Pharmacy team training Dry Eye syndrome. Refresher training to help ensure you are up-to-date with dry eye syndrome

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1 Pharmacy team training Dry Eye syndrome Refresher training to help ensure you are up-to-date with dry eye syndrome

2 Section One: How the eye works Contents Section One: How the eye works 03 Section Two: Dry eye syndrome 04 Section Three: Advice and OTC options 06 Section Four: Next steps 12 Section Five: Knowledge test 13 Section Six: Certification 14 How this training was developed This training has been developed by bringing together senior representatives from the pharmacy community and eye health experts to outline how to offer the best care and advice to patients. The training is designed for the pharmacist to use with the wider pharmacy team. Areas of particular relevance are signposted with blue and pink flags [key: pink flag of particular relevance for the pharmacist/ blue flag of particular relevance for the pharmacy assistant]. The key learning outcomes of this training module are that all members of the pharmacy team will be equipped to: Recognise the symptoms of dry eye syndrome and understand possible causes. Identify more serious ocular conditions that need sign-posting to a healthcare professional. Provide useful help and advice to patients on treatments to help manage dry eye syndrome, self-help techniques to minimise the impact of the condition, and ways try to help prevent the symptoms from recurring. 2 UK/ART/12/008

3 Section One: How the eye works Introduction Dry eye syndrome (keratoconjunctivitis sicca or keratitis sicca) is one of the most commonly occurring eye conditions and can be extremely frustrating for the patient. Dry eye syndrome symptoms are believed to affect up to 30% of adults over the age of 50. i Around 70% of those patients use pharmacy as the first port of call for dry eye symptoms. ii Pharmacists can play a key role in advising and empowering patients to successfully manage dry eye syndrome directly; through offering both lifestyle advice and consultancy on the wide variety of effective products available in the pharmacy. On average, UK pharmacists recommend eye drops to 30 patients per month. iii Parts of the eye iv Front of the eye Light enters the front of the eye through the clear cornea and lens. It is important that they are both clear as this allows the light to pass directly through the front of the eye to the retina. The cornea focuses the light towards the retina. The lens fine tunes the focussing of this light. Tears form a protective layer at the front of the eye and also help to direct the light coming into the eye. The iris, the coloured ring at the front of the eye, changes the size of the pupil which allows different amounts of light into the eye. The pupil gets smaller in bright conditions, allowing less light in; and gets bigger in dark conditions, allowing more light in. Cornea Iris Pupil Vitreous Choroid Macula Middle eye The middle of the eye is filled with a jelly-like substance called the vitreous. This substance is clear and allows light to pass from the front to the back of the eye. Back of the eye The retina is a light-sensitive layer, consisting of rod and cone cells. These cells collect the light signals directed onto them and send them as electrical signals to the optic nerve. Rod cells are concentrated around the edge of the retina; they help you to see things that aren t directly in front of you - assisting with mobility by stopping you from bumping into things - and aiding with vision in dim light and to see movement. Cone cells are concentrated in the centre of the retina where the light is focused by the cornea and lens; this area is called the macula. Cone cells give the detailed vision used for detailed activities such as reading, watching TV and seeing people. The optic nerve is made up of thousands of nerve fibres; these fibres pass the electrical signals along to the brain where they are processed. Retina Lens Conjunctiva Optic nerve UK/ART/12/008 3

