1/25/2019

I spy with my little eye Objectives • Describe the normal structure and functions of the eye, and identify structures which help protect the eye • Identify the principles of providing basic eye care which should be taught to all patients with eye disorders • Name five diagnostic tools commonly used to diagnose eye diseases • Determine and identify common Common ophthalmic disorders ophthalmic conditions in community pharmacy AND NOVEL TREATMENTS • Identify novel treatments available for common ophthalmic conditions

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Anatomy of the Functions of the human eye

• https://www.youtube.com/watc h?v=BEtdh-G8wFE

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What is the most complex Structures that help organ in the body? protect the eye

• The human eye functions much like a digital camera • The bony structures of the (the bony cavity that – Light enters the eye through the , the clear front surface of the contains the eyeball and its muscles, nerves, and blood eye, which acts like a camera vessels, as well as the structures that produce and drain • The works much like the diaphragm of a camera--controlling how much light reaches the back of the eye tears) protrude beyond the surface of the eye – It does this by automatically adjusting the size of the • The are short, tough hairs that grow from the • The eye’s crystalline lens sits just behind the pupil and acts like autofocus edge of the camera lens, focusing on close and approaching objects – The upper lashes are longer than the lower lashes • Focused by the cornea and the crystalline lens, the light makes its way to and turn upward the – The lower lashes turn downward – This is the light-sensitive lining in the back of the eye. Think of the retina • Eyelashes keep insects and foreign particles as the electronic image sensor of a digital camera. Its job is to convert away from the eye by acting as a physical barrier images into electronic signals and send them to the and by causing the person to blink reflexively at • The optic nerve then transmits these signals to the visual cortex of the brain sensation(s) which creates our sense of sight

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1 1/25/2019

Structures that help protect the eye Tears

• The upper and lower reflexively close quickly (blink) to form a mechanical barrier that protects the eye from foreign objects, wind, dust, insects, and very bright light • Pharmacists Beware: • On the moist back surface of the eyelid, the loops around to cover the front surface of the eyeball, right up to the edge – https://www.youtube.com/watch?v=7wMqzF6_q9s of the cornea • Tears consist of a salty fluid that continuously bathes the surface of the eye to keep it moist and transfers oxygen and nutrients to the cornea, which lacks the blood vessels that supply these substances to other tissues • Tears also trap and sweep away small particles that enter the eye. Moreover, tears are rich in antibodies that help prevent infection. The eyelids and tears protect the eye while allowing clear access to light rays entering the eye.

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Eye Hygiene, National Basic Eye Hygiene Eye Institute

• Have a comprehensive dilated eye exam, this is the only way to detect diseases in Good lighting (avoid dark and bright lights) the early stages • Know your family’s eye health history Rest eyes on distant object • Eat right to protect your sight, diets rich in fruits/vegetables, particularly dark leafy greens. Research has shown there are eye health benefits from eating fish high in Don’t rub eyes omega-3 fatty acids, such as salmon, tuna, and halibut • Maintain a healthy weight, being overweight or obese increases your risk of Report: eye , , vision changes, tearing developing diabetes and other systemic conditions • Wear protective eyewear Do NOT share eye make up • Quit smoking or never start. Research has linked smoking to an increased risk of developing age-related , , and optic nerve damage, all Clean eye from inner to outer canthus of which can lead to blindness • Give your eyes a rest. Try the 20-20-20 rule: Every 20 minutes, look away about 20 Vitamins A & B are important feet in front of you for 20 seconds • Clean your hands and your contact lenses properly, wash your hands and Wear contacts appropriately disinfect contact lenses as instructed and replace them as appropriate • Practice workplace eye safety 9 10

Eye disorder statistics

General Practice Assessment and Evaluation

• Infective 44% • Foreign body 29% • 15% • Corneal abrasion 15% Expect 2 - 5 % of all general • Meibomian Cyst 8% • Eye injury/trauma 15% • 5% • Infective Conjunctivitis 9% consultations to be eye related • Cataract 4.8% • Allergic Conjunctivitis 3% • Abrasion/ Foreign body 3% • Blepharitis 3% • 2.3% • Other conditions 26% • Stye 2% • Macular disease 1.1% • 1.1% • No abnormality 1.8% • Other conditions 11.9%

