CPD: MANAGEMENT OF EYE CONDITIONS

Continuing Professional Development CPD CPD

This module is suitable for use by community pharmacists as part of their Continuing Professional Development. After reading this module, in the magazine or online, complete the post-test on our website at www.pharmacynewsireland.com and include in your personal CPD ePorfolio.

AUTHOR BIO: Jacqui Murray is a pharmacist with experience in both hospital and community settings. She studied with the IPU to qualify as a pharmacy technician, where soon after made the transition to studying pharmacy in UCC. Since graduating in 2017, she has continued to work in a community setting, gaining valuable experience as both a support and relief pharmacist. Writing for a health publication such as IPN, is a new venture, one that has allowed her to combine her interest in both research and pharmacy.

Management and Treatment of Eye Conditions

60 Second Summary

For both adults and children, the pharmacy is often the first point of contact in seeking advice on new or chronic eye symptoms. Serious eye conditions such as age-related macular degeneration (AMD) is the leading cause of sight loss in Ireland in people over the age of 50. Recent research carried out on people with AMD in this age bracket and living in the Republic of Ireland, showed an estimated overall prevalence of over 7%. Dry AMD, the more prevalent of the two, is caused by the slow progressive atrophy of the retinal pigment epithelium (RPE), a monolayer of cells located beneath the photoreceptor cells in the retina whose function is to nourish these cells and to remove waste products. Conjunctivitis is the inflammation or infection of the conjunctiva, a thin translucent membrane that covers the anterior surface of the sclera and the inner surfaces of the eyelids. Allergic conjunctivitis can be seasonal or perennial and occurs when the eyes come into contact with an allergen such as pollen, animal dander or dust mites.

Infective conjunctivitis, subdivided into bacterial and viral, usually affects both eyes but can begin in one with symptoms developing in the second eye within 24-48 hours.

Dry eye syndrome is one of the most common ocular conditions worldwide with prevalence rates as high as 57.5%. A survey carried out by the PSI, found that 58% of the population surveyed attended the pharmacy frequently, 47% sought advice first from a pharmacist on a medicine and a further 25% would seek general healthcare advice from their pharmacist.

Eye Conditions

The pharmacy is often the first point of contact in seeking advice on new or chronic eye symptoms in both adults and children. Many of the symptoms seen in allergic conjunctivitis or dry eye for example are treatable with over the counter products but recognising when to refer for further examination is important.

Age-Related Macular Degeneration (AMD)

Serious eye disease such as AMD, is the leading cause of sight loss in Ireland in people over the age of 50. Recent research carried out on people with AMD in this age bracket and living in the Republic of Ireland, showed an estimated overall prevalence of over 7%. 1

The macula, which is located at the central retina and appears as a yellow pigmented spot, is responsible for central and spatial vision providing the ability to see fine detail such as reading, writing and facial recognition. 2 AMD affects central vision over time but typically peripheral vision remains intact and can be classified as either early or late with the latter further subdivided into dry or wet. In early AMD, eye sight is not affected and signs of retinal hence the importance of having regular eye tests, putting pharmacies in a prime position to counsel patients on keeping up regular visits to an optometrist. 3

Dry AMD, the more prevalent of the two, is caused by the slow progressive atrophy of the retinal pigment epithelium (RPE), a monolayer of cells located beneath the photoreceptor cells in the retina whose function is to nourish these cells and to remove waste products. In dry AMD, deposits made up of lipids and proteins, known as drusens build up leading to deterioration of the photoreceptors necessary for vision. Wet AMD can develop rapidly, resulting in severe loss of vision but is less common. It is caused by the formation of abnormal new blood vessels (neovascularisation), which can leak blood and fluids resulting in retinal scar tissue, Reflection - Is this area relevant to my practice? What is your existing knowledge of the subject area? Can you identify any knowledge gaps in the topic area?

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destruction of the photoreceptors and detachment of the RPE. 4, 2, 3

Increasing age, hypertension, a poor diet and lack of exercise are all risk factors in developing AMD. Smoking has shown to be the most consistent modifiable risk factor in developing AMD and pharmacists are in a good position to provide counselling to patients on smoking cessation therapies and educational resources to enable patients to quit. Studies have shown that people who have a family history (a parent or sibling) of AMD can place them at a greater risk of developing AMD and therefore should have their eyes checked regularly. However, it does not mean AMD will definitely occur as various environmental factors as well as genetic factors are implicated in its development. 5

In the early stages of AMD, patients may experience only minimal blurring of their central vision. A blind spot can develop where progress tends to be slow in dry AMD but more rapid in wet AMD. Other symptoms include distortion of vision, where straight lines appear wavy or crooked, difficulty in recognising faces, requiring a brighter light to read, difficulty in reading and driving, reduced contrast and changes in the way colour is seen. It is also possible for dry AMD to progress into wet AMD and any sudden changes in vision patients should seek immediate medical assistance. 3

Currently there is no treatment for dry AMD. As progression tends to be slow, improving a patient’s quality of life through the use of low vision aids is important to help alleviate concerns of potential loss of independence e.g. hand-held magnifiers and lamp magnifiers to name but a few. Patients may find it helpful to source these through low vision clinics or their optician, where the most appropriate aids can be recommended.