4 Section Two: Dry eye syndrome What is dry eye syndrome? Dry eye syndrome is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. i Dry eye syndrome can affect anyone but is more common in older people, and is more common in women than men. v For many cases of dry eye syndrome there is no single identifying cause. The most common causes include: age; menopause; cataract and refractive surgeries; gland dysfunction; medical conditions and medication; various environmental and lifestyle factors. We often only notice tears when crying, due to an emotional response or as a reaction to something; cutting onions for example. However, they play an extremely important role in maintaining the health and function of the eyes. The eye is always covered by a thin layer of liquid known as a tear film. The tear film is maintained each time a person blinks and performs a number of important functions which include: v vi lubricating the eye surface keeping it clean and free from dust, grit and other waste products. supplying oxygen and nutrients to the eye surface. protecting the eye from infection. aiding sight by helping to direct light coming into the eye. The tear film is made up of three layers, produced by different glands in the eye: Lipid/ oil layer Produced by the meibomian glands, it is the outermost layer of the tear film. It is a dense and oily layer that seals moisture to the eye, allowing for the free flow of the eyelid over the eye, and smooths out the surface. Aqueous/ water layer Produced by the lacrimal glands, it lubricates, smoothes irregularities of, and delivers nutrients to, the corneal surface as well as washing away waste products. Mucous/ mucin layer Produced by the conjunctival goblet cells, this layer is closest to the surface layer of the eye and spreads tears over the corneal surface as well as protecting the cornea against foreign substances. Lipid/ oil layer Aqueous / water layer Mucous/ mucin layer 4 UK/ART/12/008

5 There are a number of physical and environmental factors that can affect the function of tears: v Ageing. Stress. Climate - dusty, windy or dry conditions. Hormonal changes e.g. the menopause for women. Environment dry, warm or air conditioning. Side effects of some medications e.g. Antihistamines, diuretics and oral contraceptives. High-visual concentration activities leading to a reduced blink rate e.g. Reading, writing. Working with computers/ screens. Some medical conditions e.g. Allergy, diabetes, rheumatoid arthritis, Parkinson s disease, ocular rosacea and Sjögren s syndrome. Dehydration. Long term contact lens wearing. Recent laser eye surgery. Impact vii Dry eye syndrome can mean patients are not able to see clearly and may experience blurred vision, which can limit and degrade the performance of common vision-related daily activities such as reading, working, watching television, using computers and driving. It is important to identify and treat the symptoms of dry eye syndrome, left untreated it can lead to more serious complications such as conjunctivitis or keratitis where the inflammation associated with dry eye syndrome damages the surface of the cornea. UK/ART/12/008 5

6 Section Three: Advice and OTC options Treating dry eye syndrome the role of the pharmacy team When a patient with suspected dry eye syndrome symptoms asks for advice there are four clear steps you should take. This refresher training will take you through each of them. Assess, Recognise, Intervene, Deter Assess The most important first step is to conduct a short semi-structured interview to establish the patient s history of the symptoms and whether there are any potential underlying causes for the dry eye syndrome symptoms to inform your actions. It can be extremely useful to ask a mixture of open ended questions to encourage the patient to provide additional information and close ended questions where you seek specific information, usually via a yes/ no answer. Useful questions to ask / areas to investigate 1. How old are you? 2. What do you do for a living? 3. How long have you worked in your present job? 4. Symptoms Patient description Duration Uni/bilateral Recurrence Affected by particular conditions e.g. smoky, dry, hot, bright Disturbed vision, length of time vision is disturbed 5. Have you tried any other remedies or medicines to help with your eye(s)? What have you tried and how much have you taken? Did this help? 6. Do you suffer from any allergies for example, seasonal allergies or allergies to certain foods or medications? 7. Are you currently taking any other prescription or over-the-counter medications? What are they? Consider offering a medicine use review 8. Do you currently wear contact lenses? 9. Have you suffered from any eye complaints or diseases before? How long have you had this condition? Are you seeing a doctor for this condition? Are you taking any medications for this condition? Can you tell me the name of the medication? 10.Have you had any previous surgery on your eyes? 11. Do you smoke? How much do you smoke? 12.Do you drink beer, wine or spirits? How much do you drink? How often do you drink? 6 UK/ART/12/008

