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Pharmacy Practice 1

PHCY 280 Eye Disorders

Spring 2016-17

Mrs. Beena Jimmy

Pharmacy Practice

School of Pharmacy

University of Nizwa

Objectives By the end of the topic, the student should be able to: • Develop history taking and perform physical

examination of a patient with Eye and Ear disorders such as conjunctivitis, ear wax impaction and swimmers ear respectively.

• Distinguish diagnosis and formulate management strategies for a patient with Eye and Ear disorders

• Recognize when to refer a patient to a doctor • Choose appropriate OTC management options for the

above mentioned diseases • Design steps for administration of eye drops, eye

ointments and ear drops

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Eye Anatomy

• Eye lids

• Conjunctiva (Sclera)

• Cornea

• Iris, pupil

• Ciliary body

• The Lens

• The Retina

Pink Eye/Conjunctivitis

• Conjunctivitis- Redness of the eye(s) & inflammation of conjunctiva, which is a transparent surface covering the white of the eye

• Affects both sexes equally at any age group • Eye can become inflamed due to infection, allergy or

irritation. • Infection may commonly be due to bacteria or virus Bacterial – Staphylococcus, streptococcus or

Haemophilus Viral – Adenovirus Allergens – Dust, Pollen causing seasonal allergic

conjunctivitis, chemicals (chlorine from swimming pool), irritation from contact lens, or animal dander

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• Questions to ask the patient

1. Eye discharge, present and what type

2. Visual changes if any refer

3. Associated rhinitis

4. Pain present and what type

Treatment varies depending on what is causing the inflammation.

Trigger points for referral

• Associated vomiting

• Clouding of cornea

• Distorted vision

• Irregular shaped pupil

• Photophobic

• Redness due to foreign body

• Redness localized around the pupil

• True/severe eye pain

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Bacterial Pink Eye

• The symptoms are a painful gritty sensation, itching, redness and a discharge.

• The discharge is sticky and purulent in bacterial infections

• Redness of the eye lasting longer than 1 week refer to clinician (except confirmed by allergic conjunctivitis)

• Bacterial pinkeye needs treatment with antibiotic eye drops or ointment (Prescription drugs)

• Chloramphenicol, Ciprofloxacin, Ofloxacin, Gentamycin are effective antibiotics

Viral conjunctivitis

• Symptoms include redness, itching, inflammation, more of a watery discharge and "cold-like" symptoms- runny nose

• Viral and bacterial conjunctivitis are very contagious.

• Usually self-limiting, Allow it to run its course.

• But if caused by herpes simplex virus or varicella-zoster, then prescription antiviral is given

• Eye drops- Aciclovir, Ganciclovir

• Symptomatic management- Zinc sulphate/ Antazoline/ naphzoline/ Xylometazoline/phenyl ephrine

• More preventive measures to be taken to prevent spreading to others

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Allergic Conjunctivitis

• Severe itching, tearing, and swelling of the eye membranes. Pain is minimal or absent.

• Typical allergy symptoms such as sneezing, itchy nose, or scratchy throat may also be present

• Identify the cause and avoid exposure to the allergen

• OTC anti-histamines (Loratadine, cetrizine) Chlorpheniramine maleate or Antazoline phosphate eyedrops can provide relief.

• Mild burning of may be possible with these drugs.

Management of conjunctivitis

• Eye ointments –longer contact time in eyes

• Eye drops- mention date of opening, discard after one month of opening

• Do not touch the tip of bottle in the eye

• OTC Oman- Phenylephrine, antazoline, naphzoline, Xylometazoline, zinc sulphate

• Dose-

• ADR-

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Non pharmacological measures

• Do not wear contact lenses until your eyes have healed.

• Cold or hot compress for symptomatic relief • Any solution or compress that you put on your eye is

sterile. • To avoid spread of conjunctivitis from one eye to

another, do not touch the other eye while treating the affected eye.

• Family members should use separate towels. Wash your hands often. Keep children home from school and day care.

Pharmacy Practice 1

PHCY 280 Ear Disorders Fall 2016-17

Mrs. Beena Jimmy

Lecturer (Pharmacy Practice)

School of Pharmacy

University of Nizwa

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Objectives

• By the end of this presentation, the student should be able to:

• Describe the disorders affecting the ear

• Discuss & recommend the management of ear wax impaction and outer ear infections

The Ear

• The ear consists of:

The pinna/ external ear, middle ear, inner ear, tympanic membrane, malleus, incus, stapes, the cochlea, eustachian tube

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• Only a limited examination of the ear is possible in community set up; pharmacists depend on patient’s ability to describe their symptoms

• Certain symptoms gives an idea of which part of ear is affected

Symptom External

ear

Middle

ear

Inner

ear

Pain √

Itch √ √

Discharge √ √

Deafness √ √ √

Dizziness √

Tinnitus √

• After history taking, examine the ear; external ear for redness, swelling and discharge

• The pinna should be manipulated to obtain best view of the ear canal.

