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CPD 44: OPTICAL HEALTH - CONJUNCTIVITIS Biography - Aaron Carlyle (MPharm MPSNI MPSI) is the supervising manager pharmacist at Brennan's Pharmacy in Buncrana, Co Donegal. He is a graduate of the University of Manchester, with a Master of Pharmacy degree. He completed his pharmacy training with Boots as a pre-registration pharmacist. Carlyle joined Brennan's in a group support pharmacist role in 2010, and took over management of the Buncrana branch later that year. In addition to his work as a community pharmacist, Carlyle is also involved in pharmacy education. He is a qualified pharmacy assessor and writes pharmacy training courses for clients in both the UK and Ireland. 1. REFLECT - Before reading this module, consider the following: Will this clinical area Educational distance be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

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- will this article satisfy those needs - or will more reading be required? learning needs - and how has my practise changed as a result? Have I identified further learning needs?

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Chronic Pain – assessment and management in primary care

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Optical Health - Conjunctivitis

60 Second Summary

ASMETTHOD Sheehan et al reported in 1996 that the estimated cost of mnemonic a pain for 95 patients to the Irish Health Services when added more effective Pain is one of the commonest reasons for patients to seek way to the amount ofofSocial Welfare payments received and 1 remembering the medical attention. A recent survey has shown that as many the lost earnings amounted to 1.9 million rangeofofeach issuespatient on medicines counter assistants following the INTRODUCTION as 8.3 visits per year to primary care physicians in Ireland 6 which pharmacists pounds at the time of referral. The recent data from PRIME WWHAM mnemonic and referring patients to 2 should seek were to symptoms of pain. A large scale survey carried Our eyesight is something thatdue everyone the pharmacist on that basis. Other pharmacies survey show that the mean cost per chronic pain patient information when an treasures, but often takes As a countries outforingranted. 15 European and Israel in 2006, screening may have a policy whereby certain conditions individual presents with is estimated at €5,665 per year across all grades of pain, result many patients with an eye problem, such as the those involving of thechronic eyes warrants an 46,394 respondents reported that prevalence symptoms. however minor often become very worried and instant referral to the pharmacist. In any which case, itwas extrapolated to €5.34 billion or 2.86% of Irish The presentation of red eye in the pharmacy is pain of moderate in adult Europeans alarmed, especially if their sight is affected.to severeisintensity important that the pharmacywas has someGDP kindper year.7 This demonstrates an urgent need for cost a common occurrence and one that can have 3first places Pharmacy is often one of the 19%. of screening tool in place for such situations many different causes. effective strategies to manage chronic pain effectively. patients will present when they are seeking so that the pharmacist personally encounters

