EYES 👁️ and EARS 👂

What should a pharmacy consultation for a patient with a red eye include?

• Subjective history: Patient-reported symptoms, including onset, pain, discomfort, discharge, itching, photophobia and visual changes.

  
  

• Objective examination: Observable signs, including visual acuity, corneal appearance, pupil size and shape, and the pattern of redness.

  
  

The aim is to distinguish common conjunctivitis from potentially serious conditions such as uveitis, keratitis and acute angle-closure glaucoma.

What features typically suggest conjunctivitis rather than a serious red-eye condition?

• Often affects both eyes, although not necessarily simultaneously or equally.

• Discharge and/or itching or grittiness may be present.

• Pupils are usually normal.

• Vision is generally unaffected.

  
  

These features help guide assessment but do not independently exclude serious disease.

What should the pharmacist establish when taking a subjective history of a red eye?

• Time of onset and whether one or both eyes are affected.

• Previous episodes.

• Type of discharge and degree/type of discomfort or pain.

• Itching, photophobia, visual changes, haloes or loss of vision.

• Associated symptoms, including upper respiratory tract symptoms.

• History of atopy/allergy.

• Contact with people experiencing similar symptoms.

• Current ocular medication.

How can visual acuity be assessed in a community pharmacy without a Snellen chart?

• Ask the patient to read small print using the affected eye while the other eye is covered. Compare the patient's vision with their unaffected eye where appropriate.

  
  

• Any change in visual acuity in a unilateral red eye that does not clear after blinking requires referral.

Why is it important to distinguish true eye pain from irritation or discomfort?

• Minor conditions such as conjunctivitis commonly cause irritation or discomfort rather than genuine pain.

  
  

• True eye pain combined with visual disturbance is a significant red flag and requires immediate referral for urgent medical assessment.

How should the eye be examined for redness and other visible signs?

• Examine in good lighting.

• Ask the patient to look straight ahead to assess the pupil, cornea and sclera.

• Gently pull down the lower eyelid while asking the patient to look up to inspect the conjunctiva.

• Assess the distribution of redness, corneal clarity, pupil size and shape, and any visible discharge or pus.

  
  

The degree of redness alone does not reliably indicate the severity of the underlying condition.

What is the difference between diffuse conjunctival redness and limbal (circumcorneal) redness?

• Diffuse superficial redness: Usually associated with conjunctivitis and dilation of superficial conjunctival blood vessels.

  
  

• Limbal/circumcorneal redness: Redness concentrated around the cornea; may indicate episcleritis, scleritis, uveitis or keratitis.

  
  

The pattern helps guide assessment, but redness alone cannot determine severity.

What are the five Ps of red-eye assessment?

1. Pain

2. Photophobia

3. Poor vision

4. Pus in the cornea or anterior chamber

5. Pupil abnormality

   
   

These are red flags requiring medical evaluation.

What is photophobia, and why is it important in a red-eye consultation?

• Photophobia is pain or discomfort when looking at a light source.

  
  

• It is an important red flag because it may indicate a more serious ocular condition. Presentations involving photophobia are often unilateral.

  
  

• The study pack describes comparing the patient's tolerance of light when viewing it with each eye.

When does blurred vision in a patient with conjunctivitis require referral?

• Bacterial conjunctivitis may cause temporary blurring when pus obscures the cornea. This may clear after blinking.

  
  

• Any change in visual acuity in a unilateral red eye that does not clear after blinking should be referred.

What is the difference between conjunctival discharge and pus within the cornea or anterior chamber?

• Conjunctival discharge: May occur with bacterial conjunctivitis and can temporarily blur vision by obscuring the ocular surface.

  
  

• Pus in the cornea: May indicate a corneal infection or ulcer.

  
  

• Pus in the anterior chamber: May form a collection at the bottom of the chamber, called a hypopyon, and indicates serious intraocular inflammation or infection.

  
  

Pus within the cornea or anterior chamber does not clear with blinking and requires urgent medical assessment.

What pupil abnormalities are concerning in a patient with a red eye?

Normal pupils should be:

• Equal in size.

• Central.

• Circular.

  
  

Unequal or irregular pupils are red flags and may occur in conditions such as anterior uveitis. Any such abnormality warrants medical assessment, particularly when accompanied by pain or visual disturbance.

What should happen if a patient has sustained trauma to the eyeball?

• Eye trauma requires urgent assessment for damage.

  
  

• referral to Accident and Emergency without delay because trauma can cause significant ocular morbidity and visual loss.

  
  

• Corneal abrasions can lead to keratitis and sight-threatening corneal ulcers.

How are corneal abrasions identified using fluorescein? And Why is a corneal abrasion clinically important?

• Fluorescein drops are administered to the eye, which is then examined under blue light. The dye collects in the corneal epithelial defect and fluoresces green, helping reveal the damaged area.

