you asked for it! ce · hordeolum, chalazion, blepharitis macular degeneration signs and symptoms...

AN ONGOING CE PROGRAMof the University of Connecticut

School of PharmacyEDUCATIONAL OBJECTIVESAfter participating in this activity pharmacists will beable to:● DISCUSS common ocular condition’s pathophysiology

and causes● IDENTIFY recent changes in available medications to

treat ocular conditions● DISTINGUISH each FDA-approved product by the con-

dition that it treats● DISCUSS barriers to care, adherence, and administra-

tion of eye drop waste● MAXIMIZE the pharmacist’s role in identifying OTC

products, referring patients for prescription strengthmedication, and counseling patients about both

After participating in this activity, pharmacy technicianswill be able to:● LIST basic facts about ocular conditions● IDENTIFY reputable sources for patients who have

ocular conditions to find information● DIFFERENTIATE between over-the-counter and pre-

scription drugs for ocular conditions● IDENTIFY patients who need referral to the pharma-

cist for recommendations or referral

The University of Connecticut School of Pharmacy is accreditedby the Accreditation Council for Pharmacy Education as a pro-vider of continuing pharmacy education.

Pharmacists and pharmacy technicians are eligible to participatein this application-based activity and will receive up to 0.3 CEU (3contact hours) for completing the activity, passing the quiz witha grade of 70% or better, and completing an online evaluation.Statements of credit are available via the CPE Monitor onlinesystem and your participation will be recorded with CPE Monitorwithin 72 hours of submission

ACPE UAN: 0009-0000-18-078-H01-P 0009-0000-18-078-H01-T

Grant funding: Alcon Laboratories, Inc.Activity Fee: FREEINITIAL RELEASE DATE: September 24, 2018EXPIRATION DATE: September 24, 2020

To obtain CPE credit, visit the UConn Online CECenter https://pharmacyce.uconn.edu/login.php.Use your NABP E-profile ID and the session code18YC78-BXT66 for pharmacists or18YC78-XPV46 for pharmacy techniciansto access the online quiz and evaluation. Firsttime users must pre-register in the Online CE Cen-ter. Test results will be displayed immediately andyour participation will be recorded with CPE Moni-tor within 72 hours of completing the require-ments.

For questions concerning the online CPE activi-ties, email [email protected].

ABSTRACT: Ocular problems—many of which cause severe vision loss or blind-ness—are on the rise in the US. Common eye diseases include glaucoma, age-related macular degeneration, dry eye, conjunctivitis and blepharitis. Pharmacystaff may be the first providers a patient approaches to consult about an eyecondition since many treatment options are available over-the-counter. Armedwith knowledge of ophthalmic conditions and treatments, pharmacists can de-termine if patients are candidates for self-treatment, evaluate the appropriate-ness of pharmacotherapy, screen for medication-induced eye disorders, andpromote proper medication adherence. Patients often use ophthalmic products;patient education should be a top priority for pharmacy staff.

FACULTY: Stefanie C. Nigro, PharmD, BCACP, BC-ADM, CDE, Assistant Professor, MCPHS University,and Elizabeth Haftel, PharmD, CDE, Assistant Professor, MCPHS University, Boston, MA.

FACULTY DISCLOSURE: Drs. Nigro and Haftel have no actual or potential conflicts of interest associ-ated with this article.

DISCLOSURE OF DISCUSSIONS of OFF-LABEL and INVESTIGATIONAL DRUG USE: This activity maycontain discussion of off label/unapproved use of drugs. The content and views presented in this ed-ucational program are those of the faculty and do not necessarily represent those of the Universityof Connecticut School of Pharmacy. Please refer to the official prescribing information for each prod-uct for discussion of approved indications, contraindications, and warnings.

INTRODUCTIONOcular problems—many of which may cause severe vision loss or blindness—areon the rise in the US. A change in vision is common. Sensitivity to light and theneed to wear glasses to see near or far are expected parts of aging. However,the development of certain age-related eye diseases including cataracts, diabeticretinopathy, glaucoma, and macular degeneration can significantly impair vision,further reducing quality of life and independence. Currently, 1.3 million peoplein the US are blind and more than $139 billion in healthcare costs are related toocular problems.1 As the population continues to age, these numbers are ex-pected to worsen.

Pharmacy staff may be the first providers a patient approaches to consult abouthis or her eye condition. Yet, many pharmacists and other healthcare providersexpress lack of confidence caring for patients with ocular conditions. With im-proved ophthalmic knowledge, pharmacists can help patients navigate over-crowded over-the-counter (OTC) aisles, understand proper use of eye careproducts, and improve overall satisfaction with their care.

You Asked for It! CE

An Octet of Ocular Conditions:Current "Eye" diology

© Can Stock Photo / ylivdesign

EYE ANATOMYThe eye is the organ of sight. Although it is small, measuring oneinch in diameter, the eye is composed of various muscles, nervesand structures. (See Figure 1) Normal vision relies on the coordi-nated interplay between the eye and brain to transform light in-to visual images.2 The eye is often compared to a digital camera,since both transmit and focus light to create a picture. Here is abrief overview of the most common structural components andtheir functions:

● Conjunctiva - A thin layer of tissue and blood vesselslocated in the front of the eye to keep bacteria and for-eign particles out of the eye.

● Cornea – A clear layer located in front of the iris to helptransmit and focus light as it enters the eye.

● Eyelid – A thin fold of skin responsible for protectingthe eye and keeping the cornea moist.

● Eye lashes – Fine hairs that grow at the base of the eye-lid to protect the eye from foreign objects and particles.

● Iris – A ring shaped tissue with a central opening (pupil)that helps control the amount of light that enters theeye. It is the colored part of the eye.

● Lens – A crystalline, bendable structure located behindthe iris and pupil that works with the cornea to auto-matically focus light onto the retina.

UCONN You Asked for It Continuing Education September 2018

● Macula – A small, central area of the retina that con-tains specialized cells to see sharp, fine details throughcentral vision.

● Retina – A light-sensing layer of nerves that line theback of the eye to convert optical images into electricalsignals.

● Optic disc – A round area in the back of the eye wherethe optic nerve leaves the retina.

● Optic nerve – A grouping of fibers that carry electricalsignals from the retina to the brain to create visual im-ages.

● Trabecular meshwork – An area of tissue locatedaround the base of the cornea responsible for drainingthe aqueous humor from the eye.

● Vitreous humor – A jelly-like fluid located behind thelens that helps protect the eye and keep the retina inplace, maintaining the eye’s round shape.

Pause and Ponder:What concerns do you have about recommending

and counseling patients on eye care products?

Figure 1. Human Eye Anatomy

© Can Stock Photo / wawritto

AN OCULAR OCTETIt is important for pharmacists to have a basic understanding ofcommon ocular disorders and their associated treatments.Armed with knowledge, pharmacists can determine if a patientis a candidate for self-treatment (See Table 1),3 evaluate theappropriateness of pharmacotherapy selection, screen for actu-al and/or potential drug interactions and side effects, and coun-sel patients on the proper use of ocular medications. Thissection will highlight eight common eye diseases and outlineavailable OTC and prescription remedies.

Acute Eye InjuryHealthcare providers treat more than 3 million eye injurieseach year in the US.4 This may be an underestimation of thetrue prevalence since only emergency room (ER), urgent carecenters, or medical offices report ocular injuries. Many patientspresenting to the ER with acute eye injury requirehospitalization.4

Superficial injury of the eye—such as corneal abrasion—is themost common injury and accounts for 42% of cases.4 Superficialinjury can occur from a simple finger scratch or poke, a mis-placed makeup brush, or even exposure to sand, dirt, and dust.Patients who experience corneal abrasions complain of pain,photophobia, a gritty feeling, and/or feeling like there is some-thing in the eye. Most corneal abrasions will heal with 48 to 72hours without any intervention. Historically, patients were in-structed to wear an eye patch to cover the injured eye for pro-tection from light and environmental factors. Currentguidelines suggest that this action is unnecessary and offers noadded benefit.5 In cases where an object penetrates the cor-nea, patients may require short courses of topical antibioticsfor infection prevention or antiinflammatories for symptomrelief.5

Other common injuries include foreign body on the externaleye, contusion, and open wounds of the eye and adnexa (thesupporting structures around the eye). Foreign objects, traumaor physical contact cause most eye injuries.6 Many injuries tothe eye are minor, but if not cared for appropriately, sightthreatening complications can develop.

