CPD 73: OPTICAL HEALTH Biography - Sinead Ryan graduated from the University of Brighton in 2008, and completed her pre-registration in Chelsea and Westminster Hospital NHS Foundation Trust, London. She worked in a number of clinical positions in London before returning to Ireland in 2011. She completed her higher diploma in community pharmacy from Trinity College Dublin in 2014. Sinead is currently working as a community pharmacist in Limerick.
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Red eye is a presenting complaint of both serious and non-serious causes of eye pathology and is one of the most common eye problems that pharmacists deal with in over the counter consultations. Due to the delicate nature of the eye and the possibility of serious complications, it is important to refer patients where there is any doubt as to the nature of the disorder. Red eye is a clinical sign caused by the dilation of the superficial ocular blood vessels, in the eye. Dilation of these vessels can result from infection, allergy, inflammation or elevated intraocular pressure. Redness (hyperaemia) of the eye can occur alone or present with accompanying symptoms of pain, discomfort, discharge and loss of visual acuity. The most common cause of red eye is conjunctivitis. There are a number of other causes of red eye, which we will explore in this article. The aim of this clinical feature is to discuss distinctive signs and symptoms of common red eye conditions that present in a pharmacy setting and the rationale for their management. It can also be used as a reference and staff training guide for OTC staff. Pharmacists and OTC staff need to take a comprehensive optical and medical history to ensure that the patients are referred appropriately while others are treated with over the counter (OTC) medication. 1. BLEPHARITIS It is one of the most common eye problems. It is a chronic inflammation of the eyelids, which can cause red or watery eyes, discomfort and
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A-Z of OTC Red Eye Conditions This information may be used and collected each month as an ongoing comprehensive programme for management in Pharmacy. The modules are suitable for use by anyone working in community pharmacy wanting to improve their effectiveness as a successful leader and manager for their continuing professional development. Why CPD? Continuing profession educational development (CPD) is a legal requirement for pharmacists. Journal-based educational programmes are an important means of keeping up to date with professional developments and from a significant element of your CPD.
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an oily or flaky discharge around the lashes. The oil glands in the eyelid may become blocked or infected (Meibomian Gland Dysfunction) which can give rise to similar symptoms. Patients complain of a gritty, itchy, uncomfortable red eye that is worse upon waking. Patients should be advised that they should wash the eyelids with specialised blepharitis lotions/gels (e.g. Blephasol®) or eyelid scrub wipes (e.g. Ocusoft or Blephasol® wipes). Non-irritating baby shampoos are recommended as lid cleansers in the past, however, some ophthalmologists advise against their use due to SLS (Sodium Lauryl Sulphate) allergy and the drying effect on the eye. Resting a warm compress such as a warm facecloth over the affected eye may soften and release any gland blockages. Commercial Warm compress products (e.g. Eyebag®) can also be used. While patients should experience some relief within one month the treatment generally needs to be continued for a few months. Ocular lubricants can be helpful to relieve the symptoms of associated dry eye. Key counselling point – Patients need to be reminded that this is a chronic eye condition and that frequent cleaning of the edge of the eyelids and warm compresses need to be continued daily for several months. 2. CONJUNCTIVITIS The majority of patients presenting to the pharmacist with red eye will have some form of conjunctivitis. The conjunctiva is the membrane covering the eye (except for the cornea) and the inner surface of the eyelids. Conjunctivitis can result from either an infection (viral or bacterial) or an allergen. Conjunctivitis is subdivided into three types- bacterial, viral and allergic conjunctivitis. Staphylococcus or Haemophilus bacteria most frequently cause bacterial conjunctivitis. The adenovirus is most commonly implicated in causing isolated viral conjunctivitis. Pollen is the usual cause of seasonal allergic conjunctivitis. Non-allergic conjunctival irritation can result from foreign bodies - wind, dust, smoke, fumes, chemical vapours and other types of air pollution. Each of the three types of conjunctivitis presents with
60 Second Summary Red eye is a presenting complaint of both serious and non-serious causes of eye pathology and is one of the most common eye problems that pharmacists deal with in over the counter consultations. Due to the delicate nature of the eye and the possibility of serious complications, it is important to refer patients where there is any doubt as to the nature of the disorder. The aim of this clinical feature is to discuss distinctive signs and symptoms of common red eye conditions that present in a pharmacy setting and the rationale for their management. The majority of patients presenting to the pharmacist with red eye will have some form of conjunctivitis. The conjunctiva is the membrane covering the eye (except for the cornea) and the inner surface of the eyelids. The main treatment for dry eyes is artificial tears which are available OTC. There are a number of products on the market with good ocular surface wetting properties which increase the moisture and lipid content of the ocular surface. Infection with herpes simplex is extremely common — about 90 per cent of the population carry herpes simplex antibodies. Primary infections with herpes simplex usually occur between the ages of six months and five years. This may involve typical symptoms of a viral illness (eg, swollen lymph glands, malaise, sore throat) or the infection may be subclinical. Giving the correct advice depends on the pharmacist and pharmacy staff being able to determine the most likely condition(s) which involves asking the right questions. Careful history taking and an awareness of signs and symptoms that are triggers for referral can ensure pharmacists safely and effectively manage red eye ophthalmic conditions.
