6. Treating Eye Ear Conditions

UCL SCHOOL OF PHARMACY

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Treating Eye & Ear Conditions

Teaching Fellow

Oksana Pyzik [email protected]

DPP room 339 @OksanaUCL_DPP


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Learning Outcomes

– Review general anatomy of the eye and ear

– Aetiology, symptoms, treatment and referral

points of common eye and ear conditions

– Differential Diagnosis; conditions to eliminate

– Differentiating between viral, bacterial and

allergic conjunctivitis

– Counselling points for common eye and ear

conditions


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Red Eye

• The most likely cause of a painless red eye is conjunctivitis.

• The next most likely cause is a burst blood vessel

• Conjunctivitis = inflammation of conjunctiva

• Characterised by varying degrees of redness, itchiness, discharge and irritation

• Can be viral, allergic or bacterial

• All are self limiting although viral can be recurrent/persist for weeks


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Incidence

• Red eye is a presenting complaint of both serious and non-serious causes of eye pathology

• Less common causes of red eye include episcleritis, scleritis, keratitis, uveitis

• Patient with undiagnosed acute closed angle glaucoma very unlikely to present with symptoms at community pharmacy (medical emergency)


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Aetiology of Conjunctivitis

• Viral conjunctivitis is most often caused by the adenovirus

• Allergic conjunctivitis is most often caused by pollen

• The various pathogens that cause bacterial conjunctivitis vary between adults and children.

• Causative organism in children: Streptococcus, Moraxella and Haemophilus Influenza most common

• Causative organism in adults:

–Staphylococcus is most common (over 50%)

–Streptococcus pnuemoniae (20%)

–Moraxella species (5%)

–Haemophilus influenzae (5%)


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Specific questions to ask patient

that presents with red eye:

• Discharge present?

• Any visual changes?

• Any pain, itch or discomfort?

• Check for location of redness

• How long?

• Any sensitivity to light?

(photophobia)

• Any other symptoms?


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Symptoms of Conjuctivitis

Bacterial Viral Allergic

Eyes Affected Both (but one eye

often affected first

by 24-48 hours)

Both Both

Discharge Purulent Watery Watery

Pain Gritty Gritty Itching

Distribution of

redness

Generalised &

diffuse

Generalised Generalised but

greatest in

fornices

Associated

Symptoms

None Cough & cold

symptoms

Rhinitis (may also

have family

history of atopy


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Identify the following condition:


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Subconjunctival Haemorrhage

• Burst blood vessel in the eye = subconjunctival haemorrhage

• Painless

• Straining or coughing can sometimes cause a blood vessel to burst on the eye surface, causing a bright red blotch..

• It can look even more alarming if you are taking medication such as aspirin or warfarin.

• Self limiting (10 – 14 days)


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Episcleritis

• Episclera lies just beneath conjuctiva

• Redness appears segmental

• Usually only one eye affected

• Painless or dull ache

• Self limiting resolves in 2 -3 weeks

• Unlikely incidence


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Bacterial conjuctivitis

• Self limiting (65% of people will have

clinical cure in 2 - 5 days)

• Chloramphenicol deregulated from POM in

2005

• No OTC treatment for viral


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Treatment for Bacterial Conjuctivitis

Bacterial conjunctivitis is largely self limiting within 2 – 5 days

• Must be stored in fridge

• Drops & ointment licensed for use in children 2+

• Instill 1 drop every 2 hours for the first 48 hours, then reducing to QDS for a MAX course of 5 days

• *IF using ointment + drops (apply ointment at night)

• –Ointment alone = apply 1 cm to eye TDS – QDS

• AVOID in pregnant/breastfeeding women, family history of blood dyscrasias including aplastic anaemia

• SE: usually minor e.g. transient stinging or burning sensation, transient blurring of vision patients should be warned not to drive or operate machinery unless their vision is clear. See summary of product characteristics (SPC) for complete list.


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NOTE:

• Patients who wear soft contact lenses

should be advised to stop wearing them

while treatment continues and for 48 hours

afterwards

• This is because preservatives in the drops

can damage the lenses


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• Alternative product:

• Propamidine Isethionate 0.1% (Golden Eye Drops),

• Dibromopropamidine Isethionate 0.15% (Golden Eye Ointment)

• Licensed 12 yrs +

• Dose for Eye Drops = 1 -2 drops up to QDS

• Dose for Eye Ointment = Apply once or twice daily

• If no significant improvement after 2 days REFER!


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Administration of Eye Drops: 1. Wash your hands

2. Tilt your head backwards until you can see the ceiling

3. Pull down the lower eyelid by pinching outwards to form a small pocket and look upwards

4. Holding the dropper in the other hand, hold it as near as possible to the eyelid without touching it

5. Place one drop inside the lower eyelid then close your eye

6. Wipe away any excess with clean tissue

7. Repeat steps 2 -6 for subsequent drops.


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General Advice

• Avoid touching the eye & spreading any infection to the other eye.

• Bathe eyelids with lukewarm water to remove any discharge

• Tissues should be used to wipe the eyes and thrown away immediately.

• Wash hands regularly.

• Hold a clean, cold damp face flannel to the eye to soothe and cleanse it.