7 Recognise and refer as appropriate Regardless of the cause of dry eye syndrome, the typical signs and symptoms are similar and usually affect both eyes: viii Eye redness. Eye irritation. Eye stinging, burning or grittiness associated with dryness. Foreign body sensation. Watery eyes; this may seem counterintuitive given the name of the condition but the eyes will often go into overdrive and produce more watery tears to try and soothe the irritation. Feelings of dryness and grittiness which get worse throughout the day. Short periods of blurred vision. Difficulty or lack of comfort wearing contact lenses. A GP should be able to diagnose dry eye syndrome and in some instances may refer the patient to an optometrist for a check-up or to an ophthalmologist. The optometrist or ophthalmologist may carry out tests to assess the quantity and quality of the patient s tears: ix The Schirmer test A small strip of paper is placed inside the lower part of the eyelids, left for five minutes, before being removed and studied to determine how wet the paper is. Tear film break up time A special dye is dropped into the eye and the patient is asked to blink a number of times to ensure the dye is in the tears properly. The eyes are then kept open without blinking. A coloured light is used to see the dye and the period between the last blink and the formation of dry patches is timed. Advising treatment with products available in the pharmacy can be considered if: 4 Typical features of dry eye syndrome 4 Symptoms worsen with driving, prolonged screen use/ reading/ writing tasks 8 Ocular pain 8 Vision loss / prolonged blurriness 8 History of ocular disease 8 Any other ocular medications When to refer? A number of signs and symptoms may suggest that the patient s dry eye syndrome is being caused by something more serious or complications have developed. It is recommended that the patient be referred to their GP if: Symptoms mainly affect one eye rather than both. There is a reduction in vision or vision loss occurs. Any associated redness of the eye is not resolving with over-the-counter measures. There is a history of ocular disease. Ocular surgery has previously been performed. Ocular prescription medications are being taken. There is a visible lid mass or abnormality. Eye pain develops other than dry eye syndrome grittiness or irritation. Symptoms are significant and the patient also wears contact lenses. UK/ART/12/008 7

8 Section Three: Advice and OTC options Could it be anything else? v Blepharitis: The symptoms of dry eye syndrome can be due to eyelid irritation or blepharitis. This is a common condition in which the eyelids become red, inflamed and accumulate cell debris around their edges. The cause is usually an infection or inflammation of any of the glands around the eye, or an infection of the eyelash roots. In these cases, eliminating the infection or inflammation can help improve dry eye syndrome. Sjögren syndrome: This is an autoimmune disorder, which can develop on its own (primary) or in combination with another autoimmune disorder (secondary). In Sjögren syndrome the body attacks the tear and saliva glands leading to dry eye syndrome and dry mouth alongside other symptoms. Treatments are available to help with dry eye syndrome symptoms and stimulate the production of saliva. Intervene Reassure the patient that their dry eye syndrome symptoms can be relieved. Although dry eye syndrome is a chronic condition, simple treatments are available to help soothe the symptoms or treat the underlying cause. The most common forms of treatment for dry eye syndrome include: vi Making the most of natural tears - Lifestyle changes that can help minimise the drying effect of the environment. - Prescription eye drops that can stimulate the production of natural tears. Using artificial tears (eye drops or gels) - Comforts eyes by supplementing natural tears, commonly used for mild cases of dry eye syndrome. Reducing draining away of tears - Plugs may be inserted to block the drainage path of tears, or the tear ducts may be blocked permanently. Both methods are intended to conserve the tears the eye produces for a longer period of time. Invasive therapy is usually considered after all other options have been tried and been unsuccessful, and can only be undertaken by a specialist Ophthalmologist. Pharmacy products There is a wide range of eye drops, ointments and gels that are available from the pharmacy without a prescription. These products soothe and comfort irritated, dry eye syndrome providing relief for occasional and frequent users. Products contain a combination of ingredients for multi-factorial improvement in eye health. The choice of which product to use will be guided by the severity of the condition, the product ingredients, suitability and usage in parallel with patient preference. The manufacturer s instructions for use with contact lenses and shelf-life once opened should be followed. Artificial tear eye drops - available with and without preservatives Mimicking the properties of tears, artificial tear eye drops contain lubricants to form a protective layer to retain moisture on the surface of the eye, help supplement the aqueous layer of the tear film and prevent further irritation. Dissipating preservatives disappear on contact with the eye surface for added comfort and protection. There are a number of different active ingredient lubricants which can be found in the different products (see table pg.10). 8 UK/ART/12/008

