By integrating eye health into everyday practice, pharmacists can support the early detection of many eye conditions
According to Vision Initiative, pharmacists, among other primary healthcare providers, can play a critical role in identifying people at risk of eye conditions, educating on eye health and encouraging people to have regular eye examinations with an optometrist.
The 2020 Vision Index Report released by Optometry Australia shows that while most Australians understand the importance of regular eye examinations, 35% of people don’t undertake regular checks and one in eight Aussies have never visited an optometrist in their lifetime.
The need for greater awareness of eye health can be seen in the fact that more than 600,000 Australians are affected by vision loss or blindness. Vision Initiative reports that most cases of vision loss or blindness can be attributed to five main eye conditions: age-related macular degeneration, cataracts, diabetic retinopathy, glaucoma and refractive error.
However, we know that 90% of vision loss is preventable or treatable. Yet, given that several ocular conditions are asymptomatic in their early stages, regular eye examinations and a greater awareness of eye health are paramount.
A focus on eye health
Khanh Nguyen, professional practice pharmacist at the Pharmacy Guild Queensland Branch and member of the Pharmacy Committee, Glaucoma Australia, says pharmacists are presented with many opportunities to discuss general eye health and vision care and encourage people to have regular eye examinations.
She says by simply asking the question “When was your last eye test with an optometrist?” a pharmacist or support staff member can start a conversation about eye health with their customers.
“Opportunities to ask this question may arise when a customer is submitting a script for medications (such as for diabetes, blood pressure, glaucoma, or medications known to have visual side effects), seeking assistance to stop smoking, purchasing over-the-counter eye drops, or even purchasing ready-made reading glasses.”
Certainly, having a customer purchase over-the-counter eye care products, such as eye drops or ready-made glasses, provides a good indication they may be having problems with their vision. It is also the perfect opportunity to ask the following questions.
- When was the last time you had an eye test?
- Have you noticed any sudden changes in your vision?
- Have you had any other symptoms (headaches, dizziness, loss of balance, eye pain)?
- Do you know where the local optometrists are?
- Do you have a family history of an eye condition?
- Do you smoke?
- Do you have diabetes?
- Are you aware that Medicare covers the cost of an eye test every 24 months?
Ms Nguyen recalls, “During last year’s lockdown, I worked at a 24-hour pharmacy in Melbourne and because the optometrists were closed and GPs were only offering telehealth services we saw a lot of eye conditions.
“This was probably very different in comparison to most other years, but because of the coronavirus situation I imagine it’s much the same if you’re practicing in a lockdown state at the moment.
“In particular, I remember Christmas Eve last year I was working a late shift at the pharmacy and a woman came in around 11pm wearing sunglasses. Immediately I saw this as an indication that something was seriously wrong.
“She told me her eye was sore but when she removed her sunglasses the eye was extremely red. She couldn’t open it, the eye was watery and painful—so all your typical red flag alerts. I asked her niece, who had driven her to the pharmacy, to take her to the eye and ear hospital nearby.
“The woman returned to the pharmacy around 2am the following morning. She explained to my colleague that the staff at the hospital had triaged her quite quickly and explained to her ‘if the pharmacist hadn’t referred you at that time, your eye condition could have escalated into a far worse scenario’.
“As it turned out, she had a urinary infection, which she was unaware of, and a secondary infection had attacked the eye. She was prescribed antibiotics and eye drops.
“The woman returned to the pharmacy a few days later when I was on duty to thank me. She had really underestimated the severity of her condition.
“As pharmacists, we’re trained to recognise the red flags and this is an example of how a timely referral can make a big difference.”
Common eye complaints: conjunctivitis
“Among the most common eye conditions that present to pharmacy are allergy eye, red eye, dry eye and sensitive eye presentations,” says Ms Nguyen.
Janelle Scully, acting lead optometrist Ocular Disease Services at the Australian College of Optometry explains that conjunctivitis is one of the most common causes of red eye and that there are three main types of conjunctivitis.