Introduction

advice on their eyes. Whether this is in relation As a general rule of thumb, any condition of those who need their expertise More recent survey data from another study, carried out most. the eye that presents with pain associated with to general information on dry eyes, or seeking visual impairment loss, should be considered 2,019 people painmany and 1,472 primaryis an effectiveUnderstanding While feel WWHAM tool for chronicorpain advice on more specificin symptoms and with chronic serious and requires immediate referral to a gaining thecountries, information necessary in responding conditions such as red, care inflamed and painful physicians across 15 European have specialist healthcare professional. Chronic is defined as pain that outlasts normal healing to symptoms, other pharmacists agree that it is painmore eyes. Pharmacies are often more accessible demonstrated that chronic apain affects 12-54% of adult Conjunctivitis is one of the most common tool best utilised by counter assistants.time If this to patients than other sources of expertise. (usually three to six months), and is most frequently 2 causes of ‘red eye’ and one that presents very Europeans, andthey its prevalence incase, Ireland is up to 13%. The may find is the then some pharmacists For the most part, they are open longer, associated with oftenmusculoskeletal in the pharmacy. disorders such as low ASMETTHOD mnemonic a more effective don’t require an appointment, is free, Impactthe PRIMEadvice (Prevalence, and Cost of Chronic Pain) study, arthritis. However,causes it canitchy, also swollen be associated way of remembering the range of issuesback on pain and treatment may be available over-the-counter, Allergic conjunctivitis eyes on the other hand, determined the prevalence of chronic and occurs when the eyes come into contact which they should seek information when an other disorders and more serious conditions can be referred to with such as depression or metabolic 4 to be as high in Ireland. The PRIME study with an allergen. individual presents with symptoms. more specialised health pain professionals suchas as35.5% disorders or neurologic conditions such as multiple the optician or doctor. was designed to investigate the prevalence of chronic pain Contact dermatoconjunctivitis and giant ASMETTHOD Mnemonic sclerosis. papillary conjunctivitis are frequently caused by in Ireland; compare the psychological and physical health As pharmacists, when considering overall eye contact lenses and lubricating eye drops. A Age of Patient health and diseases thatprofiles affect the eye, we of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised asmost nociceptive Infective conjunctivitis is one of the need to have knowledge and skills in a number S Self or someone else 4 commonly observed ocular conditions seen in pain-related disability. Responses to survey questions were or neuropathic. Nociceptive pain is caused by an active of areas. As well as understanding the structure practice. It is cause by a variety of pathogens, M Medication the patient is currently taking, fromto1,204 and function of the eye, obtained it is essential know;people. illness, injurynotably and/orthose inflammatory process associated that are either bacterial or viral inwith including OTC medicines how to respond to eye symptoms, common origin. tissue damage i.e. Nociceptive pain actual or potential E problem, Exact patient experience diseases of the eye, howDespite drugs and the diseases magnitude of the chronic pain is Viral conjunctivitis tends to besecondary more prevalent results from activity in neural pathways to actual relate to eye problems and how to keep eyes 2,5 time of Time, duration or change with in adults. Its duration can be prolonged and both under-recognised andTundertreated in primary care. healthy. or potential tissue damage. Nociceptive pain is mediated in some cases, have lasting consequences symptoms

Indeed, up to 38% of patients reported being inadequately depending on the case.musculoskeletal system, by pain receptors located in skin, 2 already solicited T their Taken already or help managed in primary care for pain symptoms. In 8 has certainly lagged behind many Ireland bone, and joints. Neuropathic pain, on the other hand, Many pharmacies will have their own protocol H pain History of condition other European states in approving POM to P addition, people with chronic reported waiting up to results from direct injury a peripheral or central for how they deal with certain conditions. This switches. Forto many years pharmacists in sensory Ireland Ohelp Other symptoms being suffered 2.2 years between seeking and diagnosis, and 1.9 may particularly be the case when dealing have called for chloramphenicol intransduction particular to at nerve; the affected nerves do not produce 2 before their pain managed. be switched from a POM to P status. Doing anything to alleviate or worsen the with conditions that theyyears consider to have the wasDadequately nociceptors.8 Pain characteristics and associated conditions condition ability to be more serious. A protocol may entail for both types of pain are shown in Table 1. RESPONDING TO EYE SYMPTOMS

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CPD 44: OPTICAL HEALTH - CONJUNCTIVITIS

hay fever season it is called seasonal allergic conjunctivitis (hay fever eyes) and when it occurs all year round, it is called perennial allergic conjunctivitis. The perennial allergic form is commonly caused by animal dander and so any patient whose symptoms follow this presentation should be asked if he or she has been in contact with animals.

