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Basic Ophthalmologic Assessment for Community Pharmacists

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Presentation on theme: "Basic Ophthalmologic Assessment for Community Pharmacists"— Presentation transcript:

1 Basic Ophthalmologic Assessment for Community Pharmacists
Evan Williams, PharmD, BCPS, BCACP Assistant Professor of Pharmacy Practice Husson University School of Pharmacy

2 Overview Conjunctivitis
Bacterial, Viral, Allergic The role of the pharmacist Things that can be confused with conjunctivitis What is an emergency When to refer to where Review administration of eye medications

3 Objectives Differentiate between serious and less serious causes of red eye Identify what symptomatology warrant referral to an eye care professional or an emergency department List important findings that would necessitate a referral to a higher level of care Describe proper eye drop/ointment application technique

4 Disclosure I have no actual or potential conflicts of interest in relation to this presentation

5 Basic Anatomy of the Eye – Orbit

6 Basic Anatomy of the Eye – Globe

7 Basic Anatomy of the Eye – Conjunctivae

8 Basic Anatomy of the Eye – Conjunctivae

9 Basic Anatomy of the Eye - Cornea
Very thin! Avascular but well supplied with nerves Apgar, D. Ophthalmology: Selected Topics. 2/2/10

10 Conjunctivitis Inflammation of the conjunctivae
Typically bacterial/viral or allergic May need to rule out other conditions If any doubt, patient should be referred

11 Conjunctivitis

12 Conjunctivitis - Hyperemia
Injection of vessels

13 Keratoconjunctivitis
More severe, intense conjunctival hyperemia Corneal involvement = keratitis

14 Chemosis Conjunctival edema

15 Red Eye Usual presentation of conjunctivitis
And many other eye problems There are many causes for red eye You need to be able to differentiate cases that can be managed in a community pharmacy setting from those that need referral Secondarily, you need to recognize the possibility of those serious disorders that need urgent or emergent ophthalmologic care

16 Evaluation of “Red Eye”
Basic 7 Location Quality Severity Timing Context Associated Symptoms Modifying Factors What do you think caused this?

17 Subjective Evaluation
How does the eye feel? How is your vision compared to before this started? When did this start? How often has this happened before? How long after surgery? How did this start? What else is wrong or different? Associated symptoms? What makes it better/worse?

18 Objective Evaluation General Other URI Manifestations Lids
Conjunctivae Cornea Objective foreign body sensation Photophobia Obvious trauma Hypopyon Hyphema

19 Less Serious Causes of Red Eye
Conjunctivitis Bacterial Allergic Viral Non-specific Lid Problems Hordeolum Chalazion Blepharitis Subconjunctivial Hemorrhage Dry Eye Syndromes Entropion Irritative Causes Pterygium Degenerative Causes Pigueculum Reactive Causes Phlyctenular keratoconjunctivitis (PKC) Apgar, D. Ophthalmology: Selected Topics. 2/2/10

20 Your Role as a Pharmacist
You can recommend an OTC product for initial management of some conditions For conditions that cannot be managed with an OTC product, you can direct the patient to the appropriate level of care in the appropriate timeframe You can recognize most conditions that need referral

21 Potentially Serious Causes of Red Eye
Any red eye in a contact lens wearer Even if it seems uncomplicated Corneal Abrasion/Ulcer Autoimmune Causes Scleritis Episcleritis Infectious Keratitis Infectious inflammation of the cornea Lacrimal System Disorders Iritis Periorbital Cellulitis Orbital Cellulitis Apgar, D. Ophthalmology: Selected Topics. 2/2/10

22 Emergency Causes of Red Eye
Acute Angle-Closure Glaucoma Penetrating Trauma To the globe or the orbit Endophthalmitis Infection within the posterior chamber Associated with trauma, including surgery Hypopyon Hyphema Apgar, D. Ophthalmology: Selected Topics. 2/2/10

23 Your Role as a Pharmacist
REFER ALL potentially serious or emergency causes of red eye You can differentiate between emergency problems that need to go the ED and those that can go immediately to the patient’s eye care professional Optometrist vs Ophthalmologist

24 Two Important Findings
Objective foreign body sensation Described as PAIN, not just a scratchy feeling Objective in that the patient cannot keep eye open for more than a few seconds Permanent squint If lights are dimmed to rule out photophobia, the eye STILL cannot be kept open Photophobia Extreme sensitivity to light Patients may wear sunglasses and avoid bright light Cannot tolerate exam light shone into eye However, in a darkened room, the eye can be held open Differential feature compared to ‘objective foreign body’ sensation REFER THESE PATIENTS REFER THESE PATIENTS

25 Additional Warning Symptoms
Any change in vision in the timeframe of the red eye symptoms that is different from the patient’s baseline Does not include obstructed vision due to discharge that can be cleared from the eye to restore normal vision Significant pain that can be localized to the eyeball (globe) itself