It is important for patients to understand that they should re-ceive prompt medical attention for almost all eye injuries; se-vere eye injuries are not suitable for self-care. Patients shouldbe discouraged from removing large objects that are lodged inthe eye or tending to major lacerations as this can potentiallyworsen vision if done incorrectly. Although it may be difficult,patients should not touch or rub the eye and surrounding area.7

Management of acute eye injuries will depend on the actualinjury. Most treatments involve supporting the injury, includingcompression, ice, and rest. Wearing protective eyewear such aseye glasses can keep the eye area protected from infection or


Table 1. Exclusions for Self-treatment of OcularConditions3

● Blunt trauma to the eye● Exposure of eye to chemicals● Head lice● Hordeolum, chalazion, blepharitis● Macular degeneration● Signs and symptoms of infection of eyelids (i.e. red,

thickened eyelids, scaling)

other foreign objects. In the case of a scratched eye, rinsing theeye with sterile saline solution will help keep it clean and reducerisk of infection. Lubricating eye drops can help minimize irrita-tion. In some cases, topical antibiotics and pain relievers may beneeded.

Ocular Vocabulary 101Chalazion

o A noninfectious bump or nodule inside the upper orlower eyelid

Hordeolumo An acute, infectious bump or nodule inside the upper

or lower eyelid (stye)Hypotrichosis

o Abnormal hair loss or reductionMetamorphosia

o Distortion of straight lines to wavy or curvyOphthalmologist

o A medical doctor who specializes in eye and visioncare. Ophthalmologists can diagnose and treat all eyediseases, perform surgery, and prescribe and fit glass-es and contact lenses

Optometristo A healthcare professional who primarily conducts eye

exams and visions tests. Optometrists can prescribeand dispense corrective lenses, identify eye abnormal-ities, and prescribe treatment for select eye disorders

Photophobiao Sensitivity to light

Photopsiao Presence of perceived flashes of light

Scotomao A partial loss of vision; a blind spot

Visual acuityo Sharp, precise vision

Xanthopsiao Yellow vision


Age-related Macular DegenerationAge–related macular degeneration (AMD) is a chronic, progres-sive, degenerative disease of the macula that results in irrevers-ible loss of central vision (See Figure 2).8 It is the leading causeof blindness worldwide and responsible for 46% of cases involv-ing severe vision loss in Americans older than 40.9,10 Causes ofAMD include a combination of heredity and environmental fac-tors including aging, smoking, cardiovascular disease, Caucasianrace, lifetime oxidative stress, and expression of vascular en-dothelial growth factors (VEGF).8,9,11

Experts widely recognize two clinical forms of AMD; “dry” (non-exudative or atrophic) and “wet” (exudative or neovascular).Dry AMD accounts for approximately 85% of cases and causesgradual, painless changes in the retinal pigment epithelium(RPE). Early in the disease, waste products accumulate withinthe macula resulting in local deposition of round, yellow, fat-likesubstances known as drusen.11,12 Upon exam, the macula showspigmentation changes. In later stages, a process called geo-graphic atrophy damages the retina. Symptoms include blurredcentral vision. Over time, fine details such as reading a book,driving at night, and recognizing faces becomes less clear. If notproperly treated, dry AMD can progress to wet AMD.

Wet AMD accounts for only 15% of cases, but its presence indi-cates disease that is more advanced. Abnormal blood vesselsgrow under the retina and macula in a process called chorodialneovasculariztion. 11,12 This occurs when VEGF binds to VEGF re-ceptors on endothelial cells. These blood vessels can hemor-rhage and leak fluid, causing the macula to elevate or detach,altering central vision. 11,12 Symptoms include metamorphopsiaand scotoma. Peripheral vision is often preserved. Patients maylose vision rapidly, sometimes over several weeks or months.

The American Academy of Opthamology endorses the classifica-tion of AMD based on the Age-Related Eye Disease Study

(AREDS).13 The clinical features of dry AMD are most consistentwith early disease and wet AMD corresponds well with advanceddisease.● Category 1 (No AMD) – No or few drusen (< 63 µm in diameter)● Category 2 (Early AMD) – Multiple small drusen, few intermedi-

ate drusen (63 -124 µm in diameter), or mild RPE abnormalities● Category 3 (Intermediate AMD) – Multiple intermediate drus-

en, at least one large drusen (125 µm or larger in diameter), orgeographic atrophy not involving the center of the fovea

● Category 4 (Advanced AMD) - Geographic atrophy of the RPE orneovascular maculopathy

Goals of treatment are to minimize or reverse visual loss and func-tional impairment.9 In addition to lifestyle changes (i.e. smokingcessation, antioxidant-rich diet) and surgical procedures, severalmedication-based treatments exist. OTC antioxidant vitamins andminerals are recommended for those with intermediate or ad-vanced AMD in at least one eye. 9 (See Table 2) Findings from theAREDS study show that high doses of vitamins C, E, and beta-caro-tene coupled with zinc and copper slow disease progression. Indi-viduals at high risk of developing advanced AMD; takingsupplements lowers risk by about 25%.13 Those with early AMDdid not appear to benefit significantly from supplementation.

In 2013, researchers published the findings from the follow-upAREDS 2 study. Investigators sought to determine if adding ome-ga-3 fatty acids and the antioxidants lutein and zeaxanthin to theoriginal AREDS formulation would further reduce diseaseprogression.14 Due to the growing safety concern that beta-caro-tene increases the risk of lung cancer in smokers,15 the research-ers substituted lutein and zeaxanthin for beta-carotene in someformulations. The study found that adding omega-3 fatty acidshad no effect on disease progression. The combination of luteinand zeaxanthin had no overall effect on AMD when added to theoriginal ARED formulation. They appear a safe alternative to beta-carotene.

Figure 2.The Amsler Grid

Ocular specialists use theAmsler grid to determine ifa patient has vision lossfrom age-related maculardegeneration.

The image on the left ishow a person with normalvision would see the grid.

The image on the left showshow AMD distorts visions


Table 2. Medications for the Treatment of Age-Related Macular DegenerationOTC Antioxidants and Minerals

Name Strength Dosage form Dosing Notes

PreserVision AREDS 2formula

PreserVision AREDS 2chewables

Vitamin C 250 mgVitamin E 200 IUZinc 40 mgCopper 1 mgLutein 5 mgZeaxanthin 1 mg(per 1 softgel or 1 chewabletablet)

Softgels

Chewable tablets

Take 1 softgel twice aday

Chew 1 tablet twice aday

Beta-carotene free andsuitable for smokers

Take with a full glass ofwater

Do not swallow chew-able tablets whole

PreserVision AREDS Vitamin A (beta-carotene)14,320 IUVitamin C 226 mgVitamin E 200 IUZinc 34.8 mgCopper 0.8 mg(per 1 softgel or 2 tablets)

Softgels

Tablets

Take 1 softgel twice aday

Take 2 tablets twice aday

Not recommended forsmokers


OcuviteAdult 50+

Vitamin C 150 mgVitamin E 20 mgZinc 9 mgCopper 1 mgOmega-3 fatty acids 250 mgLutein 5 mgZeaxanthin 1mg(per softgel)

Softgel Take 1 softgel daily Beta-carotene free andsuitable for smokers


I capsEye vitamin and mineralsupplement

Vitamin C 256 mgVitamin E215 IUZinc 42.3 mgCopper 1.8 mgLutein 3.33 mgZeaxanthin 1.67 mg(per 2 tablets)

Tablets Take 2 tablets twice aday

Beta-carotene free andsuitable for smokers


VEGF InhibitorsGeneric

(Brand name)Mechanism of action Type Dosing Notes

Pegaptanib(Macugen)

Binds to VEGF receptors onendothelial cells to inhibit neo-vascularization

Pegylated modifiedoligonucleotide

0.3 mg intravitreally ev-ery 6 weeks

Monitor for increases inIOP 2-7 days post injec-tion

Bevacizumab(Avastin)

