College of PharmacyFourth year-Clinical Pharmacy. 2015-2016

"EYE DISORDERS"

Conjunctivitis:

- Redness of the eye is one of the common ophthalmic problems seen in the community pharmacy, and conjunctivitis (bacterial, viral, or allergic) may responsible for most cases of this problem.

- Conjunctivitis is an acute inflammation of the conjunctiva, the transparent surface covering the white of the eye and the inside of the eyelids.

- In the conjunctiva there are tiny blood vessels, which are normally almost invisible.

- The conjunctiva can become inflamed due to infection, allergy or irritation. - The blood vessels dilate and become more obvious, making the eye look red or

pink. - Pharmacist should differentiate types of conjunctivitis, and to differentially

diagnose the cases that required referral.

Patient assessment with red eye:

Duration:

- Minor eye problems are usually self-limiting and resolve within a few days.- Therefore, any ocular redness (apart from Subconjunctival hemorrhage, and

allergic conjunctivitis) that last more than 1 week requires referral.

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Discharge: - Most commonly seen in conjunctivitis. It can vary from watery to mucopurulent

depending on the form. (See the table 1 below).

Associated symptoms: - Rhinitis: sign and symptoms of an upper respiratory tract infection points

towards viral cause of conjunctivitis. (See the table 1 below)- Visual changes: Any loss of vision, photophobia, or haloes around the objects

---------------referral.- Pain/discomfort/itch: True pain------------------referral. Pain associated with

conjunctivitis is often described as a gritty/ foreign-body type pain. (see the table 1 below)

Location of redness:

- Redness localized near or around the pupil (colored part of the eye) ---------------

referral.

- Generalized redness or redness towards the corners of the eye is more indicative

of conjunctivitis. (See the table1 below)

Table: 1: symptoms help to distinguish the different type of conjunctivitis:

allergicViralbacterialbothBothBoth , but one eye

affected a day or so before the other

Eyes affected

wateryWateryPurulentDischarge

itchingGritty feelingGritty feelingPain

GeneralizedGeneralizedGeneralized and diffuseDistribution of redness

Rhinitis (may also have family history of allergy)

Cough and cold symptoms

None commonlyAssociated symptoms

Management:Bacterial conjunctivitis (Chloramphenicol eye drop)

- Chloramphenicol eye drop (but not ointment) becomes OTC in the UK in 2005. - Dosage: The dosage for the OTC product (for adults, and children aged two years

and over) is one drop every two hours for the first 48 hours, then one drop every four hours for a further three days. Patients can be advised that (Sleep need not be interrupted in order to administer eye drops).

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Treatment timescale:- If the symptoms do not improve within two days, the patient should be referred

Adverse effects: - Adverse effects are usually minor, such as a transient burning or stinging

sensation in the eye when applying drops. - Although some reports have suggested an association between the topical use of

Chloramphenicol in the eye and aplastic anemia, this is extremely rare with eye drops and several studies have failed to prove a link.

Contra-indication: - The OTC product should not be recommended to pregnant or breast feeding

women or for children under two years.- Guidance on OTC Chloramphenicol eye drops lists other circumstances in which

the patient should be referred. These include: Copious purulent discharge that reaccumulates after being wiped away. Patients with glaucoma or who have had eye surgery or laser treatment in the past

six months.

- Contact lens wearers are prone to eye infections. Those with conjunctivitis should be referred to doctor, in some cases; the practitioner may advise the patient to return to the pharmacy to purchase Chloramphenicol.

- Contact lenses should not be worn during an eye infection (because bacteria can survive on lenses and re-infect the eye) or if eye drops are used (soft lenses should not be worn for 24 hours after the course of chloramphenicol drops is complete).

Allergic conjunctivitis: 1-Nonpharmacological advices

- Applying cold compresses to the eye 3-4 times daily will reduce redness and itching.

- Other measure includes avoiding or reducing the exposure to the causative allergen (if possible).