Module 1 June 2012

Contact dermatoconjunctivitis and giant papillary conjunctivitis are frequently caused by contact lenses and lubricating eye drops. Eye drops that contain a preservative agent, commonly benzalkonium chloride, are long established irritants. Hence, patients that present with symptoms of irritation that can be linked to onset of use of eye drops should be advised to switch to preservative-free formulations. These do however have a shorter expiry once opened (28 days) and start at a higher price point, which may explain why they are less commonly prescribed/purchased as first line treatments. However, these are the eye drops of choice for patients that wear contact lenses and have great susceptibility to irritation.

sionals in Ireland

anagement in primary care

Asking such questions, either by this method or another of preference will help those consulting with the patient or their representative to gain a more compete picture of the situation and ehan et thereby al reported in 1996 that estimated cost of allowing them to the make more informed decisions howHealth to proceed. n for 95 patients toabout the Irish Services when added

General Presentation The general presentation of conjunctivitis is that of various symptoms. Differentiating between these will help categorise the type of conjunctivitis involved or point to a different diagnosis.

he amount of EYE Social Welfare payments received and RED • Red eye is commonly one of the most lost earnings of each patient amounted 1.9 millionis common symptoms. It can present The presentation of red eye in thetopharmacy 6 bilaterally and in just one eye. nds at the time of referral. Theand recent fromhave PRIME a common occurrence onedata that can different Accurate of • Patients also often describe irritation and vey showmany that the meancauses. cost per chronicdiagnosis pain patient the cause is vital and requires specific skills the sensation of grittiness and discomfort. stimatedand at €5,665 per year across all grades of pain, knowledge. Some of these causes can be This shouldn’t be described as pain and ch was extrapolated to €5.34 billion or 2.86% Irish dealt with in the pharmacy whilst othersofcan any presentation of pain should be cause be7 much more serious. an As urgent a general rulefor of cost for concern and may suggest an alternative P per year. This demonstrates need thumb, any condition of the eye that presents diagnoses. ctive strategies to manage chronic pain effectively.

with pain associated with visual impairment or loss, should be considered serious and requires immediate referral to a more specialist derstanding chronic pain healthcare professional. Other causes of eye can as be pain muchthat lessoutlasts sinisternormal and occur onic painred is defined healing much more often. A red eye can sometimes e (usuallyindicate three toasix months), and is in most burst blood vessel the frequently eye, caused by straining ordisorders coughing.such Thisas is called ociated with musculoskeletal low subconjunctival haemorrhage and, k pain and arthritis. However, it can also bealthough associated it looks severe, it should clear up on its own h other disorders such weeks. as depression or metabolic within several Topical tear supplements orders orcan neurologic conditions such as multiple help if the eye is uncomfortable and the rosis. redness is simply being caused by dryness. Other cause of ‘red-eye’ are infection or allergy. In many cases this is caused by conjunctivitis.

n (acute or chronic) can be categorised as nociceptive CONJUNCTIVITIS europathic. Nociceptive pain is caused by an active is one ofprocess the mostassociated common with ss, injuryConjunctivitis and/or inflammatory causes of ‘red eye’ and one that presents very ual or potential tissue damage i.e. Nociceptive pain often in the pharmacy. The term ‘conjunctivitis’ ults from refers activity pathways secondary actual toinanneural inflammatory condition that to affects conjunctiva, which is the thin otential the tissue damage. Nociceptive paintransparent is mediated mucous membrane covering the white of the pain receptors located in skin, musculoskeletal system, eye. It8 can become inflamed due to a variety of e, and joints. Neuropathic pain,subdivided on the other reasons and is normally intohand, origins areinjury eithertoinfective or non-infective in ults from that direct a peripheral or central sensory nature. This cando benot further divided into acute at or ve; the affected nerves produce transduction chronic conjunctivitis. 8 iceptors. Pain characteristics and associated conditions both types of pain are shown in Table 1.

Another common occurrence is discharge. This may be watery, clear, sticky or purulent depending on the cause. A further symptom of significance is photophobia – this may also suggests corneal involvement. Visual acuity should be unaltered - in conjunctivitis any alteration in vision should be minimal, related to tearing and discharge blurring the visual field. Consideration should be given to a differential diagnosis if there is any significant visual loss.