Recombinant hu-manized monoclo-nal IgG1 antibody

1.25 mg intravitreallyevery 4 to 6 weeks

Off-label use; not FDAapproved for maculardegeneration

Ranibizumab(Lucentis)

Fab fragment ofbevacizumab

0.5 mg intravitreally ev-ery 4 weeks

One-third the size of be-vacizumab; shorter t ½and higher VEGF bindingaffinity vs. bevacizumab

Aflibercept(Eylea)

N/A 2 mg intravitreally every4 to 8 weeks

Higher potency, bindingaffinity and duration ofaction vs. other VEGFinhibitors

OTC = over the counter; VEGF = Vascular endothelial growth factor; t ½ = half-life; IOP = intraocular pressure


blindness or vision loss in at least one eye.21 Uveitis can occurat any age, although the average age of onset is 40 years.22

Several types of uveitis exist. The most common form, anterioruveitis, affects the iris and anterior vitreous. Many factors con-tribute to the development of uveitis: eye injury, viral or bacte-rial infection, and comorbid inflammatory disorders such asrheumatoid arthritis. Most causes are idiopathic.23 Eye com-plaints include redness, pain, blurred vision, photophobia, andpresence of floaters. Such symptoms can present suddenly andcan rapidly worsen.

Treatment of anterior uveitis depends on whether the cause isbelieved to be infectious or non-infectious. Infectious uveitis istreated with appropriate antibiotics or antivirals. Topical (or insome cases systemic) corticosteroids are the mainstay of treat-ment. (See Table 3) They are normally tapered over six to eightweeks to control local inflammation rapidly, since untreatedinflammation can result in macular edema.23 If symptoms recurwhen steroids are tapered or discontinued, therapy should con-tinue. Higher potency steroids like prednisolone acetate 1%may be needed to achieve adequate concentration in the aque-ous humor.24 Patients are instructed to instill one drop into theaffected eye(s) every one to two hours until inflammation re-solves. Topical NSAIDs can be used if steroids are contraindicat-ed, but are not preferred (See Table 3).23 Drugs known to dilatethe eye and paralyze the ciliary muscle are used short term un-til inflammation has subsided; they help to control pain. (SeeTable 4) Any increases in IOP should be managed with appro-priate eye drops. Beta-blockers are used most often. Prosta-glandins should be reserved for last because of their associationwith inflammation.24

In neovascular AMD, intravitreal injection therapy with VEGFinhibitors is the preferred first-line therapy.9 Historically, thetreatment armamentarium for AMD was limited to photody-namic therapy (PDT). PDT combines a photo sensing dye andlaser therapy to destroy abnormal blood vessel growth. Al-though PDT slows disease progression, it does not improve visu-al acuity.16 Four VEGF inhibitors have been studied in thetreatment of neovascular AMD; pegaptanib, bevacizumab, ra-nibizumab, and afilbercept. (See Table 2) These agents offer thebenefit of slowing vision loss, and in some cases improve visualacuity.9 Despite improvements in vision, VEGF inhibitors raiseseveral safety concerns. Repeated intravitreal injections cancause increased intraocular pressure (IOP), eye pain, ocularhemorrhage, retinal detachment, sensitivity to light, andendophthalmitis.17

Blepharitis and UveitisBlepharitis is a common ocular disorder that affects 37% to 47%of patients seen in ophthalmologist and optometrist settings.18

When the eyelid’s sebaceous glands become clogged, inflamma-tion ensues resulting in red, irritated, and itchy eyes.19 Twotypes of blepharitis exist. Anterior blepharitis describes inflam-mation of the outside of the eyelid, near the base of the lashes.Seborrheic dermatitis and staphylococcus bacteria are the twomost common causes. Inflammation of the meibomian glands inthe inner eyelid causes posterior blepharitis. Seborrheic derma-titis and acne/rosacea increase risk of developing posteriorblepharitis.19 Blepharitis is not contagious and rarely causes vi-sion loss.19

Practicing good eyelid hygiene helps reduce the risk of bothtypes of blepharitis. Keeping the eyelids clean can help minimizeinfection. Applying warm eyelid compresses several times dailywill loosen any crusts. Patients can also be instructed to cleantheir eyelids by gently rubbing a 1:10 solution of babyshampoo:warm water along the base of the lid, rinsing, and re-peating as necessary.20

For bacterial, severe, or refractory cases, patients can apply top-ical bacitracin or erythromycin to the eyelid one or more timesdaily for a several weeks.20 A short course of topical corticoster-oids can also be used to help reduce ocular inflammation. If top-ical treatments fail to improve symptoms, oral tetracyclineantibiotics (doxycycline, minocycline) can be tried until symp-toms resolve, usually within two to six weeks.20 Despite ade-quate eyelid hygiene and treatment, most cases of blepharitiswill recur.

Uveitis is defined as intraocular inflammation of the uvea. Theuvea provides necessary nourishment and blood supply to theretina. It is located in the center of the eye and contains the iris,choroid, and ciliary body. (See Figure 1 on Page 2) Unlikeblepharitis, uveitis can cause irreversible, sight-reducing tissuedamage. It is estimated that 35% of patients with uveitis exhibit

© Can Stock Photo / rob3000


Table 3. Anti-Inflammatory Topical drugs5,27,38

Drug Class Drugs in ClassGeneric (Brand)

Mechanism of Action Side Effects Clinical Notes

Topical antihista-mines

Azelastine 0.05% solution(Optivar)

Olopatadine 0.1% solution(Patanol) or 0.2% solution(Pataday)

Ketotifen 0.025%Solution (Zaditor and Ala-way)

Histamine receptor antag-onist

Mixed mast cell stabilizerand histamine receptorantagonist

Dry eyes, burning in theeye, blurred vision

Alaway and Zaditor areavailable over the counter

Topical mast cellstabilizers

Cromolyn 4% solution(Crolom)

Lodoxamide 0.1% solution(Alomide)

Blocks release of hista-mine from sensitized mastcells

Burning in the eye

Topical steroids Prednisolone acetate 1%(Pred Forte)

Fluorometholone 0.1% so-lution, suspension andointment (FML)

Loteprednol 0.5% gel,ointment or solution(Lotemax)

Unknown mechanism ofaction, but similar to sys-temic corticosteroids. In-volves decreasinginflammation

Raised intraocular pres-sure, blurred vision, in-creased tears, woundhealing defect, secondaryinfection

Avoid overuse due to pos-sible systemic steroid ef-fects

Topical NSAIDs Ketorolac 0.4% and 0.5%solution(Acular and Acular LS)

Diclofenac 0.1% solution(Voltaren)

Blocks prostaglandin com-plex formation and pro-duction, resulting inpotent analgesia

Burning in the eye, corne-al edema, infection, irrita-tion, iritis

Only use for a maximumof 5 days at a time

Cannot be used while pa-tient is wearing contactlenses

Table 4. Medications Used for Dilation38



Cycloplegics Cyclopentolate 0.5%-2%

Atropine 1%(Isopto Atropine)

Blocks action of thesphincter muscle, lead-ing to pupil dilation andparalysis of the ciliarymuscle

Blurred vision, burningsensation of the eye,photophobia

Press down on nasolacri-mal duct after instilla-tion to avoid systemiceffects

Pause and Ponder:What ocular conditions do you counsel on the most?

Cataract Post-Surgical CareCataracts account for 50% of all vision impairment in the US,affecting approximately one in every six adults over the age of40.25 A cataract is an age-related, progressive degradation ofthe crystalline lens in one or both eyes. Slowly over time, theeye’s lens becomes less flexible, more opaque, and thicker.Certain medical conditions such as hypertension, diabetes, andtobacco abuse accelerate tissue breakdown within the lens.The lens then becomes cloudy leading to impaired vision, or insome cases, blindness. Patients often have difficulty readingsmall print, impaired nighttime driving, and decreased func-tional independence.

Three types of cataracts exist: nuclear, cortical, and posteriorsubscapular. Currently, no medications are approved for thetreatment of any type of cataract. Symptomatic cataracts aremanaged with surgery. Surgery has been shown to improvequality of life and is more cost-effective than other methods.25

Medications are often prescribed before and after cataract sur-gery for symptomatic treatment and prevention of post-opera-tive complications.

