Selected Issues in Ophthalmology
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Evan Williams, PharmD, BCPS, BCACP Assistant Professor of Pharmacy Practice Husson 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 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 I have no actual or potential conflicts of interest in relation to this presentation http://www.southbayophthalmology.com/wp-content/uploads/2010/05/eyelidanatomybandw.jpg http://www.southbayophthalmology.com/wp-content/uploads/2010/04/G021.jpg http://media.mansmed.com/data/media/4/conjunctiva_01_anatomy.jpg http://www.anatomyatlases.org/firstaid/images/eyeB.jpg Very thin! Avascular but well supplied with nerves Apgar, D. Ophthalmology: Selected Topics. 2/2/10 http://www.lab.anhb.uwa.edu.au/mb140/corepages/eye/images/cor20he.jpg Inflammation of the conjunctivae ◦ Typically bacterial/viral or allergic May need to rule out other conditions If any doubt, patient should be referred http://www.firstvieweyecare.com/wp-content/uploads/2011/04/conjunctivitis.png Injection of vessels http://upload.wikimedia.org/wikipedia/commons/thumb/5/58/Hyperemia_conjunctiva.jpg/1024px-Hyperemia_conjunctiva.jpg More severe, intense conjunctival hyperemia Corneal involvement = keratitis Conjunctival edema 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 Basic 7 ◦ ◦ ◦ ◦ ◦ ◦ ◦ Location Quality Severity Timing Context Associated Symptoms Modifying Factors What do you think caused this? 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? General Other URI Manifestations Lids Conjunctivae Cornea Objective foreign body sensation Photophobia Obvious trauma Hypopyon Hyphema Conjunctivitis ◦ ◦ ◦ ◦ Bacterial Allergic Viral Non-specific Dry Eye Syndromes Entropion Irritative Causes ◦ Pterygium Lid Problems ◦ Hordeolum ◦ Chalazion ◦ Blepharitis ◦ Pigueculum Subconjunctivial Hemorrhage Apgar, D. Ophthalmology: Selected Topics. 2/2/10 Degenerative Causes 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 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 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 REFER THESE PATIENTS 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 REFER THESE PATIENTS 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 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 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 http://www.uptodate.com.ezproxy2.library.arizona.edu/contents/conjunctivitis?source=machineLearning&search=pink+eye&selectedTitle=1~150&sectionRank=1&anchor=H19#H6 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 http://www.uptodate.com.ezproxy2.library.arizona.edu/contents/conjunctivitis?source=machineLearning&search=pink+eye&selectedTitle=1~150&sectionRank=1&anchor=H19#H6 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 ◦ Pain, photophobia, visual changes (aside from discharge), corneal lesions, or limbal flush Highly contagious http://www.uptodate.com.ezproxy2.library.arizona.edu/contents/conjunctivitis?source=machineLearning&search=pink+eye&selectedTitle=1~150&sectionRank=1&anchor=H19#H6 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 Adenoviral http://webeye.ophth.uiowa.edu/eyeforum/cases/cases-i/case28/Adenovirus3_01192005.jpg HSV Blepharoconjunctivitis http://www.herpes.com/images/herpes-in-the-eye.jpg http://s3-media1.ak.yelpcdn.com/bphoto/3V3c9HeHD7JmP2KzefkWJg/l.jpg 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 ◦ Pain, photophobia, visual changes (aside from discharge), corneal lesions, or limbal flush http://www.uptodate.com.ezproxy2.library.arizona.edu/contents/conjunctivitis?source=machineLearning&search=pink+eye&selectedTitle=1~150&sectionRank=1&anchor=H19#H6 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 http://www.intechopen.com/source/html/44009/media/image5_w.jpg http://webeye.ophth.uiowa.edu/eyeforum/atlas/photos/allergic-blepharitis1.jpg 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 Pterygium ◦ Benign, fibrous, wedge shaped growth of tissue that may grow into the cornea ◦ Common in people from hot, dry climates ◦ Requires surgical removal Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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) Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 http://www.cmej.org.za/index.php/cmej/article/viewFile/2673/2903/15652 http://www.artisanoptics.com/Documents%20and%20Settings/27/Site%20Documents/Condition%20Images/Herpes%20Simplex%20Keratitis.jpg 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 Blood in the anterior chamber – REFER http://www.varga.org/hyphema.jpg http://www.ttuhsc.edu/som/ophthalmology/eyeatlas/Anterior%20Chamber/spontaneous_hyphema_with_clot_secondary_to_warfarin.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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10 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 Recognize the red flags: ◦ ◦ ◦ ◦ Objective foreign body sensation Photophobia Change in vision Eyeball Pain These all require REFERRAL! 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 Apgar, D. Ophthalmology: Selected Topics. 2/2/10Vire 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) b) c) d) e) Emergent referral to the hospital Urgent referral to her eye care professional Cyclosporine Ophthalmic Emulsion Oxymetazoline 0.025% soln eye drops and remove offending agent Erythromycin Ophthalmic Ointment and remove offending agent Which of the following are warning signs that require EMERGENT referral to the ED? I. II. III. a) b) c) d) e) Objective Foreign Body Sensation Any Red Eye in Contact Lens Wearers Photophobia I only II only I and II only I and III only I, II, and III 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) b) c) d) e) HSV Conjunctivitis – use an OTC lubricating eye drop and seek further tx if it doesn’t resolve within 2 days Corneal Lesion – Refer to her eye care professional as soon as possible Hypopyon – Refer emergently to the ED Hordeolum – suggest an OTC antihistamine/lubricating combo product and refer to her eye care professional as soon as possible Corneal Lesion – Refer emergently to the ED Questions Thank you!