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2 1/25/2019

Quick Counseling/Best Practices Pharmacy Scenarios

• Always wash hands prior to using eye drops/ointment • What do you do when you see a patient with new onset Loss of Vision in one eye this morning? • Contact lenses should be removed prior to using – * referral, Johns Hopkins University in Baltimore medication, unless designed specifically for use with researchers found that micro vascular changes – contact lenses trouble in the smaller vessels of the eyes or kidneys – • After using eye drops close eyes gently for 3 minutes appeared to be linked to the presence of atrial and tilt head forward as looking at the ground (gravity fibrillation will help draw the drop onto the cornea & avoid tight • 9 out of every 1000 people with some micro vascular squeezing of the eyelid and blinking) disease developed A Fib • After placing ointment in lower conjunctival sac, close eyes for 1-2 minutes (vision may be blurry-temporary) • It increased to more than 24 per 1000 people who • If multiple drops are being used, wait at least 5 minutes had vessel damage in both the eyes and kidneys went onto develop afib (the connection is still unclear) before instilling the next drop • If using both drops and ointment, place drops 10 minutes prior to ointment

https://www.health24.com/Medical/Eye/News/Eyes-may-indicate-atrial-fibrillation-risk-20131119 13 14

Pharmacy Scenarios Pharmacy Scenarios

• an elderly woman presents with & n/v? Your differential is Gastroenteritis (stomach flu) but • A patient comes to the pharmacy complaining about seeing , haloes, and flashes of light. what could It be more? is your recommendation? – * referral, there are 6 serious illnesses that could cause blurred vision according to the utilization review accredidation committee of Specialty – * Referral needed, this could be an early sign of retinal Tear pharmacies or detachment or something even more severe. – Diabetes: results in damaged blood vessels in the retina. Can cause blurred and/or spotty vision – Seek urgent advice about floaters and flashes if they are very marked or sudden and can lead to blindness or macular degeneration in onset, associated with pain, or changes in your vision, of if both floaters and flashes are occurring together – Stroke: impedes blood flow in the brain and can cause blurry/double/loss of vision, dizziness, drooping facial muscles, confusion, balance problems, difficulty speaking, loss of feeling in arm – Seek advice if you develop persistent haloes – Multiple Sclerosis: causes inflammation along the optic nerve that connects your eyes to the – Seek advice for any new symptoms, even if less severe than this, if you have brain, which can lead to blurry sight, loss of color vision, and pain previously lost the sight in one of your eyes, so that your new symptoms affect – Brain tumor: pressures build inside the skull & can cause blurred vision, drowsiness, headaches, your only functioning eye. seizures, nausea, and vomiting – Migraine headaches: can cause blurred vision, sensitivity to light, spots can occur before and during migraine episodes – Glaucoma: puts an unhealthy amount of pressure on the eyes, and is known as a silent disease. The Glaucoma Research Foundation recommends that you have your eyes checked once every two to four years when under 40 years of age; every three to five years from age 40 to

54; at least every two years after age 55; and every year after age 65! Flashes, Floaters and Haloes Authored by Dr Mary Lowth, Reviewed by Dr Adrian Bonsall | Last edited 31 Jul 2018 | Certified by The Information Standard

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Real Patient Scenarios Diagnostic Tools • A patient is asking how often her daughter should get an eye exam? – The correct answer is: one to two years. • Snellen Chart • A patient asked me what increases a child's chances for having eye problems, her • Ophthalmoscope daughter is 4 yrs old and she is worried? • Fluorescein – The correct answer: Premature birth, crossed eyes, a family hx of , etc. • A patient in the eye care aisle asked, what is the reason for getting my eyes dilated at • Pen-torch with cobalt filter the eye doctor aside from the extra charge? • Pin hole – The correct answer is: to allow for a better view of the interior of your eyes. • An indication of was written in the sig. – The correct answer is: this is the technical term for crossed/turned eyes. • If you pass a vision screening, a comprehensive eye exam is unnecessary. – The correct answer is: false. Screenings can identify people who are at risk for vision problems. Screenings can miss serious vision or eye health problems. • People over age 60 should have their eyes examined at least: – The correct answer is: every year. As you get older, risk for eye disease increases • My son has a learning disorder and not doing well in school, should I get him tested for ADHD, etc? – The correct answer is: children who have trouble seeing or interpreting what they see often have trouble with their schoolwork. It might work getting an eye exam to rule this out first. 17 18

3 1/25/2019

VISION SAMPLES READY FOR SOME EYE SCENARIOS ?

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This 42 yr old patient presents with a 2 day History of gritty, red left eye which has become sticky over the last 24 hrs. His right eye doesn’t feel right today as well. His vision is normal.

