Orthoptic Exercises

1. Fusional Reserve Exercises

Treatment of choice for exo-deviations up to 20D. The ability to converge at the relevant distance is trained, the positive fusional reserves. Training negative fusional reserves is more difficult but can produce good results.

2. Free-Space Techniques

The fusion of two stereo pairs by over/under converging in free space. First px needs to have physiological diplopia demonstrated with two large targets (eg two pencils). If the px can't see the two targets then gross suppression is indicated. If px is only heterophoric this can easily be broken down. Following this the px can progress to exercises like the three cats. This exercise can be used in both exo and eso deviations. If BV is present at one fixation point then theoretically it should be able to be achieved at all distances.

3. Near to Far Tracking

Pen to nose exercises. Take care as fusion isn't always achieved but px doesn't report the diplopia due to suppression.

4. Step Vergence

Introduce prism before the eyes while patient fixates a target - introducing disparity and the vergence system is stimulated to retain fusion. The prism is then removed when fusion is established. A series of repetitions are performed to strengthen fusion.

5. Sliding Vergence

A target is fixated w/a variable prism stereoscope or risley prism and the amount of prism is increased until blur/break/recovery. Repetition can improve the fusional amplitude

6. Near to Far Jumps

Exercises accommodation and vergence together. Must maintain clear single vision.

Facility Training - Prism Flippers

These consist of two pairs of prisms mounted on a horizontal bar with base in prism on top of the bar and base out on the bottom. The idea is to flip between them when the patient is viewing at a certain distance.

Treatment of Strabismus

Functional and cosmetic results must be considered. Note a patient rarely complains about binocular status if the strab has been longstanding. Clinical objectives should be realistic in relation to the initial binocular status.

Surgery

• 15% of strabs have no refractive component so surgery is necessary. If only a small component of it is refractive then referral is probably necessary. It's not always the size of the strab rather the overall cosmesis that is important.
• GOAL OF SURGERY 1 - Functional binocularity (10%). Improvement of functional binocularity when prisms don't work, restoration of binocular alignment following injury or disease. Development of binocular vision by providing alignment or by improving comitance, prevention of sensory anomalies, corrections of head turns/tilts
• GOAL OF SURGERY 2 - Cosmetic improvement - Large angle strabismus is cosmetically unacceptable especially w/kids.

Timing of Surgery

• Infantile strabismus - Early as ocular alignment is important, later if there's already a limited prospect wrt binocular function
• Acquired childhood strabismus - a child up to the age of 6 who had binocular fusion - immediate restoration of BV essential
• Acquired adult strabismus - usually from disease. If incomitant immediately refer to determine aetiology. Comitant disorders should receive vergence training or prismatic correction. If these alternatives are unsatisfactory and a cosmetically unacceptable strab is present then consider surgery

Pharmacological Treatment

• Miotics can be used to reduce innervation to the vergence system as less accommodative drive is required. It produces an accommodation that is peripheral to the vergence system so less accommodative convergence is required at near. This reduced AC/A ratio, reducing an ESOT to and ESOP and maybe then try exercises.
  
• Miotics can also be used as a diagnostic trial to distinguish between an accommodative and a non-accommodative SOT in infants. If a miotic is instilled and the SOT is reduced then it's accommodative or related to the AC/A ratio.
• They can also be used as therapy but bifocals are preferred. Miotics caused reduced VA due to both the miosis and accommodation spasm.
• Atropine can be used long term to control accommodative esotropia although it's not advised due to the toxicity of the drug, the use of bifocals to read and photophobia. Cyclopentolate has some short term use

Optical Correction

• Correcting the rx provides a clear retinal image which prevents amblyopia and creates the correct balance between accommodation and convergence. Cycloplegic refraction should always be considered in young patients to determine the full extent of the underlying problem. If the refractive correction achieves binocular vision then consider prescribing the full amount.

Manipulation of AC/A Ratio Using Modified Presentation

• Over-correcting myopes can control XOP/T. It is not practical to undercorrect myopes as VA is reduced. Consider the maximum plus correction if BV achieved - supplemental exercises can be given to improve fusional reserves.

Bifocals

• Useful in non-refractive conditions w/abnormal AC/A ratio.
• Convergence excess - give extra plus at near
• Convergence insufficiency - give extra minus at near
• Divergence excess - increase minus at distance
• Divergence insufficiency - increase plus at distance (NB not v. practical)
• Use a large bifocal fitted to a lower pupil margin
• You can estimate the add lens power by measuring the AC/A ratio - for example if the distance = 18D exop/t and near = 8D exop and the pd is 60mm
• AC/A = 6 + (-8-(-18))/2.5

Prismatic Correction

• Used in small comitant vertical deviations and can also be useful in small horizontal phorias that aren't amenable to refractive correction or orthoptic exercises.
• Prism power is determined w/Sheard's criterion (often stated as "the opposing fusional reserve to the blur point should be at least twice the degree of the phoria" but can be up between two to four times)
• Sheard's Prism = (2xPhoria - fusional reserve)/Fixation Vergence

Fixation Disparity

• Remember to only give prism to px w/symptoms. Many patients have a fixation disparity but have no difficulty w/headaches etc. The amount of prism to neutralise the disparity is not always related to the angular subtense of the error. Stability plays a key role (?)

Orthoptic Therapy

• Preferred to surgery as it offers best chance of functional cure. Aim is to give stable, comfortable, functional BV.
• Can train sensory fusion, disparity vergence and accommodation. One principle is to establish sensory fusion prior to training motor fusion. Both can be trained simultaneously but priority should be given to anti suppression training.
  

Review of Strabismus

General Crap

Strabismus can be either concomitant or incomitant. Binocular functions always suffer but in fact it's the effect on monocular vision which are of the greatest concern - amblyopia.

The incidence of strabismus is 3-4% in caucs and more prevalent in girls. In the black population of the USA it's only 0.6%. Esotropia beats exo 5:1 in Europe but in Japan exotropia is more prevalent.

The risk of strabismus is much greater if either of your parents have it so screening has to be encouraged if that's the case. 60% of kids w/strabismus have a close relative w/strabismus. At present it's unknown how the strabismus trait is transmitted. I'm going to say 'genes an' tha'. The strabismus itself isn't inherited but some factor that predisposes the patient to the strabismus is.

Comitant Strabismus

• Infantile EsoT - early onset (up to 6 months), large and relatively stable angle of strabismus. Px usually emmetropic and rarely have more than a low degree of hyperopia or astigmatism
• Late onset EsoT - often familial, starting at 6mths and being most prevalent at 1-2 years. Accommodative factors have an important role together with hyperopia and anisometropia. AC/A ratio is abnormal. Binocularly can be restored if the eyes can be re-aligned by optical, prismatic or orthoptic means
• Exo deviations - onset variable. They progress from latent stage to intermittent and finally a constant angle. These include convergence insufficiency and divergence excess, which both readily respond to orthoptic treatment.
• Microtropia - small angle strabismus with HARC, eccentric fixation, amblyopia, a low or anisometropic refractive error, peripheral fusion and low grade stereopsis that can be recorded using a Titmus fly test.

Treatment of comitant strabismus is via correction of refractive error (or prisms), orthoptics, pharmacological treatment or surgery.

The synkinetic relationship between accommodation and convergence is attributed to the observations of Donders. Fusion is usually sufficient to maintain binocular vision but the phoria can break down without sufficient fusional amplitude and a tropia results. Correction of the refractive component can restore the phoric conditions in many cases. The presence of esotropia in the absence of a refractive error indicates that the aetiology of strabismus can't be solely attributed to refraction.

Incomitant Strabismus

• Myogenic types - inc. myasthenia gravis, different forms of myogenic dystrophies/myopathies, maldevelopment/formation of eye muscles eg SO tendon sheath syndrome of Brown, Duanes retraction syndrome and effects of muscle entrapment in orbital fractures
• Neurogenic types - lesions of the 3rd, 4th and 6th nerves whether congenital or acquired.
• Disruption of supranuclear control of ocular motor function - gaze palsies

All new incomitancies must be referred. Once the correct diagnosis wrt CNS disease or neuromuscular function has been established it may be possible to relieve the diplopia. This usually requires surgery and then prism. In lesions restricted to localised muscles or nerves the prognosis for control is better than that for supranuclear lesions.

General Pathophysiology of Strabismus

• Abnormality of the fusion mechanism - if poor fusion exists then the influence of precipitating factors like hyperopia, anisometropia, trauma and illness may cause the eye to become strabismic. Loss of fusion in childhood leads to an esodeviation and loss in adulthood leads to an exodeviation. This is probably due to the differences in muscle tonus.
• Brain Damage - higher incidence w/Downs Syndrome, Cerebral Palsy, Hydrocephalus. Depending on the condition 40-60% of patients present with strabismus. Children suffering from disease in general (eg heart lesions) have 4-6 times higher frequency of strabismus.
• Neuromuscular anomalies - factors connected w/orbital mechanism, eye muscle function, brainstem and cerebral function, accommodation and convergence coupling, the eye movement system and the development of oculomotor function.
• Reflexological theories - suggested that strab is due to disturbance of the oculomotor reflexes. Eye position during foetal life depends upon subcortical reflexes initiated by stimulation of the eye muscle proprioceptors and the vestibular organs. After birth the light stimulation initiates the development of the oculomotor reflexes which supersede the older subcortical reflexes. Esotropia would depend on an abnormal development of the oculomotor reflexes and consist of a predominance of the monocular abduction reflexes over those for conjugate movements and abduction. However all this stuff would be secondary to sensory changes.

Motor Factors Related to Strabismus

Disruption of fusion with the subsequent onset of strabismus can be caused by several motor and sensory mechanisms in isolation or in combination.