NON-INFECTIVE CONJUNCTIVITIS Allergic conjunctivitis Allergic conjunctivitis causes itchy, swollen eyes and occurs when the eyes come into contact with an allergen. This variant of the condition can be subdivided into four main types: • Seasonal allergic conjunctivitis • Perennial allergic conjunctivitis • Contact dermatoconjunctivitis • Giant papillary conjunctivitis When allergic conjunctivitis presents during the

In allergic conjunctivitis it is usual for both eyes to be affected, however atypical presentation may result in only one eye being affected and would not out rule a diagnosis. An itchy eye is also a typical indicator, and so the patient should be asked if they have experienced an itch. Other common symptoms can include a watery discharge and a feeling of intraocular irritation. Ballooning out of the conjunctiva (chemosis) and swelling of the eyelid can also occur, albeit less frequently. TREATMENT Once the cause of the allergic symptoms has been identified, patients should be advised to avoid the allergen to control symptoms and avoid future flare-ups. For example, if grass pollen is a confirmed cause, patients should be advised to avoid grassy areas particularly in the morning time when pollen counts are at their peak. Simple steps such as wearing sunglasses, eye rinses and closing windows at home can help. With the avoidance of the suspected/confirmed allergen, symptoms generally resolve spontaneously. However, in the case of un-resolving symptoms, patients should be referred to their ophthalmologist for further investigation and/or therapeutic management. Ocular symptoms due to hay fever can often be treated effectively with eye drops containing sodium cromoglicate, a mast cell stabiliser and anti-histamines (e.g. antazoline, azelastine (POM)). Sodium cromoglicate 2% can be used prophylactically, if necessary, throughout the hay fever season in adults and children. Meanwhile, antazoline sulphate 0.5% azelastine 0.05% can be used in adults and children over 12 years, however the latter is reserved for prescription only status in Ireland. Oral antihistamines, e.g. chlorpheniramine, cetirizine can also be used and to alleviate general hayfever symptoms, although their effect specifically on eye symptoms tends to be more moderate. Furthermore, topical eye drops are traditionally preferred to oral formulations as there is reduced potential for systemic sideeffects. Patients should also be reminded that

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CPD 44: OPTICAL HEALTH - CONJUNCTIVITIS

