Worksheet: Opthalmic Infammatory and Dry Eye Conditions

Eyelid Inflammation Disorders (Blepharitis, Hordeolum/Stye/Chalazia)

• Styes are usually self-limiting and resolve in 7-14 days.

• Reassure patients that styes will often get worse before they get better. This is a sign that inflammation is working to heal the problem.

• Hot compresses can be used to treat styes, chalazion, and blepharitis. Best use includes providing steady and regular application: 10-15 min each treatment and 3-5 times per day. Special products can be used but usual household products like washcloths and diluted no-tears baby shampoo can also be recommended if cost/access is a barrier to care.

• Three things patients shouldn’t do if they have a stye: 1) wear eye makeup 2) wear contacts 3) pop or squeeze it.

• Managing blepharitis is largely (choose): preventative.

Conjunctivitis

Bacterial Conjunctivitis	Viral Conjunctivitis	Allergic Conjunctivitis*
Causes: common: Staph aureus or Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis More severe: STD related require systemic tx	Causes: common cold virus (adenovirus), other viruses Severity: most are mild (exceptions: EKC, HIV or Herpes Zoster related disease)	Causes: common allergens including pollens, mites, animal dander, molds
Common defining features: thick mucus sticky discharge that often matts eye shut after sleeping. One or both eyes.	Common defining features: Watery, weepy discharge. One or both eyes.	Common defining features: Red and Itchy. Often other body parts affected too e.g. nasal passage, throat, and mouth.
Common topical antibiotic eye drops or ointments (Top Drugs bolded): Fluoroquinolones (name root: “floxacin”): moxifloxacin (Vigamox, Moxeza), ofloxacin (Ocuflox), ciprofloxacin (Ciloxan), besifloxacin Aminoglycosides: gentamicin, tobramycin +/- steroid tobramycin/dexamethasone (Tobradex)   “poly” antibiotic +/- steroid: trimethoprim/polymixin B (Polytrim), neomycin/polymixin b/dexamethasone (Maxitrol) Macrolide: Erythromycin (generic) Azithromycin Sulfacetamide	Management: No topical or systemic treatment for common viral conjunctivitis. Resolves on own in days to 2-3 weeks. Symptom treatment may provide some relief.	Common topical eye drops or ointments (Top Drugs bolded): Mast cell stabilizers Alcaftadine [OTC] Cromolyn Lodoxamide Nedocromil Antihistamines Azelastine Cetirizine Olopatadine [OTC-Pataday] Mast cell stabilizer/Antihistamines Ketotifen [now OTC] Topical antihistamines are often combined with a topical decongestant/vasoconstrictor which makes them more effective but has the downside of possible rebound redness or should be avoided in certain patient populations due to CV risk. Ketotifen represents the best new product on the market and has advantages of twice daily dosing, use in children age three and up, and since it is not combined with a decongestant its days of use is not limited. Oral antihistamines may also be used but their “drying” nature can be problematic for sensitive eyes. If sx limited to just eye, local therapy often tried first before systemic. Avoiding the allergen cause/source if possible is also recommended.

A patient has recurrent bacterial conjunctivitis and still has some antibiotic eye drop from 2 months before available at home. Can they use it? Why or why not? 

No, they should not use it because it could spread the infection or reinfect them. Drops should be thrown away after that treatment course and a new bottle obtained if necessary.

If the conjunctivitis is limited to the conjunctival structures and does not involve the cornea or lens, it is likely to be vision

 non-threatening.

T/F: If the patient complains of chronic red/pink eye or is not responding to treatment, they should seek the care of an eye care specialist

True.

What tips were shared in the video for a "pink eye"?

Infectious (bacterial or viral) conjunctivitis is contagious and spreads by contact, so good hand hygiene washing with soap and water is essential. Do not share personal items, wash pillowcases regularly, and throw away old makeup. When using eye drops, don't touch the top of the bottle to the eyelashes or fingers as this can contaminate it. Contact lens wearers should assume the pink eye is related to their contacts, throw away the current pair and their case, and seek professional help. You must seek medical treatment if there is pain or vision changes (indicating something more serious that could be sight-threatening), or if it does not resolve in the usual timeframes/respond to treatment.

Ketotifen

Ketotifen is the safest and most effective product on the market for allergic conjunctivitis. It is effective immediately, only dosed twice daily, doesn't contain a vasoconstrictor, and can be used in children as young as 3 years old.

Symptom-Based Ophthalmic Treatments

Symptom	Common Treatments (Top Drugs bolded)	Notes
Inflammation	Manage underlying reason for inflammation (e.g. infection in bacterial conjunctivitis, allergic reaction). Cold compresses can reduce puffiness/provide temporary relief but may restrict blood flow which might be helpful depending on the reason for inflammation (e.g. blocked gland). Following certain eye procedures or for systemic inflammatory diseases with eye involvement, common topical eye drops or ointments may be used: Steroids [severe inflammation] Dexamethasone Fluorometholone Loteprednol (Alrex, Lotemax) Prednisolone  NSAIDs [mild inflammation] Diclofenac Flurbiprofen Ketorolac (Acular)	Steroid eye drops restricted to short term use due to risk of increased intraocular pressure
Dryness	Popular brands artificial tears/eye lubricants [OTC]: Liquifilm Refresh Systane For severe, chronic dry eye syndrome such as Sjogren’s Syndrome or keratoconjunctivitis sicca: Cyclosporine (Restasis) Lifitegrast	Tears are a complex mix of fatty oils, water, mucus, and more than 1,500 different proteins. They keep the surface of the eye smooth and protected from the environment, and from bacteria or viruses that can cause disease. All are generically referred to as “replacement or artificial” tear but may contain different ingredients singularly or in combination such as: mineral oil, glycerin, propylene glycol, polyethylene glycol, dextran, hypromellose, carboxymethylcellulose
Redness	Brimonidine Naphazoline Tetrahydrozoline	Rebound redness can occur with overuse

Non-pharmacologic measures for dry eye include:

Avoiding environments that increase evaporation of tear film. Dusty and dry places should be avoided if possible. Using humidifiers or repositioning workstations/seating areas away from heating and air conditioning vents may help alleviate dry eyes. Avoiding prolonged viewing of computer screens and wearing eye protection (sunglasses or goggles) in windy outdoor environments is also protective.

Artificial tear products vary in viscosity according to the ingredients used in their preparation

Increased ocular contact time provides greater resistance to tear dilution. Mild dry eye cases may be treated with less viscous products which are less likely to blur vision. Ointments are usually reserved for use at night or for severe cases of dry eye.

more on artificial tears

Artificial tear lubricants may consist of preservatives, inorganic electrolytes to achieve tonicity and maintain pH, and water-soluble polymeric systems. There are many products on the market. The lubricating agents in them are similar but buffering agents, preservatives, pH and other formulation components vary.

 common class of lubricating ingredients

substituted cellulose ethers. These solutions are colorless and vary in viscosity depending on their grade and concentration. Polyvinyl alcohol and povidone are two other vehicles/agents commonly used as ocular lubricants. Their most important property is their ability to stabilize the tear film which reduces evaporation.

Studies have shown that formulations of artificial tears without preservatives

are less likely to irritate the ocular surface. Non-preserved products should be discarded after opening. Though costlier, purchasing non-preserved single-use containers is available.

Ocular topical decongestants/vasoconstrictors

Ocular topical decongestants/vasoconstrictors like phenylephrine are labeled to be used cautiously by patients with hypertension or other cardiovascular disorders, glaucoma, diabetes, hyperthyroidism, and during pregnancy