SCENARIO 1

• What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) D) Stye E) Viral Conjunctivitis

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Allergic Conjunctivitis Viral Conjunctivits

Perennial conjunctivitis Vernal conjunctivitis

Follicular changes Hemorrhagic changes Atopic conjunctivitis Giant papillary conjunctivitis

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How would you treat What are the clinical features? this patient?

What do we see in pink eye? • Use hand sanitizer and/or wash hands thoroughly after touching Similar Conditions eyes/nasal secretions • Contagious acute infection • Allergic, bacterial, or viral • Avoid touching the noninfected eye after touching the infected eye • May accompany the common cold conjunctivitis • Avoid sharing towels or pillows or other viral infections (like • Blepharoconjunctivitis is the • Avoid swimming in pools chickenpox, measles, etc.) dual combination of • Usually caused by adenovirus conjunctivitis with blepharitis • Eyes should be kept free of discharge and should NOT be patched • Symptoms (inflammation of the eyelids) • Small children with conjunctivitis should be kept home from school – Irritation • is the • Viral conjunctivitis lasts 1 wk in mild cases to up to 3 wks in severe – Photophobia combination of conjunctivitis cases – Watery discharge (purulent and (corneal • Use cool compresses for symptomatic relief discharge may indicate inflammation) bacterial conjunctivitis) • In severe cases, may benefit from topical corticosteroids (eg, 1% prednisolone acetate qid) • Oral corticosteroids may be used,, but must be ruled out first (by fluorescein staining and slit-lamp examination)

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This 19 year old student is complaining of irritation of the eye lids. It has become much worse recently while studying for exams

SCENARIO 2

• What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

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What are the clinical features? How would you treat this condition?

What do we see? Similar Conditions • Non-pharmacologic treatment: – Warm compress 15-20 minutes 2-4 times daily • Swollen eyelids • Dry eye – Eyelid massage to clean our oil accumulated in eye • Greasy eyelids • Conjunctivitis glands • Crusted eyelashes (pink eye) – Eyelid scrub from kit or make at home with a few drops of baby shampoo and warm water with cotton • Flaking of the skin pad or gauze around the eyes – Use anti-dandruff shampoo for scalp • Loss of eyelashes • Pharmacologic treatment: – Artificial tears solution – Lubricating eye ointment

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5 1/25/2019

This 21 year old patient presented to his pharmacist with a red painful swelling over his eye lid.

scenario 3

• What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

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What are the clinical features? How would you treat this condition?

• The first thing you should do is cleanse your eyelids. You can use What did we see? Similar Conditions diluted tear-free baby shampoo on a cotton ball, washcloth, or • The first signs are pain, • (kah-LAY-zee-on) is an makeup remover pad. Then rinse your eyelids with warm water and redness, swelling and enlarged, blocked oil gland in the eyelid gently pat them dry. tenderness – Mimics a stye for the first few • Also, be sure to wash your hands before and after touching the stye • Styes typically don't cause days, then turns into a painless • Stop wearing eye makeup/contacts temporarily & discard old hard, round bump later on vision problems makeup or applicators that could be contaminated • Milia or "milk spots" are tiny white • Styes are caused by cysts appearing on the outer skin layer • You can encourage a stye to heal faster by applying warm staphylococcal bacteria (epidermis) of the eyelid & around the compresses for 10 to 15 minutes, three or four times a day • Styes ARE contagious eyes/nose – May use teabags – Dead skin cells don't slough off • The goal of this therapy is to bring the stye to a head, but do NOT • Most styes heal on their own normally and are trapped at the • Never "pop" a stye base of a sweat gland or hair try to pop a stye follicle, forming a raised "pinhead" • Ibuprofen or acetaminophen may be helpful is pain is associated • Other eye problems can bump that looks similar to a accompany styes whitehead

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A 31-year-old male patient gives history of acute painful vesicular eruptions on the right side of his forehead.

Scenario 4

• What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

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What are the clinical features? How would you treat this condition?

What do we see? Similar Conditions • Double check dosing on facts.. • Cornea is hazy • Herpes Simplex – Acyclovir 800mg FID x 7 days • Pupil is dilated Keratitis – Valacyclovir 1000mg TID x 7 days • Glaucoma • Keratic – Famciclovir 500mg TID x 7 days precipitates on • Uveitis endothelium – Prednisolone drops??? • In conjunction with – Blephritis – Conjunctivitis –

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Scenario 5

• What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

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What are the clinical features?