If a gonococcal ocular infection is left untreated, rapid and severe corneal involvement is inevitable. The resulting ulceration and, ultimately, perforation lead to profound and sometimes permanent loss of vision. Contact lens wearers are a group who need Module 1 Infected infants may also have other localized further consideration, particularly those who 2012or gonococcal infections, such June as rhinitis present with repeated infections. Consequently, proctitis. These cases require immediate referral they are at risk of more serious condition and pharmacy has a role identifying these INFECTIVE CONJUNCTIVITIS developments such as that of bacterial corneal cases as different from simple acute bacterial ulcers. Incontent these contact lens-related professionals cases, distance learning for healthcare in Ireland an making the appropriate conjunctivitis Infective conjunctivitis isEducational one of the most the gram-negative Pseudomonas species referrals. commonly observed ocular conditions of bacteria tend to predominate. Typically, seen in practice. It is cause by a variety of Chlamydial conjunctivitis is less common than first line antibiotics such as chloramphenicol pathogens, notably those that are either the other types of conjunctivitis. Chlamydia are infective for such gram-negative strains, bacterial or viral in origin. Common causes of are mycoplasms, which are essentially midway resulting in repeated infections. The bacteria bacterial conjunctivitis include staphylococci, between a virus and a bacterium, however, may be introduced to the ocular surface with streptococci, gonococci, and Chlamydia. unlike bacteria, they do not have a cell wall. contact lens handling via a contaminated case Complications are expected to develop only Chlamydial conjunctivitis is more common or solution, or from prolonged contact between in cases caused by extremely pathogenic in younger adults and frequently presents in the cornea and the back surface of the contact bacteria, such as C trachomatis or Neisseria individuals that have a systemic chlamydial lens where colonies of bacteria may exist in/ gonorrhoeae. A variety of viruses can be infection. It too can present in neonates, born to on the contact lens matrix. As a result good responsible however those of most prominence mothers with active chlamydial infection. There contact lens hygiene should be advised. include; adenovirus, herpes simplex virus (HSV), is approximately a 50 per cent risk of a baby or varicella-zoster virus (VZV). CONTACT LENS CARE acquiring the infection during birth if the mother has an active infection. As such, chlamydial BACTERIAL CONJUNCTIVITIS Always conjunctivitis should be suspected in any Bacterial conjunctivitis is usually considered a infant younger than 30 days presenting with • Wash and dry your hands before touching self-limiting illness and one that is benign and conjunctivitis, as onset is typically between five any lenses affects infants and children more often than and 14 days following birth. adults. In some less frequent circumstances it • Clean, rinse, and disinfect your lenses each can be serious, and signify a severe underlying In chlamydial conjunctivitis the eye will be red time you remove them systemic disease or result insignificant and often the redness will appear a darker • Keep all solution bottles closed whenSheehan not etshade al reported 1996 that the estimated cost ocular and systemic morbidity. In adults of red in when compared with the level ofof Introduction in use Staphylococcus aureus is considered to be redness associated with bacterial or allergic pain for 95 patients to the Irish Health Services when added responsible for around 55% Pain of is cases, one of with the commonest reasons for patients to seek conjunctivitis. Discharge can vary from watery • Clean your lens case daily and let it air to dry, the amount of Social Welfare payments receivedThe and 20% attributed to Streptococcus pneumoniae, to mucopurulent in adults and neonates. 1 has shown thatthree as many medical attention. A recent survey and replace it every months 10 per cent by Moraxella spp, 5 per cent eyelid of may be swollen and chemosis may the lost earnings each patient amounted to 1.9 million as 8.3 year to primary care physicians Irelanddate marked on by Haemophilus influenzae andvisits 5 perper cent alsotime be present. If there a misdiagnosis 6 • Use solution beforeinexpiry pounds at the of referral. Theisrecent data fromand PRIME 2 by Pseudomonas aeruginosa. In infants and chloramphenicol eye drops are used, the eye were due to symptoms of pain. A large scale survey carried bottle or discard survey show that the mean A cost per chronic pain patient children, the most common bacteria causing will not improve. chlamydial cause must be out in 15 European countries Israelcontacts in 2006,before screening • and Remove you go swimming conjunctivitis are Streptococcus pneumoniae, out because an untreated is estimatedruled at €5,665 per year across all chlamydial grades of pain, 46,394 respondents reported that the prevalence of chronic Moraxella catarrhalis and Haemophilus can€5.34 causebillion conjunctival andof Irish extrapolated to or 2.86% • Schedule regular appointments with which was conjunctivitis influenzae. Staphylococcus streptococcus corneal scarring, which can affect vision. painand of moderate to severe intensity in adult Europeans was your eye care professional as he or she 7 GDP per year. This demonstrates an urgent need for cost are Gram positive bacteria, haemophilus and recommends 19%.3 VIRAL CONJUNCTIVITIS pseudomonas are Gram negative bacteria and effective