College of Pharmacy

Fourth Year. Clinical Pharmacy

Minor Eye Disorders
1-Conjunctivitis
Conjunctivitis (bacterial, viral and allergic forms) is
the most common ocular condition encountered by
community pharmacists (1).

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 (2). Pharmacist should differentiate types of conjunctivitis, and to
diagnose the cases that required referral (1).

Patient Assessment with Red Eye:

A-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 (1).

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

mucopurulent depending on the type (1) . (table -1)
Mucopurulent discharge is more suggestive of bacterial conjunctivitis especially if
the eyes are glued together (1).

However, patient with copious purulent discharge that re-accumulates after being wiped
away required referral (2).
When to refer (red eyes) (1).
C-Associated rhinitis: Sign and symptoms of -Clouding of the cornea
an upper respiratory tract infection points -Associated vomiting
towards viral cause of conjunctivitis (1). (table - -Redness caused by a foreign body
1) -Irregular-shaped pupil or abnormal
pupil reaction to light
D-Visual changes: Any loss of vision, -Photophobia
photophobia, or haloes around the objects -True eye pain
required referral (1). -Distortion of vision
-Redness localized around the pupil
E-Pain/discomfort/itch: True pain required referral (1).
Pain associated with conjunctivitis is often described as a gritty/ foreign-body type pain
(1)
.(see the table -1)

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F-Uni or bilateral eye involvement: A foreign body or trauma is usually unilateral,
whereas conjunctivitis may start as unilateral and then become bilateral (1).

G-Location of redness: Redness localized near or around the pupil (colored part of the
eye) required referral (1).Generalized redness or redness towards the corners of the eye is
more indicative of conjunctivitis (1). (See the table1 below)

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

(1)
:
Bacterial Viral Allergic
Discharge Purulent watery watery
Pain Gritty feeling Gritty feeling itching
Distribution of Generalized and Generalized Generalized; but
redness diffuse greatest in fornices
Associated None commonly Cough and Rhinitis (may also
symptoms cold have family history
symptoms of atopy)

Management
A-Bacterial conjunctivitis.
Nonpharmacological advices (1).
1-Bathe the eyelids with lukewarm water to remove any discharge.
2-Tissues should be used to wipe the eyes and thrown away immediately.
3-Avoid wearing contact lenses until symptoms have resolved.
4-Wash hands regularly and avoid sharing pillows and towels.

Pharmacological therapy:
Chloramphenicol Eye Drop and ointment:

Note: Bacterial conjunctivitis is regarded as self-limiting (65% of people will

have clinical cure in 2 to 5 days with no treatment) yet antibiotics are routinely
given by medical practitioners (and pharmacists) as they are considered clinically
desirable to speed recovery and reduce relapse (1).

1-In 2005, chloramphenicol eye drops and in 2007 chloramphenicol ointment became
OTC in the UK (1).

Dosage: The recommended dosage for the drops is one drop every 2 hours for the first
24 hours and then reducing to four times a day (1) (Treatment for 5 days is usually
adequate, but treatment should be continued for 48 h after resolution of symptoms)
(12)
. Patients can be advised that (Sleep need not be interrupted in order to administer
eye drops) (3).The course should be completed even if symptoms improve (4).

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The ointment, if used in conjunction with the drops, should be only applied at night .
approximately 1 cm of ointment should be applied to the inside of the eyelid, after which
blinking several times will spread the ointment (1).

If ointment used alone, then the ointment should be used 3 or 4 times a day (1).

In pregnancy and breastfeeding there is a lack of manufacturer data for them to

recommend their use. Practically, during pregnancy hygiene measures should be adopted
and if absolutely necessary they can be used in breastfeeding women (1).

Treatment timescale:
If the symptoms do not improve within two days, the patient should be referred (3).

Adverse effects:
Side-effects such as mild stinging or burning in the eye on application and blurring of
vision are usually minor and transient (4).

Note: Patients with glaucoma or who have had eye surgery or laser treatment in the past
six months required referral (2).

B-Allergic conjunctivitis:
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 (5).

Pharmacologic-therapy
These include Mast cell stabilizers (sodium cromoglicate), Sympathomimetic e.g.
Naphazoline , Anti-histamine (Antazoline) , and Decongestants—antihistamine
combination (Naphazoline-Antazoline) (1).(See table -2)

Note: A sympathomimetic decongestant should not be used for more than 7 days (12).