debris. If this course of action does not resolverecommended. the symptoms then the patient should be referred for a course of topical antibiotics with a typical course of treatment lasting 5 to 7 Key is counselling Point – Patients should be advised t days. In general, the use of topical steroids only prescribed by a consultant omega 3 such as fish oil supplements and flaxseed oi ophthalmologist to their associated CPD 73: due OPTICAL HEALTHside effects. from dry eye syndrome and can be taken alongside oc
Conjunctivitis – Chamydial
C. Conjunctivitis – Chamydial
which are available OTC. There are a number the three main symptoms of redness, discharge C. CONJUNCTIVITIS – CHAMYDIAL The of patients presenting to the pharmacist with red eye will have some form of thanThe Chlamydial conjunctivitis is less common types ofa conjunctivitis. It found is more and majority discomfort. ofother products onisthe market ocular episclera layer ofwith thegood eye underneath Chlamydial conjunctivitis is less common than presents conjunctivitis. The conjunctiva is the membraneprevalent covering inthe eye (except for the cornea) younger adults and frequently in patients with systemic chlamydial surface wetting properties which increase layer presents as redness (hyperaemia) as a result of A. CONJUNCTIVITIS - ALLERGIC other types of conjunctivitis. It is more prevalent the moisture and lipid content of the ocularand and the inner surface of the eyelids. Conjunctivitis can result from either anred, infection (viral infection. eyeand appears the discharge can vary from alayer. watery to mucopurulent found in this Episcleritis is subdivided into two s in youngerThe adults frequently presents in surface.in A few examples of these products Allergic conjunctivitis is usually a bilateral is subdivided or bacterial) or an allergen. Conjunctivitis three bacterial, viral and in someinto cases thetypeseyelids are swollen. ItThe can present neonates, born to mothers with patients with systemic chlamydial infection. ® are Geltears (Carbomer 940/Polyacrylic ocular condition caused by pollen or other allergic conjunctivitis. Staphylococcus or Haemophilus bacteria most frequently eye appears red, the discharge can varycause fromthat a 50 active chlamydial infection. It is estimated per cent babies® acquire the infection (Dextran 70), Artelac Acid), Tearsof Naturale a) Sectorial episcleritis is where one part ®ofifthe eye is allergens. Typical symptoms are red, itchy to mucopurulent in some cases the bacterial conjunctivitis. Theand adenovirus is mostwatery commonly implicatedand in causing isolated (Hypromellose), Lacri-Lube® (Liquid Paraffin), eyes associated with tearing burning that b) Diffuse episcleritis is when the entire eye is affected eyelids are swollen. It can present in neonates, Liquifilm Tears® (Polyvinyl Alcohol). Patients viral conjunctivitis. Pollenthe is patient the usual cause of seasonal allergic conjunctivitis. Non-allergic gradually disappear when is no born to mothers with active chlamydial with mild dry eye may benefit from instillation longer in proximity to the particular allergen. conjunctival irritation can result from foreign bodies - wind, dust, smoke, chemical infection. It is estimated that fumes, 50 per cent of Episcleritis is artificial commonly self-limiting and resolves of one of these tear drops up to four The condition is often associated with runny vapours and other types of air pollution. Each of the three types of conjunctivitis presents babies acquire the infection if the mother has treatment. rare cases episleritis has been associa times a day. In However, in moderate to severe nose, itching of the soft palate of the mouth an active infection at the time of birth. Patients with the threeApproximately main symptoms ofof redness, and sneezing. 