strategies to manage chronic pain effectively. moraxella is Gram variable. Never Viral conjunctivitis tends to be more prevalent More recent survey data from another study, carried out in adults. Its duration can be prolonged and In simple acute bacterial conjunctivitis, • pain Allow soaps, cosmetics, in 2,019 people with chronic and 1,472 primary or other substances in some cases, havepain lasting consequences Understanding chronic the eye is usually red because blood vessels to touch your lenses depending on the case. Adenoviral infection care physicians across 15 European countries, have dilate, and there is nearly always a yellowis usually (butasnot always) mild andnormal self- healing Chronic is defined pain that outlasts • Touch the tip of a lens care solution bottle to pain white mucopurulent discharge. Therefore, is demonstrated thatit chronic pain affects 12-54% of adult limited, whereas herpes viruses can cause any surface, including your fi nger or the useful to ascertain if such a yellow discharge time (usually three to six months), and is most frequently significant associated keratitis and uveitis. Viral in Ireland is up to 13%.2 The lens was present on waking. Europeans, If the answerand is its prevalencecontact associated conjunctivitis with musculoskeletal such as low is highly disorders contagious, usually for “yes”, then the patient nearly always has PRIME (Prevalence, Impact and Cost of Chronic Pain) study, • Reuse any lens care solution 10-12 days from onset itascan long as the eyes are back pain and arthritis. However, also be associated a bacterial conjunctivitis.onOther signs and the other hand, determined the prevalence of chronic red. Patients should avoid touching their eyes, symptoms will include unilateral presentation, withfor other disorders such as depression or metabolic • Use eye 4drops or solutions not intended shaking hands, and sharing towels, among pain to be as high Ireland. The PRIME study an uncomfortable (gritty or burning) red eye,as 35.5% inuse with contact lenses disorders orother neurologic conditions such as multiple activities. lids that are often stuck was shut designed on wakingtoand investigate the prevalence of chronic pain sclerosis. • Wear your contact lenses in the presence of occasionally mild photophobia is present. Adenoviral conjunctivitis is more common in Ireland; compare the psychological physical health or fumes harmful and or irritating vapours Bacterial conjunctivitis is usually self-limiting in adults than in children, and are is by far the profiles of those with and without chronic pain; and explore taking 7 to 10 days to resolve. Advice should Pain (acutemost or chronic) cancause be categorised as nociceptive common of viral conjunctivitis. • Wear lenses for more than the prescribed centre around the discontinuation of disability. contact 4 Responses to survey questions were pain-related Adenoviruses are pain also is implicated in causing or neuropathic. Nociceptive caused by an active time lens wear if appropriate, swabbing if there the common cold (rhinoviruses are the main obtained from 1,204 people. illness, injury and/or inflammatory process associated with is a large quantity of discharge, and careful • Swap contact lenses with anyone cause) and the usual modes of transmission two to three times daily lid hygiene. Often actual or potential tissue damage i.e. Nociceptive pain are contaminated fingers, medical instruments Gonococcal related pain conjunctivitis usually the will magnitude problem, chronic is however, most patients Despite (or parents) want of the swimming pool water. Patients with to viral results fromand activity in neural pathways secondary actual presents in neonates (ophthalmia 2,5 neonatorum) immediate treatment and the options currently both under-recognised and undertreated in primary care. conjunctivitis typically present with an acutely and sexually active young adults. Affected or potential tissue damage. Nociceptive pain is mediated available in Irish pharmacies are limited. If red eye, watery discharge, conjunctival swelling up to 38% reported being inadequately infants typically develop bilateral discharge advice and reassuranceIndeed, isn’t satisfying for of patients by pain receptors located in skin, musculoskeletal system, and a gritty feeling. Photophobia is possible 2 three five symptoms. days after. Transmission of the managedpreparation in primary care for theirtopain In the patient then an anti-infective and in8 such cases aspain, can symptoms of hand, a cold bone, and joints. Neuropathic on the other Neisseria organism to infants occurs during containing propamidine addition, isetionatepeople 0.1% with chronic pain reported waiting up to or flu can be present. vaginal delivery. In adults, the organism is could be recommended, or the patient can results from direct injury to a peripheral or central sensory 2.2 years between seeking help and diagnosis, and 1.9 usually transmitted from the genitalia to nerve; the Adenoviral conjunctivitis will usually resolve at be referred to their GP for suitable treatment. the affected nerves do not produce transduction 2 and then to the eyes. spontaneously within two weeks and no The patient should be told to take care notpain to washands years before their adequately managed. 8 systemic absorption can still occur. As such, formulations should not be used for prolonged as they can have a greater propensity to cause rebound symptoms. This effect is seen for instance in the prolonged use of xylometazoline eye drops which can still cause rebound nasal congestion when used for periods exceeding 7-10 days.