Endopthalmitis is an acute eye infection characterized by eyedischarge and a white cloudiness on the retina. It occurs aftercataract surgery in about one out of every 1000 patients.26 Pa-tients may experience eye pain, redness, and vision loss. Be-cause endopthalmitis can result in complete blindness, eyesurgeons widely prescribed pre-operative antibiotic eye dropsin the past.26 However, povidone eye drops are administeredduring surgery for additional infection prophylaxis. Recentstudies have shown that there is no clinical advantage for pa-tients using topical antibiotics prior to the the


Technician TutorialCalculating days supply for eye drops

Most eye drop containers hold 5 to 15 mL of product. Verifyhow many mL are in the container prior to dispensing. OnemL of product contains approximately 20 drops. 56

Example:A patient brings in a prescription for ketotifen fumarate (Za-ditor) 0.025% for the treatment of allergic conjunctivitis.The directions read, “Instill 1 drop into both eyes twice dai-ly, every 12 hours.”

You have a 5mL bottle in stock. Calculate the days supply.● 2 drops per dose x 2 doses per day = 4 drops/day● 20 drops per ml x 5 ml = 100 drops per bottle● 100 drops total / 4 drops per day = 25 days supply

procedure over instillation of 5% povidone iodine solution dur-ing the procedure. Thus, most physicians have discontinued thispreoperative practice in favor of povidone during surgery.25

Post-operatively, several medication management strategiesexist. Unfortunately, no controlled trials directly compare vari-ous post-operative regimens. Topical steroids, NSAIDs and anti-biotics, alone or in combination, have been widelyrecommended. Ketorolac or prednisolone acetate are oftenprescribed to help with pain and inflammation after theirprocedure.25

© Can Stock Photo / megija

ConjunctivitisConjunctivitis is a common eye disorder, affecting approximately6 million people each year.27 Conjunctivitis is a broad term de-scribing a plethora of ocular eye conditions, all involving the thinconjunctiva membrane of the sclera and inside of the eyelids.When the conjunctiva becomes inflamed or infected, the medicalcondition is classified as “conjunctivitis.” Three types exist; bacte-rial, allergic, and viral.28 Understanding the different types of con-junctivitis is important for proper treatment selection.

Viral and bacterial conjunctivitis are both infectious in nature. Vi-ral conjunctivitis is the most commonly diagnosed form of thedisease—accounting for 80% of cases—and is often caused byadenovirus.28 It’s accompanied by systemic viral symptoms, suchas fever, pharyngitis, and cough. Bacterial conjunctivitis is causedby Staphylococcus aureus, Streptococcus pneumonia, or Haemo-philus influenzae. One can differentiate between bacterial andviral conjunctivitis by evaluating symptoms. In viral conjunctivitis,patients complain of watery discharge (sometimes purulent)along with a burning, gritty feeling in the eye. In bacterial con-junctivitis, patients have considerable amounts of thick, purulentdischarge throughout the day along with redness. In some in-stances, clinicians take cultures of eye discharge to determine thecause of conjunctival infection.27

Viral conjunctivitis may persist for two to three weeks, but doesnot require any medical treatment. Although self-limiting, viralconjunctivitis is contagious and easily transmitted via contami-nated hands, medical instruments, doorknobs, swimming pools,etc. Patients should engage supportive measures similar to anyother viral infection such as drinking plenty of fluids, resting, us-ing OTC decongestants (when appropriate), and applying warmcompresses to the eye. Some patients may also benefit from OTCeye treatments, such as artificial tears and topicalantihistamines.27

Bacterial conjunctivitis is also a highly contagious. Many assumethat bacterial conjunctivitis must be treated with a topical antibi-otic, but this is not necessary in all cases. Some studies haveshown that there is no difference in clinical improvement be-tween patients treated with antibiotics and those treated withsupportive measures only.29 However, antibiotic use is associatedwith faster symptom resolution. It is recommended that patientswait to use topical antibiotics because of the increase in antibiot-ic resistance. If a patient has a positive bacterial culture, he orshe should be treated with topical antibiotics.27

A recent study assessed the overprescribing of topical antibioticsfor acute conjunctivitis. Of note, 60% of patients with conjunctivi-tis were prescribed and filled prescriptions for topical antibioticsor combination steroid/antibiotic agents. This prescribing prac-tice is of great concern since combination steroid/antibiotic prod-ucts are not recommended due to growing concern aboutbacterial resistance.29

If antibiotics are indeed indicated, several options exist. Stud-ies have failed to demonstrate that one broad-spectrum topicalantibiotic is superior to another. Providers choose an appropri-ate topical antibiotic based on patient allergies, preference, andcost. If a bacterial culture has been taken, the results can guidedecision-making. Common antibiotics include erythromycin, to-bramycin, moxifloxacin, ofloxacin, etc. (See Table 5) Treatmentwith topical antibiotics ranges from five to 14 days dependingon the chosen agent and severity of disease.27

Unlike infectious conjunctivitis, allergic conjunctivitis affects40% of the population. The conjunctiva becomes inflamed inresponse to allergens in the environment. Ninety percent of allcases of allergic conjunctivitis are seasonal. Common symptomsinclude redness, photophobia and itchiness; purulent dischargeoccurs less frequently with allergic conjunctivitis comparedwith infectious conjunctivitis. Symptoms are usually bilateral.Patients can also exhibit systemic symptoms of allergies such asrhinitis, atopic dermatitis, asthma, and itching. For most, aller-gic conjunctivitis is a self-limiting and self-treatable conditionand does not require provider referral. Patients may resort toprovider intervention if their allergic conjunctivitis does not re-solve with the use of OTC products.27

If conjunctivitis is deemed to be allergic, patients are encour-aged to avoid their personal allergens—pollen, trees, dust—-when possible. Patients experiencing symptoms can try oralfirst or second-generation antihistamines (loratidine, fexofena-dine, etc.). Persistent symptoms can also be managed with ap-propriate OTC ocular products such as topical antihistaminesand/or mast cell stabilizers (See Table 3). OTC ketotifen pro-vides excellent relief of symptoms. Olopatadine is a mixed anti-histamine and mast cell stabilizer, and often works well forpatients who have failed all OTC therapies.28


© Can Stock Photo / soupstock

UCONN You Asked for It Continuing Education September 2018 Page 11

Table 5. Topical Antibiotic Medications5,27



Aminoglycosides Gentamicin 0.3% oint-ment and solution(Gentak)

Tobramycin 0.3% oint-ment and solution(Tobrex)

Disruption of bacterialcell protein synthesisleading to cell death

Irritation Tobramycin is also avail-able in combination withdexamethasone(TobraDex)

Fluoroquinolones Ciprofloxacin 0.3% oint-ment and solution(Ciloxan)

Moxifloxacin 0.5% solu-tion(Vigamox)

Ofloxacin 0.3% solution(Ocuflox)

Levofloxacin 1.5% solu-tion(Iquix)

Gatifloxacin 0.3% solu-tion(Zymar)

Interferes with DNA gy-rase, stopping the syn-thesis of bacterial DNA

Retinal detachment,burning sensation, eyepain, dry eye, reducedvisual acuity

Macrolides Azithromycin 1% solu-tion(Azasite)

Erythromycin 0.5% oint-ment

Inhibition of protein syn-thesis via binding to ri-bosomal 50S subunit inbacteria

Abnormal vision Azithromycin rarely pre-scribed, but used inplace of erythromycindue to drug shortages

Sulfonamides Sulfacetamide 10%solution and ointment(Bleph-10)

Bacteriostatic to preventsynthesis of bacterialdihydrofolic acid

Application site irritation

Polypeptides Bacitracin500units/gramointment

Inhibition of cell wallsynthesis

Contact dermatitis Difficult dosing as pa-tients often given in-structions in gramsrather than easier dos-ing formats

Combination products Trimethoprim/ polymyx-in B(Polytrim)

Polymyxin is bactericid-al- increase bacterial cellmembrane permeability.Trimethoprim interfereswith bacterial biosynthe-sis

Eye irritation

Dry EyeTears play an important role keeping the cornea moist. Made ofa mixture of oil, water, and mucous, tears nourish and protectthe eye.30 Dry eye occurs when tear production decreases, tearevaporation increases, and/or the composition of tears isimbalanced.30 Dry eye can occur at any age, but is more com-mon in older adults as tear production naturally declines withage.3 Common symptoms of dry eye include blurred vision, feel-ing that something is stuck in the eye, and sensations of stinging,burning, or scratching. Excessive watering of the eyes can alsooccur as they try to compensate for irritation and inflammation.More severe cases may cause ocular damage and visual impair-ment.

