I spy with my little eye

1. I spy with my little eye Common ophthalmic disorders AND NOVEL TREATMENTS

2. 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 ophthalmic conditions in community pharmacy • Identify novel treatments available for common ophthalmic conditions

3. Anatomy of the human eye

4. Functions of the human eye • https://www.youtube.com/watch?v=BEtdh-G8wFE

5. What is the most complex organ in the body? • The human eye functions much like a digital camera • Light enters the eye through the cornea, the clear front surface of the eye, which acts like a camera lens • The iris works much like the diaphragm of a camera--controlling how much light reaches the back of the eye • It does this by automatically adjusting the size of the pupil • The eye’s crystalline lens sits just behind the pupil and acts like autofocus camera lens, focusing on close and approaching objects • Focused by the cornea and the crystalline lens, the light makes its way to the retina • This is the light-sensitive lining in the back of the eye. Think of the retina as the electronic image sensor of a digital camera. Its job is to convert images into electronic signals and send them to the optic nerve • The optic nerve then transmits these signals to the visual cortex of the brain which creates our sense of sight

6. Structures that help protect the eye • The bony structures of the orbit (the bony cavity that contains the eyeball and its muscles, nerves, and blood vessels, as well as the structures that produce and drain tears) protrude beyond the surface of the eye • The eyelashes are short, tough hairs that grow from the edge of the eyelid • The upper lashes are longer than the lower lashes and turn upward • The lower lashes turn downward • Eyelashes keep insects and foreign particles away from the eye by acting as a physical barrier and by causing the person to blink reflexively at sensation(s)

7. Structures that help protect the eye • The upper and lower eyelids reflexively close quickly (blink) to form a mechanical barrier that protects the eye from foreign objects, wind, dust, insects, and very bright light • On the moist back surface of the eyelid, the conjunctiva loops around to cover the front surface of the eyeball, right up to the edge 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.

8. Tears Tears • Pharmacists Beware: • https://www.youtube.com/watch?v=7wMqzF6_q9s

9. Basic Eye Hygiene Good lighting (avoid dark and bright lights) Rest eyes on distant object Don’t rub eyes Report: eye pain, photophobia, vision changes, tearing Do NOT share eye make up Clean eye from inner to outer canthus Vitamins A & B are important Wear contacts appropriately

10. Eye Hygiene, National Eye Institute • Have a comprehensive dilated eye exam, this is the only way to detect diseases in the early stages • Know your family’s eye health history • 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 omega-3 fatty acids, such as salmon, tuna, and halibut • Maintain a healthy weight, being overweight or obese increases your risk of developing diabetes and other systemic conditions • Wear protective eyewear • Quit smoking or never start. Research has linked smoking to an increased risk of developing age-related macular degeneration, cataract, and optic nerve damage, all of which can lead to blindness • Give your eyes a rest. Try the 20-20-20 rule: Every 20 minutes, look away about 20 feet in front of you for 20 seconds • Clean your hands and your contact lenses properly, wash your hands and disinfect contact lenses as instructed and replace them as appropriate • Practice workplace eye safety

11. Expect 2 - 5 % of all general consultations to be eye related

12. General Practice Infective Conjunctivitis 44% Allergic Conjunctivitis 15% Meibomian Cyst 8% Blepharitis 5% Cataract 4.8% Abrasion/ Foreign body 3% Glaucoma 2.3% Stye 2% Macular disease 1.1% Uveitis 1.1% No abnormality 1.8% Other conditions 11.9% Assessment and Evaluation Foreign body 29% Corneal abrasion 15% Eye injury/trauma 15% Infective Conjunctivitis 9% Allergic Conjunctivitis 3% Blepharitis 3% Other conditions 26% Eye disorder statistics

13. Quick Counseling/Best Practices • Always wash hands prior to using eye drops/ointment • Contact lenses should be removed prior to using medication, unless designed specifically for use with contact lenses • After using eye drops close eyes gently for 3 minutes and tilt head forward as looking at the ground (gravity will help draw the drop onto the cornea & avoid tight squeezing of the eyelid and blinking) • After placing ointment in lower conjunctival sac, close eyes for 1-2 minutes (vision may be blurry-temporary) • If multiple drops are being used, wait at least 5 minutes before instilling the next drop • If using both drops and ointment, place drops 10 minutes prior to ointment

14. Pharmacy Scenarios • What do you do when you see a patient with new onset Loss of Vision in one eye this morning? • * referral, Johns Hopkins University in Baltimore researchers found that micro vascular changes – trouble in the smaller vessels of the eyes or kidneys – appeared to be linked to the presence of atrial fibrillation • 9 out of every 1000 people with some micro vascular disease developed A Fib • It increased to more than 24 per 1000 people who had vessel damage in both the eyes and kidneys went onto develop afib (the connection is still unclear) https://www.health24.com/Medical/Eye/News/Eyes-may-indicate-atrial-fibrillation-risk-20131119

15. Pharmacy Scenarios • an elderly woman presents with blurred vision & n/v? Your differential is Gastroenteritis (stomach flu) but could It be more? • * referral, there are 6 serious illnesses that could cause blurred vision according to the utilization review accredidation committee of Specialty pharmacies • Diabetes: results in damaged blood vessels in the retina. Can cause blurred and/or spotty vision and can lead to blindness or macular degeneration • 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 • Multiple Sclerosis: causes inflammation along the optic nerve that connects your eyes to the brain, which can lead to blurry sight, loss of color vision, and pain • Brain tumor: pressures build inside the skull & can cause blurred vision, drowsiness, headaches, 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!