• Mechanical factors in the orbit - Anomalies of the check ligaments that connect the muscles and surrounding tissue are considered important in the aetiology of strabismus. More important still are anatomical variations in the insertions of the EOM on the globe. Mechanical factors are the most likely cause in cases of cranio-facial malformations eg Brown's.
• EOM - the particular muscle fibre (the orbital singly innervated muscle fibre) may have a prominent role in ocular motility. It is highly oxidative and fatigue resistant due to its extensive capillary network. It is the last of the six basic morphological fibre types to develop its adult features and is more susceptible to alterations in its innervations - both neural and vascular. The changes in length/tension that are characteristic of strabismus may be attributable to variations from normal in this singly innervated muscle fibre and its associated microvasculature under the influence of neural and environmental factors.
• Brainstem control of eye movements - specific lesions of the brainstem can be identified wrt strabismus. Abnormal vestibulo-ocular function has been reported in patients with early onset strabismus. Slight abnormalities of balance and gait have been shown in children with eso but not exotropia. These disturbances could represent signs of dystfunction in the cerbellopontine control of gait of postural control. Duane's and Moebius' syndromes are both down to an abducens palsy due to hypoplasia or aplasia of the abducens nucleus.

In Conclusion

The aetiology of strabismus is poorly understood and is likely to be multifactorial. The adaptive systems are most likely to be involved with the cause of the strabismus rather than the short lasting phasic components.

VKC and AKC

VKC

VKC is a recurrent bilateral, external ocular inflammation primarily affecting boys/young adults living in warm/dry climates. It's an allergic disorder in which IgE and cell-mediated immune mechanisms play an important role. About 3/4 of patients have a family history of atopy. Such patients often develop asthma and eczema in infancy. The onset of VKC is usually after five years and the condition eventually resolves around puberty, rarely persisting beyond the age of 25 years. It may occur on a seasonal basis w/peak incidence over late spring and summer.

SYMPTOMS - intense ocular itching which may be assoc w/lacrimation, photophobia, foreign body sensation and burning. Thick mucous discharge and ptosis also occur. There are three main types: Palpebral, Limbal and Mixed. Limbal signs are far more common in dark skinned races while tarsal and conjunctival signs are more common in lighter skinned races.

CLINICAL FEATURES

• Palpebral VKC - diffuse papillary hypertrophy, most marked on superior tarsus. The papillae enlarge and have a flat-topped polygonal appearance reminiscent of cobblestones. In severe cases the connective tissue ruptures giving rise to giant papillae which may be coated with copious mucus. As the inflammation settles the papillae shrink and become more separated but often do not disappear.
• Limbal VKC is characterised by mucoid nodules scattered around the limbus with discrete white superficial spots composed mostly of eosinophils at the apices of the lesions

KERATOPATHY

• Punctate epithelial erosions involving the superior cornea are the earliest findings
• Shield ulceration is a serious problem which may be complicated by bacterial keratitis and rarely perforation.
• Plaque formation may occur when the base of the ulcer becomes coated w/desiccated mucus. This results in defective wetting by tears, prevents re-epithelialisation and predisposes to subepithelial scarring and vascularisation

TREATMENT

Topical

• Steroids are indicated for keratopathy but may be required as short-term therapy for severe discomfort in px w/only conjunctivitis. Fluorometholone should be used since it has a weaker ocular hypertensive effect that dexamethasone or prednisolone.
• Mast cell stabilisers such and nedocromil and lodoxamide are used as prophylactic therapy that reduces the need for steroids. They don't have the side effects of steroids but are no good at controlling acute exacerbations.
• Antihistamines are also effective
• Acetylcysteine 0.5% has mucolytic properties and is useful in the treatment of early plaque formation

Supratarsal steroid injection of betamethasone or triamcinolone is effective in patients with severe disease unresponsive to conventional therapy.

Surgical treatment might be necessary for severe shield ulcers that are resistant to medical therapy. This may involve debridement, superficial keratectomy, excimer lase phototherapeutic keratectomy as well as amniotic membrane transplantation to enhance re-epithelialisation.

ATOPIC KERATOCONJUNCTIVITIS

A relatively rare, but potentially serious condition which most often affects young men w/atopic dermatitis.

CLINICAL FEATURES

• Lids are red, thickened and fissured, w/staph. bleph also common
• Conjunctivitis primarily involves the inferior forniceal and tarsal conjunctiva. Infiltration of the tarsal conjunctiva results in a pale and featureless appearance. During exacerbations there may be chemosis, limbal hyperaemia and papillary hypertrophy. In advanced cases cicatrizing conjunctivitis many develop
• Keratopathy is the main cause of visual impairment and is characterised by punctate epithelial erosions. More advanced lesions include persistent epithelial defects, shield-shaped anterior stromal scars and peripheral vascularisation.
• Complications inculde aggressive herpes simplex keratitis and microbial keratitis

TREATMENT

Similar to that of VKC but more prolonged.

• Topically antibiotics and lid hygiene, preservative free lubricants may prove useful during exacerbations, steroids are affective for short term treatment of inflammatory exacerbations and for keratopathy, mast cell stabilisers such as sodium cromoglycate are effective and should be used throughout the year as prophylaxis against exacerbation and as steroid-sparing agents. NSAIDs such as ketorolac are also effective and may be used in combination w/a mast cell stabiliser. Antihistamines are less effective in AKC than VKC.
• Supratarsal steroid injections when topical treatment is ineffective
• Systemic antihistamines for severe itching, antibiotics such as azithromycin 500mg once daily for three days may be effective in reducing inflammation. Cyclosporin may be useful in severe cases.
  

Conjunctivitis

SIMPLE BACTERIAL CONJUNCTIVITIS

Common and usually self-limiting, most commonly effects children. Spread of the infection is usually down to direct contact with infected secretions.

Presentation is w/acute redness, grittiness, burning and discharge. On waking the eyelids are frequently stuck together and difficult to open as a result of the accumulation of exudate during the night. Usually both eyes involved but one may become infected after the other

Signs - eyelids crusted and may be oedematous. Discharge initally watery mimicking viral conjunctivitis but becoming mucopurulent within a few days. Mucous strands may develop in the lower fornix. Injection is maximal in the fornices and least at the limbus. The tarsal conj has a beefy red appearance and shows mild papillary changes. Superficial punctate epithelial erosions are frequent but innocuous.

Treatment - often resolves itself within 10-14 days. First, clean eyelids and lashes of discharge. Broad spec antibiotic like chloramphenicol (every 1-2hrs) or fusidic acid (qid for 48 hours then bd) should be administered in drop form and as ointment at bed time until discharge has ceased.

VIRAL CONJUNCTIVITIS

Adenoviral keratoconjunctivitis can vary from almost inapparent disease to full blown infection. Transmission of this highly contagious virus is via respiratory or ocular secretions and dissemination by contaminated towels or tonometer heads. Incubation period is 4-10 days. Following the onset of conjunctivitis the virus is shed for about 12 days.

Causative viruses are

1. pharyngoconjunctival fever (PCF) is most frequently caused by adenovirus types 3, 4 & 7. It is transmitted by droplets and typically infects children who also develop an upper respiratory tract infection. Keratitis develops in about 30% of cases but is seldom severe.
2. Epidemic keratoconjunctivitis (EKC) is most frequently caused by adenovirus types 8 & 19. The infection is transmitted by hand to eye contact, instruments and solutions. It does not cause systemic symptoms. Keratitis, which may be severe, develops in about 80% of cases.

The conjunctivitis presents w/acute watering, redness, discomfort and photophobia frequently involving both eyes.

Signs

• Eyelid oedema
• Watery discharge and conjunctival follicles
• Subconjunctival haemorrhages, chemosis and pseudomembranes in severe cases

Treatment

• Largely symptomatic and supportive. Spontaneous resolution occurs within two weeks. Antiviral agents are avoided unless the inflammation is very severe.

Keratitis

• Signs: Stage 1 occurs within 7-10 days of the onset of symptoms and is characterised by a punctate epithelial keratitis which resolves within two weeks. Stage 2 is characterised by focal white subepithelial opacities which develop beneath the fading epithelial lesions. They are thought to be an immune response to the virus. Stage 3 is characterised by stromal infiltrates which gradually fade over months or years.
• Treatment w/topical steroids is indicated only if the eye is uncomfortable or VA diminished by stage 3 lesions. The steroids don't shorten the natural course of the disease but merely suppress the corneal inflammation so that the lesions tend to recur if steroid therapy is discontinued prematurely
  
• Treatment is w/topical steroids and indicated only if the eye is uncomfortable or VA dimini
  

Keratoconjunctivitis Sicca

Symptoms

• Irritation, foreign body sensation, burning, a stringy mucus discharge and transient blurring of vision.
• Less frequently - itching, photophobia and a tired or heavy feeling
• Px w/filamentary keratitis may complain of severe pain brought on by blinking
• Symptoms frequently exacerbated on exposure to conditions assoc w/increased tear evaporation - aircon, wind or prolonged reading.
• Symptoms may be improved by lid closure

Tear Film Abnormalities

• Mucus strands and debris are an early sign. In the normal eye as the tear film breaks down the mucin layer becomes contaminated w/lipid but washes away. In dry eye the lipid contaminated mucin accumulates in the tear film and tends to move w/each blink
• Tear meniscus becomes concave, irregular and thin
• Froth in the tear film or along the eyelid margin occurs if MGD also present.
• Examine the tbut w/slit lamp or schirmer
  

Keratopathy

• Punctate epithelial erosions in the inferior cornea
• Filaments are small comma shaped mucus strands lined w/epithelium attached at one end to the corneal surface. The unattached end moves w/each blink
• Mucus plaques. Stain w/rose bengal and are seen in conj. w/mucus plaques.

Treatment

• Preservation of existing tears by reducing room temp, room humidifiers
• Art. tears w/hypromellose (tears naturale)
• Art tears w/PVA (liquifilm tears)
• Art tears w/sodium hyaluronate
• Art tears w/NaCl
• Art tears w/povidone
• Gels - viscotears, gel tears. Carbomer gels
• Ointments
• Reduction of tear drainage w/punctal plug
  

Anti-infectives II

FORTIFIED OPHTHALMIC ANTIBACTERIAL PRODUCTS

• For severe, ulcerating infections of the cornea. Certain antibiotics can be prepared as special concentrated solutions to manage the bacterial infection with an antibiotic w/proven efficacy against the bacterial strain responsible for the infection. This can only be done providing laboratory culture tests have been performed w/isolates from the infected eye. It's important that the therapy be very intensive and be administered to a hospitalised patient eg q15 to q30 minutes for 24h, at q1h q2h for the next day or so...
• These are only made in a hospital pharmacy as and when needed. Short shelf lifes and unpreserved.
• Some of the more commonly used fortified antibiotics are the aminoglycosides as fortified 1% gentamycin or neomycin. Fortified polymyxin B solutions may be used for indentified gram -ve infections. Fortified cephalosporin eyedrops can be used for gram positive ulcers.