Many factors contribute to the development of dry eye. Post-menopausal women, contact lens wearers, those diagnosed withselect endocrine and inflammatory disorders (i.e. diabetes, thy-roid, vitamin A deficiency, rheumatoid arthritis), and those en-gaging in prolonged screen time appear at highest risk. Tearevaporation can also occur when a person is exposed to aller-gens or dry, windy climates. Transient cases of dry eye are oftenreported after eye injuries and surgery secondary toinflammation.3

Treatments for dry eyes aim to restore or maintain normal tearproduction, minimize irritation and prevent further oculardamage.3 Most cases of occasional, mild dry eye are suitable forself-treatment. The primary treatment approach for dry eye isuse of OTC ocular lubricants, including artificial tears and non-medicated gels and ointments. (See Table 6) Most popular areartificial tears. Artificial tears are specially formulated with wa-ter-soluble polymers, inorganic electrolytes, and preservatives.3

All artificial tears provide moisture. However, the product’s abili-ty to reduce evaporation, heal wounds, and protect the eye willdiffer depending on its composition. Products can also vary inviscosity. Solutions with higher viscosities will allow longer sur-face contact time and are less susceptible to tear dilution.3 Com-bining artificial tears with non-medicated gels and ointments canfurther enhance the product’s retention time. Preservative-freeformulations may cause less irritation but expire shortly afteropening.3 Patients should be counseled about the risk of con-tamination and infection with preservative-free formulas.

More severe cases of dry eye are treated with prescription med-ications or ocular inserts. Immune-suppressing corticosteroidsand cyclosporine (Restasis and Cequa) help control inflamma-tion. Corticosteroids are recommended for short-term use onlygiven their side effect profile. Cyclosporine decreases cornealdamage, increases basic tear production, and reducessymptoms.31 Drops should be administered in the affectedeye(s) twice a day, every 12 hours. Each bottle is for single-useonly. If artificial tears are used concomitantly, 15 minutes shouldelapse between product applications. Common side effects in-clude burning, redness,


tearing, discharge, pain, itching, and stinging. Pharmacy staffshould remind patients that cyclosporine’s therapeutic effectsmay take several months. 31

An artificial tear insert such as Lacrisert may be an option forindividuals with moderate to severe dry eye symptoms. Madeof hydroxypropyl cellulose, the patient places the insert be-tween the lower eyelid and eyeball once daily. As it dissolves, itreleases lubricants that stabilize and thicken tear film to pro-long tear film breakup.32 If used improperly, corneal abrasioncan occur. Common side effects include blurred vision, discom-fort, eyelid edema, and photophobia.

Patients may ask if supplementation with omega-3 fatty acidsrelieves symptoms of dry eye. Findings from the 2018 Dry EyeAssessment and Management Study (DREAM) call this recom-mendation into question. Participants with moderate to severedry eye disease were randomly assigned to 3000 mg fish-de-rived n-3 eicosapentaenoic and docosahexaenoic acids or oliveoil placebo daily. After 12 months of supplementation, no sta-tistically significant differences in dry eye symptom severityscores were observed between the groups. 33

Pharmacists can provide additional non-pharmacologic recom-mendations for the management of dry eye. When appropri-ate, patients should be advised to break up prolonged periodsof screen time. Wearing sunglasses with wrap around framescan help reduce exposure to wind and dust. Use of a humidifierwill help reduce dry air.

Patients who self-treat mild, occasional dry eye should follow-up with their healthcare provider for further evaluation ifsymptoms do not improve, or worsen, after 72 hours.3

© Can Stock Photo / DJTaylor


Table 6. Over-the-Counter Ophthalmic Lubricants3

Artificial TearsProduct Ingredients Suggested Dosing

TheraTears Sodium carboxymethylcellulose (0.25%) Instill 1 to 2 drops in affected eye(s) as needed

Refresh Tears Carboxymethylcellulose Sodium (0.5%) Instill 1 to 2 drops in affected eye(s) as needed

Systane Ultra Polyethylene Glycol 400 (0.4%),Propylene Glycol (0.3%)

Shake well before using. Instill 1 to 2 drops in af-fected eye(s) as needed

GenTeal TearsPreservative free

Dextran (70 0.1%),Hypromellose 2910 (0.3%)

Instill 1 to 2 drops in affected eye(s) as needed .Make sure container is intact before use.

SoothePreservative free

Glycerin (0.6%), Propylene Glycol (0.6%) Instill 1 to 2 drops in affected eye(s) as needed

Blink tears Polyethylene Glycol 400 (0.25%) Instill 1 to 2 drops in affected eye(s) as needed oras directed by your eye care professional

Non-Medicated GelsSystane Gel Nighttime Protec-tion

Hypromellose (0.3%) Instill 1 or 2 drops in the affected eye(s) as needed

Refresh Liquigel Carboxymethylcellulose Sodium (1%) Instill 1 or 2 drops in the affected eye(s) as needed

Non-Medicated OintmentsGenTeal Nighttime PM ointment Mineral oil (3%), white petrolatum (94%),

inactive ingredient anhydrous liquid lanolin3%.

Apply 1 or more times per day as directed

Systane Nighttime Mineral oil (3%), white petrolatum (94%),inactive ingredient anhydrous liquid lanolin3%.

Pull down the lower lid of the affected eye and ap-ply a small amount (one-fourth inch) of ointmentto the inside of the eyelid

* Not inclusive list

Color of Bottle Cap Medication ClassPink Anti-inflammatories/steroidsRed Mydriatics and cycloplegicsOrange Carbonic anhydrase inhibitorsYellow Beta-blockersLight green Adrenergic agonist combinationsOlive green Anti-inflammatory, immunomodulatorsDark green MioticsTurquoise Prostaglandin analoguesDark blue Beta-blocker combinationPurple Adrenergic agonistsTan Anti-infectivesGray Nonsteroidal anti-inflammatoriesBlack Cytotoxics

An Eye-Opening FactDid you know that manufacturers voluntari-ly use a color-coding system for topical ocu-lar medications’ caps and labels?

Since 1983, manufacturers have used thissystem to increase patient safety. TheAmerican Academy of Ophthalmology (AAO)proposed the system after many patientswho had trouble distinguishing among vari-ous ocular medications experienced seriousadverse events.

The AAO selected specific Pantone colors(which are standardized and reproducible)for each drug class according to the natureof the disease being treated, the product'sside-effect profile, and the risk of serioussequelae if a product is inadvertentlyswitched with another.Adapted from Color Codes for Topical Ocular Medication. Available at https://www.aao.org/about/policies/color-codes-

topical-ocular-medications. Accessed September 18, 2018.


GlaucomaGlaucoma is the second leading cause of blindness in the world.Approximately 8.4 million are blind from the disease.34 It is acomplicated medical condition characterized by increased IOPand disc abnormalities that can lead to optic neuropathy andfield vision loss. Two forms of glaucoma are widely recognized:open angle and angle-closure glaucoma (i.e. closed angle).

Open angle glaucoma (OAG), the more common type, affects45 million adults worldwide.34 It primarily affects adults overthe age of 40. The pathogenesis is poorly understood, but reti-nal cell death is believed to contribute to increased IOP. IOP de-pends on the balance between production of aqueous humorand its outflow through the trabecular meshwork. In OAG,aqueous humor outflow is diminished. Patients do not oftencomplain of symptoms when they have OAG largely becausesymptoms do not occur until later stages. This can delay diag-nosis and as a result, treatment. OAG is usually discovered dur-ing routine eye exams.35

IOP can be elevated (> 21 mmHg) or within the normal range,so a diagnosis of OAG must include visual field loss and opticnerve damage; IOP is not a diagnostic factor.