• Adult: gently but firmly hold the helix and pull it up

• Infant or young child: gently but firmly hold the lobule and pull it down and back.

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Ear Disorders

• Ear wax impaction

• Swimmers ear

Ear Wax Impaction • Ear wax is a necessity: protecting the ear drum &

providing acidic medium to guard against infection • Predisposing factors- Narrow ear canal, people

who use hearing aids or ear plugs, smaller or oddly shaped ear, elderly

• Symptoms- temporary deafness/decreased hearing, ear pain, itching, fullness sensation and ear discomfort.

• Inquire patient’s habit of ear cleaning • It is extremely important to eliminate associated

ear disorders eg. trauma of the outer ear, foreign bodies lodged in the outer ear

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When to Refer?

• Dizziness & tinnitus (a severe spinning sensation, loss of balance, or inability to walk)

• Foreign body

• Pain due to middle ear disorder

• Failure of OTC medication

• Persistent vomiting or high fever

• Sudden loss of hearing

Management • Topical use /Putting cerumenolytic solutions (soften/

dissolve wax) into the ear canal • Oil based- Glycerol, almond oil, olive oil • Water based- Docusate sodium, peroxide-based ear

drops- hydrogen peroxide, Carbamide peroxide • Sodium bicarbonate and sterile saline solution. • Glycerol is the drug of choice • Very safe, no interaction, safe in children • Dose- 3-5 drops into the affected ear b.i.d, plug

cotton wool moistened with the drops or smeared with petroleum jelly to retain the liquid and be kept in for at least 1 hour or overnight, can be used for 3-5 days

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Management

• Peroxide based products- carbamide peroxide; do not plug ears unlike glycerol, but retain medicine in the ear by keeping the head tilted and then wipe away excess. Patients experience mild effervescence in ear.

- Docusate sodium- use enough drops to fill the affected ear, not more than 2 consecutive nights

• Syringing or manual removal are done by experts at hospital

• Fluid intake is to be increased and proper ear cleaning techniques is to be practiced

Otitis Externa

• Otitis externa (OE)/ Swimmer’s ear involves

inflammation and infection of the skin in the outer ear canal .

• Symptoms include ear pain, itching, hearing loss, redness of outer ear and clear odourless discharge.

• Irritation- depends on the severity, provokes the patient to scratch, resulting in trauma and pain

• Discharges are usually not so purulent • No dizziness & no tinnitus

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Prevalence & Etiology

• OE can be precipitated by - ear trauma (scratching, foreign bodies, use of cotton buds /Q-tips) - swimming (especially in polluted water) - chemicals (hairspray, hair dyes, shampoo, continuous use of ceruminolytics) - skin conditions (eczema, seborrhoeic dermatitis, psoriasis).

• It is a common disorder amongst children especially those fond of swimming in contaminated water due to prolonged exposure of the ear skin to water/moist humid environment

• Referral to the doctor may be necessary for accurate diagnosis.

When to Refer? • Ear pain in children below 6 yrs

• Severe pain and fever

• If symptoms continue for more than 7 days after OTC treatment

• Mucopurulent discharge

• Pain when touching the mastoid area

• Growth on pinna especially in the elderly

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Management

• Control of pain & inflammation are the primary objectives

• Systemic/oral use of analgesics (paracetamol) & antihistamines- to control pain and itching/irritation.

• Topical use of choline salicylate containing ear drops; not suitable to children below 1 yr, repeat ever 3 to 4 hours

• Mild infections- Acetic acid 2%; has both antibacterial and antifungal effects

• It works by increasing the acidity of the ear canal, making it more difficult for pathogens to grow

• ADR- skin irritation, stinging of skin

• If there is severe infection- prescription antibiotics, steroids and/or antifungal drugs

• Antibiotics include ciprofloxacin, flucloxacillin, neomycin, polymyxin (not OTC)

• Steroids include hydrocortisone as anti-inflammatory agents

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Non Pharmacological Management

• Advise the patient on how to use ear drops and cleaning ears

• Don't wear an earplug, hearing aid or headphones before pain or discharge has stopped, clean the same.

• Avoid getting water in your ear canal when bathing. Use a cotton ball coated with petroleum jelly to protect your ear during a bath.