“Infectious conjunctivitis may be caused either by a bacterial infection or a viral infection. Both will present with a red eye and should not be associated with any pain or visual disturbance. Typically, viral conjunctivitis will have a watery discharge, whereas bacterial conjunctivitis is more likely to have a mucopurulent discharge.
“Both allergic and viral conjunctivitis can present with a watery red eye. However, allergic conjunctivitis is often associated with itchiness and there can also be symptoms of allergic rhinitis. It will usually be bilateral. Viral conjunctivitis may appear similar; however there will not usually be any associated itch.”
Treatments may include antibiotic eye drops, such as Chloramphenicol, for bacterial conjunctivitis; artificial tears or lubricating eye drops for viral conjunctivitis and antihistamine drops for allergic conjunctivitis.
Pharmacists can also discuss optimum hygiene practices, to keep the eyes clean and also prevent the spread of infection. This might include bathing or cleaning eyelids with cotton wool in sterile saline, avoiding wearing contact lenses until the infection has cleared, and not sharing towels or face cloths.
Ms Scully adds, “Although there are over-the-counter treatment options available for conjunctivitis, it can be difficult to diagnose the cause of a red eye through history and general observation alone. An optometrist has the expertise and equipment (namely a slit lamp) to provide a thorough examination of the eye to rule out more serious and sight threatening conditions which may masquerade as conjunctivitis, as well as determining an appropriate management plan for the patient.
“Furthermore, symptoms of eye pain, flashing lights, excessive discharge, loss of vision and sensitivity to light are some of the potential red flags, which should trigger an urgent referral to an optometrist or other suitable eye care provider.”
Dry eye: knowing when to refer
“Dry eye disease affects hundreds of millions of people worldwide although the lack of a standardised definition and diagnostic criteria means that its prevalence has been reported as anywhere from 5% to 75% of the population,“ says Ms Scully.
First-line treatment for dry eye generally involves the use of preservative-free ocular lubricants, such as aqueous tear supplements and lipid tear supplements. Lid wipes can be used to treat inflammation of the eyelids (blepharitis). While warm compresses can assist with meibomian gland function.
Sophie Koh, national professional services advisor at Optometry Australia, says it’s also important to consider the underlying cause of dry eye, which can be multi-factorial.
“The risk of dry eye increases as we age. It is also much more prevalent in females. Certain medications, such as anti-depressants, hormone replacement therapy and the contraceptive pill are also known to cause dry eyes.
“A person’s general health, including their diet (for example, low intake of omega-3 fatty acids) and whether or not they smoke can also affect the eyes. People with systemic conditions like thyroid disorders, diabetes and rheumatoid arthritis are also at greater risk of dry eye.”
While most cases of dry eye are mild, it’s important to recognise when referral is necessary. NPS MedicineWise refers to the NICE guidelines, which state that the following factors warrant referral to an optometrist or ophthalmologist:
- moderate–severe eye pain, photophobia, marked redness in one eye or reduced visual acuity (demands same day referral)
- deteriorating vision
- ulcers or signs of corneal damage
- persisting or worsening symptoms despite appropriate treatment for four weeks
- associated disease requiring specialist treatment, e.g. Sjögren’s syndrome, eyelid deformities.
The emergence of mask-associated dry eye
There are claims a new dry eye phenomenon has arisen from wearing face masks. Mask-associated dry eye (MADE), as it has been termed, may become a growing issue as the coronavirus pandemic continues.
Optometrist Professor Lyndon Jones from the Centre for Ocular Research and Education, explains, “Masks significantly reduce the outward spread of air. However, exhaled air still needs to disperse and when a mask sits loosely against the face the likely route is upwards. This forces a stream of air over the surface of the eye, creating conditions that accelerate tear film evaporation, leading to dry spots on the ocular surface and discomfort.