9 Some types of eye drops contain preservatives to primarily prevent bacteria growing whilst the drops are in use but can also make the product more stable and extend its period of use. For patients experiencing severe symptoms and who need to use drops more than 4-6 times per day, there is a potential that they may develop sensitivity to the preservative. For these patients, you can recommend a product from the range of preservative-free drops that are also available in the pharmacy. Preservative-free drops may also be more suitable for patients who have recently undergone LASIK-eye surgery. The preservatives in many eye drops are not compatible with contact lens wear, for example benzalkonium chloride, as soft contact lenses absorb them. However, there are various preservatives, for example Oxyd, that do not have this effect and are suitable for use with contact lenses. Eye drop patient information clearly states if they are suitable for use with lenses. Preservative-free drop options are also available; they do not affect contact lenses. The manufacturer s instructions for use of drops with contact lenses should always be followed. In addition to the active ingredient, eye drops may also contain: x Mineral nutrients, such as potassium, magnesium, and calcium, to provide nutrients to the eyes and help protect and promote a healthy tear film. Antioxidant vitamin B12 to provide additional protection to the surface of the eyes. Mild-to-moderate cases of dry eye syndrome can often be successfully treated with eye drops from the pharmacy. There are many different types made by different companies. You may want to discuss the different combinations of ingredients available in the different brands to help the patient find a brand they would like to try. It is suggested that patients trial a particular brand for about a month to see if it works for them, and if not, they can move on to another. Liposome sprays xi The lipid layer in the tear film stabilises the water layer and slows its evaporation. Eye mists or sprays contain the major lipid found in the tear film in a stable form and are designed to deliver these to the tear film by application to the closed eyelid. Artificial tear gels vi Artificial tear gels produce a transparent, lubricating, moistening film on the surface of the eye. Gel products contain different active ingredients to tear eye drops, which makes them more viscous and allows the gel to cling to the surface of the eye. As a result they are longer-acting as they are not washed out of the eye as quickly as non gel based eye drops. Due to the increased viscosity, gels can blur vision. Gels are for those that need a little more relief from their dry eye syndrome symptoms and can be used during the day or at night. Contact lenses should not be worn during treatment with gels. Ointments vi If a patient s eyes don t fully close when they are asleep, tears can evaporate more easily and dry eye syndrome can feel worse in the morning. Ointments are used to provide overnight relief of dry eye syndrome symptoms; they are more sticky than drops and so can lubricate the eye for longer. Ointments tend to be applied just before bed as they can cause blurry vision. Ointments can also be used with drops during the day but concurrent use is not usually recommended as the ointment may make drops less effective. If both types of treatments are being used, the eye drops should be applied first and the patient instructed to wait for at least five minutes before applying the ointment. Contact lenses should not be worn during treatment with ointments containing paraffin (in any form, one of which can also be known as mineral oil). UK/ART/12/008 9

10 Section Three: Advice and OTC options xii xiii Non-prescribed pharmacy products for dry eye syndrome symptoms TYPE Artificial tear eye drops Liposomes Artificial eye gels Ointments ACTIVE INGREDIENT(S) Hypromellose Carmellose sodium Polyvinyl alcohol Hydroxyethylcellulose, sodium chloride Dextran 70 Sodium hyaluronate Polyethylene glycol, propylene glycol Liposome spray Carbomer Lanolin Liquid paraffin White soft paraffin If the patient s dry eye syndrome symptoms fail to respond to the conservative treatment available in the pharmacy, they should be appropriately referred. Other treatment options Prescription eye drops If artificial tears are not managing dry eye syndrome symptoms, there are various prescription eye drops available. There are antibiotics to reduce eyelid inflammation, and also eye drops to reduce inflammation that contain the immunesuppressant ciclosporin or that contain corticosteroids to control inflammation. xi v Alternative remedies There is very limited evidence on the use and effectiveness of alternative remedies on dry eye syndrome. With a varied range of alternative medicines available the pharmacist can provide a key role in advising on any suggested benefits and ensuring they are of no risk to the patient. Surgery xi If dry eye syndrome fails to respond to other types of treatment, then following appropriate referral and consultation surgery may be considered. There are two potential types of surgery that may be undertaken: Punctal occlusion uses small plugs to seal the tear ducts, which prevents tears from draining away and means the eyes should remain moist. Temporary plugs made of silicone are used first and if successful, are subsequently replaced with more permanent plugs. Salivary gland autotransplantation is usually only recommended for the most severe cases after all other interventions have been tried. This is an operation to remove some of the glands that produce saliva in the mouth and grafting or placing them on the side of the eyes. The saliva produced by the glands acts as a substitute for tears. 10 UK/ART/12/008

