Lecture 17A: Minor Ailments & Responding to Symptoms in Community Pharmacy | Eye & Ear Health

Anatomy of the eye

Overview of the eye

Sclera:

• White of the eye, protects the eye and keeps its shape

Conjectiva:

• Clear tissue covering the white part of the eye and inner eyelids

Cornea:

• Transparent dome shaped covering at front of the eye, refracts the light entering the eye onto the lens

Meibomian glands:

• Oil glands along the edge of eyelids where the eyelashes are found, the oil extcreted is part of the tear film

Iris:

• Coloured part of the eye, controls the amount of light entering the pupil

Lens: 

• Responsible for ‘fine focusing’ light onto the retina

Pupil: 

• Circular opening at the center of the iris, through which light passes into the lens of the eye

Cilary body:

• Attached to the iris and holds the lens in place

Retina:

• Millions of light sensitive cells, light is converted to electric signals sent to the brain which interprets them as an image

Macula:

• Small snesitive area of the retina, provides vision for fine work/reading

Red eye

• Inflammation of the conjectiva, most common with opthalmic complaint

• Can occur alone, or with pain, discharge or altered vision

• Take accuarte history to aid diagnosis

• Causes can be serious and non serious

• Treatment is dependent on cause

Bacterial Conjuctivitis

• Inflammation of conjunctiva caused by bacterial infection, usually streptococcus pneumoniae, S. aureus and haemophilus influenzae

• Very common, occurs at any age, equally affects men and women

• One eye affected a day before the other, contagious

• Symptoms: gritty/burning feeling, generalised redness, purulent discharge, eyelids stuck together on waking

• Contact lens wearers and immunocompromised people at risk of complications

Management of bacterial conjunctivitis

• Usually self limiting, resolves within 5-10 days without treatment

• Clean discharge away with cotton wool soaked in cooled boiled water

• Avoid wearing contact lenses until resolved

• Sever symptoms: Chloramphenicol 0.5% eye drops (P), 1 drop 2 hourly for 2 days then 4 hourly, 5 day course

• Chloramphenicol 1% eye ointment (P) apply 4 times a day, preferred in younger children

• Chloramphenicol not licensed OTC for children under 2 years

• Self care: use separate towels, wash hands thoroughly 

Allergic Conjunctivitis

• Inflammation of the conjenctiva caused by allergens

• Affects both eyes, not contagious, occurs seasonally or with allergen exposure

• Symptoms: itchy, watery eyes, generalised redness

• Associated with snezzing, itchy throat

Management of allergic conjunctivitis

• Avoidance of the allegen would alleviate symptoms

• Topical mast cell stabilisers e.g. Sodium cromoglicate 2% eye drops (P) 1-2 drops up to 4 times a day, slower acting, may sting

• Oral antihistamine e.g. loratadine 10 mg tablets (GSL/P) 1 daily, cetirizine 10 mg tablets (GSL/P) 1 daily

• Self care: avoid allergens if possible, avoid eye rubbing

Dry eyes

• Can be caused by reduction of tear production, alteration in tear composition, increased evaporation of tears from the eye or increased tear drainage

• Medication induced e.g. diuretics, antihistamines

• Common with increasing age, especially in women

• Usually affects both eyes

• Symptoms: eyes look normal but burn/feel gritty, irritataed, vision unaffected

• Often associated with blepharitis 

Management of dry eyes

• Chronic condition - no cure

• Reduce use of contact lenses

• Avoid long periods without blinking - staring at a screen

• Avoid antihistamines - exacerbate dry eyes

• Artificial tears e.g. Hypromellose 0.3% eye drops (P), Viscotears 0.2% eye gel (P), Hylo forte 0.2% eye drops

Subconjunctival Haemorrhage

• Spontaneous rupture of a blood vessel under the conjunctiva

• Can be triggered by coughing

• More common in older people - use of aspirin, anticoagulants

• Symptoms: a portion or a large part of the white of the eye becomes bright red, no pain, vision is unaffected

• May look alarming

Manageement of subconjunctival haemorrhage

• Symptoms resolve without treatment within 10-14 days

• Give reassurance 

• Measure blood pressure 

• Safety-net (pain, vision changes)

Stye

• Bacterial infection (often staphylococcus) of eyelash follicle or oil gland

• Fairly common, may experience 1-2 times in the lifetime

• Symptoms: small painful red lump on the outer eyelid, sensitive to touch

• May be associated with bacterial conjunctivitis

• Blepharitis may increase risk of stye

Management of stye

• Self limiting, resolves within a few days or weeks without treatment

• Antibiotic use including topical, isn’t recommendedWarm compress 10-15 minutes, 3-4 times daily to encourage the drainage of pus

• Avoid puncturing or squeezing the stye

• Avoid makeup and contact lenses

Blepharitis

• Chronic inflammation affecting the margin of the eyelids, vaused by bacteria staphylococci or seborrhoeic dermatitis

• Common, usually develops in middle age

• Symptoms: stickiness and yellow scales at roots of eye lashes, worse in the morning

• Commonly associated with dry eyes, seborrhoeic dermatitis and rosacea

Management of blepharitis

• Chronic condition - no cure, aim to reduce flare ups

• Long term lid hygiene - solution/wipes to cleanse eyelids  e.g. Blephaclean, Blephasol 