The primary goal of treatment for OAG is to lower IOP to pre-vent vision loss. Lowering the IOP has proven to decrease dis-ease progression.35 Eye drops are the treatment of choice. Theyreduce IOP by either decreasing the aqueous humor production(beta-blockers, carbonic anhydrase inhibitors), increasing aque-ous outflow (prostaglandins), or both (alpha-agonists). (See Ta-ble 7) Combination therapy should be considered whenmonotherapy fails to reach the IOP target. Prostaglandins arethe preferred first-line treatment. Prostaglandins are dosedonce a day, offering an advantage for patients with adherenceproblems. They also have minimal systemic side effects com-pared to other agents. The most frequently prescribed prosta-glandin is latanoprost.34 Patients using prostaglandins should beadvised of side effects including eyelash growth and iris pig-mentation changes.

A second line agent can be added if IOP goals are not met.Some providers may choose to discontinue the prostaglandinaltogether in favor of a second line medication. Second line op-tions include beta-blockers, topical carbonic anhydrase inhibi-tors, and alpha-adrenergic agonists. Topical beta-blockers,including timolol and betaxolol, lower IOP and have few ocularside effects. These medications should however be used withcaution because of the possibility of systemic side effects suchas hypotension, decreased heart rate, and increased airwayresistance.34 Carbonic anhydrase inhibitors such as dorzolamideor brinzolamide are commonly used as adjunctive therapies butrarely as initial therapy. Currently, the only commercially avail-able alpha-adrenergic agonist is brimonidine. Brimonidine hasbeen found to lower rates of visual field disturbances more

than topical beta-blockers.36 Although it effectively slows OAG’sprogression, many patients discontinue brimonidine because ofocular allergy. This chronic itchy eye associated with brimoni-dine often leads poor adherence.36

If patients do not respond to topical medications, surgery is anoption. This procedure is called laser trabeculoplasty and in-volves the trabecular network, releasing pressure from the eye.Some patients who have the procedure still require topicaltreatment after the fact.37

Unlike OAG, angle closure glaucoma usually presents as anacute condition. It is characterized by the blockage of aqueoushumor flow caused by the peripheral iris contacting the periph-eral cornea. This blockage causes a sharp, dangerous increasein IOP. Patients with acute angle closure glaucoma complain ofsevere ocular pain, blurred vision, and halos. Patients can alsoexperience general nausea and vomiting. Acute angle closureglaucoma is a medical emergency. Without prompt treatment itcould lead to temporary or permanent vision loss.37

Treatment of angle closure glaucoma involves similar medica-tions to OAG but with different administration schedules. Onedrug commonly used for symptom relief is pilocarpine. Pilo-carpine quickly reduces pressure in the eye when administeredas one drop every 15 to 60 minutes for two to four doses untilIOP drops within the acceptable range. Topical beta-blockerscan be used in combination with pilocarpine. Miotic agents arealso an option to increase aqueous humor outflow and help topull the iris into place. This pulling allows for the closed angle inthe eye to open and pressure to be released. Following relief ofthe acute episode, patients will use topical prostaglandins, be-ta-blockers, etc. in a manner similar to OAG.37

© Can Stock Photo / rob3000

Table 7. Topical Medications for the Treatment of Glaucoma34


Mechanism of Action Side Effects Storage &Administration

Beta-Blockers

** Yellow cap

▪ Timolol 0.25% or 0.5%solution or gel-formingsolution (Timoptic)▪ Betaxolol 0.5% and0.25% suspension andsolution (Kerlone and Be-toptic)▪ Levobunolol 0.5% solu-tion (Betagan)

Decrease aqueous humorproduction

Allergic conjunctivitis,keratitis.

Monitor for systemic sideeffects, such as bradycar-dia, fatigue

Use with caution in pa-tients with restrictive air-way diseases

Dosed 1-2 times daily

Prostaglandins

** Turquoise cap

▪ Latanoprost 0.005%soultion(Xalatan)▪ Bimatoprost 0.01% so-lution (Lumigan)▪ Travoprost 0.004% (Tra-vatan Z)

Increase aqueous humoroutflow

Increased eyelashgrowth, periocular hyper-pigmentation, uveitis, flu-like symptoms

Do not use in patientswith uveitis or macularedema.

Latanoprost must bestored in the refrigerator.

Good for 42 days once atroom temperature

Use in the eveningAlpha adrenergic ag-onists

** Purple cap

▪ Brimonidine 0.15% and0.2% solution(Alphagan)

Improve outflow of aque-ous humor. Decreasesaqueous humor produc-tion. Decreases venouspressure

Allergic conjunctivitis, drymouth, dry nose

Do not use with MAOIs

Usually administered 2-3times a day

Carbonic anhydraseinhibitors (topical)

** Orange cap

▪ Dorzolamide 2% solu-tion (Trusopt)▪ Brinzolamide 1%(Azopt)


Corneal edema, allergicconjunctivitis, metallictaste

Do not use in patientswith sulfa allergies

CombinationTherapy

▪ Dorzolamide 2%/timolol0.5% (Cosopt)▪ Brimonidine 0.2%/timolol 0.5% (Combigan)▪ Brinzolamide 1% /bri-monidine tartrate 0.2%(Simbrinza)


Burning in the eye,blepharitis, blurred vi-sion, excessive tear pro-duction, itchy eye

Watch for systemic ef-fects of beta blockers

Miotics

** Dark green cap

▪ Pilocarpine 2% solution(Pilor)

Increase outflow of aque-ous humor.Contracts ciliary musclesin the eye to open thetrabecular meshwork

Headache, sweatingwhen absorbed systemi-cally

Do not use with uveitis


Please see the table on page 12 for a complete list of cap colors by drug class.


Retinal Detachment Perioperative CareRetinal detachment is most frequently characterized by a breakin the retina, sometimes complete but most often partial. Thisallows fluid located in the vitreous cavity to leak into the sub-retinal space disrupting vision. Breaks in the retina are causedby various factors and the type of detachment is categorizedbased on the underlying cause. Rhegmatogenous breaks areassociated with age, myopia, ocular surgery, and trauma.38

Tractional breaks occur when scarring is present on the retinalsurface and vitreous cavity caused by proliferative diabeticretinopathy. Additional causes of tractional breaks include eyeinjury, sickle retinopathy, and retinal vein occlusion. Exudativeretinal detachment is associated with inflammatory eye condi-tions (uveitis), maculopathy, and vascular conditions.38

Patients with retinal detachment often experience photopsia,floaters, opacities, black dots, and visual field defects. With afull tear of the retina, the patient loses vision in that eye. Pa-tients with such symptoms should be referred for emergencycare. Treatment for retinal detachment is limited to surgical re-attachment. The severity of the condition determines howquickly the surgical reattachment should occur. Three types ofsurgical procedures are available for retinal reattachment:scleral buckling, vitrectomy, and pneumatic retinopexy.38

Following surgery, patients will need a variety of treatmentsincluding topical antibiotics, pain relievers, steroids, cycloplegicagents, and/or beta-blockers. Antibiotics, such as ofloxacin, areused to prevent post-operative endophlamitis. Prednisolone orother topical steroids are used to help with inflammation asso-ciated with the surgery. Some physicians recommend as few asfour days of post-operative medications, while others adviselonger regimens.38 It is currently unknown which treatmentcombinations and durations of therapy are most effective; ther-apeutic decisions are at the provider’s discretion.38

MEDICATION-INDUCED OCULAR DISEASECountless topical and systemic medications can cause undesir-able ocular side effects. Some effects can be minor causingtransient dryness and irritation, while others can be more seri-ous resulting in vision loss. The extent of such side effects is re-lated to the dose, duration of use, and individual patientcharacteristics.39 Prompt discontinuation of the offending drugcan often reverse ocular damage. In some cases however, thedamage may be irreversible. As medication experts, pharma-cists are best suited to assist with the detection and preventionof such side effects. This section highlights several widely usedmedications known to cause ocular side effects.