touch the infected eye as the condition is easily transferred to the other eye and to others. Eye make up could also be contaminated and should be replaced.

Chronic Pain – assessment and management in primary care

nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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CPD 44: OPTICAL HEALTH - CONJUNCTIVITIS over several weeks, Conjunctival injection and watering. A point of particular note is whether the tip of the nose is affected. If it is, there is significant risk of ocular complications (Hutchinson's sign)

Module 1 June 2012

sionals in Ireland treatment is necessary. Chloramphenicol does, however, have some anti-adenoviral activity. Again, the patient should be advised to take care not to transfer the infection to an unaffected eye. In addition, care should be taken not to transfer the infection to other people (e.g., hand towels should not be shared). Referral to a GP or specialist should be considered with any pain or visual disturbance, photophobia, and any prolonged or repeated episodes.

anagement in primary care

Aside from symptomatic and supportive treatment, both ocular herpes simplex and herpes zoster are often managed with topical and/or systemic antiviral agents including acyclovir, famciclovir, and valaciclovir. Despite sometimes being prescribed however, topical corticosteroid therapy can lead to severe ocular complications as a result of uncontrolled virus proliferation. Therefore, topical corticosteroids should not be used in the management of infectious conjunctivitis unless under the direction of an ophthalmologist. Treatment with corticosteroids can prolong the course of the disease and also place the patient at risk for other steroid-induced ocular complications, such as glaucoma and cataracts DIFFERENTIATING BACTERIAL, VIRAL AND ALLERGIC CONJUNCTIVITIS

Often it is not an easy task to make clear distinctions between bacterial, viral or allergic conjunctivitis. Ultimately, analysis following a sample from the eye via swabbing provides for the most accurate diagnosis. This however is not practical in a pharmacy setting. Therefore, it is important to be make patients aware of when they need to be referred to a more specialist practitioner. This is particularly important in severe, resistant, atypical cases or in immunosuppressed patients, where swabbing n for 95 patients to the Irish Health Services when added for culture and sensitivities is important. Ocular infections due to herpes simplex virus he amount of Social Welfare payments and (HSV), or varicella-zoster virusreceived (VZV) are Evidence suggests that in adult patients, there becoming more prevalent, however theymillion are lost earnings of each patient amounted to 1.9 is a significant chance that the infection is forms of conjunctivitis that won’t usually be nds at the time of referral.6 The recent data from PRIME bacterial when there is a combination of the treated within the pharmacy setting. However, following: vey showit that the mean chronic pain patient is important tocost knowper when to refer such patients and there is also a need to advise • A positive previous history of infectious stimated at €5,665 per year across all grades of pain, patients on the condition and any prescribed conjunctivitis. ch was extrapolated to €5.34 billion or 2.86% of Irish medicines they may have to use. Herpes 7 • An itch present. P per year. This virus demonstrates urgent needthe for cost simplex (HSV) canan closely mimic presentation of ocular adenovirus infection. ctive strategies to manage chronic pain effectively. • A mucopurulent discharge ('glue eye')

Treatment and management is mainly symptomatic and supportive. Cold compresses and topical vasoconstrictors such as preparations container xylometazoline or artificial tears may provide symptomatic relief. Topical antibiotics are rarely necessary, because secondary bacterial infection is uncommon. Patients also need to discontinue contact lens wear until 24 hours after symptoms have fully ehan et resolved. al reported in 1996 that the estimated cost of