“As well as worsening symptoms in patients with pre-existing dry eye disease, mask-associated dry eye can affect the elderly who typically have a poorer quality tear film, contact lens wearers, and masked people working extended hours in air-conditioned settings and/or while using digital screens.”
Given that mask wearing is essential to help reduce the spread of COVID-19, there are a few simple actions people can take to reduce the onset of mask-associated dry eye.
Mask wearers can be advised to:
- ensure their mask fits well and tape the top edge of the mask during prolonged wear
- apply lubricating eye drops
- limit time in air-conditioned environments and take regular breaks when using digital screens.
Chronic eye conditions: glaucoma
Given that 90% of blindness and vision loss is preventable or treatable if detected early, reminding people of the importance of regular eye examinations is crucial and something pharmacists can easily do.
“In anyone with an underlying condition, such as diabetes, pharmacists can start a discussion about the importance of regular eye checks. However, it’s important to provide some education around this. Rather than just reminding someone to visit their eye prescriber or optometrist, it’s helpful to explain why and to discuss the potential short-term and long-term consequences of not having regular eye checks,” says Ms Nguyen.
Glaucoma is among the top five eye conditions associated with blindness and yet, according to Glaucoma Australia, of the 300,000 Australians with glaucoma, 50% are unaware they have the condition.
Glaucoma can develop slowly, and is often asymptomatic. In many cases, it’s not until the disease reaches an advanced stage that it is detected.
Knowing who is most at risk can assist with detection—and potentially help save someone’s sight. Key risk factors include:
- a family history of glaucoma
- experiencing elevated eye pressure
- aged 50+
- having diabetes
- being short or long sighted
- long-term use of corticosteroids
- previous eye operation or injury
- a history of high or low blood pressure
- being of Asian or African descent.
“A lot of the time eye health may not be maintained because of compliance. A patient may be on a regular medication, not necessarily an eye drop but something to manage blood pressure or sugar levels, and non-adherence can impact the longer-term side effects, which might be related to eye health.
“Promoting adherence is all about education. If someone is on multiple eye drops for their glaucoma, every time the person comes into the pharmacy you can remind them that they should administer the eye drops five minutes apart. Reinforce why they need to use the medication—because of the long-term side effects.
“In some cases people may not use their eye drops because they get red eyes afterwards and might be embarrassed by this but never address the problem. They might not realise there are other solutions and instead they don’t use anything.
“Glaucoma is a progressive disease but there are ways to manage it. It’s important to comply with a medication regime and have regular reviews,” says Ms Nguyen.
Similar to glaucoma, diabetes-related eye disease is often asymptomatic until it reaches an advanced stage and outcomes of late treatment are usually inferior to early intervention.
Furthermore, while every person with diabetes is at increased risk of diabetic retinopathy, diabetes also increases a person’s risk for developing cataracts and glaucoma.
“It’s important to not wait for signs or symptoms of eye problems, because by the time symptoms occur the damage is done and treatments are less effective,” says Diabetes Australia CEO Professor Greg Johnson.
“This is why regular diabetes eye checks are so important—so that any problems can be found early, before the damage is significant, and when treatment is easier and more effective.
“Diabetes eye checks can get overlooked easily when there are so many other aspects to managing diabetes, and health in general. But the good news is that vision loss from diabetes is preventable if acted on early. Regular checks are possibly the most important thing people can do to keep their eyes in good health.”
He adds, “We know that there’s a lack of awareness in the community generally and among those affected by diabetes about diabetes-related eye disease. The fundamental capacity of community pharmacy to raise this as a discussion point with every person with diabetes that they encounter is wonderful.
“Everyone with diabetes should have an eye check every two years. Those in a high-risk group, such as Indigenous and Torres Strait Islanders, should have an eye examination every year.”
Diabetes Australia is encouraging patients with diabetes to sign up to www.keepsight.org.au, as this reminds them to get the necessary diabetes eye checks at the right time.