MANAGEMENT OF FUNGAL INFECTIONS OF THE EYE

Any bacterial or viral infection that fails to respond to therapy may be the result of an opportunistic infection w/fungi or even protozoa and required the use of a different type of fortified antibiotic. Few specific anti-fungal drugs exist and even fewer are specifically indicated for use in ocular infections caused by fungi and protozoa let alone for topical ocular use.

Fungal infections are normally already severe by the time a diagnosis is made so they are managed by a specialist. Many are initially diagnosed as viral infections because the acute/sub acute red eye, lacrimation, little or no discharge and marked foreign body sensation and photophobia suggest HSV. Even punctate staining and dendrites have been reported. Buuuut if linear railway-track like infiltrates are present that may be a clue that the infection is fungal/protozoan.

Suspect a fungal/protozoan infection if there's a failure of the red eye to show a positive response to antibacterial or antiviral therapy over 3 to 4 weeks. As a general rule anything like this should be assumed to be a fungal or protozoan infection unless proven otherwise - appropriate measures should be taken. Unusually high levels of pain (more than the level of 'red eye' would suggest) are another indicator. The reason for this is mayhaps the way the infective organism associates with the corneal nerves. The diagnosis will be made in part on the detection of fungal hyphae in scrapings from the ocular surface or maybe the patient's contact lens case that they have let rot into ming. NB Treatment of fungal infections can only be done via a major hospital centre as the drugs used need to be prepared by a specialist pharmacy. The therapies include:

• Topical Antifungal Drugs eg Natamycin 3% or 5% ophthalmic suspension. This suspension can be prepared in a hospital pharmacy w/a power and a suitable vehicle for the powder. There's a US commercial product that they may be able to use too, NATACYN. If prepared it needs to be stored in a refrigerator at 4 degrees C. Treatment for fungal keratitis should be q1hr for 3 to 4 days, day and night. Thereafter the dosing can be reduced to q2hr or q3hr. A less intensive regimen could be used if it's only fungal keratitis or fungal blepharitis. If there isn't any improvement within 7 to 10 days then the causative organism is not likely to be a susceptible fungus. The treatment period is normally 14 to 28 days if responsive but more established cases may require weeks.
• Imidazole Antifungal Drugs eg econazole and ketoconazole can be prepared in a hospital pharmacy also. They have a broad spectrum of activity against various fungi. They work generally by altering protein synthesis and so are fungistatic. The regimen is the same as Natamycin, again w/established cases taking several weeks. They can also be used orally.
• Polyene Antibiotics eg amphotericin B. This is primarily marketed as an antifungal for i.v. use (PoM Fungizone or PoMHP Amphocil) but the powder can be reconstituted in sterile water and made into eyedrops that have to be protected from light and kept in the fridge. The drug binds to sterols in cell membranes and can exert a fungistatic or fungicidal action depending on intensity of use. It's reserved for case where the initial condition is already severe or a condition which hasn't responded well to Imidazole or Natamycin. 0.1% concentration is used because the drug is very toxic. Regimen is every 30 mins or every hour for 2-3 days then reducing the frequency over the course of 7-10 days

MANAGEMENT OF PROTOZOAN INFECTIONS OF THE EYE

The example here is the mighty Acanthameoba. There isn't really a fixed treatment for these infections. All represent last stage measures to try and save a cornea and even the entire eye and may need to be continuted for even 6 to 9 months. Following diagnosis w/history, scrapings etc. Hospital-based therapies have included

• First a topical disinfectant like 0.2% chlorhexidine q1hr for a few days then down to q2hr or q4hr if the infection is under control
• then add concurrent intensive therapy w/a broad spec antibiotic like gentamycin 1% eye drops q2hr. The fortified gentamycin will be HP. The antibacterial therapy is to aid the sterilization of the ocular surface and this should reduce any possible replication of the ameobae (they feed on bacteria). In later stages a broad spectrum combo antibac therapy like Neosporin eyedrops may be used instead on a similar intensive regimen
• Use an oral anti-infective like ketaconazole 200-400mg (PoM Nizoral). This can be used concurrently with the disinfectant eyedrops since this antifungal has some effect on protozoan plasma membranes as well and can be protozoocial. Again this is HP. These sorts of drugs are far less effective against acanthameoba cysts.
• An adjunct corticosteroid therapy is essential if scarring of the corneal tissue is to be kept to a minimum. At some point after initial therapy the decision to start using corticosteroids has to be made. Generally they haven't been started until at least 4 days after commencement of the intial treatment. When used it's PoM Maxidex or PoM Pred Forte @ q6hrs.
• Adjunct therapies should also include cycloplegics and narcotic analgesics AND oral antifungal drugs if the ocular infection is associated w/skin or mucous membrane infections.

BONUS MATERIAL!!!!!! THERAPEUTIC USES OF CYCLOPLEGIC DRUGS

When certain inflammatory diseases of the eye there are special uses of cycloplegic-mydriatic drugs. These uses are para-therapeutic and a substantial extension of the use of these drugs for diagnostic purposes. Homatropine and Atropine are the standard cycloplegics for this use but cyclopentolate can still be used. In such uses the instillation of the cycloplegic is repeated at an interval and duration appropriate for the severity of the inflammation and associated complications eg posterior synaechiae. A single use might be advocated to reduce the risk of development of iris adhesions, BDS use might be routine for recurrent iritis, while more frequent and prolonged use might be appropriate for substantial intraocular inflammation when administered concurrently w/anti-inflammatory drugs.

• Used as PROPHYLACTIC MEASURE to reduce chance of posterior synechiae
• Used as SUPPORTIVE MEASURE - to promote px comfort
• as a MANAGEMENT OPTION to break pos. synechiae - you can just keep piling the drops in until they break!
  

Other Anti-Infectives & Their Uses

There are a variety of ocular and peri-ocular infections that require use of antibacterials other than the ones outlined in the last post. For example chlamydia and viral, fungal or protozoan infections. Some of these are monitored by GPs but if the cornea is involved the ophthalmologist will probably be responsible for treating it.

DISINFECTANTS FOR OCULAR USE

Iodine is a general purpose disinfectant which was widely used before the introduction of other topical anti-infective drugs. It is still used today in a specially prepared form - povidone iodine PoM HP Betadine - to routinely cleanse the eyelid and periocular skin prior to surgery. It damages the phospholipid membranes of organisms inc. all microbes and thus exerts a disinfectant effect. As the product is bacteriocidal further spread of infection should be prevented.

CHLAMYDIAL EYE INFECTIONS AND THEIR TREATMENT

Chlamydia is usually an STD but can be assoc w/some forms of respiratory tract disease and the causative agent of trachoma, a major cause of blindness. The infection of the conj causes inclusion conjunctivitis characterised by a florid follicular reaction. Management is best done at an STD clinic. Treatment options include

• PoM Aureomycin was once available as a topical chlortetracycline ointment but could still be available from a hospital pharmacy. This is a protein synthesis inhibitor that is effective on chlamydia. Treatment should be QDS over a period of 2 to 4 weeks usually along w/systemic tetracycline. Not recommended for use in children and eyelid photosensitivity reactions may occur.
• Topical erythromycin ointment. This is another protein synthesis inhibitor that's active on chlamydia, classified as a macrolide antibiotic. It's not marketed in the UK but a pharmacy prepared or imported ointment can be used. Treatment is again QDS for 2-4 weeks w/oral erythromycin or tetracyclines.
• Oral tetracyclines or macrolides. Standard treatment for chlamydial infections requires the use of systemic antibiotics. Tetracyclines include doxycycline (PoM Vibramycin) or minocycline (PoM Minocin) while macrolides include erythromycin (PoM Ilosone) or azithromycin (PoM Zithromax). Treatment is BD for 2-4 weeks or a single mega dose of azithromycin. There are many drug-drug interactions to be considered simply because the macrolide antibiotics can interfere with the biotransformation of many other drugs.

ACNE, ROSACEA AND THE EYE

Patients w/acne or rosacea are more likely to present with blepharitis or blepharoconjunctivitis. The causative agent of acne is propionobacterium acnes and is susceptible to a range of antibiotics.

• Topical (skin) benzoyl peroxide. This chemical decomposes slowly to give active oxygen radicals that have general antibacterial/antiseptic actions. In addition the chemical acts as a drying agent and a keratolytic action to promote keratin removal. Used as topical lotions or gels from once daily to QDS. Eg GSL Acnecide, GSL Nericur, GSL panoxyl. Contact with eyes and mucous membranes should be avoided.
  
• Topical (skin) salicyclic acid. Has both antibacterial and keratolytic properties. Used as a topical lotion - GSL Acnisal.
• Topical (skin) metronidazole. Binds to protein and is bacteriostatic. General use for acne/rosacea as a topical gel - PoM Rozex.
• Topical or oral erythromycin - a macrolide antibiotic that blocks protein synthesis and is bacteriostatic. Used on its own as a topical lotion or gel (eg PoM Eryacne) or in combination with benzoyl peroxide (eg PoM Benzamycin gel) or zinc acetate (PoM Deteclo). Also used orally for chronic cases - PoM Erymax or PoM Tiloryth.
• Topical or oral tetracyclines - several different drugs are available, all being bacteriostatic protein synthesase inhibitors.
• Topical tretinoin - essentially an irritant that stimulates vitamin A dependent division of sub-epidermal cells and in doing so acts as a keratolytic - promoting removal of superficial/overlying keratin plugs. Used as a topical skin product at 0.025% concentration in lotions, gels or creams. Avoid eyes, mouth, mucous membranes.
• Topical isotretinoin/topical skin adapalene - similar to tretinoin above

PSORIASIS

A chronic skin condition often assoc w/acne-like conditions and for which similar treatment options are available eg antiseptics such as povidone-iodine, salicyclic acid or coal tar lotions. Can also be treated w/topical retinoids like tazaratolene (PoM Zorac gel) or oral retinoids such as acitretinin (PoM Neotigason). An alternative to retinoids is to use topical vitamin D analogues eg tacalcitol (PoM Curatoderm gel) or calcipotril (PoM Dovonex cream).