11 Deter There are a number of self-help techniques that you can recommend to patients with dry eye syndrome. These aim to prevent dry eye syndrome symptoms and minimize the impact of aggravating conditions on the eyes: Avoid dry situations such as overheated or air conditioned rooms, windy or breezy conditions or smoky places. If the patient smokes, encourage quitting. Reduce exposure to second-hand smoke. - Offer support, advice and quitting aids/ products available through the pharmacy. Offer a medicines use review to assess whether medications the patient may be taking could be linked to dry eye syndrome. Investigate any potential allergies which could be an underlying cause. - Offer support, advice and allergy products available through the pharmacy. Moisten the surrounding air at home or at work by using a humidifier. Eliminate draughts in the home using draught excluders. A diet high in omega-3-fats has been suggested to help prevent dry eye syndrome. xv - Incorporate eating 2 portions of oily fish such as mackerel or salmon into the weekly diet. - Offer support, advice and vitamin/ nutritional supplements available through the pharmacy. Keep well hydrated by drinking lots of water. Ensure correct workstation set up; this includes desk, chair, computer and screen. - Direct patient to the UK Health and Safety. - Executive (HSE) Working with VDUs leaflet on their website for practical tips to help with this. - When at work, most companies will have a representative responsible for health and safety that can help with workstation assessment to meet UK regulations. Take regular breaks to rest your eyes when carrying out activities that require intense visual concentration such as reading, writing or using a computer monitor. Consciously blink the eyes regularly. When outdoors wear wraparound glasses to reduce drying effect of the wind. Practice good eye hygiene to keep eyes clean and help prevent dry eye syndrome and blepharitis. - Warm compress; soak a cloth or cotton wool pad with hot water (not boiling avoid excessive heat) and apply to each closed eye for 5-10 minutes. - Massage; gently roll a clean first finger over your eyelids in a circular motion. - Cleanse; use cotton wool bud and hot water (not boiling avoid excessive heat) to clean the upper and lower eyelid along the lash base and remove any crustiness. - Offer cosmetic accessory products available through the pharmacy to support this. UK/ART/12/008 11

12 Section Four: Next steps Follow-up A patient may try more than one eye product before they find one that suits them. It is important to ensure the patient is supported as much as possible. Encourage the patient to pop back to let you know how they are getting on with a new technique or product. It is also good practice to encourage the patient to return for regular more structured reviews. There are many sources of information that patients may find helpful to go to for further advice and support. (Please note Bausch + Lomb have no involvement or responsibility for the content within these sites.) A few of them are listed here. If the patient has any of the following concerns when seen at follow up advise to see their GP as they may need to be referred to an ophthalmologist for a more detailed assessment: Their symptoms persist or have become worse after using the over-the-counter product. Do check the product information for specific details. They have experienced eye pain. They have experienced a change in vision. The Royal College of Ophthalmologists The Royal College of Ophthalmologists champions excellence in the practice of ophthalmology for the benefit of patients and the public. Their website contains information for the general public and those in the ophthalmology profession. The information for the public includes frequently asked questions and information booklets on a number of conditions affecting the eye, including dry eye syndrome. Web: Royal National Institute of Blind People (RNIB) is the leading charity offering information, practical and emotional support and advice to almost two million people with sight loss. Their helpline is available from Monday to Friday 8.45am to 5.30pm. Outside these times, there is a voic service, which will be responded to as soon as possible. Helpline telephone: Web: Age UK Age UK has a vision of a world in which older people flourish. Age UK aims to improve later life for everyone through their information and advice, campaigns, products, training and research. Age UK has information about eye tests and a number of conditions affecting the eyes on its website. Their advice lines are open between 8.00am and 7.00pm. Age UK advice: Web: NHS Direct NHS Direct provides health advice and reassurance from healthcare professionals online and via 24 hour helplines. England: Web: Scotland: Web: Wales: Web: NHS Choices is the online front door to the NHS. It is the country s biggest health website and gives all the information you need to make choices about your health. Web: 12 UK/ART/12/008