2-pharmacologic-therapy - These include mast cell stabilizers (sodium cromoglicate), sympathomimetic e.g.

naphazoline, anti-histamine (antazoline, levocabastine), and decongestants - antihistamine (naphazoline - antazoline).

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Table 2: Summary of some eye drops used for allergic conjunctivitis.

dose OTC Use in children

Side effects

pregnancy Notes

Mast cell stabilizers (sodium cromoglicate)

1 drop four times daily

>12 years Local irritation, blurred vision,

Safe It is a prophylactic agent (given continuously when the person is exposed to allergen)

Sympathomimetic e.g.Naphazoline 1 drop four

times daily>12 years Local

irritation,

They should be limited to short-term use (to avoid rebound effect)

Anti-histamine

Antazoline

levocabastine

1 drop 2-3 times daily

1 drop 2-4 times daily

> 5years

> 12 years

Local irritation, bitter taste

Local irritation, blurred vision,

Safe

Avoid in glaucoma

If no improvement is seen within 3 days , treatment should be stopped (unlikely to be of benefit)

Decongestants - antihistamine(Naphazoline -

Antazoline)

1 drop 2-3 times daily

>5 years Local irritation, bitter taste

They should be limited to short-term use (to avoid rebound effect), Avoid in glaucoma

Viral conjunctivitis:- Viral conjunctivitis is usually self-limiting, with symptoms resolving over 1-3

weeks. 1-Nonpharmacological advicesThe condition is highly contagious therefore the patient should:1-Wash the hand after touching the eye.2-Avoid sharing towels or any other objects that might come in contact with infected eyes. 2-pharmacologic-therapy

- Viral conjunctivitis is treated by ophthalmic decongestant which had been discussed under allergic conjunctivitis.

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Eyelid Disorders:

- Blepheritis: is characterized by a dysfunction of lipid secretion which is caused either by increased production of sebum from the sebaceous glands located at the base of the eyelids or due to staphylococcal infection.

- Styes: are caused by bacterial infection and can either be external (outside the surface of the eyelid) or internal (in the inner surface of the eyelid).

- Occasionally, internal stye can evolve into Chalazion (a granulomatous inflammation that develops into a painless lump).

Signs and symptoms:- Typically blepheritis is bilateral with typical symptoms of red, scaly (excessive

crusty debris or skin flaks around the eyelash) thickened eyelid margins often with loss of the eyelashes.

- Itching and burning are the most common complaints.- While patient with stye will present with swollen upper or lower lid which will be

painful and sensitive to touch, whereas Chalazion present as a painless lump.

Patient assessment:Lid involvement:

- If the majority of the lid margin is inflamed and red then this suggests Blepheritis. Stye tends to show localized lid involvement.

- Patients with Inward -or -outward –turning lower eyelid ----------------------referred.

Other existing conditions:- Patients who suffer from Blepheritis often have coexisting hyper-proliferative

skin conditions such as psoriasis or dandruff.- Patients with swollen eyelid and associated feeling of being unwell -------------

referred.

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Duration:- A long standing history of sore eye is indicative of blepheritis which is a chronic

persisting condition (although it may be intermittent with period of remission).

Eye involvement:- Conjunctivitis is a common complication of blepheritis.

Medication:

- Many products (especially cosmetics) can results in itching and flaking skin that mimics blepheritis.

- If OTC treatment has failed --------------referred.

ManagementBlepheritis:

- The goals of treatment are to control the disorder with good lid hygiene and to provide symptomatic relief. Therefore careful lid hygiene is the mainstay of therapy.

- The patient can implement good lid hygiene by using hot compress for 15-20 minutes, 2-4 times daily.

- This step softens any crusted matter that is already present on the eyelids and easing its removal.

- The hot compresses also melt thickened skin oils inside the glands along the eyelid margins & this increases the flow of secretions. Since some of the glands may be blocked by excessive oils, and heat can open them.