MANAGEMENT OF VIRAL INFECTIONS OF THE EYE

Certain viral infections of the eye can be managed easily and with a favourable outcome providing a prompt and correct diagnosis is made and the appropriate referral is arranged so that therapy is instigated and adhered to. In considering viral infections the differential diagnosis is very important. Things to consider

• HSV - acute onset, initial symptoms include foreign body sensation, itching, tingling or moderate jabbing pain. Objective early signs for HSV corneal positive staining w/flu or rose b may be punctate initially (especially in infant cases) but these small foci soon coalesce to form either linear or branched patterns. At a later stage if significant epithelial erosion has occurred (ie there were substantial dendrites) then infiltrating stromal keratitis can develop.
• EKC - acute onset, initial symptoms include slight irritation and itching accompanied by profuse lacrimation. Objectively there could be superficial punctate keratitis or the appearance of subepithelial discrete opacities that are non-staining. At a later stage the condition should resolve to a quiet eye despite residual epithelial or subepithelial deposits.
• HZ - subacute onset, initial symptoms include itching maybe assoc w/periocular skin + eyelid tenderness as well as involuntary twitching. Objectively: early onset pseudo-dendritic (feathery) corneal patterns may be evident that may stain positively although not very well w/flu or rose bengal. Such pseudodendrites may be mucous plaques that change position/size/shape on the cornea on a daily basis. The removal of these plaques will be painful and then the area will stain well w/rose bengal. Such signs are usually preceded by pain especially for the eyelid skin or peri-ocular facial skin and eruptions/blisters may develop on the skin. In later stages HZ may resemble HSV.

MANAGEMENT OF EKC

• EKC is not generally indicated for treatment with antiviral drugs. Management includes use of eye baths and decongestants like naphazoline 0.01% as needed to reduce lacrimation and promote ocular comfort. Also possibly a mild to moderate corticosteroid eg betamethasone to reduce the further development of corneal epithelial infiltrates. Such therapy should be q6hrs and should be tapered after 7 days. General hygiene to stop cross-infection is important. The total treatment period is not more than two weeks.

MEASUREMENT OF HERPES SIMPLEX INFECTIONS (HSV)

• Prompt management w/antiviral drugs and care should be taken to prevent infection of the other eye if the condition is unilateral (it often is). Ophthalmic antivirals work by stopping the virus replicating DNA. They are generally pro-drugs that need to be biotransformed into their active form by infected epithelial cells.
• Regardless of the severity of presenting signs treatment can be commenced with aciclovir 3% ophthlamic ointment PoM Zovirax 4.5g tube at q2hr or q3hr especially for the first 24hrs at which time the regimen reduced to q4hr. Such a treatment should be maintained for seven days only w/examinations at days 1, 3 & 7. Again it's important that therapy be continued for a few days after resolution is clearly underway so if everything looks good after seven days another 3-5 would be good.
• Stuff like zovirax cold sore cream obvs isnt for the eyes but could be used if the eye infections are assoc w/mouth ulcers.
• If the HSV infection is severe at presentation systemic administration of antiviral drugs such as aciclovir PoM Zovirax tablets is needed. In addition the recovery from the HSV infection can be acheived by removing the virus-infected corneal epithelial cells before beginning antiviral therapy ie debridement under intense topical anaethesia w/lots of tetracaine 0.5% or cocaine 4% eye drops. Epithelial cell resurfacing then needs to be carefully reassessed on follow-up visits.
• If the infection is severe and the corneal stroma is involved w/deep lesions careful use of strong ocular corticosteroids eg PoM Maxidex or Pred Forte providing the patient can be seen on a daily basis to ensure that there's no further progression of the dendritic/infiltrating ulcers. Mydriatic cycloplegic use is also recommended to offset the iritis and flare.

MANAGEMENT OF HZ INFECTIONS

Two options. Often hard to differentiate between a HZ and a HSV so treatment may be a bit wrong initially!

• For milder cases of HZ affecting the cornea where it's fairly certain that HSV isn't present it should be treated as an inflammatory condition w/PoM Maxidex, PoM Pred Forte or PoM Betnesol eyedrops qds perhaps w/antibiotic eyedrops after removal of the epithelial plaques by rubbing. Follow-up should be every 24hr to ensure that further infection does not develop. This topical treatment should best be accompanied by oral antivirals as zoster (aka shingles) is usually a systemic infection. PoM Zovirax 3-5x200mg/day for 5-10 days. Topical antivirals a la HSV are needed if further dendrites appear.
• In more severe cases w/eyelid vesicles/pustules/general mucopurulent discharge and general encrustation or if dendrites keep on developing, treat as if there were HSV present with topical acyclovir. Careful steroid therapy is appropriate as long as the px can been seen every 24 to 48 hours until the condition is clearly resolving. The corticosteroid needs to control the stromal involvement but without worsening the condition by delaying re-epithelialisation or facilitating a secondary infection. Mydriatic cycloplegic treatment is also essential to offset the iritis and flare. Systemic corticosteroids PoM Prednisolone may be needed. Cold compresses and adjunct use of ocular lubricants may provide much needed symptomatic relief.

I'm going to start a new post now cos this is fucking huge

Ophthalmic Antibacterial Agents & Their Uses

Three main types of topical ocular antibiotic

• Antibacterial Chemical Agents
• Broad Spectrum Antibiotics
• Narrow Spectrum Antibiotics

Guidelines for Use

• Recognition of infection as being bacterial as opposed to viral, fungal or protozoan. Bacterial often leave substantial encrustation on lashes. Bacterial inf of the conjunctiva is usually accompanied w/yellowy-white gummy muco-purulent discharge (as opposed to white and stringy in allergic reactions). Lids may stick together, especially overnight. Viral and fungal infections are more commonly accompanied by profuse tearing without discharge/encrustation. Involvement of conj may spread to cornea also.
• History tends to be acute - irritation/signs are sufficient to make px come in straight away. However px w/minor infections and who already have a bit of ocular irritation might not notice. Perhaps that case can be managed simply w/better ocular hygiene
• Selection of appropriate primary and secondary therapy: Product Selection, Treatment Regimen & Predicting Outcome. Often product selected w/regimen and that's it. Shotgun approach involves choosing drug, using on px, give px a small supply and regimen and get them to come back in a day or two. From there if improvement move on to a written order/refer for Rx. Using a broad spectrum antibiotic will usually work. Most things can be managed w/out cultures being taken.
• Product selection and use - allergies - more likely w/aminoglycoside antibiotics eg neomycin but chloramphenicol can cause sensitization if inappropriately used. Will there be a fridge to put the chloramphenicol in and will the px use it? Will overnight treatment be necessary? In which case - ointments!

Regimens & Px Education

• Initially around 5x a day at regular intervals NOT AS NEEDED TELL THEM THIS. If more severe broad spec stuff can be administered every couple of hours for the first day or two. Ophthalmic viscous solns 'morning and night'. If v severe use drops and ointment. w/round the clock drops. If it's really bad and they need to do that maybe refer. If there's any corneal involvement then initially should definitely be every two hours. Note all this stuff down obvs.
• Duration of therapy: Good regimen is 7 to 10 days but some products will suggest just 5. Treatment should be until 2 or 3 days after infection no longer apparent.
• Never assume px knows what they are doing. Take time to educate on instillation, application, hygiene, storage and disposal of the pharmaceuticals. Px needs to understand importance of compliance. If they aren't going to be able to comply w/drops dispense ointment.
• Ideally no px should be given anti-infective drugs w/out the opp. for a follow-up. Patient must be told to come back at a specific time if the condition doesn't improve? Could do quick phonecall if all seems ok and then sort something else out. If all seems ok can usually instruct px to continue w/therapy until 2-3 days after they think it has subsided. Such a follow-up visit doesn't need to include a full eye test.
• If eye appears worse on follow-up then appropriate changes in therapy need to be made and the px referred, at least for cultures. In rare cases it should always be considered that the infection is actually fungal or viral and that you got it wrong, doofus.

Bit on Management of Infections

• Styes or many other inflammatory infections of the eyelash follicles/glands/accessory lacrimal glands can be readily managed w/ocular hygiene and maybe some anti-infective ointment. If untreated they can sometimes develop into chronic conditions or something more serious (orbital cellulitis!) which would require urgent referral.
• Lids should be cleansed w/lid scrubs then the ointments worked into the lid margin and antibac drops used if the bulbar conj is also affected. Nightly and morning use of the ointments should sort it out. Although these drugs have little action on the bacteria inside the inflamed loci they should stop the infection spreading IE THEY ARE BACTERIOSTATIC not bacteriocidal.
• w/styes the same sort of treatment will work, w/eyelid margin cleansing w/warm compresses for 5 to 10 mins to promote expression of the infected foci before starting w/the antibacterial agents. Longer term/recurrent conditions maybe need broad spectrum antibiotics or combination products and the therapies should be alternated 2 weeks at a time. This greatly reduces the chance of resistance developing.

USING OPHTHALMIC ANTIBAC DRUGS IN CHILDREN

Kids often develop a sticky red eye that's caused by communally transmitted bacteria eg in school. These conditions will often resolve w/careful ocular hygiene - for example a twice daily wash w/an astringent along w/ a cotton bud to remove the discharge. If antibiotics are deemed necessary then caution is advised - don't overexpose the eye to the antibiotics and limit their repeated & chronic use.