The herpes simplex virus (HSV) occurs equally among young/middle-aged males and derstanding females chronic in contrastpain with herpes zoster virus, which is more commonly found in the elderly. onic painThe is defined as pain outlasts normal (94healing primary infectionthat is often subclinical often occurring in childhood or e (usually99% threeoftocases) six months), and is most frequently adolescence. Ocular infection occurs with ociated with musculoskeletal disordersthen such as low reactivation of the virus which lies dormant k pain and arthritis. However, cancondition also be associated in the trigeminal nerve.itThe usually lasts 2-3 such weeksasand the eye(s)orpresents with h other disorders depression metabolic staining such causing classical orders orreddening neurologicand conditions as amultiple dendritic corneal ulcer. Patients complain of rosis. foreign body sensation, reduced vision, and light sensitivity. This is typical of around 80% of cases. n (acute or chronic) can be categorised as nociceptive

europathic. Nociceptive pain isocular caused by an active Herpes zoster related conditions are reactivationprocess of a dormant varicellass, injurycaused and/orby inflammatory associated with zoster virus which gives rise to shingles of ual or potential tissue damage i.e. Nociceptive pain the innervated dermatome. In 15% of cases ults from of activity in neural pathways secondary actual shingles, the eye is affected, so givingtorise herpes zoster Nociceptive ophthalmicus. Unlike herpes otential to tissue damage. pain is mediated simplex eye infection, it is more common pain receptors located in skin, musculoskeletal system, in elderly patients. Symptoms can include 8 e, and joints. Neuropathic pain, the otherillness hand, conjunctival watering, inflon uenza-like fatigue, (degrees of painsensory in the ults from with direct injury neuralgia to a peripheral or central distribution of the ophthalmic nerve), vesicular ve; the affected nervesthe do forehead, not produce transduction at rash affecting lesions progressing 8 iceptors.to Pain characteristics and associated pustules then to crusting, eventually conditions healing both types of pain are shown in Table 1.

No cold / flu like symptoms

When patients describe their eyes glued together in the morning, this doesn't necessarily mean that there is a purulent discharge. Viral and allergic conjunctivitis often result in lids that are matted shut in the morning. However, these patients actually have crusting of the lashes due to drying of tears and serous secretions, not the wet, sticky, mucopurulent matting characteristic of bacterial conjunctivitis. CHLORAMPHENICOL POM TO P? Ireland has certainly lagged behind many other European states in approving POM to P switches. This is despite good evidence in favour of doing so for some well established medicines that have good safety records and positives benefit /risk profiles. For many years pharmacists in Ireland have called for chloramphenicol in particular to be switched from a POM to P status. In the UK, the case for allowing pharmacists to initiate supply was compelling and the Medicines and Healthcare Regulatory Authority (MHRA) assessment report made it clear that it believed the down regulation of the medicine from POM to P status was a very positive move in healthcare.

This move allowed for ready access for patients and one which outweighed any potential increased risk. The switch was made in 2004 and the unmet clinical need quickly became apparent, with a significant increase in the number of units of chloramphenicol supplied throughout community pharmacies which was met by a subsequent decrease in unnecessary GP referrals. Hope remains that in the not too distant future that such changes will come about in Ireland. In the case of conjunctivitis, such a change will enable pharmacists to effectively deal with this condition more robustly, allowing treatment where suitable referring those specific cases where appropriate. REFERENCES 1.

Rietveld RP, Riet G, Bindels PJ, et al; Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms. BMJ. 2004 Jul 24;329(7459):206-10

2.

http://www.pjonline.com.elib.tcd.ie/news/ keeping_an_eye_on_things_eye_health_problems

3.

http://emedicine.medscape.com/article/1191730overview

4.

http://www.pjonline.com.elib.tcd.ie/news/ what_can_europe_learn_from_the_british_ experience_of_pomtop_switching

5.

http://www.bmj.com/content/335/7627/985

6.

Sheikh A, Hurwitz B, van Schayck CP,McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD001211

7.

http://www.aafp.org/afp/1998/0215/p735.html

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Holden BA1, La Hood D, Grant T, et al, Gramnegative bacteria can induce contact lens related acute red eye (CLARE) responses. CLAO J. 1996 Jan;22(1):47-52.

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Hans de Groot, Paul L P Brand, Wytske F Fokkens et al, Allergic rhinoconjunctivitis in children, BMJ 2007;335:985

10. http://www.patient.co.uk/doctor/infectiveconjunctivitis-pro

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