- Each application of a compress should be followed by lid scrubs.- Lid scrubs: eye lid cleansers are commercially available. however, a self-made

lid cleanser for lid scrubs can be made from various brand of baby shampoo (e.g. Johnson) by mixing 1/4 tsp of shampoo in one cup of tepid warm water -----mixed to a bubbly froth------scrubbing the lid using a clean, cotton-tipped applicator using the following procedure:

1-wash hand thoroughly 2-apply few drops of the eyelid cleanser solution to a cotton-tipped applicator or gauze pad. 3-close one eye-----clean the upper eyelid and eyelash using side-to side strokes. 4-open the eye ----look up----clean the lower eyelid and eyelashes using side-to-side strokes. 5-repeat the procedure on the other eye using a clean applicator or a gauze pad. 6-Rinse the eyelids and eyelashes with clean, warm water. 7- Followed by another dry cotton swab to brush off any crusting.

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Stye and Chalazion:- Stye and Chalazion typically respond well to hot compress applied 3-4 times

daily for 5-10 minutes each time.- Gentile pressure, applied by rolling the compress gently around the affected area

is recommended; a fresh, clean compress should be used with each treatment.- Clearing usually occurs with 1 week.-- If either disorder (i.e. Stye and Chalazion) does not drain within one week --------

referral.

Subconjunctival hemorrhage :

- The rupture of a blood vessel under the conjunctiva causes Subconjunctival hemorrhage.

- A segment or even the whole eye will appear bright red. - It occurs spontaneously but can be precipitated by coughing, straining or lifting.- There is no pain and the patient should be reassured that symptoms will resolve

in 10 -14 days without treatment. - However, a patient with history of trauma should be referred to exclude ocular

injury.

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Smoking and Nicotine Replacement Therapy (NRT)

- There are over a billion smokers in the world (about 1/3 in china) and tobacco is the single most important avoidable cause of death, and an estimated 500 million of the world's current population will die from tobacco-related illness.

- Each year more than 440,000 deaths, or 20% of the total deaths in the United States, are caused by smoking.

How smoking damage health:

Three compounds of real clinical importance have been identified in tobacco smoke, these are:

- Tar-based products: which have carcinogenic properties (about 43 carcinogenic compounds)

- CO: which reduce the O2 carrying capacity of RBCs- Nicotine: which produce dependence

Health risks from smoking:- Cigarette smoking substantially increases the risk of:

(1) Cardiovascular diseases such as stroke, heart attack, and sudden death (2) Non-malignant respiratory diseases including emphysema, asthma, chronic bronchitis, and chronic obstructive pulmonary disease.(3) Lung cancer, and other cancers (e.g., mouth, pharynx, larynx, esophagus, stomach, pancreas, uterus, cervix, kidney, ureter, and bladder).

- In addition there are many compounds in tobacco that induce hepatic enzyme causing increase in the clearance (reduce half life) of many drugs e.g. (theophylline clearance increased by about 60-100%).

Passive Smoking:- Nonsmokers are affected by side-stream smoke and become passive smokers.- There is an increased risk of lung cancer and Ischemic Heart Disease caused by

passive smoking.- Exposure to environmental tobacco smoke (passive exposure) has been cited as

the cause of 3,000 lung cancer deaths and 35,000 to 40,000 heart disease deaths in the United States every year

- Childhood asthma, middle ear diseases, sudden infant death syndrome, and other diseases are strongly linked to parent smoking.

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Facts about the benefits of smoking giving up:- In 20 minutes, blood pressure and pulse rate return to normal.- In 8 hours, CO level reduce by half and oxygen level returns to normal.- After:

1 day lung start to clear the mucus. 2 days, the sense s of taste and smell improve 3 days, breathing become easier and bronchioles begin to relax. 2-12 weeks, circulation improves. 3-9 months, lung function increase by up to 10 %. 5 years, the risk of heart attack falls to half that of smoker.