Such childhood infections are often caused by Staphlococcus SP which is a gram +ve bacterium. Other causes include streptococcus (+) and haemophilus (-). Gram negative bacteria are also the cause of upper respiratory tract and ear infections. All of these could be rapidly responsive to broad spectrum antibiotic therapy by less so to narrow spectrum. In newborns it's important to distinguish infections from the above bacteria and more serious infections from more virulent gram positive organisms like gonococcus and chlamydia which would require more careful treatment (ophthalmia neonatorum)

CURRENTLY AVAILABLE UK ANTIBACTERIAL DRUGS
***revised laws in 2005 (SI 764-766) mean that all optometrists may sell and supply P medicines containing anti-infectives***

Three main types - broad spectrum antibiotics, narrow spectrum antibiotics and general purpose antibacterial drugs

General Purpose Diamidine Ophthalmic Antibacterials

• For mild infections of the conj and eyelids where there isn't subtantial mucopurulent discharge. These drugs belong to a class called 'amidines' which indirectly block production of DNA, mRNA and protein synthesis by interfering w/the cell's purine uptake. So the infection can't spread. These are usually bacterostatic then aren't they - slowly down the growth of bacterium as opposed to wiping it out.
• There is no evidence to support the prophylactic use of these drugs for corneal or conjunctival abrasions or other foreign body injuries. They are all P Medicines
• Propamidine 0.15% P Golden Eye drops/Brolene eye drops 10ml bottle
• Dibromopropamidine 0.15% P Golden Eye ointment/Brolene eye ointment 3.5g tubes w/lanolin (possible allergies)
• Recommended doseage = 4x a day. Medical attention should be sought if the eyelid condition doesn't show improvement within two days.

BROAD SPECTRUM OPHTHALMIC ANTIBIOTICS

These are suitable for the management of acute onset, mild and mod-severe infections of the external eye. Important that these products are applied regularly eg at least 4 times a day for drops. All the broad spectrum antibiotics are expected to show similar efficacy.


1. Chloramphenicol

• Inhibits protein synthesis in bacteria - bacteriostatic. Interferes w/assembly of amino acids into peptide chains so that the synthesis of key peptides and proteins is slowed down and the overall rate of bacterial cell division is too.
• Indicated for use to manage bacterial infections of eyelids, conjunctiva and cornea. It can be expected to be effective against the majority of bacteria causing infections of the external eye but isn't expected to show useful efficacy against gram negative pathogens like pseudomonas sp.
• Chloramphenicol 0.5% eyedrops in multidose bottles are now readily available as P Medicines in 10ml bottles eg P Optrex Infected Eyes Eye Drops, P Golden Eye Antibiotic Eyedrops. Also PoM chloramphenicol minims 0.5%. Chloramphenicol eyedrops are preserved w/phenylmercuric nitrate and P Meds include a note saying a band keratopathy could develop w/use of the preservative. It would disappear once the drops were discontinued.
• Ointments w/1% chloramphenicol are also available eg P Optrex Infected Eyes Eye Ointment, PoM Chloromycetin, PoM Chloramphenicol eye ointment. All 4g tubes.
• Recommended doseage is 5x/day initially and continued treatment should be 4x a day for 7 days. PoMs containing Chloramphenicol can be used on infants but the P Medicine eyedrops are not currently licensed for infant use.
• WARNINGS: Not intended for repeat use, some would advise caution when doing 7 days worth. Warning indicating possibility of aplastic anaemia but evidence for this is weak

2. Gentamycin PoM used in hospital eye clinics
3. Neomycin PoM indicated for styes, bleph,
4. Tetracyclines - interfere w/protein chain in different way to chloramphenicol

NARROW SPECTRUM ANTIBIOTICS

• Suitable for amangement of some acute onset, mild-moderate severity bacterial infections of the external eye ie conjunctivitis and blepharoconjunctivitis. Current UK example is Fusidic Acid. Only active against some of the more common causes of infection
• Again fusidic acid inhibits protein synthesis but at a slightly different place to chloramphenicol. In order for a protein to be assembled the mRNA needs to be repeatedly bound and unbound to specific sites on the ribosomes. An enzyme called translocase is responsible for this step and fusidic acid acts by indirectly interfering with the translocase.
• Fusidic acid is usually bacteriostatic but can become bacteriocidal w/high doses. The problem is some common causes of infection eg streptococcus pneumonia or haemophilus influenzae are less likely to show significant sensitivity to fusidic acid. Both of the above are often also assoc w/throat or ear infections.
• Available as viscous eyedrops PoM Fucithalmic contains 1% fusidic acid in a viscous solution of a 0.5% carbomer gel. Indicated for BD usage but can be applied four times a day in the first couple of days if the infection is serious enough. The twice daily regimen is especially useful for children providing that they don't have naso-pharyngeal or ear infections too. It's applied into the lower cul-de-sac like an ointment.
• Fusidic acid can be used as a chloramphenicol alternative in cases of corneal/conjunctival abrasion. Also in chronic recurrent blepharitis a patient may respond well to it along w/the appropriate hygiene measures. The drops should in that case be applied to the lid margin with a cotton bud. It can be used as an alternative to chloramphenicol or framycetin eye ointments, being switched every two weeks or so to increase the chance of an effect and reduce the chance of resistance developing.

BROAD SPECTRUM COMBINATIONS PoM
Bacitracin Zinc, Polymyxin B, Gramicidin

NSAIDS, Corticosteroids & Their Ophthalmic Use

Inflammation of tissues if not too severe can be managed by anti-histamines and NSAIDs. If the inflammation is more severe then corticosteroids are useful.

Corticosteroids can act as anti-inflammatory agents as well as having a number of other effects on the body. Therapeutic corticosteroids work to directly block the production of inflammatory mediators (prostaglandins) while NSAIDs act as inhibitors of the enzymes that produce the prostaglandins.

OCULAR NSAIDs

Uses

• For seasonal allergic conjuntivitis eg diclofenac sodium 0.1% avail as PoM Voltarol Ophtha Multidose 5ml. For use QDS to reduce redness, discomfort and lacrimation assoc w/SAC. Supplemental anti-histamines will probs be needed to reduce residual itching etc. They shouldn't normally be used for more than a few weeks - then mast cell stabilisers can take over.
• As a topical analgesic. Again diclofenac sodium 0.1% can be used in the management of pain/discomfort after abrasions of the cornea and conj and also after refractive surgery. This is usually for a short period of time eg QDS for 2 days.
• Before & after general surgery to the eye eg cataract surgery or the extraocular muscles in strabismus surgery

The use of anti-inflammatory drugs on the eye has been promoted whenever there was evidence of the possible development of inflammatory signs/where clear inflammation was present or the eye had been subjected to trauma where inflammation was an expected sequel to the trauma. By reducing the tissue production of prostaglandins NSAIDs can be very effectively used prophylactically.

Different Preparations

• DICLOFENAC SODIUM is marketed as PoM Voltarol multidose w/a unit dose for those w/allergy to preservatives (thiomerosal). As a NSAID is can reduce the risk of CM oedema post-cataract ops. It also maintains mydriasis during surgery and has sufficient anti-inflammatory efficacy to be used to manage general ocular inflammation after surgery too for up to 4-6wks. It means narcotic analgesics (corticosteroids) can be used less. There is now a P oral diclofenac that an optom can sell or at least recommend.
• KETOROLAC TROMETAMOL ophthalmic solution 0.5 (PoM Acular 5ml bottle) is indicated as a prophylactic for inflammation and associated symptoms following cataract surgery. Its use is similar to diclofenac eg TDS for the day prior to surgery and then TDS for up to three wks (ie better than Voltarol)
• FLURBIPROFEN ophthalmic solution (PoM Ocufen 10x0.4ml SDUs) 0.03%soln in 1.4% PVA. Only indicated for intensive use as a general anti-inflamm drug for cataract ops, esp in case where corticosteroids are contraindicated.

Additional Supply optoms can use topical diclofenac sodium to control pain following eg recurrent corneal erosion w/chronic tear film instability - painful episodes of loss of poorly adherent epithelium.

CORTICOSTEROIDS FOR OPHTHALMIC USE

• Corticosteroids take a relatively long time to work ie days so way need to be given for several days before any effect is obvious whereas NSAIDs can produce effects in hours. Antihistamines can produce effects between minutes and hours
• No routine access to optoms but should be on future lists. Px currently has to go to GP or ophthalmologist since nurse prescribers can only access non-ocular steroids.

Indications for use

Primarily for non-infectious inflammatory disorders

• Assoc w/chronic chemical or drug irritation of the eyelids that leads to oedema of the eyelid margins and palp. conj. eg those w/severe allergic reactions of any type, seasonal allergies, acute or subacute allergic blepharitis from airborne sources or contact w/chemicals or drugs etc
• Chronic irritation of palp/bulbar conj assoc w/repeated exposure to allergens (eg Vernal Conjunctivitis) or assoc w/mechanical-chemical irritation (eg CLPC)
• For superficial punctate keratitis of almost any aetiology, generalized diffuse keratitis of a non infectious aetiology, toxic keratitis and when there's non-ulcerating active stromal involvement
• For acute/subacute/chronic inflammatory conditions of the sclera, anterior uveal, iris and cornea assoc w/mechanical, chemical or bacterial trauma
• Adjunct use in generalized iritis & anterior uveitis

CLINICAL USE OF CORTICOSTEROIDS

DOSING

• Should be started at 3-4x a day when the presenting signs are mild to moderate, in very severe cases every two hours for the first 24 only. In many cases you're only going to use them short term anyway and up to 3wks maximum. Should show improvement in 48h and definite improvement in 7 days. In some cases if there isn't a great improvement in primary care might need to be referred to ophthalmologist. In special cases the therapy can continue for many months and we have to start paying attention to the various side/adverse effects
• Therapy shouldn't be abruptly discontinued. Slowly reducing dose should allow us to see how inflamed the eye actually is and avoid there being an acute rebound response. Reduce to twice a day then once a day after a day or so and monitor. Should allow us to see true status of corneal/conj surfaces including any sign of infection

FOLLOWUP

• Mild-Moderate -review after a week, more severe every three days til substantial resolution of condition has occurred. Periodic examinations (every 2 weeks) are necessary for longer term treatments to monitor the efficacy of the steroid regimen, to allow appropriate changes in regimen and monitor the adverse effects
• Assessment should include general inspection inc eyelid eversion, slit lamp w/anterior chamber assessment for cells/flare and evaluation of pupil/iris esp for signs of acute inflammatory reaction. Patient records should include notes as to inflamm magnitude. Allow safety of use of drugs should be reconsidered every time - is an infection (bacterial, viral, fungal, protozoan) present? Are adverse reactions developing?