Supplementation with ocular nutrients, discussed in greater detail below, has shown to be effective in AMD at improving vision and this is something their doctor will most likely include in their management plan. Antiangiogenic drugs are used to slow progression of wet AMD. The VEGF (Vascular Endothelial Growth Factor) inhibitors, ranibizumab and aflibercept, prevent VEGF-A (and other growth factors in the case of aflibercept) from binding to their receptors thus preventing endothelial cell proliferation, neovascularisation and vascular leakage, all of which are implicated in wet AMD. 6

Both medications are delivered via intravitreal injection at monthly intervals. Ranibizumab is continued until there is maximal improvement in visual acuity and no changes in other signs

or symptoms of the disease. After three consecutive months aflibercept is spaced out to bimonthly due to its greater half-life. 7, 8 Several clinical trials have shown that ranibizumab can improve visual acuity in over 90% of patients, however since there is currently no prevention for the development of AMD and these treatments are used in management of wet AMD, early detection is key as well making changes to known modifiable risk factors such as smoking. The macular pigment (MP) which is concentrated in the foveal region of the eye is composed of the carotenoids, lutein (L), zeaxanthin (Z) and meso-zeaxanthin (MZ). The MP functions to absorb blue light, act as an antioxidant and it has been suggested that low MP density at the centre of the macula could be a risk factor in developing AMD which may be due to a decrease in its functional ability. 9

L and Z must be obtained from the diet and are commonly found in dark green leafy vegetables and orange or yellow fruits and vegetables whereas, MZ which is the dominant macular carotenoid, is primarily formed through isomerisation of lutein. 10 MP profiles or concentrations can vary between individuals and a study carried out in healthy individuals showed that atypical profiles were more common in patients with established risk factors for AMD (smoking and increased age). 9

Age-related eye disease studies (AREDS) carried out on supplementation with L and Z in combination with antioxidants showed an increased benefit in reducing the risk of progression to advanced AMD. Interestingly upon addition of omega 3 fatty acids, neither harmful nor beneficial effects were found, however, other research shows a potential benefit especially if a patient’s diet is low in fish intake and supplementation products often contain omega 3 fatty acids. 11 Supplement comparison studies have consistently shown that when MZ was added, a superior and more efficacious response was achieved than in the L and Z groups alone. A large and recent RCT found that participants who received all three carotenoids experienced greater clinical improvement in their vision upon trial completion when compared to the group not receiving MZ. 12

Conjunctivitis

Conjunctivitis is the inflammation or infection of the conjunctiva, a thin translucent membrane that covers the anterior surface of the sclera and the inner surfaces of the eyelids. It acts as a physical barrier to prevent microbes from entering and works to lubricate the eye by secreting mucin from its goblet cells which form a part of the tear film. Conjunctivitis, depending on presenting symptoms can be either allergic or infective. 13, 14

Allergic Conjunctivitis (AC)

Allergic conjunctivitis can be seasonal or perennial and occurs when the eyes come into contact with an allergen such as pollen, animal dander or dust mites. Symptoms occur in both eyes and include generalised redness which extends to the inner surface of the eyelids. Other symptoms of AC include sore, itchy, watery eyes and swelling of the eyelids. Patients may experience associated symptoms of allergic rhinitis such as a runny or blocked nose and sneezing. 15

Treatment of AC typically involves the use of OTC eyedrops that contain either an antihistamine or a mast cell stabiliser. Antazoline, an antihistamine is found in combination with xylometazoline, a sympathomimetic that constricts the blood vessels to reduce redness. It is recommended for rapid relief of the initial symptoms of the allergic reaction but not intended for use

longer than seven days due to the risk of rebound hyperemia 16 and is licensed for use in adults and children over 12 years. Use is contraindicated in patients with glaucoma and in patients receiving treatment with monoamine oxidase inhibitors or within 14 days of stopping such treatment. 17

Sodium cromoglicate, a mast cell stabiliser can be use prophylactically while exposed to the allergen. It does not provide rapid relief from the symptoms but can be effective at controlling symptoms over a longer period of time and is suitable for use in adults and children although data is limited to the recommended minimum age of use. Patients should avoid rubbing the eyes as this can cause mast cell degranulation and worsening of the symptoms. Other counselling points include; the use of wrap-around sunglasses in reducing exposure to the allergen and using a cool compress or lubricating eye drops to help to ease symptoms. 18, 19

