Ocular changes

A patient inquiry about stronger reading glasses or red or painful eyes may provide pharmacists with an opportunity to screen or refer patients to an optometrist with a few tailored questions.

Ocular changes such as deteriorating vision, redness or pain can signal other diseases or conditions that warrant immediate treatment or long-term management.

In general, diabetes, undiagnosed or poorly controlled hypertension, Graves’ disease, temporal arteritis, metastatic tumour, a dry-eye presentation of Sjogren’s syndrome, retinal ischaemic conditions and even acquired brain injury may all be involved with deteriorating vision.

Specific ocular conditions that failing eyesight may also pinpoint include glaucoma, macular degeneration and cataracts. And if a person complains of needing stronger reading glasses, or is experiencing pain, redness or secretions, pharmacists can take the opportunity to delve deeper.

A complaint of dry eyes requires clarification. End-of-day dryness is often a lipid dysfunction (the most common variety), whereas aqueous deficient dryness (e.g. Sjogren’s syndrome) can be anytime.

Several oral medicines can exacerbate borderline dry eye, hence the presentation may only be of recent onset in conjunction with a change in medicines.

Eye pain can be caused from as minor an irritation as an eye lash through to conditions of uveitis or corneal infection.

Perth optometrist Michael Doyle, who has served on the boards of Optometry Australia and the Cornea and Contact Lens Society of Australia, suggests that pharmacists should consider changes to a patient’s gait or cognition, or fatigue or headache, as red flags for further discussion. They should also consider querying any recent lifestyle changes or ocular specifics, such as asymmetry of redness, secretion, vision or pain.

A good start is to ask questions about the patient’s general health and the timing of their last assessment by a general practitioner, says Mr Doyle.

‘Is the vision loss unilateral, and is it recent?’ he suggests asking. ‘Any double vision? Any changes in ambulation ability – falls or new difficulties with ambulation?’

Mr Doyle suggests pharmacists should ‘beware of any red eye presentation’ and to ask about any pain/soreness or significant vision loss, as ‘conjunctivitis has neither’. Clarify itch (allergy) from soreness, he says.

Contact lens wearers in particular are at a much higher risk of bacterial and fungal infections, he warns. Beware, especially, of contact lens wearers with redness or pain as bacterial keratitis needs to be ruled out. And even a 24-hour delay in treating a Pseudomonas infection with antibiotics can be devastating.

Any unilateral red eye such as conjunctivitis should be diagnosed only after excluding conditions such as a corneal foreign body or corneal infection (herpes), Mr Doyle suggests.

Pharmacists can refer patients to an optometrist for further examination with any sudden presentations of eye pain/soreness, or orbital inflammation, especially if the patient is unwell, he also points out.

Another referral reason is excessive watering or discharge, especially with recent diplopia or vision deterioration in otherwise healthy individuals.

AP asked Mr Doyle and a community pharmacist for recent experiences with ocular cases, and both provided some top tips for pharmacist referrals.

Michael Doyal, WA optometrist

Michael Doyle FACBO, GradCertOcTherap

Independent practice owner, Bassendean Optical Perth, Western Australia

Case 1

A young boy had complained to his grandmother about a sore eye around lunchtime. Mild redness and watering had been evident but then subsided.

The grandmother was later in the shopping centre and checked with a pharmacist as the eye was still watering slightly. The child, however, was happily running around playing. The pharmacist saw no problem but recommended a quick review by the nearby optometrist – me – to be sure.

When the boy presented with a boisterous personality and no gross difficulties demonstrated, I didn’t expect to find anything abnormal. However, a slit-lamp examination showed his iris was stretched and protruding slightly through his cornea!

The boy had no pain, and his eye was white (normal) but with an awfully disfigured iris.

Further questioning revealed he had been playing a small guitar with his grandmother’s seam unpicker. This had flicked into his eye with such force as to penetrate the cornea, grab the iris, spring back and plug the hole!