Preservatives – Preservatives are commonly added to eyedrops to reduce product contamination. Thiomersal and ben-zalkonium chloride containing preservatives can irritate cornealand conjunctival cells causing local redness and inflammation.3

Patients with such sensitivity should opt for preservative-freeformulations when possible.

Corticosteroids – Use of topical and systemic corticosteroids (e.g.prednisone) causes structural and functional changes within theeye. Steroids reduce aqueous humor outflow resulting in in-creased IOP.39 Clinicians should monitor patients with preexistingOAG for worsening disease. Bilateral, posterior subcapsular cata-racts have also been linked to long-term (more than 1 year),high-dose (more than 10 mg/day) steroid use.40 Cataract surgerycan successfully retore vision loss from steroids.

Anticholinergics – Various anticholinergic drugs (histamine an-tagonists, tricyclic antidepressants, paroxetine, tiotropium, etc.)induce photophobia and mydriasis thus increasing the risk for an-gle-closure glaucoma.39 Additionally, the drying effects of antich-olinergics reduce tear production and may cause or worsen dryeye.3

Hydroxychloroquine – Hydroxychloroquine use can result in irre-versible, toxic retinopathy.39 Metabolism of retinal cells is be-lieved to cause the problem, although the mechanism is poorlyunderstood. Factors that increase risk of developing retinopathyinclude the following41:

● Long durations of treatment● Doses greater than 5 mg/kg/real weight/day● Comorbid renal disease● Use of concomitant tamoxifen

A basic fundus exam is recommended prior to the start of thera-py. After five years of treatment, yearly exams arerecommended.41

Amiodarone - Amiodarone can cause reversible optic neuropathyand photophobia. Corneal deposits and degeneration causeblurred vision and the appearance of colored rings or halosaround objects.39 Ocular changes happen gradually over severalmonths. Eye screenings should be done at baseline, and every sixmonths during the first year.42 Annual follow-up is recommendedthereafter.

Tamsulosin – Tamsulosin has high affinity for the α1A receptorfound in the smooth muscle and iris dilator. Blocking this recep-tor triggers iris prolapse (“floppy eye syndrome”) and impairs pu-pil dilation, making dilator drops used in cataract surgeryineffective.43 Patients considering cataract surgery should discussuse of tamsulosin or any alpha-blocker with their surgeon assoon as possible.

Digoxin – Digoxin toxicity can manifest with visual abnormalitiesof the retina. These include reduced visual acuity, xanthopsia,discoloration of objects, and photophobia.42 Symptoms are re-versible upon discontinuation. Maintaining normal serum levelsof digoxin (0.5-2 ng/mL) can minimize ocular side effects.


TRENDS IN EYE CARENew TechnologiesEye drops are the mainstay of treatment for most ocular disor-ders; more than 90% of available ocular products are formulat-ed as eye drops.44 Unfortunately, the cornea hampers mostdrug absorption.44 New drug delivery systems are needed toovercome these barriers. By doing so, drugs can penetrate thecornea and maintain therapeutic concentrations in the ocularspace. New delivery systems have become widely available inrecent years. These include ointments, emulsions, gels, suspen-sions, and nanoparticles. Nanoparticle technology is of particu-lar interest since most products are associated with low rates ofocular irritation. Solubility and bioavailability are alsoenhanced.44 Common nanoparticle formulations include lipo-somes, nanomicelles, and nanospheres.

New ProductsA handheld stimulator, TrueTear, is the first Food and Drug Ad-ministration (FDA) approved device for dry eye. The drug-freedevice comes with disposable tips that are inserted into thenose to help stimulate tear production. The neurostimulationtechnology is similar to well known devices like pacemakersand TENS devices used for back pain. It is recommended forthose suffering from severe dry eye symptoms.45

In late 2017, the FDA approved a new drug class of eye dropsfor the treatment of OAG and ocular hypertension. The ap-proved agent, latanoprostene bunod ophthalmic solution0.024% (Vyzulta) has a novel mechanism of action combiningthe function of prostaglandins to increase the outflow of aque-ous humor and nitric oxide donation to relax the trabecularmeshwork for greater humor outflow.46 Safety studies indicatelatanoprostene bunod seems have a side effect profile similarto other prostaglandins. Although its exact place in treatmentfor OAG is unknown at this time, researchers believe that thisdrug will be useful.

In August 2018, the FDA also approved cyclosporine A ophthal-mic solution 0.09% (Cequa) to increase tear production in pa-tients with dry eye. It is purported to provide the highestFDA-approved concentration of cyclosporine A. The product us-es nanomicellar technology, to improve solubility and productpenetration. The most common side effects include pain uponadministration and conjunctival hyperemia.47

New Uses for Old ProductsWomen rely on make-up to enhance their natural beauty. Re-cently, prostaglandin analogues have been formulated into var-ious cosmetic products, sparking a billion dollar beauty craze.48

Several prostaglandin-containing products are available to as-sist, both OTC and by prescription. They are marketed to en-hance eyelash length, volume, and color. Only bimatoprost0.03% (Latisse) is FDA-approved to treat hypotrichosis of theeyelashes. Revitalash, LiLash, and MD Lash Factor (among oth-

ers) are cosmetic options available without a prescription. Theseserums are co-formulated with vitamins, extracts, andpeptides.48 OTC products’ safety and efficacy have not been firm-ly established.

BARRIERS TO MEDICATION ADHERENCE:AN OPPORTUNITY FOR PHARMACISTSPatients who don’t take their medications as directed have diffi-culty achieving treatment outcomes. In the case of glaucoma orAMD, poor adherence can lead to progressive vision loss andblindness. For dry eye or allergy sufferers, quality of life may bereduced if symptoms are untreated. Actual rates of medicationnonadherence are often underestimated. For patients with glau-coma, adherence to standard eye drops varies from 30% to80%.49

Medication nonadherence takes many forms. It is not limited tofailing to take the medication. Medication nonadherence alsoincludes incorrect administration. A recent study evaluated theeye drop instillation technique of 164 patients with glaucoma orocular hypertension.50 Patients were asked at baseline to self-assess the degree of difficulty they had with administering theirdaily eye drops. Study personnel observed participants’ adminis-tration technique at baseline and 12 weeks later. Approximately88% of patients self-reported no difficulty in using eye drops atbaseline. However, when researchers observed these patients,they noted errors such as the bottle touches the eye, the eyedrop misses the eye, and more than one drop administered werenoted.50 Interestingly, a majority of the patients enrolled hadbeen using eye drops for more than a year prior to the start ofthe study and received counseling on how to properly adminis-ter eye drops. These findings reinforce the need to not only en-sure patients take their medications, but do so correctly!

Several barriers have been linked to poor adherence with ocularmedications. Common reasons include skepticism about the dis-ease and its impact on vision, skepticism that medications areeffective, poor understanding of the disease itself, poor self-effi-cacy, forgetfulness, cost, complexity of the medication regimen,side effects, difficult administration techniques, and life stress.49

The greater number of barriers identified, the more likely a pa-tient will be non-adherent.49

Complex medication regimens - Recommend simplification ofthe dosing regimen when possible. Switch from multiple dailydoses to once daily or twice daily regimens. This minimizes theneed for patients to carry their drops with them throughout theday and lessens the interference of dosing during work, school,or other important times. Fewer daily doses have been linkedwith better rates of adherence.51 Alternatively, pharmacists canrecommend use of fixed-dose combination products when avail-able. Some examples for the treatment of glaucoma include Cos-opt (dorzolamide/timolol), Combigan (brimonidinetartrate/timolol) and Simbrinza (brinzolamide/brimonidine).

Use of combination products may also offer the advantage ofreducing ocular exposure to preservatives and lessen thechances of multiple container contaminations.

Forgetfulness – Forgetting to take one’s medication is the mostfrequently cited reason for nonadherence.52 It’s natural to for-get things once in a while, especially when things get busy.However, repeated forgetfulness can impact a patient’s abilityto reach his or her therapeutic goals. Using mobile applications(apps) can help improve adherence, even for patients who arenot technologically savvy.53 Free options include MyMeds Med-ication Management and Dosecast Medication Reminder. Otherstrategies to minimize forgetfulness include simplifying the reg-imen so there is less to forget, providing patients with medica-tion calendars or schedules, and scheduling more frequentfollow-up, thus holding patients accountable.