• Damage to the corneal epithelium can allow infection and inflammation to develop, potentially progressing to keratitis or a corneal ulcer. These complications can threaten vision and require appropriate assessment and treatment.

What are the main advantages and limitations of administering medicines directly to the eye?

Advantages:

• Non-invasive administration.

• Direct access to accessible structures such as the conjunctiva.

• Fewer systemic drug effects than many systemic routes.

• Convenient self-administration.

Limitations:

• Physiological barriers restrict penetration into the interior of the eye.

• Tears, blinking and drainage reduce drug contact time.

• Correct administration and patient compliance can be problematic.

• Systemic absorption and adverse effects can still occur.

Why is topical administration suitable for conjunctivitis but more challenging for diseases inside the eye?

• Conjunctivitis: The target is the accessible conjunctival surface, so little tissue penetration is required. Instilling drops can also flush bacteria and debris from the eye.

• Anterior chamber disease: The drug must cross physiological barriers, particularly the corneal epithelium and stroma, to reach the target site.

Why is only one eye drop administered at a time?

The tear chamber has limited capacity:

• Approximately 30 µL in a non-blinking eye.

• Approximately 10 µL in a blinking eye.

• The tear volume itself is approximately 7 µL.

• An eye drop is approximately 25–50 µL.

  
  

A large proportion of the drop may spill onto the cheek or drain through the nasolacrimal duct. Additional drops can therefore be wasted.

What are the disadvantages of topical ophthalmic preparations?

• Some elderly or disabled patients may lack the manual dexterity needed to use dropper bottles.

• Preparations may cause stinging or burning.

• Penetration into the vitreous is generally poor.

• The vehicle may support contaminant microorganisms if contaminated.

• Preservatives may cause allergic or toxic reactions.

• Compatibility with contact lenses is limited.

• Systemic absorption and adverse effects remain possible.

Why might an eye ointment be preferred at night or for a child?

• Longer ocular residence time allows prolonged drug contact.

• Night-time use can reduce the inconvenience of blurred vision.

• Ointments are less readily washed out by crying, which can be useful in paediatric patients.

However, the formulation must be suitable for ocular use. Some ointment bases are inappropriate where there is a risk of intraocular contamination.

How does a topically administered drug reach the anterior chamber? And Why should a drug intended to enter the anterior chamber have both lipid and water solubility?

• The main route is through the cornea. The drug must cross the corneal epithelium, stroma and endothelium. The properties of these layers mean that a drug's solubility characteristics strongly influence its ability to penetrate.

• The corneal epithelium favours lipid-soluble drugs.

• The corneal stroma favours water-soluble drugs.

• The endothelium presents a comparatively minor barrier.

Therefore, a drug with both lipid and water solubility can cross the different corneal layers more effectively.

What is a prodrug, and what example is given in the study pack for ophthalmic delivery?

• A prodrug is an inactive or less active drug form that is converted into its more active form after absorption.

  
  

• Dipivefrine is given as an example: it is a prodrug of adrenaline designed to pass through the cornea more readily before conversion to the active drug.

What factors can influence ocular bioavailability?

Drug-related factors:

• Molecular size.

• Partition coefficient.

• Diffusion coefficient.

• Drug concentration.

• Degree of ionisation.

Formulation-related factors:

• pH and tonicity.

• Formulation design and vehicle.

• Viscosity and precorneal residence time.

Tear-protein binding and enzymatic breakdown within the eye can also reduce ocular bioavailability.

Which form of a drug generally crosses the corneal membrane more readily: ionised or non-ionised? Why?

• The non-ionised form generally permeates lipid membranes more readily than the ionised form.

  
  

• The balance between ionised and non-ionised drug depends partly on drug properties and pH. The pH of the formulation and the buffering capacity of the tears can therefore influence corneal absorption.

Why are ophthalmic solutions commonly buffered near physiological tear pH?

• tear pH range of approximately 6.5–7.6, with a mean around 7.

  
  

• Buffering near this range can help minimise irritation and support tolerability. However, solubility and stability requirements may necessitate a different formulation pH.

What are the purposes of common excipients in ophthalmic solutions?

Excipients may be added to:

• Maintain stability and sterility.

• Adjust pH using buffering agents.

• Adjust tonicity for ocular tolerability.

• Increase viscosity and prolong precorneal residence time.

• Support drug absorption.

• Reduce microbial contamination using preservatives where required.

Why are preservatives used in multidose ophthalmic preparations, and what precautions are needed?

• Preservatives help minimise microbial contamination during the product's use.

• Examples: benzalkonium chloride and phenylmercuric acetate.

• Preservatives may cause ocular toxicity or allergic reactions.

• Avoid touching the eyeball with the dropper because contaminated fluid may be drawn back into the container.