26 Bacterial Conjunctivitis
Characterized by purulent drainage at the corners of the eye and the border of the eyelid Eyelids crusted shut in the morning This is not a reliable differential feature Will continue purulent discharge throughout the day More discharge will appear within minutes of wiping it away Usually begins unilaterally but often becomes bilateral within a few days Lacks Pain, photophobia, visual changes (aside from discharge), corneal lesions, or limbal flush Highly contagious

27 Bacterial Conjunctivitis

28 Bacterial Conjunctivitis
Common organisms include S. pneumoniae, Haemophilus sp., M. catarrhalis in kids Add S. aureus in adults Hyperactue = hyperpurulent due to N. gonorrheae Can be vision threatening – needs emergent referral Apgar, D. Ophthalmology: Selected Topics. 2/2/10

29 Bacterial Conjunctivitis – GC

30 Bacterial Conjunctivitis
Bacterial conjunctivitis is self-limiting in most cases Topical antibiotics probably shorten the course of the infection if given before day 6 If treatment is deemed necessary Erythromycin ointment Can have therapeutic effect with “close” application Polymyxin/Trimethoprim drops or Bacitracin ointment Avoid fluoroquinolone drops due to resistance Avoid aminoglycosides due to toxicity

31 Viral Conjunctivitis Characterized by watery discharge and scratchy feeling Eyelids may be crusted shut in the morning Less commonly than with bacterial Often there are other viral URI manifestations Usually begins unilaterally but often becomes bilateral within a few days Lacks Pain, photophobia, visual changes (aside from discharge), corneal lesions, or limbal flush Highly contagious

32 Viral Conjunctivitis Commonly caused by adenovirus Self-limiting
Can also be caused by other “cold” viruses Rhinovirus, coronavirus, coxsackievirus, VZV Most potentially serious cause is HSV Know how to tell the difference Self-limiting 1-3 weeks Some patients will benefit from topical OTC products recommended for allergic conjunctivitis HSV is treated with antivirals We will not cover this Apgar, D. Ophthalmology: Selected Topics. 2/2/10

33 Viral Conjunctivitis Adenoviral

34 Viral Conjunctivitis

35 Viral Conjunctivitis - HSV
HSV Blepharoconjunctivitis

36 Viral Conjunctivitis - VZV

37 Allergic Conjunctivitis
Characterized by watery discharge and scratchy feeling Eyelids may be crusted shut in the morning Less commonly than with bacterial Often there are other allergic manifestations Usually initially bilateral Can be unilateral if due to eye medication applied only to one eye Lacks Pain, photophobia, visual changes (aside from discharge), corneal lesions, or limbal flush

38 Allergic Conjunctivitis

39 Allergic Conjunctivitis
Conjunctival follicles

40 Allergic Conjunctivitis
Some patients will benefit from OTC topical lubricants Multiple artificial tear products Can also use or add a decongestant (alone or + antihistamine) Oxymetazoline 0.025% soln Tetrahydrozoline 0.05% soln Also available with zinc sulfate Naphazoline 0.025% and 0.05% soln Ketotifen 0.05% soln Also has mast cell stabilizing properties Apgar, D. Ophthalmology: Selected Topics. 2/2/10

41 Other Selected Eye Problems
The following slides briefly describe things that can be confused with simple conjunctivitis Many need to be referred, although some can be treated initially with OTC products

42 Lid Problems Blepharitis Hordeolum Chalazion
Can be bacterial, viral, or allergic May occur alone or with conjunctivitis Hordeolum Acute infectious process of one of 3 glands in the eyelid Fast onset and painful Chalazion Chronic inflammation due to blockage of meibomian glands of eyelid Take a long time to form, non-painful Apgar, D. Ophthalmology: Selected Topics. 2/2/10

43 Staph Blepharitis

44 Allergic Blepharitis

45 Hordeolum

46 Chalazion

47 Subconjunctival Hemorrhage
Bleeding from conjunctival capillaries Usually asymptomatic Someone else points it out to patient or they look in a mirror Usually due to trauma Rubbing eyes Sneezing/Coughing Rarely associated with extreme BP Resolves spontaneously over several days Apgar, D. Ophthalmology: Selected Topics. 2/2/10

48 Subconjunctival Hemorrhage

49 Dry Eye Syndromes Chronic disorder
Hx will reveal chronic nature if acute exacerbation Often, patients will already be on a lubricant product and possibly ophthalmic cyclosporine Apgar, D. Ophthalmology: Selected Topics. 2/2/10

50 Entropion

51 Irritative Conjunctivitis
Pterygium Benign, fibrous, wedge shaped growth of tissue that may grow into the cornea Common in people from hot, dry climates Requires surgical removal Apgar, D. Ophthalmology: Selected Topics. 2/2/10 https://www.eyecancer.com/content/images/cms/pterygium.jpg

52 Degenerative Conjunctivitis
Pingueculae Common, benign, usually asymptomatic yellow or white deposit on the conjunctiva near the medial or lateral limbus Can become inflamed short term (pingueculitis) Apgar, D. Ophthalmology: Selected Topics. 2/2/10