WARNINGS

• Generally contraindicated in purulent infections. Can mask and interfere with concurrent bacterial infections in which lots of gunk may obscure other conditions/underlying infections. Any infection should be managed properly using an antibiotic. Get infection under control before starting w/steroids generally. The eye quietening effects of the roids may not show all of the expected early signs and symptoms of an infection
• Excessive topical ocular roid therapy may retard the natural re-surfacing/healing processes of the surface membranes. Do not overuse - nothing more that q4 or q6 except in initial treatment of v.severe conditions (see above) Can lead to stromal thinning and loss of cornea!
• IOP may be raised and 'steroid glaucoma' induced. IOP should be periodically assessed. Only really 'common' in a specific bunch of people who are predisposed ('steroid responders'). Time period where IOP rise can be detected = 2 to 3 weeks - this is why steroid use is normally limited to around this time cos any chance of a rise happening within the first two to three weeks is minimal. Check the IOPs beforehand!

CONTRAINDICATIONS

• Concurrent active HSV infection. Can exacerbate it. Initial slit lamp w/flu should rule HSV out
• Concurrent fungal/protozoan infections. Again may exacerbate
• Active tuberculosis infections. Same again
  

PRODUCTS (more potent as you go down)

• Hydrocortizone as eyedrops/ointment can be used for relatively superficial non-infectious inflammatory conditions of the eyelids or conjunctiva where there is no major defect or sign of ulceration 1% PoM eyedrops 10ml bottle, 0.5% PoM generic ointment 3g tubes. Used by hospitals and GPs
• Betamethasone is indicated for use in moderate inflammatory conditions of eyelids, conj, cornea and ant seg assoc w/allergic, chemical or mechanical trauma. 0.1% eyedrops (PoM Betnesol) or 3g tube ointment PoM Betnesol white soft paraffin/liquid paraffin
• Dexamethasone is generally for moderate inflammations but can be used intensively for severe inflammations including as a post-op steroid. Avail as eye drops 0.1% w/hypromellose 0.5 in 5ml or 10ml bottles and also minims for post-op use. Some combos w/antibac drugs are also available
• Prenisolone is indicated for moderate or severe inflammations. Prednisolone sodium phosphate ophthalmic solution is available at 0.5% in a 10ml bottle and minims are available for A&E or post-op one off uses. PoM Pred Forte 1.0% is also avail in 5ml and 10ml bottles. No generic products but some in combo w/antibacs
• Fluorometholone - potent but used in UK at 0.1% for mild-moderate inflammations when a rapid response is deemed appropriate. Avail as eye drops at 0.1% concentration w/PVA in PoM FML Liquifilm 5ml or 10ml bottles
• Rimexolone and loteprednol are indicated for intensive use either to manage uveitis or for post-op use. They are 'soft' corticosteroids that have substantial anti-inflam effects but are biotransformed so rapidly to what appear to be inactive metabolites that the side effects profile is lessened
  

Mast Cell Stabilisers

Seasonal allergic conjunctivitis peaks in the spring and in the autumn. Perennial allergic conjunctivitis is ongoing and can have a peak depending on where you live. 'Sealed up homes' in the winter are bad for it. Allergic conjunctivitis involves sustained release of histamines and prostaglandins by conjunctival mast cells. Mast cell stabilisers attenuate this release.

Severity of symptoms needs to be ascertained first. Intermittent mild-moderate itching can be solved w/eye baths, decongestants or anti-h eye drops. Moderate-severe = hyperaemia/injection, lacrimation, mucus discharge, nasal stuffiness will respond to mast cell stabs in conjunction w/oral antihistamines. Severe = chronic oedema of lid margins and conj, w/infiltrates and badass discomfort/foreign body sensation. This may also need NSAIDS or topical corticosteroids.

Guidelines for use

NB These drugs aren't 'cure-all'

• C/I - Known allergy to drugs or ingredients (BkCl??) Can do patch test to work out what Px is allergic to
  
• IND - for prophylactic use to offset the severity of ocular reactions to allergens
• NOT for occasional use or provision of short term or acute relief of the symptoms of allergic conj. That's topical ocular decongestants or antihistamines
• Dosing needs to be regular and continuous - every four or six hours depending on severity. Should start using them before peak of season to facilitate development of tolerance and to prevent palp conj changes/damage. Remember you're attenuating symptoms not actually getting rid of them
• Px education is really important - regular doses are the only way it's gonna work. Maintenance of a 'quiet' eye throughout the day may take 2 to 4 weeks of QDS although some improvement can be shown in 7 to 10 days. For VKC it could take 4 to 8 weeks to reach the maintenance state. May still need topical decongestant after extreme exposure.

Available Preps

All P Meds in 5-10ml bottles

• Sodium Cromoglicate 2% widely avail as P eg Opticrom Allergy Eye Drops, Clarityn Allergy Eye Drops (not w/anti-h like the tablets!) likely w/BkCl & EDTA. Can use w/CLs before and after but not during. Wait 5 minutes at least before putting lens in.
• Lodoxamide (2nd gen MCS) PoM Alomide (additional supply only) and P Alomide Eye Drops 0.1% concentration. P Med is indicated for Seasonal Allergic Conj & CLPC although shouldn't be used w/lenses in.
• Nedocromil Sodium avail as PoM. Canary yellow colour so can't be used w/CL wear at all

NOTE!11 Cobblestone Papillae = VKC, Lumpy = CLPC, Meaty Papillae on lower lid = chalmydial infection - refer to GP for oral MCS.

SUPPLEMENTALLLLLL: ORAL ANTI-HISTAMINES FOR ALLERGIC CONJ

Additional supply only. Very good if you have a runny nose an all. Note some older drugs induce drowsiness. Any pharm dispensing will advise Px of this. Newer antihistamines are non-sedating so there won't be any drug induced drowsiness.

Some antihistamines do have sympathomimetic potential so again their use in Px w/cardiac probs, HBP, Epilepsy, Asthma, Liver & Kidney disease is not recommended. There was a general warning in 1994 for use of some of these products esp terfenadine cos it could create cardiac arrthymias that were maybe fatal. Terfenadine is PoM. This doesn't apply to all the other antihistamines but again their use ain't recommended.

Current available SL and P Meds

• Chloramphenamine eg P Piriton, Calimal, Pollenase in 30 to 60 tab packs w/syrup for kids. Useage up to QDS.
• Acrivastine eg P Benadryl Allergy Relief 7, 12, 24 tablets. Dosage up to QDS
• Clemastine SL/P Allereze and P Tavegil. Dose = bd or up to every four hours
• Loratidine eg P Clarityn 7-14 tab packs. Once a day
• Cetirizine P Benadryl one-a-day P Cetirizine P Piriteze. Also oral syrups for paediatric use

All these prods don't have substantial risk of ADRs.

Ophthalmic Topical Astringent Eyedrops, Decongestants + Antihistamines

AGAIN CAN SELL + SUPPLY GSL, SL, UNLICENSED PRODS IN COURSE OF PRACTICE

Topical decongestants and antihistamines are needed when the px's ocular irritation/discomfort is a chemical irritant, an allergen or both. Oral antihistamines are used too.

1. TOPICAL ASTRINGENT EYEDROPS

Astringents are meant to have some sort of cleansing action beyond that of saline. Borate eye washes were astringent and used to be the main treatment for anything. They are revived in the form of these eyedrops and known as 'natural' cleansers/moisturisers. They are normally indicated for prn use for any form of MILD eye irritation/discomfort which proves to be responsive.

• P Optrex Eye Drops 10ml bottle w/witch hazel
  
• SL Optrex refreshing eye drops 10ml bottle w/witch hazel and glycerin
• P Zinc Sulphate 0.25% Eye Drops 15ml bottle

2. EYE BRIGHTENER PRODUCTS

These have no medical definition and are generally used by people who have slightly irritated/tired eyes w/hyperaemia that is unacceptable cosmetically. They contain small amounts of both astringents and decongestants and the products have similar warnings to those prods w/higher concentrations. They also contain natural/plant type stuff.

• SL Vital Eyes Brightener 10ml bottle w/flower petal extracts, small amount of witch hazel, trace amounts of zinc sulphate 0.02% and naphazoline 0.005%
• SL Optrex Fresh Eyes Brightener 8ml w/witch hazel, borate buffer, naphazoline 0.01% and BkCl. Similar drops can contain plant extracts, glycerine and EDTA

3. TOPICAL DIRECT ACTING DECONGESTANTS/DECON+ANTI-HIS COMBOS

Usually P Medicines. The decongestant activity is a result of direct alpha adrenergic action or direct histamine H1 blocking action - either attenuating vasodilation or even causing vasoconstriction. It's suggested that some alpha 2 receptors are also affected by the drug and that would relieve signs/symptoms such as discomfort, puffiness, chemosis and reflex lacrimation. If Anti-H is also included then expect efficacy against itchiness symptoms too. All the products contain BkCl and EDTA usually as preservative

• All products are meant to provide occasional relief of symptoms associated w/mildly irritated eyes and also improve the cosmetic appearance of the external eye, used eg 2-3 times daily. They aren't for use to whiten eyes that just need a wash. q2hr = excessive use
• Cause of irritation should be identified. If there's a genuine allergic component then use something w/anti-h. For dirt and dust an eyewash might have better results.
• They don't work as prophylactic agents. They have a slight affect but that's probs due to reflex tearing providing a mini 'eye wash'.
• Excessive use can cause rebound effects and an induced red eye. This is due to a mild toxic reaction or type IV allergic reaction due to prior sensitization to any of the ingredients of the eyedrops.

