Cause of conjunctivitis can be either allergic or infective.

A community pharmacy is really well placed with often the longest opening hours compared to any other healthcare providers. However, the biggest draw into a pharmacy for an acute eye condition or any minor injury or ailment has been over the fact that the pharmacist will see the patients straightaway, with no prior appointment.

And it really helps that pharmacists have a great deal of knowledge and expertise to support patients with these conditions. These patients leave a pharmacy with great advice and treatment which supports the NHS in reducing pressures on the already stretched GP surgeries and Urgent Care centres.

Rajan Shah, a superintendent pharmacist in West Ealing, London, says: “I see a lot of patients with long term conditions such as glaucoma too. During regular conversations with them and during medicine use reviews, I always provide my patients with extra support to help them get the best out of their medication by ensuring their understand why their treatment is prescribed, provide information on the medicine supplied and check that the patients can administer eye drops correctly.

“Often, I advise on compliance aids, for example, devices which can be placed over the eye to direct the dose and those to assist with opening dropper bottles.”

From his experience, three of the most common complaints presented in a pharmacy almost on a daily basis are:

Red eye

Conjunctivitis is the most common cause of red eye and is an inflammation of the conjunctiva in the eyelid. Conjunctivitis commonly affects both eyes, although one may be affected more than the other. If both eyes are affected, and in the absence of any warning signs or symptoms, the conjunctivitis will probably have either an allergic or an infective cause.

  • In infective, there is usually a discharge that may be pussy in bacterial conjunctivitis but clear and watery in viral conjunctivitis. A discharge of pus that collects in the inner corner of the eye or that prevents easy opening of the eyelids on awakening is a sign of bacterial conjunctivitis. This may be unilateral but usually affects both eyes. It can be clinically difficult to distinguish between bacterial and viral conjunctivitis, because, although the symptoms and signs are described differently in textbooks, there is often confusion, clinically speaking.
  • The commonest cause of allergic conjunctivitis is hay fever and is often seen in young people and there is usually a clear watery discharge in addition to an itchy or gritty sensation on the surface of the eye.

A subconjunctival haemorrhage (caused by a burst blood vessel) appears as a red spot or may cover the white of the eye. Although the condition can provoke anxiety in the sufferer, it is harmless and will heal spontaneously without treatment within a few weeks if no accompanying symptoms are present.

A unilateral red eye is more likely to be related to a condition within the eye, such as iritis (inflammation of the iris) or glaucoma. Symptoms include pain within the eye, photophobia, visual impairment, and hazy, small, irregularly shaped and unreactive pupils. Iritis may progress to cause cataracts (if the lens is involved) or glaucoma. In such cases, diagnosis and treatment must take place at an early stage to avoid permanent damage.

Inflammed eyelid

Inflammation of the margin of one eyelid is likely to be caused by a small abscess or stye, which is an infection of a hair follicle gland at the base of an eyelash. The infection can cause redness and irritation around the affected area with possible progression to pain and swelling of the eyelid. Styes are common and often recurrent; the inflammation will be localised at first but may spread to involve the rest of the eyelid, which will become tender and painful. After one or two days, the stye will usually come to a head and may burst or may simply shrink and resolve.

Blepharitis is caused by inflammation of the glands of the margin of the eyelid, most noticeably the eyelash roots. The condition is commonly associated with seborrhoeic dermatitis or dandruff, or it may be allergic; in this case, concurrent conjunctivitis may also be noticed.

Dry eyes

When a patient presents with symptoms of a dry eye condition, such as irritation, grittiness, burning, soreness, watery eyes and visual disturbances generally affecting both eyes, a detailed history should be recorded by the pharmacist because it may elicit information about contributing factors. The main types of dry eye are aqueous deficiency, evaporative or a combination of the two.

The ultimate goal of dry eye treatment focuses on symptomatic relief, usually using tear supplements like Hypromellose or Carbomer gel. However, these treatments alone can be unsuccessful, especially if other contributing factors are not appropriately managed.

Patients experiencing intermittent or mild symptoms of dry eye can benefit from advice on management from a pharmacist. Initially, patients can be given appropriate lifestyle advice to try to reduce the symptoms of their condition. This includes: using humidifiers, stopping smoking, taking regular breaks from the computer to encourage blinking, ensuring the top of the computer monitor is at eye level to reduce the aperture width between the eyelids, and increasing dietary omega-3 fatty acid intake or oral supplements.

The key points in assessing patients with eye conditions:

When to refer an eye disorder?

  • Pain in the eye (in contrast to superficial itchiness, grittiness or soreness)
  • Disturbance in vision
  • Suspected infection in contact lens wearer
  • Pupils appear abnormal or uneven
  • Pupils have abnormal or uneven reaction to light
  • Upper eyelid drooping (ptosis)
  • Recurrent lump under upper eyelid
  • Recurrent subconjunctival haemorrhage
  • Babies under 3 months old or babies with a squint
  • Existing eye disease
  • Bulging of eyes (proptosis)
  • Dry eyes (unless previously seen by a doctor)
  • Any associated headache
  • Systemically unwell

In summary, it must be said that pharmacies have an enormous potential to be the first port of call for patients with eye care problems; and as a gatekeeper for signposting patients when further treatment is required.

Good working relationship between pharmacy and optometry is a clear win-win

Meanwhile, it must be noted that community pharmacists’ involvement fits well within the broader NHS picture of increased prevention and supported self-care. Patients can instantly visit their local pharmacies to resolve issues around minor ailments rather than seeking an appointment at their GP surgery which could take up to several weeks.

OTC medicine

The new government policy that came out earlier on this year relating to OTC medicines support that, in that some commonly prescribed OTC medicines are no longer available for GPs to prescribe. Therefore, it’s down to the pharmacists to support patient self-care supplying the relevant OTCs, freeing up GP and secondary care’s time.

Differential diagnosis

But where pharmacists are more involved in initial differential diagnosis, Daniel Hardiman McCartney, clinical adviser at The College of Optometrists, would encourage them to consider the local optometric services across the country where either the patient returns in a couple of days with no improvement or there is a red flag to be mindful of.  In some areas of England there are minor eye condition services (MECS) which are NHS-funded services run by optometrists who are commissioned to provide an examination and arrange the most appropriate treatment either by an independent prescribing optometrist or, in some cases, a prescribing group directives.

IP optometrists

Secondly, community pharmacists need to be aware of the presence of independent prescribing (IP) optometrists in their areas of operation. There has been a steady increase in the number of IP optometrists over the last five years. Optometrist independent prescribers can prescribe any licensed medicine (except for controlled drugs or medicines for parenteral administration) for conditions affecting the eye, and the tissues surrounding the eye.

Collaborative working

Hardiman-McCartney says: “It may be useful for community pharmacists to get in contact with their local optometrists to find out what services they are able to provide, so patients can be directed appropriately.  A good working relationship between pharmacy and optometry is a clear win-win for all concerned.  In larger communities, a list of services for reference for all the pharmacy team may act as a practical aid.”

Shared education

On providing evidence-based care, pharmacists and optometrists draw from the same resources, such as NICE and Cochrane reviews (www.cochranelibarary.com). Cochran’s a case in point with the recent, systematic reviews on lubricating eye drops useful for all clinicians advising on dry eye. Hardiman-McCartney would like to see more education and training delivered collectively for pharmacists and optometrists.

“There is a great alignment in the communities we serve and the environment that we operate, there is scope for closer collaboration in education, training and professional development, evidence-based practice delivered in a commercial environment is something that unites us.”

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