70% patientsdischarge and discomfort. cases of dry eyes artificial tears would need to with suspect chamydial conjunctivitis should be rheumatoid arthritis. Recurring episodes of episcler with allergic conjunctivitis also have hay-fever, be instilled more frequently. To overcome this referred. of the three types of conjunctivitis asthma Features and/or eczema. issue, preparations containing a longer-acting polymer, polyacrylic acid/PVA (e.g. Liquifilm Key Practice Point Chlamydial conjunctivitis Cold compresses and tear substitutes are Tears®) or carbomer 940 (e.g. Geltears®) or should be suspected in an infant younger than useful in relieving burning and dry eyes in high weight and concentration of sodium 30 days presenting with conjunctivitis as patients with a mild allergy. While first and hyaluronate, eg Hylo Tear or Hylo Forte) onset is typically between 5 and 14 days second generation oral antihistamines are should be used for patients with moderate to following birth. effective in treating allergic conjunctivitis, severe dry eyes. These products have a longer topical ophthalmic products are superior in D. CONJUNCTIVITIS – VIRAL retention time in the eye and symptom relief is treating the ocular symptoms and reduce obtained with fewer instillations. Patients who Viral conjunctivitis is usually caused by an systemic side effects. Products containing wear contact lenses or are allergic/sensitive or adenovirus that is a highly contagious organism Sodium Cromoglicate 2% (e.g. Optichrom) can intolerant to the preservatives in dry eye drops with an incubation period of 4 to 10 days. be used prophylactically throughout hay-fever should use preservative free and contact lens Typically the patient presents with a red eye season in adults and children. Xylometazoline compatible drops. The single dose unit eye with watery discharge with follicular (white 0.5% and Antazoline sulphate 0.5% can be drops (e.g. Minims) in order to reduce exposure used in adults and children over 12 years to lesions) changes on the cornea and tender to preservatives which reduces eye irritation. reduce symptoms. If OTC medications do not lymphadenopathy. Quite often it presents Lubricating ointments are retained longer than provide effective relief within 7 days or the unilaterally. General hygiene measures, ceasing the liquid dry eye drops. The patient’s vision condition worsens patients should be referred contact lenses’ wear and ocular lubricants are can become blurred after instillation of ointment for further investigation. important in reducing the length of and this could affect activities such as driving viral conjunctivitis. Key Counselling Points - Advise the patient so they are not generally recommended for day to wear wrap-around sunglasses and allergen Key Counselling Point - Patients should be time use. They are, however, a useful adjunct to avoidance to reduce symptoms/flare ups. Eye advised to wash hands, remove contact lenses artificial tears if used at bedtime (e.g Vitapos). A. containing Conjunctivitis - Allergic should not be drops Xylometazoline and avoid touching the eye area. If the patient does not respond to artificial used for periods exceeding 7 days in order to tear substitute treatment after two months 3. CORNEAL ULCER avoid rebound nasal congestion. Allergic conjunctivitis is usually a bilateral ocular condition caused by pollen or other then the patient should be referred for further investigation. corneal ulcer cantearing appear and as a white/ allergens. Typical symptoms are red, itchy eyesAassociated with burning that B. CONJUNCTIVITIS – BACTERIAL greyish opacitytoonthe theparticular surface ofallergen. the cornea gradually disappear when the patient is no longer in proximity The In certain cases where the patient is elderly, Bacterial conjunctivitis is usually a self-limiting accompanied with a red eye appearance condition is often associated with runny nose, itching of the soft palate of the mouth and the symptoms of dry eye can be caused by condition with a fairly rapid onset of redness (hyperaemia). This can possibly be caused drooping of the lower eyelid. Ectropion is where and discharge. The discharge is usually sneezing. Approximately 70% of patients with by allergic conjunctivitis also have hay-fever, overuse of contact lenses or a history of the lower eyelid droops away from the eye and purulentand/or sticky discharge sleeping with contact lenses. The presence asthma eczema. with the lids stuck turns outwards. Entropion is where the eyelid together and crusted. Bacterial conjunctivitis of an opacity on the cornea would require turns inwards towards the eye. It usually occurs tends to cause a papillary reaction which is a urgent referral as this condition can be as the patient becomes older when the tissues diffuse subconjunctival oedema. This can be sight threatening. and muscles of the eyelids become weaker. quite marked causing the eyelids to swell with Key Counselling Point - Patients need to be The drooping eyelid