Guidelines for use

• Contrainds: Narrow angle glaucoma - adverse effect is angle closure
• Warnings for systemic diseases - shouldn't be recommended to anyone with HBP, Heart Probs, Stroke, Hyperthyroidism. Any sympathomimetic drug could increase BP. These prods don't contain high concs of the drugs but they are frequently overused and could produce systemic effects.
• Interactions - carefully supervise use if px taking MAO inhibitors/anti-depressants
• Not for use w/eye infections, will just relieve symptoms and do nowt else. Even mask them

Current drops available

• Naphazoline 0.01% alph-adrenergic eg P Murine. Also w/witch hazel 12% eg P Eye Dew Clear. All preserved w/BkCl. Also w/blue dye for cosmesis in Dazzling Eye Drops
• Xylometazoline 0.05% as a-1 and a-2 adrenergic in combo w/antazoline 0.5% as histamine H-1 blocker. Preserved w/BkCl and EDTA eg P Otrivine-Antistin

Topical Anti-H drops on their own are additional supply only.

Artificial Tears/Oc. Lubricants

UK OPTOMS MAY SELL & SUPPLY. USE OF ART. TEARS SHOULD BE SUPERVISED

• Art. tears is name for various avail preparations for tear film deficiencies thru stuff like ocular surface disease or use of systemic medications. These are medicinal products
• SIMPLE art. tears re-wet the eye but don't really act as a quality lubricant. They usually contain some salts and one or two polymers and have a viscosity that is similar to/slightly increased from human tears that's acheived w/low concs of various polymers.
  
• Artificial tears are generally iso or slightly hypotonic to the tear film and have a pH that is slightly acid to normal tears ie 6.5-7.5. pH is geared towards stability, comfort not so much.
  
• COMPLEX art. tears have a slightly different set of polymers (2 or more)
• Cellulose polymers such as hypromellose, carmellose and hydroxyethylcellulose are often used
• P-Polymers like PVA, PEG, Povidone and 'Tween' (which also has surfactant properties) are used also
• New prods could include sodium hyaluronate which is in 'rewetting drops' and not officially desig. art. tears. Also guar gum is found in ce marked rewetting drops and does provide a bit more lubrication than the trad polymers.

ASSESSMENT PRE RECOMMENDING ART. TEARS

1. Objectively evaluate the tear film/oc surface using flu/rose b and measuring the tear prism/tear break up time. Important to get some sort of quantitative assessment that you can compare w/after using the art tears for some time.
2. Establish a true baseline condition - good to get px to stop using the ophthalmic prods they're using for a day before a detailed ee. Knowing the true nature of the px's condition can be helpful when selecting a prod to use.
3. Consider px preferences - important for compliancy. Some artificial tears sting and some don't, some smell/'taste' funny, some people won't like initial blurring of vision, be good w/multidose bottles etc etc etc
4. Preserved or non-preserved? The vast maj of px will be fine with multidose art. tear w/preservative but some will develop allergy. Unit dose & preserv. free are available if the patient might experience adverse reactions or feels that 6x a day use is needed
5. General allergy to eyedrops. need to work out if px is sensitive to a specific ingredient w/questioning before beginning NB no art tear/oc lub can be expected to compete w/an ongoing disease process or display satisfactory efficacy if there's poor ocular/peri-ocular hygiene.
6. Cost. Simpler products = cheaper. Unit dose forms = expensive. Larger bottles = cheaper.
7. Choose regimen. For the most part simple art tears are designed for use prn for the relief of mild & uncomplicated symptoms arising from stuff like
   

• working for extended periods in environment which may irritate eyes
• from inadequate blinking due to over-tiredness
• A dry atmosphere
• -----One or two drops can be expected to simply wash out tear film debris and irritants

8. Px Education & Communication: Give correct instructions, don't assume intelligence, get them to come back

FOR UNCOMPLICATED DRY EYE SYMPTOMS

All multi use bottles contain preservatives (usually BkCl) and include (ALL P MEDICINES)

• Saline eyedrops w/out polymers P NaCl Eyedrops. Minim version is 0.9%
• Hypromellose/hydroxypropylmethylcellulose 0.3% P Brolene Cool Eyes
• Hypromellose 0.32% P Artelac 10ml bottle
• Hypromellose 0.5% P Isopto Plain 10ml bottle
• w/PVA 1.4% P Liquifilm Tears 15ml bottle
• w/PVA 1.8%, Povidone 2%, NaCl, KCl & Amisol, Preserved w/EDTA & Polyquarternium-42: Clinitas Ultra 3 3ml bottle

Single dose options

• NaCl P Minims 0.9%
• Hypromellose 0.32% P Artelac SDU 0.5mlx30 or 60
• Hypromellose 0.3% w/dextran 0.01% SL Tears Naturale 0.5mlx28
• Hydroxyethylcellulose 0.44% as P Minims Artificial Tears
• Carboxymethylcellulose 0.25% in hypotonic mixed salts vehicle buffered w/borate & phosphate. foil sachets as 'Theratears'
• PVA 1.4% w/povidine 0.6% P Liquifilm Tears Preservative free

OCULAR LUBRICANTS & OTHER PREPS aka A STRONGER ARTIFICIAL TEAR W/MORE LUBRICATION

This sort of stuff is for a patient who actually has a dry eye ie Keratoconjunctivitis Sicca and needs something stronger than an artificial tear. They are indicated for use when there is a non-infective or non-toxic chronic irritation and inflammation of the conj w/poor traction of the lids across the ocular surface eg a px w/Sjorgens.

A lubricant does not replace the tear film with a simple aqueous fluid but w/a lubricating film with long residence time at the ocular surface. As such it doesn't improve the hydration of the ocular surface, merely reduces friction and the patient's symptoms which can usually be summed up w/BURNING! PAIN! SOMETHING IN IT! Actually supplementing the lubrication with artificial tears can be useful.

Selection of a lubricant depends on how much friction needs to be reduced and for how long. For example if you step up w/ nightly use of a lubricating gel or ointment then the px might change regimen from simple artificial tears every hour to lubricating tears every 3 or a liquid gel every 4 or 6 hours. NB Ointment during the day = matted lashes and smeary vision so not v popular for that.

As well as allergy to ingredients

• not to be used as primary therapy in follicular conjuntivitis
• use w/caution in toxic keratitis from excessive use of ophthalmic pharmaceuticals or systemic medications
  
• use w/caution in cases of vernal keratoconjunctivitis or atopic conjunctivitis. Other anti-inflamm drug therapy needed in that case

Examples of oc lubs

• Cellulose Polymer prods at 1% level eg Hypromellose P Isopto-alkaline (more comfort for px) Eye-Drops
• Sodium Hyaluronate is widely used in CL rewetting soln and 0.2% in Ocusan 20, 20x0.5ml or at 0.4% in SL Clinitas Soothe
• Carbomer Gels SL Optrex Dry Eye Liquid Gel for use 3 or 4 times a day and before bed. Also P Geltears and P Liquivisc. These contain a special polyacrylic acid gel that forms a coat on the eye's surface that thins rapidly with each eyeblink.
• Lubricating ointments (use 0.5-1cm long ribbon) w/low quantities of liquid paraffin or mineral oil, white paraffin & lanolin eg P Lacrilube 3.5g tube, P Lubritears 5g tube
  
• Bland ointments w/higher concs of yellow soft paraffin and lanolin eg P Simple Eye Ointment generic 3.5g or 4g tubes. Yellow Paraffin is older & a bit more lubricating than white
• ADDNL SUPPLY ONLY Acetylcysteine eye-drops
• Glycerol/Castor oil: glycerin can be formulated from hosp. pharmacy by diluting w/water. Castor oil was once widely used and avail in minims.
  

Contact Lens Rewetting Solns etc

OPTOMS CAN SELL & SUPPLY GSL, SL & UNLICENSED PRODS IN COURSE OF PRACTICE AS LONG AS THEY HAVE A SECURE RETAIL PREMISES. THIS INCLUDES ALL OF THIS STUFF.

CL Rewetting solns

• For re-wetting a CL whilst in place on the eye.
• available to the general public SL/GSL for use as needed
• Question whether px should stay on em if they need them more than once an hour
• also 'CLs w/moisturisers' (in polymer matrix) now avail but no proof that they work yet
• Generally contain saline, a polymer, probs a wetting agent like poloxamer. Multi use bottles will have a preservative that isn't BkCl. More likely to be allergic to preservative or wetting agent.
  
• Wide range of multi-dose and unit dose products
• EG1 B&L Rewetting eye drops 10ml bottle w/NaCl, Hypromellose & a wetting agent. Preserved w/sorbic acid 0.25% & EDTA
• EG2 Blink revitalising eye drops 10ml bottle w/PVA 1.4%, phosphate buffer & chlorite/peroxyde preservative. Also avail as unit dose w/EDTA

• Regular use MAY offset adverse reactions to CL solns and MAY help keep CLs/oc surfaces clean. BUT these things are NOT LICENSED FOR THE TREATMENT OF THE CONSEQUENCES OF OCULAR SURFACE DRYING eg pitting staining or seal staining

What they should do

• Should promptly relieve symptoms - pretty much just provide comfort
  
• Help reduce chance of oc surface drying
• Older CL wearers may be more in need of them
• No standards yet on what makes a good rewetting drop

Moisturisers (SL/GSL)

• Supposed to provide soothing & refreshing effects for tired eyes
• NOT considered as true replacements w/tear deficiency
• Shouldn't be used with or just before CL wear and long term use should really be monitored esp w/multidose bottles
• All contain a polymer and various 'special ingredients'. No medicinal claims allowed to be made although 'dry eye'/'lubrication' could be written on bottle. Dry eye being the symptom! If you see signs of dry eye you're going to need at least an artificial tear.
  
• Used as needed for temporary relief of ocular discomfort
• EG1 SL Vital Eyes moisturiser 10ml bottle w/hydroxymethylpropyl cellulose 0.4%, Vit A and Vit E. Preserved w/chlorbutanol and polyhexanide
• EG2 SL Extreme Cooling Rohto Zi for Eyes 8ml bottle w/polysorbate 80 preserved w/chlorhexidine, Vit B6, Vit E, Potassium L-Aspartate and plant extracts like menthol for which no medicinal claims are made.