C-Viral conjunctivitis:
Viral conjunctivitis is usually self-limiting, with symptoms resolving over 2-3 weeks (5).
Nonpharmacological advices:
Viral causes are highly contagious and the pharmacist should instruct the patient to follow
strict hygiene measures (e.g., not sharing towels, washing hands frequently),which will
help control the spread of the virus (1).

Pharmacologic-therapy
Viral conjunctivitis is treated by ophthalmic decongestant which had been discussed
under allergic conjunctivitis (4).

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 Table -2: Doses of some eye drops used for allergic conjunctivitis (1).
Drug Use in children Dose
Mast cell stabilizers >6 years 1 drop four times
(sodium cromoglicate) daily
Sympathomimetic : >12 years 1 drop 3-4 times daily
Naphazoline
Anti-histamine : >12 years 1 drop 2-3 times daily
Antazoline
Decongestants— >12 years 1 drop 2-3 times daily
antihistamine :
(Naphazoline-Antazoline)

Table -3:Hints about conjunctivitis (1).

Children and school children with conjunctivitis do not need to be kept
away from schools.
Patients who wear soft contact lenses should be
advised to stop wearing them while treatment
Contact lens wearers continues and for 48 hours afterwards. This is because
preservatives in the eye drops can damage the lenses.
These must be stored in the fridge. If they are put into
Chloramphenicol the eye cold it will be uncomfortable, so patients
drops should be told to remove them from the fridge prior to
use to allow them to warm up to room temperature.

2-Dry Eye
Dry eye is among the most common disorders affecting the anterior eye (5).the condition
is chronic with no cure (1).
Essentially, a reduction in tear volume or alteration in tear composition causes dry eyes.
Underproduction of tears can be the result of increased evaporation from the eye,
increased tear drainage and a decrease in tear production by the lacrimal gland (1).

Patient Assessment with Dry Eye:

A-Age: Dry eye is most often associated with aging process, especially postmenopausal
women (5). Dry eye is rare in children and required referral (1).

B-Symptoms: Usually affecting both eyes. Symptoms that are frequently reported are
eyes that burn, feel tired , itchy, irritated (decreased tear production results in irritation
and burning) or gritty and feel as if something is in the eyes (1, 6).

C-Clarifying questions: Have you had daily, persistent, troublesome dry eyes for more
than 3 months? Do you have a recurrent sensation of sand or gravel in the eyes?
A positive response to at least one of these questions would indicate dry eye syndrome
(1)
.

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D-Associated Symptoms: Normally no other symptoms are present in dry eye. If the
patient complains of a dry mouth, check for medication that can cause dry mouth (table -
4). If medication is not implicated, then symptoms could be due to an autoimmune disease
(1)
.
Sometimes the lower eyelid turns outward (a condition called Ectropion), this will over
expose the conjunctiva to atmosphere leading to eye dryness. Referral is required (1).

Management:
1-Dry eye are managed by instillation of artificial tear preparations. They act by
stabilizing the tear film and Table -4: Medication that can cause dry eye (1).
(5)
decreasing tear evaporation) . -Diuretics
-Drugs that have an anticholinergic effect – e.g.,
2-Drops can be divided into tricyclic antidepressants (TCAs) and antihistamines
those which contain a -Isotretinoin
preservative and those which -HRT (particularly oestrogen alone)
do not ( i.e. preservative free). -Androgen antagonists
The preservative is nearly -Cardiac arrhythmic drugs, beta-blockers
always benzalkonium chloride, -Selective serotonin reuptake inhibitors (SSRIs)
usually present at 0.01 per cent. When to refer (1)
Preservatives can damage the corneal
-Associated dryness of mouth and other
epithelium (6). If a product causes mucous membranes
irritation or if soft contact lenses are -Outward turning lower eyelid
worn, consider switching to one that is
preservative-free. If more than 4-6 applications are used daily, consider using a
preservative free product as the risk of irritation from the preservative increases with the
frequency of dosing (4).
Note: benzalkonium chloride itself can cause eye irritation. If symptoms persist, or are
worsened by the eye drops, it may be worth trying a preservative-free formulation or
single-dose unit preparations (1).

3-The dosage of all products marketed for dry eye is largely dependent on the patient’s
need for lubrication, and is therefore given on an as-needed basis (1).

4-All products are pharmacologically inert and none are known to interact with any
medicine, only cause minimal and transient side effects and can be given to all patient
groups (1).