  
  

ophthalmic preparations are generally discarded one month after opening. Always check the specific product's instructions because discard periods vary.

Why might a suspension provide prolonged drug delivery?

• The suspended drug particles must dissolve before they can be absorbed. If the formulation remains at the ocular surface, drug can be released over a longer period.

  
  

• corticosteroids are commonly formulated as suspensions.

How do viscosity-enhancing polymers improve ophthalmic formulations?

They increase formulation viscosity, helping the preparation remain on the ocular surface for longer and potentially improving drug absorption.

Examples:

• Hydroxypropylmethylcellulose (HPMC): Increases viscosity.

• Poloxamer 407: Can increase viscosity at the higher temperature encountered in the eye, producing an in-situ viscosity change.

  
  

Such approaches can support less frequent administration in suitable formulations.

Why must formulators consider drug partitioning when preparing an ophthalmic ointment?

• lipophilic drug may preferentially remain in the oily ointment base rather than partition into the cornea.

  
  

• The drug must be able to leave the vehicle and enter the ocular tissue for effective absorption.

Why should certain ointment bases be avoided when intraocular contamination is possible?

lanolin, petroleum and vegetable oils as unsuitable where there is a risk of contamination of the internal eye because these bases can be toxic to intraocular tissues.

How do eye drops and eye ointments differ?

Property	Eye drops	Eye ointments
Visual effect	Usually minimal blurring	Significant blurring
Drug–eye contact time	Relatively short	Relatively long
Peak tear concentration	High	Low
Contact lenses	Avoid soft lenses unless the product is preservative-free and suitable	Incompatible
Administration	Depends on container and technique	Can be messy and awkward

What is otalgia? What are the two broad causes of otalgia?

Otalgia is the medical term for earache or ear pain. It is common in both children and adults.

• Local causes originating in the ear.

• Referred pain originating elsewhere but felt in the ear through shared sensory nerve pathways.

How are local causes of otalgia usually investigated?What should be considered if a patient has earache but the ear appears normal?

By examining the pinna, ear canal and tympanic membrane (eardrum)

Referred pain from another area supplied by cranial nerves that also provide sensation to the external or middle ear.

What is otitis externa? What are the main causes of otitis externa?

Inflammation of the external ear canal, ranging from mild allergic dermatitis to severe cellulitis.

* Infection, commonly involving Pseudomonas bacteria or fungi.

* Allergic reactions.

* Trauma.

* Irritation.

What are the predisposing factors, symptoms and typical season of otitis externa?

Predisposing factors:

• Frequent moisture exposure in the ear canal, e.g. swimming.

• Trauma from cleaning with cotton buds.

• Pre-existing allergies or skin conditions, e.g. psoriasis.

Symptoms:

• Itching, redness and tenderness.

• Pain.

• Narrowing of the ear canal due to inflammation.

Season: Common in summer.

What is acute otitis media, and how does it develop?

• Inflammation of the middle ear cleft, commonly following an upper respiratory tract infection.

• Infection/inflammation ascends via the Eustachian tube.

• The Eustachian tube becomes blocked, causing eardrum retraction initially and inflammatory exudate to develop in the middle ear.

• Increasing middle-ear pressure produces severe otalgia (earache).

• The eardrum becomes congested and bulging.

What are the clinical features and possible complications of acute otitis media?

• Severe earache (otalgia), particularly in children.

• Fever and tachycardia.

• The patient may feel generally unwell.

• Eardrum rupture may occur, causing blood-stained discharge.

• Rupture can relieve pain because pressure in the middle ear decreases.

Which patients can be treated for acute otitis media under NHS Pharmacy First, and which medicines may be supplied?

• Eligible children and young people aged 1–17 years, subject to the clinical pathway and relevant patient group direction (PGD).

• Possible treatments:

• Phenazone 40 mg/g + lidocaine 10 mg/g ear drops — symptomatic pain relief in eligible patients without eardrum perforation.

• Amoxicillin — antibiotic treatment when indicated and there is no relevant penicillin allergy.

• Clarithromycin — alternative antibiotic for eligible patients with a reported penicillin allergy.

• Erythromycin — for eligible pregnant patients aged 16–17 years with a reported penicillin allergy, as specified by the pathway.

Antibiotics are not automatically required for every case; the pathway assesses symptom severity, duration and other clinical factors.

What age group is covered by the Pharmacy First acute otitis media pathway, and who is excluded?

• Age range: 1–17 years.

• Excludes recurrent acute otitis media, defined as:

3 or more episodes in 6 months, or

4 or more episodes in 12 months.

• Pregnant individuals under 16 years are also excluded.

What clinical features support a diagnosis of acute otitis media under the Pharmacy First pathway?

Acute-onset symptoms:

• Older children: earache.

• Younger children: holding, tugging or rubbing the ear.