Astringent Eyewashes (GSL/SL)

• Usually saline w/small amount of phosphate buffer or are a mix of boric acid and sodium borate. Borate has more cleansing power than simple saline 110-300ml bottles are usually available. They often contain a preservative like BkCl or Thiomerosal and other astringents to promote cleansing like witch hazel/hamamelis water and glycerin (eg Optrex Eye Lotion) or maybe petal extracts (eg SL Vital Eyes Eye Wash)
• Often used @ end of working day for general cleansing/washing away of gunk. Often comes with goggle-style 'cap'. Bottle should be for one individual and thrown away after rel. short amount of time.
• Once actually formed mainstay of treatment. Non-medicinal for use p.r.n.

Emergency Eyewashes

• Eg when splashing chemical in eye very large volumes of eyewash (eg Optrex Emergency Eyewash 500ml or even tap water) are available to be continuously applied for at least 15 mins.
• More elaborate solns are formulated for use in operations like Balanced Salt Soln w/NaCl, KCl, MgCl2 etc

Lid Scrub/Hygiene Products

• Cleanse eyelid margins and lashes: meibomian glands, glands of moll, glands of zeis. NB If the lid margin is also inflamed it's probably blepharoconjunctivitis. Eyelid margin discomfort and decreased tear film stability can develop in cases of mild->moderate blepharitis or blepharoconjunctivitis which may be assoc w/meibomian gland dysfunction.
  
• General cleansing w/this stuff should reduce the chance of other intra-epithelial/glandular/hair follicle infections of the eyelid margin
• You can use baby shampoo but it must be diluted and prepared immediately before each use. Much more likely to be successful w/proper product and treatment regimen
• SUPRANETTES (SL) - individually packaged wipes. Coarse gauze
• BLEPHARCLEAN (SL) wipes w/medium gauze, BLEPHASOL (SL, 100ml bottle)
• Wipes moistened w/soln containing mix of surfactants w/soothing agents & plant extracts (Hamamelis again)
• SL STERILID = foam gel w/natural oils, SL BLEPHAGEL = gel

Special Irrigation Solutions

• When toxic chemical or something is splashed into the eye the irrigation needs to be very aggressive to get rid and relieve discomfort. Oedema of the cornea/conj might be involved too
• Used as diagnostic aid to clear corneal oed so you can see in, an astringent for mucus threads, treatment for Fuch's dystrophy.
• Available to some hospital optoms if the ophthalmologist lets em have it
• EG1 Hypertonic NaCl 2% or 5% several drops over 15-20mins may be required. Hospitals can use other 'hypertonics' like glycerin 10-50% diluted w/sterile water
• EG2 Trisodium edetate (0.37-4%) - higher concs of EDTA than are found in eyedrops (<0.1%) used as therapy for band keratopathies that develop after systemic calcium imbalance
  

Access To/Use Of Medicines & Other Products by UK Based Optoms

NOTE: It's up to the GOC to make rules prohibiting/regulating sale and supply. They haven't done this yet but they have decided to provide guidelines to the college for generation of 'rules' pertaining to the scope of practice.

There are a couple of categories we need to know about; use and supply & use.

USE AND SUPPLY

• The optom may administer w/in course of practice and supply to px if 'in course of practice' (+if in an emergency if PoM - in 2005 all GSL & P medicines no longer bound by that so optom can obtain from company/pharmacy and sell @ retail price)

STAINING AGENTS

• Fluorescein sodium (P)
• Rose Bengal (P)
• These are logically reserved for use only cos px has no use for em

MYDRIATICS & DECONGESTANTS (sympathomimetics)

• phenylephrine hydrochloride up to 10% (P)
• xylometazoline hydrochloride (P)
• naphazoline salts (P)
• adrenaline and ephedrine salts (P) NOT AVAIL NOW

ANTIALLERGICS

• Antazoline up to 1% (P)
• Sodium Cromoglicate up to 2% eyedrops (P)

ART TEARS/LUBRICANTS/EYEWASHES/MOISTURISERS & IRRIGATION SOLNS

• anything suitable for eye irrig w/NaCl, witch hazel or other natural extracts, zinc sulphate and/or viscosity enhancing polymers (like PVA, hypromellose, hydroxyethylcellulose, dextran, povidone, carbomer, hyaluronate) designated as art. tears, ocular lubricants, moisturisers or rewetting solns. Also contains P products w/white or yellow liquid paraffin, lanolin

CYCLOPLEGICS & MYDRIATICS (anti-muscarinics)

• Cyclopentolate (PoM)
• Tropicamide (PoM)
• usually for diagnostic use only but could be supplied to px 'in an emergency'

ANTIMICROBIAL AGENTS

• Chloramphenicol drops up to 0.5% (P)
  
• Chloramphenicol ointment up to 1.0% (P)
• Propamidine (P)
• Dibromopropamidine (P)
• Fusidic Acid Viscous Eyedrops (PoM)

MIOTICS (parasympathomimetics)

• Pilocarpine salts and carbachol. Recently removed but avail to additional supply optoms

USE ONLY CATEGORY

• Optom may administer pharms containing these drugs but not supply to px under any circumstances or indeed use themselves.

TOPICAL ANAESTHETICS

• Tetracaine hydrochloride (PoM)
• Oxybuprocaine hydrochloride (PoM)
• Proxymetacaine hydrochloride (PoM)
• Lidocaine hydrochloride (PoM)
• this includes combos w/flu.

FURTHER BUMF

The optom used to have other antimicrobial agents, an anti-inflammatory agent and an alpha adrenoceptor blocker available for use only but they done got removed from the list.

Detailed records of P and GSL don't need to be kept by law but records of all PoMs used do, both wrt stock and on the px records.

The optom may also add a label to pre packaged pharmaceuticals without holding a manufacturer's licence for assembly of pharmaceuticals; there isn't a requirement to though. P and GSL pharms shouldn't be relabelled though unless specific permission to a specific optom is given. The label must include the px's name, directions for use, "keep out of reach of children", "for external use only" and the name and address of the supplying optom.

Use of Medicines by Optometrists Part One Sort Of Intro

Only those medicines designated for use by optometrists, orthoptists and opticians should be used on the public at large.

The MEDICINES ACT determines the use of drugs by optometrists

• Originally prepared in 1968, passed into law 1972, further defined for optometrists in 1978
• Act & its consequences periodically reviewed by drug advisory panel w/optom reps
• Original sections of act relevant to optoms are part III sections 51, 52, 57 & 58.
• Recent revisions of the law (notably SI's 764, 765, 766) mean that a large number of prods for ophthalmic use are now unlicensed and available for unrestricted sale ie not really pharmaceuticals anymore, but CE marked. SO optoms can advise on their use and supply them to the public providing it's in the course of their professional practice ie not food supplements or something we know nowt about. This includes CL related stuff as well as stuff designed for temporary relief for uncomf/irritated eyes + include herbal remedies & natural crap.
• A registered pharmacist can supply an optom w/certain pharms on receipt of an official signed order ie request on optom's letterhead. These are the specified PoMs (Mydriatics, Cyclopentolate, Chloramphenicol, Fusidic Acid) or P Medicines for diagnostic or therapeutic use. Optom must specify the exact quantities & keep accurate records
• Optom is allowed to use these drugs on their patients as part of eye evaluation or to administer them in an 'emergency'. In a similar 'emergency' the optom can supply certain PoMs to their patients if it has a 'use and supply' designation as opposed to 'use only'.
• In 2005 changes involving SIs 764, 765, 766 meant that the 'emergency' bit is only extended to the exempted PoMs. Px can administer any of this stuff themselves and optom can arrange for a personal supply w/a written order similar to a prescription. This includes 'entry level' optoms btw.
• Law changes in 2005 and 2007 meant that access to chloramphenicol was extended to the public at large with its reclassification as a P medicine. So optometrists could actually sell and supply that without it needing to be an emergency.
• One interpretation of 2007 change - optom should be on premises when P meds sold? Only actually _implies_ that. Optom maybe has to know Px as Px. Probably best!
• Sale and supply of prods that aren't the PoMs could be considered as a retail sale and no more but it would be best to keep a record.

The OPTICIANS ACT as relating to optometry and as revised in 2005 also provides indirect guidelines on the use of drugs by optoms

• 'ophthalmic optician' is now 'optometrist' and optom is as of SI.3299 (1999) allowed to diagnose eye diseases rather than simply arranging for referral and to use various drugs to treat the conditions. This implies making note of condition in px's records and noting reasons why not referred.

Three Main Classifications of Drogs:

1. GSL: Avail for public at large, unsupervised use, considered generally safe. Any retailer may sell as long as they have a secure premises (eg locked optom's office). Recently some prods aren't even GSL anymore so are 'non medicinal'. This includes eye vitamin products.

2. P MEDICINES: Generally sold/supp by registered pharmacist under supervision. Some avail from Hosp P for use by professionals. Also known as OTC. Considered generally safe for the public w/out supervision BUT the ingredients/concs/uses indicate that a control step is necessary - practitioner can make assessment of px's suitability - will be expected to ask a few questions relating to the C/I, specific precautions, possible drug interactions and warnings on potential adverse drug reactions. Pharm/optom assumes responsibility for giving appropriate instructions, then it's up to the px. Sold from behind counter w/px's verbal request. Some P classifed prods aren't available to the public but available to optoms for professional use upon production of a signed order. Can be supplied in bulk.

3. PoMs: The restricted access is more to ensure the safety of the general public since PoM listings designate those pharmaceuticals that contain drugs (or higher concs of drugs) which require some supervision. PoMs can be changed to P Meds whenever it can be established that use by the public@large doesn't produce any ADRs. It can go the other way also. Optom can obtain exempted PoMs by way of written order requesting supply & quantity, eg

• 10x 4g tubes of Chloramphenicol Eye Ointment 1%

Some of these are of the type that could be used in an emergency in which case optom can supply px directly or provide pharm w/a written order for a specific patient.