Side effects – Many conventional eye drops and ointments cancause local stinging or irritation upon administration. Highlyconcentrated products or excessive application of such prod-ucts can enter the circulation through the conjunctival vessels,thus increasing the chance for systemic side effects. Timolol forexample can decrease heart rate if it enters the systemic circu-lation. How a patient perceives or experiences these side ef-fects contributes greatly in his or her decision to take or nottake subsequent doses. Fortunately, this behavior is modifiable.When a patient complains of such side effects, pharmacistsshould verify the patient’s administration technique is correct(See ‘Administration technique’ below); identify any errors; andcorrect the patient’s technique. If side effects persist, the pre-scriber should be contacted to see if any alternative medica-tions could be tried. This includes finding preservative freeformulas, ingredients with lower concentrations, or an alterna-tive with less frequent dosing.

Cost – High co-payments and deductibles can keep patientsfrom filling their prescriptions. If ultimately a patient does pickup a prescription after a cost-related delay, he or she may bemore prone to change the frequency of administration to makethe supply last longer. Fortunately, information about medica-tion cost is widely available. Most insurance companies publishtheir preferred drug formulary online. If patients do not haveaccess to a computer, they can call the insurer directly to askabout copayment information and/or less expensive alterna-tives. Pharmacists can also identify and recommend OTC andprescription generic products, which tend to be less expensive.In some cases, use of fixed-dose combination products mayhelp reduce overall medication costs and number of individualco-payments. Many manufacturers offer patient assistance pro-grams or coupons to offset drug costs for those who cannot af-ford their medications. Each program has different eligibilitycriteria. Pharmacists can help patients enroll in such programs.

Patients should be discouraged from sharing eye drops in aneffort to minimize cost. Shared containers can become contam-inated and increase the risk of infection among users, especiallyif the product is preservative-free.

Since eye drops can be costly, every effort should be made tominimize product waste. If the drops do not fall onto the eye,spillage down the cheek and face can occur. With proper instil-lation, eye drop waste should be minimal. Most eye drop con-tainers are intended to last more than 30 days when packagedin 5 mL and 10 mL bottles (See Technician Tutorial on page 8).If a patient is running out of medication early, pharmacistsshould suspect waste and reassess administration technique.

Skepticism about the disease – It is important to understand apatient’s beliefs about their disease. Several ocular conditionsare largely asymptomatic and progress slowly. Consequently,patients may not be aware of the disease severity or the degreeof vision loss that can occur. Rates of nonadherence are higherwhen patients are symptom free.54 Pharmacists can teach pa-tients about their disease and help correct any educationalgaps or misconceptions. Patients can be encouraged to learnmore about their disease(s) by visiting the National Eye Insti-tute at https://nei.nih.gov/ or MedlinePlus athttps://medlineplus.gov/.

Skepticism of product effectiveness – Conventional eye dropsare absorbed through the cornea and conjunctival mucosa andvessels. This offers an advantage over systemic medicationsthat cannot easily penetrate the aqueous humor and cornea.55

However, depending on the formulation of the eye drops (pH,buffers, tonicity adjusters, etc.), the product can evaporatefrom the eye’s surface leaving patients to question whether theproduct is effective or not. Patients need to be educated thatproduct evaporation is common and does not signify reducedefficacy. Frequent dosing helps overcome the short contacttime. However, if a patient remains skeptical, pharmacists canrecommend alternative formulations. Ophthalmic ointmentsand gels prolong ocular contact time and improve drug bioavail-ability thus reducing the need for multiple doses.55 Such dosageforms are associated with blurred vision. For this reason, night-time dosing is preferred. As new formulations come to market,patients will have a greater number of options.

Pause and Ponder:What are some of the most common reasons

that patients do not take their ophthalmicmedications as directed?


Administration technique – To maximize product effectiveness and mini-mize side effects, proper administration of ocular products is needed. Phar-macists and pharmacy technicians should note that many patients, as theyage, develop arthritis in their hands and may have difficulty with the admin-istration technique. For this and many other reasons, ophthalmic productsare often used incorrectly; therefore patient education should be a top pri-ority for pharmacy staff. Different dosage forms require different tech-niques.

Eye drop administration technique3

1. Inspect the product. Solutions will be clear. Suspensions will be cloudy.2. Wash hands thoroughly.3. Remove contact lenses unless the product is designed for use with con-

tact lenses.4. Tilt head back.5. Gently grasp the lower outer eyelid below the lashes and pull the eyelid

away from the eye to create a pouch.6. Place dropper over eye by looking directly at it. The tip of the dropper

should NOT touch the eye.7. Before applying a drop, look up.8. As soon as the drop is applied, release the eyelid slowly. Close eyes gen-

tly for three minutes by placing your head down as though looking atthe floor (using gravity to pull the drop onto the cornea). Minimizeblinking or squeezing the eyelid.

9. Use a finger to put gentle pressure over the opening of the tear duct.10. Blot excessive medication from around the eye.11. If multiple drops are needed, wait five minutes before instilling the next

drop.12. If using a suspension, shake it well before instilling. If using suspensions

with other dosage forms, use the suspension drop last since it has thelongest retention time in the tear film.

13. If using both drops and ointments, instill the drop at least 10 minutesbefore the ointment so that the ointment does not become a barrier tothe drop’s penetration of the tear film or cornea.

Eye ointment administration technique3

1. Wash hands thoroughly.2. Tilt head back.3. Remove contact lenses. Contact lenses are not compatible with oint-

ment use.4. Gently grasp the lower outer eyelid below the lashes and pull the eyelid

away.5. Place ointment tube over eye by looking directly at it.6. With a sweeping motion, place ¼ to ½ inch of ointment inside the lower

eyelid by gently squeezing the tube. AVOID touching the tube tip to anytissue surface.

7. Release the eyelid slowly.8. Close eye gently for 1-2 minutes.9. Blot excessive ointment from around the eye.10. Vision may be temporarily blurred. Avoid activities that require good

visual ability until vision clears.


The American Academy of Ophthalmology offers a comprehen-sive patient education site called Eye Health A-Z. Pharmacystaff can refer patients to the site (https://www.aao.org/eye-health/a-z) when they have questions about any type of oph-thalmic condition. In addition to covering age-related maculardegeneration, blepharitis, cataracts, corneal conditions, con-junctivitis, dry eye, and glaucoma, it covers dozens of otherconditions. The University of Texas Health Science Center atSan Antonio also has a patient information page on eye diseas-es and conditions (http://uthscsa.edu/eye/patientinfo.asp) andit offers the advantage of providing the information in bothEnglish and Spanish.

CONCLUSIONOcular diseases are common and impact patients in many ways.From minor eye irritation to severe vision loss, these conse-quences can greatly influence a patient’s quality of life. Luckily,pharmacists are widely accessible and can play a critical role inscreening appropriate self-care candidates, selecting drug ther-apy and providing patient education (see Figure 3). Pharmacistscan also teach patients about new drug products and techno-logical advancements in eye care. Because adherence to ocularmedications is poor, pharmacists and their staff need to be wellversed on ways to improve the medication management pro-cess. Only then can patients achieve their goals.

Best❶Be COMMUNITY CHAMPIONS and talk to aging patientsabout the importance of screening for glaucoma and age–related macular degeneration❷Collaborate with local ocular care specialists to enhanceinformation transfer and improve patient safety❸Counsel, counsel, counsel and demonstrate propertechnique for instilling eye drops and ointments. Ittakes just a few minutes!

Better❶Always ask about potential adherence issues (especially ar-thritis) when filling prescriptions for ophthalmics❷Recognize that cap color means something when dispensingophthalmics and make a note of it! This can increase safety.❸ Know the basic treatment approaches for commonophthalmic products, especially conjunctivitisand dry eye, which are common

Figure 3. Advancing Pharmacists and Pharmacy Technicians Role in Ocular Health

© Can Stock Photo / ymgerman

Good❶Be familiar with ocular conditions in gener-al, and the red flags that indicate referral to anocular specialist❷Educate patients about the differences be-tween eye conditions and eye products


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