What do we see? Similar Conditions • Separates retinal cells from the • Diabetic , blood vessels in layer of blood vessels that the back of your eye can deteriorate provides oxygen and and leak fluid & causes the retina to nourishment swell, which may blur or distort your vision • Onset includes • stays lying on – Sudden appearance of many top of the retina & pulls up on the floaters retina, which distorts your vision – Flashes of light in one or both eyes (photopsia) • Macular degeneration, center of your – Blurred vision retina begins to deteriorate. This causes symptoms such as blurred – Gradually reduced side (peripheral) vision central vision or a blind spot – A curtain-like shadow over your • pigmentosa, is a visual field degenerative disease that affects the retina

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How would you treat Novel Treatments this condition?

• Surgery is almost always used • Tecnis Symfony, new lens placed during cataract • Injecting air or gas into your eye, injects a bubble of air which surgery provides new surface for both near and far sided pushes the area of the retina containing the tear against the wall of vision difficulties the eye, stopping the flow of fluid into the space behind the retina • Fluid that had collected under the retina is absorbed by itself, and • Prokera clips a piece of amniotic membrane tissue in the retina can then adhere to the wall of your eye. You may need to between two rings made out of a clear, flexible material hold your head in a certain position for up to several days to keep to heal damaged surfaces the bubble in the proper position • Vector Thermal Pulsation technology, sends heat into • Indenting the surface of your eye. This procedure, called scleral the glands inside your lids. This combination of heat plus (SKLAIR-ul) buckling, involves the surgeon sewing (suturing) a piece of silicone material to the white of your eye () over the pressure, massages blockages and liquefies/clears the affected area obstructions causing symptoms • Draining and replacing the fluid in the eye or vitrectomy, the surgeon removes the vitreous along with any tissue that is tugging on the retina and air, gas or silicone oil is then injected into the vitreous space to help flatten the retina 43 44

Novel Treatments OTC Novel Treatments

• Argon laser, scars the retina (strengthens it) so it bonds • Soothe XP emollient lubricant eye drops, contains to the underlying tissue & prevents further retinal mineral oils, seals in moisture, and protects against detachment further irritation • iStent, shunt to relieve eye pressure instead of the customary eye drops to help with glaucoma • TrueTear is a handheld stimulator that comes with daily disposable tips that are inserted into the nose, device • Lumify (brimonidine) first approved by the FDA in a stimulates nerves in the nose to produce tears (reaction higher dose as a prescription glaucoma drug called is like what occurs when you cut into an onion) Alphagan, reduces eye redness by causing constriction • Serum tears, eye drops made from your own blood of the blood vessels in the eye, decreasing both blood serum improved symptoms of ocular surface disease flow and oxygen getting to the eye's tissue

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Lumify vs Visine RX Novel Treatments

• Once a person stops using drops containing Visine (tetrahydrozoline), the blood vessels are no longer constricted • As vessels open again, they can become even larger than • Lucentis before, as nutrients and oxygen return to the eye. The • Eylea enlarged arteries pump more blood to make up for lost time, which can cause increased redness in the eye (rebound • Xiidra effect) • Rhopressa • The key difference in the way the two drugs work is that Visine targets a receptor in the eye's arteries, while Lumify • Vyzulta acts on a receptor in the veins • Bausch and Lomb claims, Lumify doesn't interrupt oxygen flow to the eye, reducing the risk of a rebound effect, but does contain benzalkonium chloride preservatives

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Summary References

• https://www.uspharmacist.com/article/managing-common-eye-conditions-in-the-pharmacy • Eye disorders are commonly seen, and • Elton M. Ocular conditions from A to Z (ii). Pharm J. 2007;278:255-258. • Berdy GJ, Berdy SS. Ocular allergic disorders: disease entities and differential diagnoses. Curr pharmacists are at the front line. Allergy Asthma Rep. 2009;9:297-303. • https://nei.nih.gov/ • Novel ophthalmic treatments may be more • https://www.prescriber.co.uk/article/managing-common-eye-problems-general-practice/ • AAO Policy Statement: Recommendations for Herpes Zoster Vaccine for Patients 50 Years and relevant today than ever before. Older. 2016. Accessed April 16, 2017 • https://www.merckmanuals.com/professional/eye-disorders/conjunctival-and-scleral- disorders/viral-conjunctivitis • Pharmacists need to stay up to date to • https://www.allaboutvision.com/conditions/styes.htm make appropriate recommendations. • https://www.mayoclinic.org/diseases-conditions/retinal-diseases/symptoms-causes/syc-20355825

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“DON’T TURN A BLIND EYE”

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