• Warm compress for 5-10 mins once or twice daily

• Chloramphenicol 1% eye ointment (P) if lid hygiene not sufficient

Refer

• Visual disturbance

• Photophobia

• True eye pain

• Trauma/foreign body

• Baby under 4 weeks with red eye

• Irregular pupil/non-reactive to light

• Previous serious eye disease

Administration of eye drops

• Wash hands

• If required clean the eye(s) with boiled and cooled water and a tissue, if they are sticky/watery

• Remove the lid from the bottle

• Lie down or sit and tilt head backwards to look at the ceiling

• Form pocket between the eye and the lower eyelid by gently pulling down the lower eyelid with a finger

• Look upwards

• With other hand, hold bottle close to eyelid as possible, ensure tip of bottle does not touch any part of the eye or finger

• Squeeze the bottle to insert one drop into the lower eyelid and close the eye for a moment

• Wipe away any excess drops with a clean tissue

• Apply slight pressure for about 30 seconds to the inner corner of the eye (this prevents drops entering the tear duct and into the back of the throat)

• Replace the lid on the bottle

• Discard bottle after 4 weeks of opening

Administration of eye oitment

• Administration is the same as eye drops however place 1cm of ointment along the inside of the lower eyelid, starting nearest the nose to outer edge

• Close the eye and blink to help spread the eye ointment over the eyeball

• When using ointment, vision may become blurry but will soon clear by blinking

Anatomy of the ear

Overview of the ear anatomy

Outer ear:

• Pinna – mainly made up of cartilage, has a firm elastic consistency, assembles sound waves and directs them down the ear canal

• Ear canal – 2/3 covered with tiny hairs, 1/3 smooth skin with glands that produce cerumen/ear wax

• Tympanic membrane/Ear drum – thin piece of skin at the end of the canal, vibrates in response to sound waves, initial conduction of sound

Middle ear:

• Cavity linked with nose through Eustachian tube, helps to keep ear pressure consistent. Consists of 3 tiny bones; Malleus, Incus and Stapes, which increase the strength of the vibrations from the ear drum before they move towards the cochlea

Inner ear:

• Cochlea – snail shell shaped, filled with fluid. Sound vibrations from the tiny bones are passed to fluid of cochlea, sound vibrations are converted to electrical impulses by tiny hairs, that are transmitted to the brain, this becomes the sound we hear

Otic health

• Affected ears

• Discharge

• Pain/discomfort

• Changes to hearing

• Associated symptoms

• Duration of symptoms

• Treatment tried

• Visual checki in/behind

Ear wax

• Ear wax is made up of dead skin cells, cerumen (wax like substance) and sebum which is naturally eliminated by jaw movement

• Ear wax cleans the ear and protects against infections and dirt, when impacted becomes a concern

• Causes include use of cotton buds, hearing aids

• More common in elderly

• Symptoms: gradual hearing loss, discomfort, ear feels full/blocked

Management of ear wax

• Remove earwax if ear wax is totally blocking ear canal and is symptomatic or need to visualise tympanic membrane

• Ear drops used to soften wax and facilitate removal

• Cerumenolytic agents e.g. olive oil (GSL), sodium bicarbonate 5% (P), urea hydrogen peroxide 5% (P) - safe and effective

• Avoid inserting cotton buds

• No evidence to support use of ear candles

• May require ear syringing or microsuction, may not be provided by GP surgeries

Otitis externa

• Inflammation of the skin of the external ear canal, caused by bacteria such as pseudomonas aeruginosa or staphylococcus aureus

• Common in all ages, more so in females

• Risk factors – swimming, use of hearing aids/headphones, trauma

• Symptoms: Ear discomfort/pain/itch, discharge, moving pinna worsens pain,

• Associated with contact dermatitis, psoriasis, skin infections

Management of otitis externa

• Manage underlying causes/risk factors

• Mild infection: Acetic Acid (EarCalm) ear spray (P), 1 spray 3 times a day

• Moderate/severe infection: Topical antibiotics +/- corticosteroid e.g. Gentisone HC ear drops (POM), Cilodex ear drops (POM)

Self care:

• Avoid ear trauma, avoid swimming/water sports for 7-10 days

• It is not contagious

• Keep ears clean and dry, pain relief – paracetamol or ibuprofen

Administration of ear drops

• Wash hands

• Clean and dry ear if needed, with a face cloth

• Warm the ear drops by holding the bottle in the hand for a few minutes

• Remove the lid from the bottle

• Lie down on your side or tilt the head, so the affected ear points towards the ceiling

• Pull top of affected ear up and back to straighten the ear canal

• Insert required number of drops into the ear canal

• Stay lying down or keep head tilted for 5-10 minutes, massage in front of the ear (to allow drops to stay in the ear and run down the ear canal)

• Wipe away any excess solution with a clean tissue

• Replace lid on the bottle

• Discard bottle after 4 weeks of opening

Refer

• Ear pain in young children

• Pain from middle ear

• Foreign body in ear

• Mastoiditis - redness, swelling, tenderness and pain behind ear

• Persistent or sedden hearing loss

• Trauma-related deafness

• Dizziness or tinnitus