• Do not wear make-up or contact lenses until the conjunctivitis has cleared.

• Do not share towels, flannels and pillow cases with others in the home while you have conjunctivitis


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Treatment Allergic Conjuctivitis

1)Mast Cell Stabilisers (Sodium Cromoglicate)

– Prophylactic agent must be used continuously while exposed to allergen (e.g. pollen for the season)

– Dose: Instill 1 – 2 drops in each eye for QDS, Age: 6+ years

2)Sympathomimetics + Antihistamines

• -Reduce redness of eye(s) limited to short term use to avoid rebound effects

• Naphazoline (sympathomimetic only) 1 -2 drops TDS/QDS

• Combo Product: Otrivin Antistin (antazoline/xylometazoline)

• Dose: Instill 1-2 drops BD/TDS, Age: 12+ years

• -Avoid in patients with glaucoma (raised intraocular pressure) CI: MAOIs, moclobemide (risk of hypertensive crisis)


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• How do these medicines work?

Which of the following do not

require referral for red eye?

A. Clouding of cornea

B. Distortion of vision

C. Itchiness of the

eye

D. Irregular shaped

pupil

E. Redness localised

around pupil Clo

uding o

f corn

ea

Distorti

on of v

ision

Itchin

ess o

f the eye

Irregu

lar s

haped pupil

Redness lo

calis

ed arou..

20% 20% 20%20%20%


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Referral Points

Answer ( C ) Itchiness does require NOT referral for red eye.

Full referral list:

–Associated vomiting

–Photophobia

–Clouding of the cornea (suggests glaucoma)

–True eye pain

–Redness caused by a foreign body (requires removal)

–Irregular shaped pupil or abnormal pupil reaction to light

–Redness localised around the pupil

–Distortion of vision


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Treating Otic Conditions


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Otic Conditions:

• Be familiar with general anatomy of the ear

• Distinguish symptoms between otitis externa “swimmers ear” (localised or diffuse) & otitis media

• Hint: Otitis media (infection of the middle ear)

• Starts with a common cold which leads to the blockage of the Eustachian tube & fluid formation within the middle ear leading to a secondary bacterial infection

• Otitis Media is the most common cause of ear discharge & usually mucopurulent

• Otitis Externa the discharge is not mucopurulent


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Otitis Media

• Rapidly accumulating effusion in middle ear

• Most common in children aged 3 – 6 yrs (recurrent OM = glue ear)

• Ear pain is predominant symptom (described as throbbing)

• Associated systemic symptoms = fever, loss of appetite

• Physical presentation = red/yellow bulging tympanic membrane

• Pain resolves on rupture of tympanic membrane which releases mucopurulent discharge

• Mostly resolves within 3 days with no treatment

• Current UK guidelines do not advocate use of antibiotics

• Treatment: paracetamol or ibuprofen


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Otitis Externa

• Characterised by itching & irritation which may lead to scratching of the skin of the ear canal resulting in trauma and pain.

• Otorrhoea (ear discharge) follows and can lead to conductive hearing loss

• On examination ear canal or external ear, or both appear red, swollen & clear discharge may be present.

• May be caused by infection or trauma


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Referral Points Otitis Externa

• Generalised inflammation of the pinna

• Impaired hearing in children

• Mucopurulent discharge

• Pain on palpitation of the mastoid area

• Patients showing signs of systemic infection

• Slow growing growths on the pinna in elderly people

• Symptoms that are not improving and have been present for 4 or more days


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Mastoid


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OTC Treatment for Otitis Externa

• Choline salicylate (Earex Plus- choline salicylate 21.6%, glycerol 12.62%) 1 years (completely fill EAM with drops and plug

with cotton wool soaked in ear drops)

• Acetic Acid (Earcalm Spray) >12 years (1 spray (60 mg) into affected ear

TDS, continue 2 days after symptoms have disappeared)

if no improvement or worsening after 48 hrs REFER!

Should not be used for more than 7 days


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Ear symptoms & affected structures


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Ear Wax Impaction

• Ear wax is produced in the outer third of the cartilaginous portion of the ear canal by the ceruminous glands.

• Most common external ear problem

• Key clinical features include: gradual hearing loss, ear discomfort, and recent attempts to clean ear.

• Itching, tinnitus, and dizziness occur infrequently


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Questions to ask the patient

• Course of symptoms

• Associated symptoms

• History of trauma

• Use of medicines


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Referral Points

• Dizziness or tinnitus (suggests involvement of

inner ear & requires further investigation

• Pain originating from middle ear

• Fever & general malaise in children

• Foreign body in the EAM

• Associated trauma related conductive

deafness

• OTC medication failure


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OTC Medicines

1) Oil Based Products e.g. Cerumol Ear Drops (Arachis – peanut oil 57.3%), Cerumol Olive Oil Drops, Earex (peanut oil, almond oil & camphor)

2) Peroxide Based Products (Exterol & Otex)

3) Docusate (Waxsol)

4) Sodium Bicarbonate

5) Glycerin (Earex advance & Earex Plus)


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How do these products work?


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• Source: “Community Pharmacy,

Symptoms Diagnosis and Treatment” by

Paul Rutter 3rd Edition

6. Treating Eye Ear Conditions

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