Eye Clinical Skills + Workshop

Steps for basic examination of the eye

1. Wash hands

2. Explain what you are about to do

• “I am now going to do a basic examination of your eye. I will gently pull down your lower and upper lid to look for any abnormalities. ”

3. Gain patient consent 

4. General observation of patient’s eyes/eyelids » redness, inflammation, discharge

5. To view the conjunctiva

• Gently pull down the lower lid and ask patient to look upwards, left and right

• Gently lift upper lid and ask patient to look down, left and right

• Note any redness, blood vessels etc

6. Ask patient to feel for any tenderness over the sinus bones

• “Do you feel any tenderness or soreness when you press over your cheekbones or forehead?” 

Steps for using ophthalmoscope to view the conjunctiva

1. Wash hands

2. Explain procedure

• “I will now use an ophthalmoscope, which is an instrument that lets me look at the back of your eye, including the retina and the blood vessels. It helps us check eye health and allows me to spot any issues. I’ll gently pull down your lower and upper lid and shine a light into your eye for a few seconds while you look straight ahead.”

3. Gain patient consent

Ophthalmoscope

6. Use middle sized light and focussing wheel on 0

7. Hold ophthalmoscope like a microphone and put index finger on dial 

8. If examining right eye of patient, hold with right hand and check with right eye and vice versa when examining the left eye

9. ‘Look directly into the light’

10. ‘Look back at me’ » to check reaction of pupils to the light

11. ‘Cover your unaffected eye with your palm and read the information printed on this card’ » note any difficult reading

When to REFER patients based on eye examination

General eye examination

• Suspected foreign body in the eye

• Any swelling around eye or face

• Photophobia » ‘do bright lights make your eyes hurt or feel uncomfortable?’

• Severe pain in the eye

• Vision affected

• Copious green/yellow smelly discharge which re-accumulates when wiped away

Ophthalmoscope

• Pupil an unusual shape or doesn’t react to light

• Cornea looks cloudy

• Restricted eye movement

Steps for eye drop administration

1. Wash hands thoroughly with soap and water

2. Avoid touching the dropper tip against the eye or anything else

3. Tilt head back to look at the ceiling

4. Pull down lower eye lid with index finger to form a pocket

5. Hold dropper tip down with other hand as close to the eye as possible without touching it

6. While looking up, gently squeeze the bottle, so that a single drop falls into the pocket made by the lower eyelid

7. Blink the drops in

8. Place finger on tear duct and apply gentle pressure

9. Wipe any excess liquid from closed eyelid/face with tissue

10. If more than one drop is to be administered to the same eye, wait at least 5 mins before instilling the next top

11. Replace and tighten cap on dropper bottle

12. Wash hands to remove any medication

Other supports

• PILs

• Administration charts

  • Check patients who have glaucoma and drive have informed the DVLA

Case Study 1

It is Saturday afternoon and Matthew Hall has asked the pharmacy assistant if he could have some eye drops as they have discharge from both eyes now for four days and is not getting better.

The pharmacy assistant has referred this request to you, as the community pharmacist.

• Your system shows only a single prescription 2 years ago for mebeverine 135mg tablets: 1 tablet 3 times a day

• You have asked Matthew to come to the pharmacy consultation room. You note their eyes are generally red and that there is some sticky discharge in both corners

• Redness in both eyes

• Sticky discharge

• Duration: 4 days and not improving

• No mention of allergy, itchiness, or watery discharge » which would suggest viral or allergic

Diagnosis:

Bacterial conjunctivitis

Treatment:

Chloramphenicol eye drops 0.5%

• 1 drop every 2 hours for 48 hours

• Then reduce to every 4 hours

• For 5 days total

Case Study 2

• Yesterday Alan Peterson came to the pharmacy to hand in a prescription for latanoprost 50 microgram / mL eye drops, one drop in each eye once a day.

• You noted when you reviewed the pharmacy MR that Alan had not received these eye drops before and asked himif it was a new prescription. You note that Alan is also prescribed Clenil 100 inhaler and a salbutamol inhaler for treatment of their asthma.

• Alan explained that they have recently started on their eye drops after being referred by their optometrist and their GP to the hospital eye clinic following their annual eye appointment. The ophthalmologist confirmed the optometrist's diagnosis of chronic open angle glaucoma.