16. Pharmacy Scenarios • A patient comes to the pharmacy complaining about seeing floaters, haloes, and flashes of light. what is your recommendation? • * Referral needed, this could be an early sign of retinal Tear or detachment or something even more severe. • Seek urgent advice about floaters and flashes if they are very marked or sudden in onset, associated with pain, or changes in your vision, of if both floaters and flashes are occurring together • Seek advice if you develop persistent haloes • Seek advice for any new symptoms, even if less severe than this, if you have previously lost the sight in one of your eyes, so that your new symptoms affect your only functioning eye. Flashes, Floaters and Haloes Authored by Dr Mary Lowth, Reviewed by Dr Adrian Bonsall | Last edited 31 Jul 2018 | Certified by The Information Standard

17. Real Patient Scenarios • A patient is asking how often her daughter should get an eye exam? • The correct answer is: one to two years. • A patient asked me what increases a child's chances for having eye problems, her daughter is 4 yrs old and she is worried? • The correct answer: Premature birth, crossed eyes, a family hx of eye disease, etc. • A patient in the eye care aisle asked, what is the reason for getting my eyes dilated at the eye doctor aside from the extra charge? • The correct answer is: to allow for a better view of the interior of your eyes. • An indication of strabismus 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.

18. Diagnostic Tools • Snellen Chart • Ophthalmoscope • Fluorescein • Pen-torch with cobalt filter • Pin hole

19. VISION SAMPLES https://www.google.com/search?q=20/40+vision+samples&tbm=isch&tbs=rimg:CfWgQfefXrtxIjgjmHED-m7tIXdImxtDzhMIaXyEYFCjSGJ4O0FlK_18i_1iIiw2wXsiKHRpPx4-1oXlSA8ZH7eoNCdioSCSOYcQP6bu0hEVpumk0pZ8PlKhIJd0ibG0POEwgRJ8ShLEnMYzUqEglpfIRgUKNIYhHex1rkfRRiOioSCXg7QWUr_1yL-EXkwPoEiinTdKhIJIiLDbBeyIocRzVyMrn-OXd4qEglGk_1Hj7WheVBHJF6o9hbDzhSoSCYDxkft6g0J2EQQSOpn7VX87&tbo=u&sa=X&ved=2ahUKEwi47u3R9YfgAhURooMKHWXIAnAQ9C96BAgBEBg&biw=1438&bih=685&dpr=0.95#imgdii=z8rQoNBhyz8FNM:&imgrc=RpPx4-1oXlQFTM:

20. READY FOR SOME EYE SCENARIOS ?

21. SCENARIO 1

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

23. Allergic Conjunctivitis

24. Viral Conjunctivits Follicular changes Hemorrhagic changes

25. What are the clinical features? What do we see in pink eye? Similar Conditions Allergic, bacterial, or viral conjunctivitis Blepharoconjunctivitis is the dual combination of conjunctivitis with blepharitis (inflammation of the eyelids) Keratoconjunctivitis is the combination of conjunctivitis and keratitis (corneal inflammation) • Contagious acute infection • May accompany the common cold or other viral infections (like chickenpox, measles, etc.) • Usually caused by adenovirus • Symptoms • Irritation • Photophobia • Watery discharge (purulent discharge may indicate bacterial conjunctivitis)

26. How would you treat this patient? • Use hand sanitizer and/or wash hands thoroughly after touching eyes/nasal secretions • Avoid touching the noninfected eye after touching the infected eye • Avoid sharing towels or pillows • Avoid swimming in pools • Eyes should be kept free of discharge and should NOT be patched • Small children with conjunctivitis should be kept home from school • Viral conjunctivitis lasts 1 wk in mild cases to up to 3 wks in severe cases • Use cool compresses for symptomatic relief • In severe cases, may benefit from topical corticosteroids (eg, 1% prednisolone acetate qid) • Oral corticosteroids may be used,, but Herpes simplex keratitismust be ruled out first (by fluorescein staining and slit-lamp examination)

27. SCENARIO 2

28. This 19 year old student is complaining of irritation of the eye lids. It has become much worse recently while studying for exams • What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

29. What are the clinical features? What do we see? Similar Conditions Dry eye Conjunctivitis (pink eye) • Swollen eyelids • Greasy eyelids • Crusted eyelashes • Flaking of the skin around the eyes • Loss of eyelashes

30. How would you treat this condition? • Non-pharmacologic treatment: • Warm compress 15-20 minutes 2-4 times daily • Eyelid massage to clean our oil accumulated in eye glands • Eyelid scrub from kit or make at home with a few drops of baby shampoo and warm water with cotton pad or gauze • Use anti-dandruff shampoo for scalp • Pharmacologic treatment: • Artificial tears solution • Lubricating eye ointment

