene to prevent spread of
infection (frequent hand washing, avoid sharing of towels
and facecloths with other people) to other people and/or
the other eye in cases where infection is still unilateral.
 Advise patient that infection remains contagious for up to
2 weeks after the second eye becomes infected.
Refer to specialist if symptoms do not resolve within 2 weeks.
13
CONJUNCTIVITIS
From box 28
30
29
Is there a palpable
preauricular node?
Yes
Chlamydial inclusion
conjunctivitis
No
32
31
Is there associated
blepharitis?
No
Acute bacterial conjunctivitis
Refer
34
Yes
Treatment
33
Chronic bacterial
conjunctivitis
Warm compresses and eyelid
hygiene to remove blepharitis
crusts.
Refer to specialist for antibiotic
treatment.
14
DRY EYE DISEASE
1
Patient presents with complaint
of foreign body sensation
2
Pharmacist greets patient
4
3
Is pharmacist
familiar with
patient?
No
Pharmacist asks questions
to know identity of patient.
Go to box 5.
Yes
5
Does patient
wear contact
lenses?
6
Yes
Refer
No
8
7
Does the eye
appear red?
Yes
See conjunctivitis
protocol
No
Go to box 9
15
DRY EYE DISEASE
From box 7
Management
9
Does patient manifest
symptoms of posterior
blepharitis?
 Eyelid hygiene and
 Artificial tears app
 Increase intake of f
reduce alcohol inge
Yes
Refer to ophthalmolog
No
12
11
Is the patient exposed
to cigarette smoke?
Yes
Dry eye due to expo
to cigarette smok
No
15
14
Is the patient using
any topical products?
No
Go to box 17
16
Yes
Dry eye due to use o
topical products
10
d warm compresses applied at least once daily.
plied 3-4 times daily or as required.
foods containing omega-3 fatty acids and vitamin A;
estion.
gist is symptoms to not improve after one week.
osure
ke
of
Management
13
 Reduce exposure to cigarette smoke.
 Increase intake of foods containing omega-3 fatty acids
and vitamin A; reduce alcohol ingestion.
 Artificial tears applied 3-4 times daily or as required.
Management
16
If patient is taking non-prescription medications:
 Advise patient to stop taking medication or suggest
alternatives without preservatives.
 Dispense artificial tears to be applied 3-4 times daily or
as required.
 Advise patient to wait 15 minutes before applying second
product.
If patient is taking prescription medications, refer to ophthalmologist for re-evaluation of treatment.
17
DRY EYE DISEASE
From box 14
17
18
Is the patient
female?
Yes
Is the patient taking
oestrogen only HRT?
No
No
20
Is patient taking
any systemic
medications?
No
21
No
Go to box 25
Does the patient
have symptoms
of dry mouth?
Yes
22
Sjögren’s syndrome
Refer to rheumatologist
18
19
Yes
Refer
23
Yes
Dry eye as a side-effect
of systemic medication
24
Management
If patient is taking non-prescription medications:
 Advise patient to stop taking medications.
 Dispense artificial tears to be applied 3-4 times daily or as
required.
 If symptoms do not improve refer to ophthalmologist.
If patient is taking medications with specialist prescription, refer
patient to specialist for re-evaluation of treatment.
19
DRY EYE DISEASE
From box 17
25
Does the patient
spend a long time in
front of a screen or
reading?
28
No
Refer
Yes
26
Episodic dry eye due to
extended visual tasking
27
Management
 Environmental modifications: control humidity, take
frequent breaks when using computer, blink frequently.
 Dietary modifications: increase intake of foods
containing omega-3 fatty acids and vitamin A;
reduce alcohol ingestion.
 Pharmacotherapy: artificial tears 3-4 times daily or as
required.
Refer to ophthalmologist if symptoms do not improve or if
patient reports frequent use of artificial tears.
20
REFERENCES
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred
Practice Pattern® Guidelines. Blepharitis. San Francisco, CA: American Academy
of Ophthalmology; 2008.
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred
Practice Pattern® Guidelines. Conjunctivitis. San Francisco, CA: American Academy of Ophthalmology; 2008.
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred
Practice Pattern® Guidelines. Dry Eye Syndrome. San Francisco, CA: American
Academy of Ophthalmology; 2008.
Bertino JS. Impact of antibiotic resistance in the management of ocular infections: the role of current and future antibiotics. Clinical Ophthalmology 2009; 3:
507–521.
Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the Pharmacy: A guide to
the management of common illness. 5th ed. Oxford (UK): Blackwell Publishing
Ltd.; 2005.
Gaby AR. Nutritional Therapies for Ocular Disorders: Part Three. Altern Med Rev
2008; 13(3): 191-204.
Galor A, Jeng BH. Red eye for the internist: When to treat, when to refer. Cleve
Clin J Med 2008; 75(2): 137-144.
Gayton J. Etiology, prevalence, and treatment of dry eye disease. Clinical Ophthalmology 2009; 3: 405-412.
Gilchrist H, Lee G. Management of chalazia in general practice. Aust Fam Physician 2009; 38(5): 311-314.
Granet D. Allergic rhinoconjunctivitis and differential diagnosis of the red eye.
Allergy Asthma Proc 2008; 29: 565-574.
Høvding G. Acute bacterial conjunctivitis. Acta Ophthalmol 2008; 86: 5–17.
Khurana AK. Comprehensive Ophthalmology. 4 th ed. New Delhi (India): New Age
International (P) Ltd.; 2007.
21
REFERENCES
Manaviat MR, Rashidi M, Afkhami-Ardekani M, Shoja MR. Prevalence of dry eye
syndrome and diabetic retinopathy in type 2 diabetic patients. BMC Ophthalmol
2008; 8:10.
Martin EA, editor; Oxford Concise Colour Medical Dictionary. 4th ed. Oxford
(UK): Oxford University Press; 2007.
Morrow GL, Abbott RL. Conjunctivitis. American Family Physician. February 15,
1998. Available at: www.aafp.org/afp/980215ap/morrow.html
Riordan-Eva P, Whitcher JP, editors; Vaughan & Asbury’s General Ophthalmology. 17th ed. USA: McGraw-Hill Lange; 2007.
Schlote T, Rohrbach J, Grueb M, Mielke J. Pocket Atlas of Ophthalmology. Stuttgart (Germany): Thieme; 2006.
Sharma NS, Ooi JL, Li MZ. A painful red eye. Aust Fam Physician 2009; 38(10):
805-807.
Tarabishy AB, Jeng BH. Bacterial conjunctivitis: A review for internists. Cleve
Clin J Med 2008; 75(7): 507-512.
22