Emergency surgery that evening brought a great result.

Other red eye presentations have included trace shards of glass trapped in the upper lid giving intermittent symptoms, as well as juvenile glaucoma with significant raised pressure.

Box 1 – Michael Doyle’s top tips for pharmacists

Q: What should pharmacists know about referrals to optometrists, including Medicare billing?

A: Private and bulk billing varies between optometrists. It would be ideal for the pharmacist to clarify with those optometrists local to them:

  • what fees are charged
  • waiting times
  • best avenue to emergency review
  • what skill/equipment level does the optometrist have to deal with in these situations.

Optometrists do not require referrals for examinations. Possibly an after-work informal chat about these items would be beneficial to all.

Q: What is a best practice working relationship between a pharmacist and an optometrist?

A: Mutual respect and understanding each other’s skill and comfort levels in dealing with primary care patients involving ocular conditions. Also, the ability to directly phone each other to clarify prescriptions and discuss medicine availability or recommended substitutions.

Q: What advice do you have for a pharmacist wishing to cultivate such a relationship?

A: Have a face-to-face meet and greet with your local optometrist and arrange a time to informally meet stating this intention. The optometrist would appreciate and be excited at this opportunity. Both camps are often too shy!

Laura Carfrae MPS, VIC pharmacist
Laura Carfrae MPS

Laura Carfrae MPS

Pharmacist, Maryborough Pharmacy, Maryborough, Victoria

Case 2

Miss X, aged 29, presented to the pharmacy with bilateral red eyes and ongoing tearing.

She had a prior history of allergic conjunctivitis, so she had self-selected ketotifen eye drops a fortnight earlier and had been using them as recommended with no response.

On questioning, the patient indicated the redness started in the left eye, and a week later the right eye followed. Both had remained red consistently over the past month or so.

Asked about other symptoms supporting allergic conjunctivitis, such as a gritty sensation or discharge, the patient said she was not experiencing any of these symptoms, and that this was atypical for her previous experience with allergic conjunctivitis.

Asked about vision changes, she said she was experiencing some floaters in her vision, especially when outside or in bright lights, and also indicated she thought this had worsened recently.

When asked about any pain, she reported a dull ache around the eyes, which was worse when she looked sideways or up and down.

Given the failure of therapy and persisting redness, we organised for the patient to be seen urgently at the local optometry clinic for assessment.

The patient returned with a prescription for dexamethasone eye drops, for use in both eyes, every hour while awake.

She had been diagnosed with bilateral anterior uveitis and had an urgent referral to an ophthalmologist who would review her after 48 hours of using the drops to perform further investigations.

Box 2 – Laura Carfrae’s red eye facts

  • Conjunctivitis usually occurs from the outside in, with a sparing of the white around the iris.
  • Most conditions that inflame the eye surface like conjunctivitis come with a sore/gritty/dry sensation; the patient’s description of what they are feeling helps to differentiate the condition.
  • Inflammation from the inside of the eye usually appears to spread out from the iris and is called ciliary flushing; this may worsen but usually does not go away.
  • Pain around the eye/behind the eye coupled with redness is worrying for intraocular pathologies like uveitis and acute angle closure glaucoma.
  • Onset of uveitis can be sudden or insidious and can be bilateral or unilateral. Depending on the duration, there may or may not be vision changes that are discernible to the patient.
  • Uveitis is the third leading cause of irreversible blindness in the developed world.
  • Research from the Centre for Eye Research Australia has demonstrated that low levels of vitamin D may be associated with more frequent and/or longer relapses of uveitis, although more research is needed to confirm this link.
  • If you have a patient with recurrent uveitis, vitamin D assessment and/or supplementation is a worthwhile discussion.

For more information on ocular changes, try PSA’s self-care cards on:

  • Red and dry eyes
  • Contact lens care
  • Glaucoma
  • Vision impairment.

These are available here.