13 Section Five: Knowledge test It s time to test what you have learnt by trying our true or false quiz. The answers are at the bottom of the page. TOPIC Dry eye syndrome CORRECT ANSWER: TRUE OR FALSE Dry eye syndrome is more common in men than women One of the causes of dry eye syndrome is a problem with the normal production of tears Assess Dry eye syndrome can result as a side effect of certain medications Symptoms of dry eye syndrome are unaffected by environmental conditions Recognise and refer Patients with dry eye will always experience dry mouth Ocular pain and vision loss are not typical symptoms of dry eye syndrome Intervene I should recommend artificial tear eye drops to supplement natural tears Surgical interventions are only recommended when other options have been unsuccessful Deter Eating a diet high in beta carotene could help dry eye syndrome symptoms Taking regular breaks from high-visual concentration activities can help dry eye syndrome symptoms v Dry eye syndrome: false, true. Assess: true, false. Recognise and refer: false, true. Intervene: true, true. Deter: false, true. UK/ART/12/008 13

14 Section Six: Certification Record your learning Once you have read through the training and completed the test on page 13, you can feel confident that you are providing the best possible advice for this common condition. For pharmacist and pharmacy technicians, by reflecting on your learning and putting your knowledge into practice you should have the evidence required to make a CPD entry. This will contribute towards the minimum of nine CPD entries per year, which reflect the context and scope of your job role. Use the questions below to help you reflect on what you have learnt and how it might affect your everyday work. If you are registered with the GPhC, remember to make an entry in your online CPD record (www.uptodate.org.uk). Otherwise, it is good practice to record it in your ongoing learning and development folder. What did I learn that was new? How have I put this into practice? Do I need to learn anything else in this area? 14

15 Apply for certification To receive a certificate to confirm that you have completed the training refresher visit Alternatively, send the following information via fax to or post to: Bausch + Lomb Pharmacy Training Dry Eye, PO BOX 500 BN11 1PX Your name Your pharmacy name and address Your job title Your address Written confirmation that you have completed and understood the training Offer feedback We want to continue to offer the best possible advice for pharmacy teams to use in supporting their customers in this area and welcome your feedback by visiting our feedback area at i Guidelines from the 2007 International Dry Eye Workshop (DEWS committee) BY MICHAEL A. LEMP, M. D. AND GARY N. FOULKS, M. D., F.A.C.S. ii B+L Data on File [CONS Global Brand Tracking Presentation-ReportREV slide 25] iii B+L Data On File [B+L PHARM De Novo research deck slide 10] iv (last accessed July 2012) v (last accessed July 2012) vi RCOD & RNIB Printed March 2011, Reviewed March Dry Eye Syndrome Information Booklet vii Impact of dry syndrome on vision-related quality of life. Am J Ophthalmol March; 143(3): Miljanovic B. et al. viii (Last accessed March 2011) ix (last accessed July 2012) x Holly FJ. Spectrum, 1990; 5:37-42 xi (last accessed July 2012) xii (last accessed July 2012) xiii (CET training, last accessed July 2012) xiv (last accessed July 2012) xv (last accessed July 2012) UK/ART/12/008 15

16 UK/ART/12/008 Prepared July 2012

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