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UCL SCHOOL OF PHARMACY

BRUNSWICK SQUARE

Treating Eye & Ear Conditions

Teaching Fellow
Oksana Pyzik
o.pyzik@ucl.ac.uk
DPP room 339
@OksanaUCL_DPP

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Learning Outcomes
Review general anatomy of the eye and ear
Aetiology, symptoms, treatment and referral
points of common eye and ear conditions
Differential Diagnosis; conditions to eliminate
Differentiating between viral, bacterial and
allergic conjunctivitis
Counselling points for common eye and ear
conditions

UCL SCHOOL OF PHARMACY


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UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Red Eye
The most likely cause of a painless red eye is
conjunctivitis.
The next most likely cause is a burst blood vessel
Conjunctivitis = inflammation of conjunctiva
Characterised by varying degrees of redness,
itchiness, discharge and irritation
Can be viral, allergic or bacterial
All are self limiting although viral can be
recurrent/persist for weeks

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Incidence
Red eye is a presenting complaint of both
serious and non-serious causes of eye
pathology
Less common causes of red eye include
episcleritis, scleritis, keratitis, uveitis
Patient with undiagnosed acute closed
angle glaucoma very unlikely to present
with symptoms at community pharmacy
(medical emergency)

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Aetiology of Conjunctivitis
Viral conjunctivitis is most often caused by the
adenovirus
Allergic conjunctivitis is most often caused by pollen
The various pathogens that cause bacterial
conjunctivitis vary between adults and children.
Causative organism in children: Streptococcus,
Moraxella and Haemophilus Influenza most common

Causative organism in adults:


Staphylococcus is most common (over 50%)
Streptococcus pnuemoniae (20%)
Moraxella species (5%)
Haemophilus influenzae (5%)

UCL SCHOOL OF PHARMACY


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Specific questions to ask patient


that presents with red eye:

Discharge present?
Any visual changes?
Any pain, itch or discomfort?
Check for location of redness
How long?
Any sensitivity to light?
(photophobia)
Any other symptoms?

UCL SCHOOL OF PHARMACY


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Symptoms of Conjuctivitis
Bacterial

Viral

Allergic

Eyes Affected

Both (but one eye


often affected first
by 24-48 hours)

Both

Both

Discharge

Purulent

Watery

Watery

Pain

Gritty

Gritty

Itching

Distribution of
redness

Generalised &
diffuse

Generalised

Generalised but
greatest in
fornices

Associated
Symptoms

None

Cough & cold


symptoms

Rhinitis (may also


have family
history of atopy

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UCL SCHOOL OF PHARMACY


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Identify the following condition:

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Subconjunctival Haemorrhage
Burst blood vessel in the eye =
subconjunctival haemorrhage
Painless
Straining or coughing can sometimes cause a
blood vessel to burst on the eye surface,
causing a bright red blotch..
It can look even more alarming if you are
taking medication such as aspirin or warfarin.
Self limiting (10 14 days)

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Identify the following condition:

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Episcleritis

Episclera lies just beneath conjuctiva


Redness appears segmental
Usually only one eye affected
Painless or dull ache
Self limiting resolves in 2 -3 weeks
Unlikely incidence

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Identify the following condition:

UCL SCHOOL OF PHARMACY


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Bacterial conjuctivitis
Self limiting (65% of people will have
clinical cure in 2 - 5 days)
Chloramphenicol deregulated from POM in
2005
No OTC treatment for viral

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Treatment for Bacterial Conjuctivitis


Bacterial conjunctivitis is largely self limiting within 2 5 days

Must be stored in fridge


Drops & ointment licensed for use in children 2+
Instill 1 drop every 2 hours for the first 48 hours, then
reducing to QDS for a MAX course of 5 days
*IF using ointment + drops (apply ointment at night)
Ointment alone = apply 1 cm to eye TDS QDS
AVOID in pregnant/breastfeeding women, family history
of blood dyscrasias including aplastic anaemia
SE: usually minor e.g. transient stinging or burning
sensation, transient blurring of vision patients should be
warned not to drive or operate machinery unless their
vision is clear. See summary of product characteristics
(SPC) for complete list.

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

NOTE:
Patients who wear soft contact lenses
should be advised to stop wearing them
while treatment continues and for 48 hours
afterwards
This is because preservatives in the drops
can damage the lenses

UCL SCHOOL OF PHARMACY


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Alternative product:
Propamidine Isethionate 0.1% (Golden Eye
Drops),
Dibromopropamidine Isethionate 0.15% (Golden
Eye Ointment)
Licensed 12 yrs +
Dose for Eye Drops = 1 -2 drops up to QDS
Dose for Eye Ointment = Apply once or twice daily
If no significant improvement after 2 days REFER!

UCL SCHOOL OF PHARMACY


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Administration of Eye Drops:


1.
2.
3.

4.
5.
6.
7.

Wash your hands


Tilt your head backwards until you
can see the ceiling
Pull down the lower eyelid by
pinching outwards to form a small
pocket and look upwards
Holding the dropper in the other
hand, hold it as near as possible to
the eyelid without touching it
Place one drop inside the lower
eyelid then close your eye
Wipe away any excess with clean
tissue
Repeat steps 2 -6 for subsequent
drops.