53 Contact Lens Wearers At risk for corneal damage
Corneal abrasions/ulcers Infectious Keratitis Usually bacterial Often Pseudomonal Fluoroquinolone use reserved for such patients This is why we refer virtually all “red eye” problems in these patients Apgar, D. Ophthalmology: Selected Topics. 2/2/10

54 Corneal Ulcer

55 Keratitis Red eye associated with limbal (or ciliary) flush
Increased injection around limbus A lesion may be visible in the cornea Discharge may be visible if infectious Purulent if bacterial Hypopyon may be present Watery if viral Symptoms include photophobia and objective foreign body sensation Apgar, D. Ophthalmology: Selected Topics. 2/2/10

56 Bacterial Keratitis

57 Viral Keratitis

58 Viral Keratitis

59 Acute Angle-Closure Glaucoma
Presents with a sudden onset of severe unilateral frontal and/or temporal headache Often associated with pupil fixed in mid dilation, red eye, “steamy” cornea, limbal flush, and decreased vision No discharge No objective foreign body sensation Medical Emergency Apgar, D. Ophthalmology: Selected Topics. 2/2/10

60 Acute Angle-Closure Glaucoma

61 Hyphema Blood in the anterior chamber – REFER

62 Administration of Eye Drops
Proper dose of all eye drops is ONE drop More than that spills out If you need to administer more, wait 5-10 minutes in between subsequent doses Try to avoid contact between the tip of the dropper and anything else Nasolacrimal Occlusion Increases contact with eye structures Probably improves absorption and efficacy Can minimize systemic absorption Recommend routinely for 2-3 minutes Apgar, D. Ophthalmology: Selected Topics. 2/2/10

63 Two Handed Technique

64 Administration of Eye Ointment
Optimal method Apply a ribbon/strip of ointment to the inside lower eyelid Warn patient that vision will be blurry for a few minutes after application Kids or “difficult” adults Any successful method Apply ribbon to lashes of upper eyelid and close eye Same thing with closed eye Body temperature usually results in at least some medication becoming liquefied so that some gets in contact with conjunctivae Apgar, D. Ophthalmology: Selected Topics. 2/2/10

65 Summary Recognize what to refer: All contact lens wearers
Chronic problem (Entropion, dry eye) Hx recent eye surgery Localized conjunctival lesion (pterygium, pigueculum) Hx of trauma to the eye or soft tissue around the eye Any question of corneal abnormality (presence of limbal flush, abrasion, ulcer, infxn) Hypopyon (pus in anterior chamber) Hyphema (bleeding in anterior chamber) Prominent HA (acute angle – closure glaucoma) Photophobia Objective foreign body sensation

66 Summary Recognize the red flags: These all require REFERRAL!
Objective foreign body sensation Photophobia Change in vision Eyeball Pain These all require REFERRAL!

67 Summary Bacterial Conjunctivitis Viral Conjunctivitis
Most are self–limited and not sight threatening Kids may not be allowed back to school – refer? Highly contagious – refer? Refer hyperpurulent (GC) and newborn conjunctivitis Viral Conjunctivitis Most are self-limited and not sight threatening OTC topical lubricants, vasoconstrictors, antihistamines Refer any suspicion of HSV or VZV Allergic Conjunctivitis Most are recurrent If inadequate response to OTC tx, refer for Rx tx Apgar, D. Ophthalmology: Selected Topics. 2/2/10Vire

68 Post-Test Questions A patient presents to your counter with what she believes is pink eye. She states that she has a little bit of crusted discharge in the mornings and her eyes feel scratchy and produce a lot of watery discharge throughout the day. Her eyes appear puffy and red, with clear, watery discharge and significant chemosis. Her right eye is more injected than the left. Upon further questioning, she states that she and her husband got a pet cat 3 days ago. Which of the following is the best treatment option for this patient? Emergent referral to the hospital Urgent referral to her eye care professional Cyclosporine Ophthalmic Emulsion Oxymetazoline 0.025% soln eye drops and remove offending agent Erythromycin Ophthalmic Ointment and remove offending agent

69 Post-Test Questions Which of the following are warning signs that require EMERGENT referral to the ED? Objective Foreign Body Sensation Any Red Eye in Contact Lens Wearers Photophobia I only II only I and II only I and III only I, II, and III

70 Post-Test Questions A patient presents to your counter to ask about a small spot on her right eye. It is very small, off-white to yellowish in color, and is at about 7 o’ clock on her iris. She reports no pain, foreign body sensation, photophobia, or changes in vision. Her eye appears normal otherwise with no redness. She states she noticed the spot 2 days ago when she was removing her contact lenses. She wants to know if there is an OTC product she should be taking. Which of the following is the likely cause of this spot and the correct method of dealing with this issue? HSV Conjunctivitis – use an OTC lubricating eye drop and seek further tx if it doesn’t resolve within 2 days Corneal Lesion – Refer to her eye care professional as soon as possible Hypopyon – Refer emergently to the ED Hordeolum – suggest an OTC antihistamine/lubricating combo product and refer to her eye care professional as soon as possible Corneal Lesion – Refer emergently to the ED

71 Questions Thank you!


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