can disrupt the drainage a puffy appearance around the eyes. Antireminded to remove contact lenses and seek infective eye drops and ointment are indicated of tears which can make the eyes red, irritated, urgent medical attention. for bacterial conjunctivitis. Drops are used dry, gritty and more vulnerable to bacterial during the day and ointment at night. Although infections such as conjunctivitis. If the patient 4. DRY EYE CONDITIONS ointment gives a higher concentration for a is experiencing these symptoms, it is advisable more prolonged time, the blurring of vision for them to have the condition checked by The eye is covered by a layer of fluid called the associated with ointments means they should their general practitioner. In mild cases, it may tear film which keeps the surface moist and only be recommended at night time. Drops and comfortable and protects the eye from infection. not require treatment. In more severe cases, ointment should be combined with cleaning Any change in the composition or amount of the a minor operation to tighten and correct the and eye-washes to remove the crusts and eyelid defect may be recommended. tear film can lead to discomfort. There are many debris. If this course of action does not resolve factors which can affect the tear film including Key counselling Point - Patients should be the symptoms then the patient should be illness, allergies, diet, atmospheric conditions advised that products containing high levels referred for a course of topical antibiotics with a and certain prescription medications e.g. of omega 3 such as fish oil supplements and typical course of treatment lasting 5 to 7 days. anti-cholinergic medicines. Patients with dry flaxseed oil have been found to protect the In general, the use of topical steroids is only eyes can complain of dry, gritty red eyes. eyes from dry eye syndrome and can be taken prescribed by a consultant ophthalmologist due The main treatment for dry eyes is artificial tears alongside ocular lubricants. to their associated side effects.
pinguecula becomes inflamed, refer for medical treatment . An inflamed pinguecula can be be an underlying systemic autoimmune condit treated with a mild steroid eye drop (e.g, Prednisolone 0.5 % Minims). condition should be immediately referred as it
Key Counselling Point – Advise the patient to use UV-A and UV-B wrap-around sunglasses to CPD 73:deterioration OPTICALespecially HEALTHwhen travelling abroad. prevent further
Key Counselling Point – Advise the patient to seek
8. Pinguecula 5. EPISCLERITIS
Red Eyes (Cosmetic)
9. Red Eyes (Cosmetic)
hydrochloride (e.g. Optrex® Red Eye, Murine® Key Counselling Point - Counsel patients A pinguecula is a slightly raised yellow-white conjunctival lesion that typically appears onof red Irritation and the Redness Eye Drops). Naphazoline with cold sores handasked hygeine to avoid Pharmacists areon often for and treatment where patient’s main concern is by Stephylo Aeyes stye (hordeolum) is usually caused Theconjunctiva episclera is a(white layer of found the ofthe theeye eye). If it travels into the cornea (pterygium) ittheir cancold affect thecause acts onredness alpha-adrenergic receptors in the walls touching their appearance eye area whilst the sore the cosmetic of eyes. The of the should be established and follicle in severe infection underneath the conjunctiva. Inflammation of of bloodand vessels causingcases them the to constrict andcan be as is active. patient’s vision. sometimes is connected to the patient’s lifestyle,the for gland example, the iscustomer maygland) had had this layer presents as redness (hyperaemia) as of Zeis (sebaceous or are the gland o therefore redness reduced. These drops 7. MEIBOMIAN CYST or they were in a smoky environment. a result of dilation of the blood vessels that are less sleep than normal There are a with number of eyeand contraindicated ineyelid patients glaucoma swelling on the margin and in severe cases Pinguecula common andis can be a sign conjunctival ageing. In addition, they can ® ® found in thisare layer. Episcleritis subdivided into of drop Red who Eye,are Murine products containing naphazoline hydrochloride (e.g. Optrex are not suitable for patients contact The opening of the meibomian glands is located bacterial in origin, yellow discharge (pus) can be see two subtypes: appear earlier in patients who live in countries with high UV exposure. On