UCL SCHOOL OF PHARMACY


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General Advice
Avoid touching the eye & spreading any infection to the other
eye.
Bathe eyelids with lukewarm water to remove any discharge
Tissues should be used to wipe the eyes and thrown away
immediately.
Wash hands regularly.
Hold a clean, cold damp face flannel to the eye to soothe and
cleanse it.
Do not wear make-up or contact lenses until the conjunctivitis
has cleared.
Do not share towels, flannels and pillow cases with others in
the home while you have conjunctivitis

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Identify the following condition:

UCL SCHOOL OF PHARMACY


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Treatment Allergic Conjuctivitis


1)Mast Cell Stabilisers (Sodium Cromoglicate)
Prophylactic agent must be used continuously while
exposed to allergen (e.g. pollen for the season)
Dose: Instill 1 2 drops in each eye for QDS, Age: 6+
years
2)Sympathomimetics + Antihistamines
-Reduce redness of eye(s) limited to short term use to avoid
rebound effects
Naphazoline (sympathomimetic only) 1 -2 drops TDS/QDS
Combo Product: Otrivin Antistin (antazoline/xylometazoline)
Dose: Instill 1-2 drops BD/TDS, Age: 12+ years
-Avoid in patients with glaucoma (raised intraocular pressure)
CI: MAOIs, moclobemide (risk of hypertensive crisis)

UCL SCHOOL OF PHARMACY


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How do these medicines work?

Which of the following do not


require referral for red eye?

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20% 20% 20% 20% 20%

Cl
o

A. Clouding of cornea
B. Distortion of vision
C. Itchiness of the
eye
D. Irregular shaped
pupil
E. Redness localised
around pupil

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Referral Points
Answer ( C ) Itchiness does require NOT referral for red eye.
Full referral list:
Associated vomiting
Photophobia
Clouding of the cornea (suggests glaucoma)
True eye pain
Redness caused by a foreign body (requires removal)
Irregular shaped pupil or abnormal pupil reaction to light
Redness localised around the pupil
Distortion of vision

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Treating Otic Conditions

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Otic Conditions:
Be familiar with general anatomy of the
ear
Distinguish symptoms between otitis
externa swimmers ear (localised or
diffuse) & otitis media
Hint: Otitis media (infection of the middle
ear)
Starts with a common cold which leads
to the blockage of the Eustachian tube &
fluid formation within the middle ear
leading to a secondary bacterial infection
Otitis Media is the most common cause
of ear discharge & usually mucopurulent
Otitis Externa the discharge is not
mucopurulent

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

Otitis Media
Rapidly accumulating effusion in middle ear
Most common in children aged 3 6 yrs (recurrent OM = glue
ear)
Ear pain is predominant symptom (described as throbbing)
Associated systemic symptoms = fever, loss of appetite
Physical presentation = red/yellow bulging tympanic
membrane
Pain resolves on rupture of tympanic membrane which
releases mucopurulent discharge
Mostly resolves within 3 days with no treatment
Current UK guidelines do not advocate use of antibiotics
Treatment: paracetamol or ibuprofen

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Otitis Externa
Characterised by itching & irritation which
may lead to scratching of the skin of the
ear canal resulting in trauma and pain.
Otorrhoea (ear discharge) follows and can
lead to conductive hearing loss
On examination ear canal or external ear,
or both appear red, swollen & clear
discharge may be present.
May be caused by infection or trauma

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Referral Points Otitis Externa

Generalised inflammation of the pinna


Impaired hearing in children
Mucopurulent discharge
Pain on palpitation of the mastoid area
Patients showing signs of systemic infection
Slow growing growths on the pinna in elderly
people
Symptoms that are not improving and have
been present for 4 or more days

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Mastoid

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OTC Treatment for Otitis Externa


Choline salicylate (Earex Plus- choline
salicylate 21.6%, glycerol 12.62%)
1 years (completely fill EAM with drops and plug
with cotton wool soaked in ear drops)

Acetic Acid (Earcalm Spray)


>12 years (1 spray (60 mg) into affected ear
TDS, continue 2 days after symptoms have
disappeared)
if no improvement or worsening after 48 hrs
REFER!
Should not be used for more than 7 days

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Ear symptoms & affected structures

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Ear Wax Impaction


Ear wax is produced in the outer third of
the cartilaginous portion of the ear canal
by the ceruminous glands.
Most common external ear problem
Key clinical features include: gradual
hearing loss, ear discomfort, and recent
attempts to clean ear.
Itching, tinnitus, and dizziness occur
infrequently

UCL SCHOOL OF PHARMACY


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Questions to ask the patient

Course of symptoms
Associated symptoms
History of trauma
Use of medicines

UCL SCHOOL OF PHARMACY


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Referral Points
Dizziness or tinnitus (suggests involvement of
inner ear & requires further investigation
Pain originating from middle ear
Fever & general malaise in children
Foreign body in the EAM
Associated trauma related conductive
deafness
OTC medication failure

UCL SCHOOL OF PHARMACY


BRUNSWICK SQUARE

OTC Medicines
1) Oil Based Products e.g. Cerumol Ear
Drops (Arachis peanut oil 57.3%),
Cerumol Olive Oil Drops, Earex (peanut
oil, almond oil & camphor)
2) Peroxide Based Products (Exterol &
Otex)
3) Docusate (Waxsol)
4) Sodium Bicarbonate
5) Glycerin (Earex advance & Earex Plus)

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How do these products work?

UCL SCHOOL OF PHARMACY


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Source: Community Pharmacy,


Symptoms Diagnosis and Treatment by
Paul Rutter 3rd Edition