Examples of the compound used are:

1-Hypromellose (hydroxypropylmethylcellulose): (Tears Naturale ® eye drop)

2-Polyvinyl alcohol (Liquifilm Tears® eye drop)
Patients with mild dry eye may benefit from instillation of one of these artificial tear
drops up to four times a day. However, in moderate to severe cases, these preparations
need to be instilled more frequently (7).

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3-Carbomers: (Liquivisc ® Gel : Viscotears ® gel): To overcome the problem of
frequent instillation , preparations containing a longer-acting polymer, known as
carbomer , have been introduced. Such preparations have a much longer retention time
in the eye and symptom relief is obtained with significantly fewer instillations (7).

4-Lubricating ointments: Ophthalmic lubricating ointments contain white soft

paraffin (Lubri-Tears ®Eye ointment), lanolin and liquid paraffin. These preparations
melt at the temperature of the ocular tissue and are retained longer than other
ophthalmic vehicles. They are not generally recommended as tear substitutes during the
day because the vision is blurred after instillation. They are, however, a useful adjunct
to artificial tears if used at bedtime (7).

5-Sodium hyaluronate
The dosage for all products containing sodium hyaluronate is on an as needed basis (1).

3-Eyelid Disorders:
A-(Stye and Chalazion):
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) (1). Internal stye generally has a
more prolonged course than external (8).
Occasionally, internal stye can evolve into Chalazion (a granulomatous inflammation
that develops into a painless lump) (1).
A chalazion can be confused with a stye. Stye often has a head of pus at the lid margin
and will be tender and sore, whereas a chalazion presents as painless lump (1).

Although styes are caused by bacterial pathogens the use of antibiotic therapy is not
usually needed. Topical application of ocular antibiotics does not result in speedier
symptom resolution (1).

Patient with stye should avoid touching the eyes and wash the hands after any contact
with infected eye (8). Without treatment, a stye will usually resolve within seven to 14
days (8).
A warm compress applied for 5–10 minutes three or four times a day might bring to a
head an external stye, and once it bursts the pain will subside and the symptoms will
resolve (1) (External stye usually drains spontaneously, but warm compress will hasten
resolution which usually occurs within 48 hours). Internal stye generally resolves within
1-2 weeks (8).

A chalazion is self-limiting, although it might take a few weeks to resolve completely

(1)
. Initial treatment for chalazion is similar to that of stye especially for small chalazion
(warm compress applied several times a day. About 25-50% resolves with this treatment.
If the lesion does not begin to resolve within few days, referral is required (8))

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If the patient complains that it is particularly bothersome and is affecting vision or
associated with eye pain. Referral in these circumstances is needed for surgical removal
(1, 8)
.

4-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. Most sub-
conjunctival hemorrhages are idiopathic (It occurs spontaneously) but can be
precipitated by coughing, straining or lifting (1). The patient will wake up with the
hemorrhage, which is not noticed until he or she looks in a mirror (11).
The condition appears alarming but is usually harmless (11). 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 (1).
Hypertension is also a possible cause so pharmacists can advise patients to have their
blood pressure checked. Anticoagulant or antiplatelet drugs (e.g. warfarin, aspirin,
clopidogrel) can also cause a hemorrhage so patients should be asked about their
medicines and those taking warfarin should have their international normalized ratio (
INR ) measured (11)

References:
1-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4th edition. 2017. And 5th edition
2021.
2-Practice guidance: OTC Chloramphenicol eye drop. Royal Pharmaceutical Society of Great Britain June 2005
3-Conjunctivitis and Chloramphenicol. The Pharmaceutical Journal (Vol 274) 11 June 2005 page 725-728.
4-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010.
5-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-
Care. 18th edition. 2016.
6-Marvyn Elton .Ocular conditions from A to Z (i). The Pharmaceutical Journal .17 February 2007 (Vol 278)
195-198.
7-Lucy C. Titcomb .Eye disorders : Over-the-counter ophthalmic preparations. The Pharmaceutical Journal .Vol
264 No 7082 p212-218 February 5, 2000 .
8-Canadian American pharmacists association (CPhA). CTMA: Compendium of Therapeutics for Minor
Ailments. 2014.
9-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008.
10-Jeannette Y. Wick. Treating Blepharitis: Annoying Condition for Patients, Vocabulary Builder for
Pharmacists. Pharmacy times. February 19, 2012.
11-Marvyn Elton .Ocular conditions from A to Z (ii). The Pharmaceutical Journal. 3 March 2007 (Vol 278)
255-258.
12-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy . A guide to the
managements of common illness. 9th edition. 2023.