Infective Conjunctivitis (IC)

Infective conjunctivitis, subdivided into bacterial and viral, usually affects both eyes but can begin in one with symptoms developing in the second eye within 24-48 hours. Causative bacteria include, S.aureus, S. pnuemoniae and H.influenzae and adenovirus accounts for a high percentage of cases of viral conjunctivitis. 19

Presenting symptoms can help to distinguish between the two but often times this can be difficult to do. A white-yellow mucopurulent discharge is typically present in bacterial conjunctivitis whereas with viral cases, the discharge tends to be watery. A gritty, sore feeling can be a symptom of both and lubricant eye drops can be used to help ease the discomfort. Sometimes in cases of viral conjunctivitis there may be associated cold-like symptoms such as a sore throat, temperature and a cough. Both types of infection are typically self-limiting but topical antibiotics have been shown to reduce duration of infection in bacterial conjunctivitis and can be prescribed if symptoms are not resolving or worsening. 20, 21

At home management is important in easing symptoms and preventing further infection. Patient’s should be advised to:

wash their hands thoroughly after any contact with the eyes use their own face cloths/towels

avoid touching the eye with any eye drop preparation as this can contaminate the product and contribute to further spread of the infection.

gently cleanse the eye with cotton wool soaked in cooled boiled water to remove sticky discharge. remove contact lenses until all signs and symptoms of infection have gone and for at least 24 hours after a course of topical antibiotics. Broad spectrum topical antibiotics typically prescribed in bacterial conjunctivitis include chloramphenicol drops or ointment and fusidic acid drops. Transient blurring of vision can occur after use of ointments and in some cases with drops and patients should be advised not to drive just after administration. They can also cause some local burning or a stinging sensation. Topical antibiotics should be continued for 48 hours after the eye appears normal. A patient should be referred to their doctor if their symptoms are not improving or they experience any of the following: true pain in the eye as opposed to a gritty feeling Macular Degeneration redness localised around the pupil

photophobia and disturbed vision such as haloes around objects

loss of/reduced vision. 19

In situations where a person presents with a child under 28 days old with symptoms of infective conjunctivitis such as a sticky discharge and redness, these patients should be referred to their GP to rule out the possibility of a more serious infection. 22

Dry Eye

Dry eye syndrome is one of the most common ocular conditions worldwide with prevalence rates as high as 57.5%. Symptoms of dry eyes can develop when the tear film, which is composed of three main components or layers, experiences a loss of homeostasis due to a number of factors. Dry eye syndrome can be classified as aqueous deficient (a decrease in tear production) or evaporative (when tears evaporate quickly) but patients can experience both.

Numerous factors are implicated in dry eye syndrome:

use of contact lenses or certain types of lenses

computer or device use where blinking may be less frequent which can result in evaporation of tears

a smoky or air conditioned environment

use of certain medications e.g. anticholinergics and isotretinoin

hormonal changes

Symptoms of dry eye include: a stinging or burning feeling a gritty sensation like there is something in the eye excessive watering and redness. Symptoms for referral include; associated dryness of mouth and other mucous membranes and outward turning of the l ower eyelid. Preservatives in eyedrops can sometimes cause irritation and worsen the symptoms of dry eye, therefore single dose unit preparations that are preservative free may be a more suitable alternative, especially if frequent dosing is required e.g. greater than 6 times per day. Prescribing guidelines indicate that in cases with mild to moderate symptoms requiring treatment of less than 6 times per day, patients can begin with products containing hypromellose, PVA or carbomer depending on preference. Due to the viscosity of carbomer, it is recommended to use this product after administration of any other eyedrops the patient may be using. 23

In situations where symptoms are severe, products that contain sodium hyaluronate which has a longer residency time in the eye may be a better choice. These products are also preservative free making them more suitable for frequent dosing if required or if the patient has an intolerance/allergy to the preservatives. Lubricating eye ointments are useful for use at bedtime due to their longer retention time and propensity to blur vision. 24

Non-pharmacological treatments include good eye hygiene, taking regular breaks from computer work and blinking the eyes more frequently. Some patients may also have blepharitis, an inflammation of the eyelid margins, where in addition to the symptoms of dry eye they can also experience itching and burning of the lid margins with skin flakes around the lashes. A survey carried out by the PSI, found that 58% of the population surveyed attended the pharmacy frequently, 47% sought advice first from a pharmacist on a medicine and a further 25% would seek general healthcare advice from their pharmacist. 25

These figures illustrate the important role pharmacy plays in helping patients with minor ailments such as some of the eye conditions listed above but somewhat more importantly our knowledge of serious eye conditions can influence a patient to seek further investigation if perhaps that was not their initial intention, thus allowing patients to receive timely and effective treatments.

References

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