31. scenario 3

32. This 21 year old patient presented to his pharmacist with a red painful swelling over his eye lid. • What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

33. What are the clinical features? What did we see? Similar Conditions Chalazion (kah-LAY-zee-on) is an enlarged, blocked oil gland in the eyelid Mimics a stye for the first few days, then turns into a painless hard, round bump later on Milia or "milk spots" are tiny white cysts appearing on the outer skin layer (epidermis) of the eyelid & around the eyes/nose Dead skin cells don't slough off normally and are trapped at the base of a sweat gland or hair follicle, forming a raised "pinhead" bump that looks similar to a whitehead • The first signs are pain, redness, swelling and tenderness • Styes typically don't cause vision problems • Styes are caused by staphylococcal bacteria • Styes ARE contagious • Most styes heal on their own • Never "pop" a stye • Other eye problems can accompany styes

34. How would you treat this condition? • The first thing you should do is cleanse your eyelids. You can use diluted tear-free baby shampoo on a cotton ball, washcloth, or makeup remover pad. Then rinse your eyelids with warm water and gently pat them dry. • Also, be sure to wash your hands before and after touching the stye • Stop wearing eye makeup/contacts temporarily & discard old makeup or applicators that could be contaminated • You can encourage a stye to heal faster by applying warm compresses for 10 to 15 minutes, three or four times a day • May use teabags • The goal of this therapy is to bring the stye to a head, but do NOT try to pop a stye • Ibuprofen or acetaminophen may be helpful is pain is associated

35. Scenario 4

36. A 31-year-old male patient gives history of acute painful vesicular eruptions on the right side of his forehead.  • What is the most likely diagnosis? A) Blepharitis B) Herpes Zoster Opticus C) Retinal Detachment D) Stye E) Viral Conjunctivitis

37. What are the clinical features? What do we see? Similar Conditions Herpes Simplex Keratitis Glaucoma Uveitis • Cornea is hazy • Pupil is dilated • Keratic precipitates on endothelium • In conjunction with • Blephritis • Conjunctivitis • Ptosis

38. How would you treat this condition? • Double check dosing on facts.. • Acyclovir 800mg FID x 7 days • Valacyclovir 1000mg TID x 7 days • Famciclovir 500mg TID x 7 days • Prednisolone drops???

39. Scenario 5

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

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

43. How would you treat this condition? • Surgery is almost always used • Injecting air or gas into your eye, injects a bubble of air which pushes the area of the retina containing the tear against the wall of 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 the retina can then adhere to the wall of your eye. You may need to hold your head in a certain position for up to several days to keep the bubble in the proper position • Indenting the surface of your eye. This procedure, called scleral (SKLAIR-ul) buckling, involves the surgeon sewing (suturing) a piece of silicone material to the white of your eye (sclera) over the affected area • 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

44. Novel Treatments • Tecnis Symfony, new lens placed during cataract surgery provides new surface for both near and far sided vision difficulties • Prokera clips a piece of amniotic membrane tissue in between two rings made out of a clear, flexible material to heal damaged surfaces • Vector Thermal Pulsation technology, sends heat into the glands inside your lids. This combination of heat plus pressure, massages blockages and liquefies/clears the obstructions causing symptoms

45. Novel Treatments • Argon laser, scars the retina (strengthens it) so it bonds to the underlying tissue & prevents further retinal detachment • 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 stimulates nerves in the nose to produce tears (reaction is like what occurs when you cut into an onion) • Serum tears, eye drops made from your own blood serum improved symptoms of ocular surface disease

46. OTC Novel Treatments • Soothe XP emollient lubricant eye drops, contains mineral oils, seals in moisture, and protects against further irritation • Lumify (brimonidine) first approved by the FDA in a higher dose as a prescription glaucoma drug called Alphagan, reduces eye redness by causing constriction of the blood vessels in the eye, decreasing both blood flow and oxygen getting to the eye's tissue

47. Lumify vs Visine • 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 before, as nutrients and oxygen return to the eye. The enlarged arteries pump more blood to make up for lost time, which can cause increased redness in the eye (rebound effect) • The key difference in the way the two drugs work is that Visine targets a receptor in the eye's arteries, while Lumify 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

48. RX Novel Treatments • Lucentis • Eylea • Xiidra • Rhopressa • Vyzulta

49. Summary • Eye disorders are commonly seen, and pharmacists are at the front line. • Novel ophthalmic treatments may be more relevant today than ever before. • Pharmacists need to stay up to date to make appropriate recommendations.

50. References • https://www.uspharmacist.com/article/managing-common-eye-conditions-in-the-pharmacy • 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 Allergy Asthma Rep. 2009;9:297-303. • https://nei.nih.gov/ • 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 Older. 2016. Accessed April 16, 2017 • https://www.merckmanuals.com/professional/eye-disorders/conjunctival-and-scleral-disorders/viral-conjunctivitis • https://www.allaboutvision.com/conditions/styes.htm • https://www.mayoclinic.org/diseases-conditions/retinal-diseases/symptoms-causes/syc-20355825