10 years, the risk of lung cancer falls to half that of smoker and the risk of heart attack fall to the same as someone who never smoked.

Smoking cessation:- Before initiating any treatment, it is important that the patient want to stop

smoking. - Researchers have designed a six stage cyclical model of change in which patients

need different types of support and advice in each stage. The model has proved effective. It includes:

Contemplation

Pre-contemplation preparation

Relapse Action

Maintenance

- Pre-contemplation : Smokers are not thinking about quitting, at least not in the next 6 months.

- Contemplation : The period of time in which smokers are seriously considering quitting smoking during the next 6 months.

- Preparation : the period in which smokers are seriously thinking about quitting smoking in the next month.

- Action: The period ranging from 0-6 months when smokers have made the overt change to stop smoking.

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- Maintenance: the period beginning 6 months after the action stage has started and continuing until smoking is terminated as problem.

- Pharmacists are encouraged to use the FIVE A's, for helping the patient quit:1-ASK: systematically identify all tobacco users2-ADVISE: strongly urge all tobacco users to quit.3-ASSESS: determine willingness to make a quit attempt.4-ASSIST: aid the patient in quitting.5-ARRANGE: schedule follow-up contact.

Nicotine Replacement Therapy (NRT)- Simple advise to quit, which take only minutes with ongoing support on each

time the client come into the pharmacy, and supplying NRT for highly dependent smokers (>15 cigarette /day ) is the most effective way to help smokers to quit.

- Nicotine produce dependence rapidly, therefore, once plasma nicotine level fall below a threshold, patient begin to suffer nicotine withdrawal symptoms and will crave another cigarette.

- Treatment is therefore bases on maintaining plasma nicotine just above this threshold using NRT.

- NRT is formulated as a Gum, Lozenges, Patches, Nasal spray, Inhalator, and sublingual tablets.

- All patients can use them, except in pregnancy (as an OTC), in addition the safety in children and adolescents of most NRT products have not been established.

- Patients with pre-existing heart disease are not contraindicated from using NRT (although products licenses for OTC products state they should not be given).

- Side effects of NRT are rare and usually limited to GIT problems associated with ingestion of nicotine when chewing gum, or local skin irritation of patches.

Nicotine patches:A- Nicorette® patches: (5mg, 10 mg, and 15 mg patches)

- Releasing approximately 5mg, 10 mg or 15 mg / 16 hours.- Apply to dry, non-hairy skin on chest, upper arm, and removed after approx. 16

hours, usually when retiring to bed.- Site next patch to different areas (avoid using the same area on consecutive days

to avoid irritation).- Usually we start with 15 mg patch daily for about 8 weeks-------10 mg patch for

2 weeks-------5 mg patch for 2 weeks.

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B- Nicotinell® patches: - 10 mg patch (releasing approx. 7 mg/24 hours), 20 mg patch (releasing approx.

14 mg/24 hours), and 30 mg patch (releasing approx. 21 mg/24 hours(.- Dose: apply to dry, non-hairy skin on trunk or upper arm, removing after 24

hours and sitting replacement patch on a different area (avoid using the same area for several days (

- Individuals smoking more than 20 cigarettes daily: Initially 30 mg patch daily for 3–4 weeks------------20 mg patch daily for 3–4 weeks ------10 mg patch daily for 3–4 weeks.

- Individuals smoking 20 cigarettes daily or fewer initially use the 20 mg patch.

C- NicoDerm CQ® patch and NiQuitin CQ® patces: - These patches have always delivered 21, 14, or 7 mg of nicotine, tapering over

the course of 10 weeks.- Dose: apply to dry, non-hairy skin site; removing after 24 hours and sitting

replacement patch on different area (avoid using same area for 7 days).- Individuals smoking 10 or more cigarettes daily: Initially 21-mg patch daily for 6

weeks----------------- then 14-mg patch daily for 2 weeks -------------------then 7-mg patch daily for 2 weeks.