examination, the lenses Alternatively, contactinlens Irritation and Redness Drops). acts on wearers. alpha-adrenergic receptors the near the eyelash margin.Eye Each eyelid Naphazoline contains wearers can use products containing Euphrasia, conjunctival will show degeneration of collagen fibres in the conjunctiva, conjunctival between 50 andvessels 70 meibomian They a) Sectorial episcleritis is where one part of the walls of blood causing glands. them to constrict and therefore redness is reduced. These a natural plant extractathat can also relieve Without treatment stye usually self-limiting an are modified sebaceous glands that secrete eye is affected. thinning, discolouration of the conjunctiva and occasionally calcification. drops are contraindicated in patients with aglaucoma and are not suitable for is patients who redness in the eye (e.g Hylo Fresh) lipid material onto the tear film which prevents Products containing Propamidine (Brolene® and are contact lenses wearers. b) Diffuse episcleritis is when the entire eye is the tears from evaporating. Blockage of these Key Counselling Point - Remind patients to If the infe Pingueculae are benign lesions and no treatment is usually indicated. However, if a compresses (Eyebag®) may be helpful. affected and inflamed. glands can cause an inflamed lesion called a remove contact lenses that cosmetic pinguecula becomes inflamed, refer for medical treatment An inflamed pinguecula can be patient will need to and be referred as ared topical or s meibomian .cyst. eye products are not recommended for long Episcleritis is commonly self-limiting and
treated mild steroid eye drop (e.g, Prednisolone 0.5 % Minims). resolveswith itselfawithin three weeks without
Small meibomian cysts (less than 0.5cm) often treatment. In rare cases episleritis has been spontaneously resolve. If the meibomian cyst associated with systemic conditions as to usedoes Key Counselling Point – Advise the such patient UV-Anot and UV-B wrap-around sunglasses(e.g. to resolve, then warm compresses ® rheumatoid arthritis. Recurring especially episodes ofwhen travelling prevent further deterioration ) can be placed against the cyst for Eyebagabroad. episcleritis can be associated with systemic a few minutes to warm the oils and free the diseases that should be referred to a doctor. obstruction that is causing the lesion. This Topical steroids and topical NSAIDs can be should be done every evening. If this action fails prescribed for severe cases. to resolve the meibomian cyst or if the cyst is larger than 1cm the patient should be Key counselling Point - Using 2WHAM and referred for further investigation. A hospital TASTER questioning techniques check the visit may be necessary for the cyst to be incised patients history and family history of systemic and removed. conditions such as rheumatoid arthritis. 8. PINGUECULA 6. HERPES SIMPLEX KERATITIS A pinguecula is a slightly raised yellow-white Infection with herpes simplex is extremely conjunctival lesion that typically appears on the common — about 90 per cent of the population conjunctiva (white of the eye). If it travels into carry herpes simplex antibodies. Primary the cornea (pterygium) it can affect the 9. Redwith Eyes (Cosmetic) infections herpes simplex usually occur patient’s vision. between the ages of six months and five years. This may involve typical symptoms of a viral Pharmacists are often asked for treatment of redPinguecula eyes where patient’s concern arethe common and main can be a sign is illness (eg, swollen lymph glands, malaise, sore ofof conjunctival ageing. In addition, they can the cosmetic appearance of their eyes. The cause the redness should be established and throat) or the infection may be subclinical. earlier in patients who live in countries sometimes is connected to the patient’s lifestyle,appear for example, the customer may had had high UV exposure. On examination, The sleep patientthan will usually an in a smokywith less normalpresent or theywith were environment. aredegeneration a number ofof eye the conjunctival There will show uncomfortable eye and, perhaps, blurred ® Red Eye, Murine® drop products containing naphazoline hydrochloride (e.g. Optrex collagen fibres in the conjunctiva, conjunctival vision. Other signs include pain (usually mild), thinning, discolouration of the conjunctiva and Irritation and Redness Eye Drops). Naphazoline acts on alpha-adrenergic receptors in the redness, tearing and light sensitivity. There calcification. may be walls of accompanying blood vessels herpetic causing vesicles them toonconstrictoccasionally and therefore redness is reduced. These the eyelid periocular skin.inThe patientwith may glaucoma Pingueculae lesions and no who drops are or contraindicated patients and areare notbenign suitable for patients have had a herpes simplex infection in the eye treatment is usually indicated. However, if are contact lenses wearers. before. Patients presenting with signs of Herpes Simplex keratitis should be referred.