• Alan Peterson has now come to collect their prescription for latanoprost 50 microgram / mL eye drops and has agreed to see you in the pharmacy consultation room to discuss their understanding of glaucoma and to check their administration technique.

What is glaucoma and what does latanaprost do?

How should the patient administer the eye drops?

Side effects?

Adherence information?

Asthma note

What is glaucoma and what does latanoprost do?

• Glaucoma damages the optic nerve due to raised pressure in the eye.

• Latanoprost helps by increasing fluid drainage from the eye, lowering pressure.

• It does not fix existing damage, but it prevents further vision loss.

• Stopping drops can lead to permanent vision impairment, even if the eyes feel “fine.”

How to use eye drops:

• One drop in each eye once daily — preferably at night.

• Tilt head back, pull lower lid down to create a pocket.

• Avoid touching eye or lashes with bottle tip.

• After instilling, press gently on the inner corner of the eye (punctal occlusion) for 1–2 minutes — reduces systemic absorption and side effects.

• If using more than one type of drop, wait 5 minutes between drops.

• Remove contact lenses before use; wait at least 15 minutes before reinserting.

Side effects

• Mild redness or irritation

• Increased pigmentation of the iris over time (eye colour darkening — often permanent)

Adherence & importance of continuation

• This is a lifelong condition.

• Drops must be used every day, even when the eyes feel normal.

• Missing doses can allow pressure to build and cause nerve damage.

Asthma note (important!)

• Latanoprost generally does not affect asthma.

• No major interaction with Clenil or salbutamol.

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

What is the normal intraocular pressure of the eye and what is used to measure this?

• 10–21 mmHg (millimetres of mercury).

• IOP is measured using an instrument called a tonometer.

So Mrs X’s IOP is higher than normal

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

IOP lowering medication for glaucoma 

1st line: Prostaglandin analogues

• Relax muscles in the interior structure  = increase aqueous humour outflow = reduce IOP

• Side effects: increase melanin so can brown the iris

• E.g. Latanoprost, Travoprost

2nd line: Beta blockers

• Decrease production of aqueous humour

• Contraindications: asthma, bronchospasm, bradycardia, hypotension

• Side effects: can get red eye at the start » if this doesn’t resolve, switch to another BB, then try a preservative free formulation or different class

• E.g. Betaxolol, Timolol

3rd line: Cholinergics / Miotics 

• Mimics action of parasympathetic NS

• Increases aqueous humour outflow = reduces IOP

• Side effects: can cause ciliary spasm affecting night vision

• E.g. Pilocarpine

3rd line: Alpha-adrenergic agonist

• Mimics action of NA on sympathetic NS

• Side effects: palpitations, headaches

• E.g. Apraclonidine, Birmonidine

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

Explain why Mrs X’s asthma is an important consideration, although these are eye drops

• Beta-blocker drops like timolol are absorbed into the bloodstream through the nasal mucosa, and can affect the lungs

• They block β₂ receptors in the bronchial smooth muscle → airway constriction

• In an asthmatic, this can cause wheezing, shortness of breath, or an asthma attack.

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

Latanoprost is a prodrug. Draw the structure of latanoprost and its active metabolite?

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

Which naturally occurring prostaglandin does the active metabolite mimic?

Prostaglandins F2α

• PGF2α acts on FP receptors in the ciliary muscle of the eye

• This increases uveoscleral outflow of aqueous humour = reduces intraocular pressure

• Latanoprost acid is a synthetic analogue of PGF2α with longer duration and better receptor selectivity

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

What is the purpose of administering latanoprost as a prodrug?

• Prodrug ester form is highly lipophilic so able to more easily cross the lipid-rich cornea into the eye = better corneal absorption

• Converted in the eye to its active acid form, allowing effective intraocular action with reduced systemic absorption

Case Study 3

Mrs X attends a GP appointment following advice from her local optician. The GP measures her intraocular pressure (IOP) that reads 25 mmHg and informs Mrs X that she has developed glaucoma. Mrs X's medical notes state that she Has a history of asthma which she also confirms to the GP. The GP prescribes her with Latanoprost eye drops.

Why should unopened bottles of latanoprost be stored in the fridge?

Latanoprost is sensitive to temperature in its pro-drug form:

• Storing in the fridge prevents ester hydrolysis = preserves shelf life