- Individuals smoking less than 10 cigarettes daily, initially 14-mg patch daily for 6 weeks ----------------------then 7-mg patch daily for 2 weeks.

- 16-or-24 h patches? 16 h patch will be suitable for most patients; however, if a patient required a cigarette within the first 20 to 30 minutes of waking then a 24 h patch should be given. Also if sleep disturbances are experienced with the 24 h patch then the patients can switch to a 16 h patch or alternatively remove the 24 h patch at bed time.

Nicotine gum:- Nicorette® gum (2 mg and 4 mg), and Nicotinell® gum (2 mg and 4 mg).- Individual who smoking 20 cigarettes or less daily initially use one 2 mg piece

when urge to smoking occurs.- Individual who smoking more than 20 cigarettes daily initially or needing more

than 15 pieces of 2 mg gum daily --------may need the 4 mg strength (max. 15 pieces of 4 mg daily).

- Not recommended under 18 years.- Treatment withdrawn gradually after 3 months.

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- Unlike the tapering process used with patch strengths, Nicorette Gum was never tapered on the basis of the strength of the product, but on the number of pieces chewed daily:

- Nicorette Gum (1 piece of gum every 1-2 hours for weeks 1-6; then 1 piece every 2-4 hours for weeks 7-9; and then 1 piece every 4-8 hours for weeks 10-12).

- The gum should be bitten intermittently and slowly (about 6 times)------until tingling or burning is felt--------place the gum between the lower or upper cheek and gums--------until the tingling subsides-------repeat the process ( keep the dosing piece in the mouth for approximately 30minutes).

Nicotine Lozenges: - Nicotinell ® 2 and 4 mg lozenges:- For the initial choice; those who smoke their first cigarette more than 30 minutes

after waking should begin with the 2-mg lozenge, and those who smoke their first cigarette within 30 minutes of waking up should begin by using the 4-mg lozenge.

- In a similar manner, lozenges are never tapered in regard to the strength used (e.g., 2 mg versus 4 mg). Rather, the patient tapers the number of pieces used daily, in a schedule identical to that used for Nicorette Gum (1 piece of every 1-2 hours for weeks 1-6; 1 every 2-4 hours for weeks 7-9; 1 every 4-8 hours for weeks 10-12).

Nicotine Microtab (sublingual):- Nicorette 2 mg ®- Dose: individuals smoking 20 cigarettes or less daily, sublingually, 2 mg each

hour; for patients who fail to stop smoking or have significant withdrawal symptoms, consider increasing to 4 mg (i.e. 2 tablets) each hour.

- Individuals smoking more than 20 cigarettes daily, 4 mg each hour (max. 80 mg daily (40 tablets)

- Treatment should be continued for at least 3 months followed by a gradual reduction in dosage; max. Period of treatment should not exceed 6 months.

- Treatment should be stopped when daily consumption is reduced to 1 or 2 tablets daily.

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Inhalation cartridge:- Nicorette inhalator® (nicotine 10 mg/cartridge)- The inhalator can be particularly helpful for those smokers who still fell they

need to continue the hand-to-mouth movement. - Dose: inhale when urge to smoke occurs; initially use between 6 - 12 cartridges

daily for up to 8 weeks, then reduce number of cartridges used by half over next 2 weeks and then stop altogether at end of further 2 weeks;

- Each cartridge lasts about 20 minutes.

Nicotine nasal spray:- Nicorette® nasal spray (nicotine 500 micrograms/metered spray). - Dose: apply 1 spray into each nostril as required to max. twice an hour for 16

hours daily (max. 64 sprays daily) for 8 weeks, then reduce gradually over next 4 weeks (reduce by half at end of first 2 weeks, stop altogether at end of next 2 weeks)

- Max. treatment length 3 months- Child under 18 years, it's not recommended.

Dr. Mohammed M. MohammedGood Luck

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