HSV virus typically affects the eyelids, conjunctiva and cornea. If the cornea is infected, the active disease is called herpes keratitis. On optical examination, the infection typically presents as a central ocular ulcer (dendritic lesion). The patient needs to be referred immediately. For a corneal dendritic ulcer, aciclovir (Zovirax®) eye ointment applied five times a day to the affected eye is usually effective. A 1cm line of ointment should be placed inside the lower conjunctival sac and the eye kept closed for 30 seconds after application. Two weeks’ treatment should be sufficient. In some cases oral treatment may be required. Patients who suffer severe or recurrent infections are at higher risk of corneal scarring.
a pinguecula becomes inflamed, refer for medical treatment . An inflamed pinguecula can be treated with a mild steroid eye drop (e.g, Prednisolone 0.5 % Minims). Key Counselling Point - Advise the patient to use UV-A and UV-B wrap-around sunglasses to prevent further deterioration especially when travelling abroad. 9. RED EYES (COSMETIC) Pharmacists are often asked for treatment of red eyes where the patient’s main concern is the cosmetic appearance of their eyes. The cause of the redness should be established and sometimes is connected to the patient’s lifestyle, for example, the customer may had had less sleep than normal or they were in a smoky environment. There are a number of eye drop products containing naphazoline
certain eyelashes are removed to release the term usecases, (unless they are using Hylo Fresh, which may be used long-term and is compatible
with contact lenses). Key Counselling Point – Advise patients that eye drops for the treatment of styes. Remind patients 10. SCLERITIS not to drive after eyeofointments. Scleritis is when theapplying scleral layer the eye becomes inflamed. This presents as severe pain accompanied by photophobia, ocular swelling (oedema) and watery eyes. There can often be an underlying systemic autoimmune condition such as rheumatoid arthritis. This condition should be immediately referred as it may be part of systemic autoimmune response. Key Counselling Point - Advise the patient to seek medical treatment urgently. 11. STYES A stye (hordeolum) is usually caused by Stephylococcus Aureus infection of the eyelash follicle and in severe cases the infection can be associated with the infection spreading to the gland of Zeis (sebaceous gland) or the gland of Moll (sweat gland). It presents as a red swelling on the eyelid margin and in severe cases the eyelid can become swollen. As it is bacterial in origin, yellow discharge (pus) can be seen and sometimes it can be painful. Without treatment a stye is usually self-limiting and will usually resolve within 7 to 14 days. Products containing Propamidine (Brolene® and Golden Eye® eye ointment) and warm compresses (Eyebag®) may be helpful. If the infection spreads and the eyelid swells, the patient will need to be referred as a topical or systemic antibiotic may be necessary. In certain cases, eyelashes are removed to release the infection and the stye resolves. Key Counselling Point - Advise patients that eye ointments are more effective than eye drops for the treatment of styes. Remind patients that eye ointments may blur vision and not to drive after applying eye ointments. 12. SUBCONJUNCTIVAL HAEMORRHAGE A subconjunctival haemorrhage is characterized by red, flat haemorrhage due to bleeding from the surface small blood vessels that run through the conjunctiva. The blood from the bleed can
bleeding disorders, hypertension, the use of to anticoagulants, conjunctivitis, scleritis or drop (us prevent complications from developing. A mydriatic sometimes used in addition to the steroid eye drop. trauma to the eye and the patient should be referred.