• Other possible symptoms: fever, crying, poor feeding, restlessness, behavioural changes, cough or rhinorrhoea.

Otoscopy findings:

• Distinctly red, yellow or cloudy tympanic membrane.

• Moderate-to-severe bulging of the eardrum, with loss of normal landmarks and an air-fluid level behind it.

• Eardrum perforation and/or sticky discharge in the external auditory canal.

Which patients with suspected acute otitis media require onward referral?

Refer to general practice or another appropriate provider if the patient:

• Is systemically very unwell.

• Has signs of a more serious illness.

• Has a high risk of complications because of pre-existing comorbidity, including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis or prematurity in young children.

Suspected serious complications include:

• Meningitis.

• Mastoiditis.

• Brain abscess.

• Sinus thrombosis.

• Facial nerve paralysis.

Suspected serious complications require urgent escalation to A&E; call 999 for a life-threatening emergency.

How does the Pharmacy First pathway guide treatment according to symptom severity and eardrum perforation?

Mild symptoms: self-care and pain relief.

Moderate or severe symptoms, without eardrum perforation: consider phenazone 40 mg/g + lidocaine 10 mg/g ear drops for up to 7 days, if eligible under the PGD.

Eardrum perforation or otorrhoea (discharge following perforation): consider antibiotic treatment according to the pathway and allergy status; amoxicillin is the pathway option when there is no relevant allergy.

Antibiotics: consider when symptoms are severe, based on clinical judgement, or have lasted more than 3 days.

If a penicillin allergy is reported, the pathway directs eligible patients towards clarithromycin; pregnant patients aged 16–17 years are directed towards erythromycin.

Treatment must follow the full pathway and applicable PGD.

What advice and safety-netting should be given to patients with acute otitis media?

• Provide self-care and pain-relief advice to all patients.

• Explain that many children recover spontaneously without antibiotics.

• Ask the patient to return to the community pharmacy if there is no improvement within 3–5 days, for pharmacist reassessment.

• Arrange onward referral if symptoms worsen rapidly or significantly, the child becomes very unwell, or there is no improvement despite taking antibiotics for at least 2–3 days.

Pharmacy First scenario: A 25-year-old man presents with earache. What treatment should you supply under the acute otitis media pathway?

Do not supply treatment under this Pharmacy First acute otitis media pathway.

The pathway covers patients aged 1–17 years, so a 25-year-old is outside its age eligibility.

Assess appropriately and direct the patient to a suitable healthcare provider.

Pharmacy First scenario: A 4-year-old has ear tugging, is otherwise well, has a perforated eardrum with discharge, and is allergic to phenoxymethylpenicillin. What treatment does the pathway indicate?

The child is within the eligible age range.

Eardrum perforation with discharge supports acute otitis media and directs the pathway towards antibiotic treatment.

With a reported penicillin allergy, the pathway indicates clarithromycin for 5 days, subject to the relevant PGD and eligibility checks.

Do not choose phenazone/lidocaine ear drops under the pathway when the eardrum is perforated.

Give self-care and safety-netting advice.

Exam point: the perforation changes the treatment pathway, and the reported penicillin allergy changes the antibiotic choice.

What is vertigo, and how does peripheral vertigo arise?

• Vertigo is a symptom, not a diagnosis.

• It is the perception of spinning or rotation of the person or their surroundings when no actual physical movement is occurring.

• Peripheral vertigo arises from altered activity in the balance organs of the inner ears.

• Differences in sensory input from the two ears reach the vestibular nuclei, causing the brain to perceive movement.

What causes benign paroxysmal positional vertigo (BPPV), and what can precipitate it?

• Otolith particles become dislodged and enter the semicircular canals.

• Certain head movements cause movement of inner-ear fluid, producing vertigo.It commonly occurs spontaneously, particularly in older people.

It may be precipitated by:

• Head injury.

• Ear surgery.

• previous episode of labyrinthitis.

Differentiate vestibular neuronitis from labyrinthitis.

• Vestibular neuronitis: inflammation of the vestibular nerve; often occurs after a viral infection.

• Labyrinthitis: inflammation involving the labyrinth and vestibular nerve; often attributed to a viral infection.

These terms were previously used interchangeably, but more specific terminology is now recommended.

What is the proposed cause of Ménière’s disease?

• Thought to result from endolymphatic hydrops (excessive accumulation or pressure of endolymph) in the inner ear.

• It may occur in association with viral or bacterial ear infections, or metabolic or immune disorders.

What causes central vertigo, and what is its most common cause?

• Central vertigo results from disturbances affecting:

Visual–vestibular interaction centres in the brainstem and cerebellum.

Sensory pathways to and from the thalamus.

• Migraine is the most common cause of central vertigo according to the study-pack content.

• Migraine may present with peripheral features and can be difficult to distinguish from early Ménière’s disease.