Key Counselling Point – Patients should be advised only to us
Key Pharmacy PointHEALTH – In certain cases this can be caused by elevated blood CPD 73:Practice OPTICAL prescribed length and no longer in order to reduce steroid pressure so taking the patient’s blood pressure may be beneficial. irritation, swelling.
13. Trichiasis 12. Subconjunctival Haemorrhage presentingiswith should be cover the whole of the sclera (white of the S Severity: mild,due moderate, severe entropian Trichiasis theuveitis inwardincluding growth iritis of the eyelashes. This can occur to ectropian, referred for further investigation. eye) or can be confined to one sector of the A subconjunctival haemorrhage is characterized by red, flat haemorrhage due to bleeding or trauma to the eyelid. In-growing eyelashes can rub previous against treatment the cornea causing T Treatment: e.g. surgery, eye. This condition is in the eye is not painful. from the surface small bloodforvessels that run through discomfort, the The blood from the previous topical Theconjunctiva. patient’spossible eye will be red (hyperaemic). The abrasion and corneal ulceration. They can alsotherapy, triggertrauma. the formation of The most common cause spontaneous typically surrounds iris but removing this is bleed can cover the whole of theissclera (whiteinof the eye) or canMedical be confined to one the sector subconjunctival haemorrhage idiopathic aredness stye. treatment involves the in-growing eyelash eyelashes a E Exacerbating factors: or wind, sunlight,with and eye not always the case. Thecause patient of the eye. This condition is in the eye is not painful. The most common forwill usually nature. The condition is painless clearing itself movements sterile fine tipped medical tweezer. The eye lash will regrow within four to six weeks. More pain (or at least discomfort) in the spontaneous is idiopathiccomplain in nature.ofThe condition is painless within 7 to 14subconjunctival days. In a fewhaemorrhage cases, the redness permanent alternative treatments include electrolysis and cryotherapy follicles. eye. Other may symptoms can include vision R Relieving factors e.g. of drythe eyehair drops clearing itself withinwith 7 tobleeding 14 days.disorders, In a few cases, the redness be associated with blurred may be associated and sensitivity to light. Iritis is diagnosed when bleeding disorders, hypertension, the use of anticoagulants, conjunctivitis, scleritis or hypertension, the use of anticoagulants, Past ophthalmic history white blood cells are detected in the aqueous conjunctivitis, scleritis orpatient traumashould to thebe eye and trauma to the eye and the referred. Exposure to another person with red eye signs fluid of the eye. Detection requires a slit lamp the patient should be referred. and symptoms, contact lens wearer, trauma, so a person with suspected uveitis should Key Pharmacy Practice Point – In certain cases thisbe can be caused by elevated blood surgery, recurrence referred. Key Pharmacy Practice Point - In certain pressure so taking the patient’s blood pressure may be beneficial. cases this can be caused by elevated blood Past medical history Iritis requires treatment with steroid eye drops pressure so taking the patient’s blood pressure Hypertension, diabetes, COAD/asthma, MS, to alleviate the pain and inflammation and may be beneficial. inflammatory bowel disease, arthritis conditions to prevent complications from developing. A should be noted. Any autoimmune conditions mydriatic drop (usually cyclopentolate 1%) is 13. TRICHIASIS must be noted also. sometimes used in addition to the steroid Trichiasis is the inward growth of the eyelashes. eye drop. Medication history This can occur due to ectropian, entropian or Systemic, topical, over-the counter, herbal, drug Key Counselling Point Patients should trauma to the eyelid. In-growing eyelashes can allergies be advised only to use steroid eye drops for rub against the cornea causing discomfort, the prescribed length and no longer in order Systems review possible abrasion and corneal ulceration. They to reduce steroid eye drop side effects e.g. Respiratory, cardiovascular, digestive, can also trigger the formation of a stye. Medical irritation, swelling. joints, skin treatment involves removing the in-growing 13. Trichiasis eyelash or eyelashes with a sterile fine tipped Five Key Practice Points for patients Family history medical tweezer. The eye lashofwill within Trichiasis is the inward growth theregrow eyelashes. This can occur due with to ectropian, presenting red eyeentropian symptoms Glaucoma, AMD, inherited retinal conditions, four to six weeks. More permanent alternative or trauma to the eyelid. In-growing eyelashes can rub against the cornea causing diabetes, and hypertension treatments include electrolysis and cryotherapy General hygiene – Wash and dry hands discomfort, possible abrasion and corneal ulceration. They can also trigger the formation of of the hair follicles. before instilling eye drops, do not allow the Social history a stye. Medical treatment involves removing the in-growing eyelash or eyelashes with a tip of the eye drop to come in contact with Living alone (e.g. can they instill eye drops sterile fine tipped medical tweezer. The eye lash will regrow within four to six weeks. More 14. WATERY EYES the surface of the eye. themselves?), driving, smoking permanent alternative treatments include electrolysis and cryotherapy of the hair follicles. Tears are necessary to keep the eye lubricated Symptoms of Red Eye Conditions that Check if patient is able to instill eye drops and clean. Causes of watery eyes (epiphora) require Immediate Referral especially if they live alone. include: dry eyes (tear production is stimulated Distortion of vision – including vision loss, by dryness), blepharitis, allergy and infection. Cease contact lenses wear. reduction or blurring Treatment is usually by tear substitute drops The expiry date of all eye drops (without and ointments. Warm compresses may also be Restriction of eye movement preservatives) is 28 days from the date useful. Prolonged excessive tear production of opening (with the exception of the Hylo is undesirable and may also be caused by a Abnormal/Irregular shaped pupil range, which is 6 months) blocked tear duct. If treatment fails after two Photophobia months the patient should be referred to a Check all OTC staff is aware of the symptoms general practitioner for further investigation. Redness caused by a foreign body requiring immediate referral. This can be treated in hospital with syringing Severe pain or swelling around the eye or insertion of punctal plugs (synethic plug that History Taking keeps the tear drainage system permanently CONCLUSION This is an example of the questions asked for a open therefore allowing tears to drain). structured ophthalmic red eye history. Symptoms such as redness, dryness, Key Pharmacy Counselling Point - The most discomfort and tearing are signs that are • Presenting complaint Reason for visit common cause of watery eyes is dry eye which common to many ocular conditions. Giving the is the opposite of what most patients believe. correct advice depends on the pharmacist and • History of presenting complaint Patients may need counselling on how a dry pharmacy staff being able to determine the eye stimulates the eye to produce excess tears. TASTER Questioning Technique most likely condition(s) which involves asking the right questions. Careful history taking 15. UVEITIS T Time course (Onset): acute or chronic and an awareness of signs and symptoms (sudden, hours, days, weeks), constant or that are triggers for referral can ensure The uvea is made up of the iris, the ciliary body intermittent? pharmacists safely and effectively manage and the choroid. There are different types of red eye ophthalmic conditions. It is important uveitis and treatment depends on the layer A Associated symptoms: location of red eye to distinguish when to recommend OTC of the uvea affected. The most common form (unilateral, bilateral, sectorial), reduced medication and when a referral may of uveitis is iritis (inflammation of the iris). It vision, blurry vision, gritty sensation, diplopia be necessary. is associated with inflammatory systemic (double vision), pain, foreign body sensation, conditions such as arthritis and Crohn’s itch, discharge, watering eyes, headache, disease but can also be idiopathic. All patients photophobia.