Dry eye in community pharmacy

Pharmacists are often at the helm of patient care – offering convenient access to a comprehensive range of services. However, too high a proportion of the population still remain unaware that the sector’s scope extends to help with dry eye syndrome too. NIHR chats to two pharmacists about their encounters with the condition, and gauge their advice for providing much needed relief to distressed individuals.

HOW REGULARLY IS YOUR ADVICE SOUGHT ON EYECARE CONCERNS?

We are asked advice on eyecare most days of the week, and sometimes several times a day. Some of these queries can be answered by our trained counter assistants but some need input from the pharmacist.

HAS THIS INCIDENCE INCREASED OVER TIME? DO YOU THINK IT WILL CONTINUE TO CHANGE?

We have noticed an increase in these types of query in general and think that this trend can be attributed to several different factors:

1 - We are situated in an area where there is an ageing population, who may be more prone to getting dry eyes
2 - There is an increase in the number of people who work regularly using computer screens
3 - We are a rural region and have extremes of often cold, windy outdoor weather combined with increasingly air-conditioned or centrally heated interiors
4 - The number of medications which can contribute to dry eyes is rising, as is the number of patients who have complex pharmaceutical needs to manage their conditions
5 - A popular young optician has just opened a practice in town, making eyecare more high profile and because we have a good relationship with him, we are able to cross-refer patients between us
6 - With increased pressure on GP time, many patients are looking to self-medicate where appropriate

With these factors in mind I can only foresee our professional expertise being increasingly in-demand.

WHAT POTENTIAL DO PHARMACISTS REPRESENT IN HELPING PATIENTS WITH DRY EYE SYNDROME?

Pharmacies are open seven days a week with no appointment necessary so patients can readily access expert advice when they need it. We are able to discuss advantages and disadvantages of the various products and engage with patients to find the most appropriate product for each individual. Pharmacists are able to respond rapidly to more complex situations and advise referral / signpost for more specialist attention to either GPs or opticians.

WHAT LEADS TO THE CONDITION’S OCCURRENCE?

As previously mentioned, increasing age, computer work, environmental conditions, and medication can be contributing factors. Wearing contact lenses, smoking, alcohol consumption and some medical conditions can also be contributing factors.

CAN YOU DESCRIBE THE TREATMENT PROCESS FOR DRY EYE SYNDROME?

General advice for patients would be:

1 - Keep your eyes clean and don’t rub them
2 - If you are using a computer screen for long periods, make sure that you take regular breaks and increase your fluid intake
3 - Use a humidifier or turn the heating down and avoid being in direct line of hot air heaters
4 - If you wear contact lenses make sure that you allow your eyes to rest by wearing glasses part of each day
5 - If you think that your medication is causing the problem, arrange to speak to your GP but don’t stop taking the medication meanwhile

More specifically, we would have a conversation about the use of drops and ointments to lubricate the eye. Drops tend to be shorter-lasting and more appropriate during
the day, while gels and ointments tend to cause some bleariness and may be more useful at night and in the morning.

An area which is expanding is the use of non-preservative-containing products since information is now being produced about the damage to the eye that can be caused by long term contact with preservatives.

Also, we would have a discussion about whether it was an occasional issue where single-dose unit forms might be appropriate or whether a larger dose container would be appropriate. We would inform the patients about the importance of avoiding direct contact with the eye and eyelashes and being aware of the 28-day expiry information, and explain about the risks of infection if this is not complied with. Where appropriate we would be able to supply the products on the Minor Ailment Scheme.

Finally, we would invite them to return if they have further issues or if the condition does not improve within a few weeks they may want to speak to their GP.

WHAT VALUE DOES THE AVAILABILITY OF OVER-THECOUNTER DRY EYE RELIEF PROVIDE FOR THE PATIENT AND PHARMACIST ALIKE?

It gives easy access and informed advice to patients and enables the pharmacist to interact with individual patients directly, promoting good relationships which may enable patients to feel more confident in asking advice on other matters. It allows us to promote the Minor Ailments Scheme to patients as appropriate. Patients also benefit from our good relationships with other healthcare professionals.

WHAT ARE THE RISKS OF LATE TREATMENT?

If left untreated dry eye can cause more severe complications such as inflammation, damage to the surface of the cornea, ulcers and vision problems. It can also affect the quality of life for an individual which then may affect their mental health and wellbeing.

HOW OFTEN DO PATIENTS WITH EYE PROBLEMS PRESENT TO PHARMACISTS? AND IN PARTICULAR, HOW RECURRENT ARE CASES OF DRY EYE SYNDROME?

It is a condition that community pharmacists deal with on a daily basis. It is a very common condition that can affect people of all ages, but it is more common in those over 50 years of age and is more common in females. It can be a chronic condition that remits and relapses so recurrent symptoms can be common. There is usually no cure but symptomatic management can be provided in community pharmacies.

WHAT SIGNS AND SYMPTOMS OF DRY EYE SYNDROME ARE EXHIBITED?

Signs and symptoms can vary from person to person but they are usually bilateral. Signs and symptoms include irritation or discomfort (often described as burning, stinging or a ‘gritty’ sensation), dryness, intermittent blurred vision, redness of eyelids or conjunctiva, itching, photosensitivity, mucous discharge, and ocular fatigue.

WHAT ARE THE MAIN CAUSES OF THE CONDITION?

Dry eye can be caused by a number of factors. These include, meibomian gland dysfunction, blepharitis, age-related lacrimal gland deficiency, low blink rate, vitamin A deficiency, malposition of the eyelids, environmental causes (high wind, allergens etc.), contact lenses, certain medication, ocular surgery, and underlying medical conditions.

WHAT BENEFITS DO PHARMACIES BOAST AS A SOURCE OF EYECARE ASSISTANCE?

Community pharmacies are ideally placed to help with dry eye syndrome for a number of reasons. They are accessible so patients do not have a delay in being seen, given advice, or a product to help. Most pharmacies stock a wide range of products to help with dry eyes. Pharmacists are well-equipped to give advice on common eye conditions such as dry eye syndrome.

ARE PATIENTS SUFFICIENTLY AWARE OF THE HELP WHICH IS AT HAND FOR EYECARE VIA PHARMACIES?

Pharmacy is becoming increasingly popular as the first port-of-call, especially for a common condition such as dry eye syndrome.

HOW CAN THIS BE IMPROVED?

There is still work to be done to promote the Pharmacy First model. The more patients that have a positive experience in their community pharmacy, the more likely they are to tell their friends and relatives, which will encourage more patients to seek help from a community pharmacy before going to their GP or optometrist.

WHAT STEPS DO YOU RECOMMEND FOR SELF-MANAGEMENT OF DRY EYE SYNDROME?

There are a number of self-management techniques that can help. Using a warm compress, lid hygiene and massage are particularly helpful if the cause of the dry eye is
blepharitis or meibomian gland dysfunction. If contact lenses are the cause, wear them for shorter periods or not at all during a bout of dry eye. If environmental factors are the cause, patients should spend less time looking at computer or phone screens, avoid airconditioned environments, increase relative humidity, avoid alcohol and exposure to cigarette smoke.

WHAT TREATMENT PATHWAYS ARE PURSUED?

The first line of treatment is tear supplements, which there are a large amount of products available over-the-counter. Drops are helpful for daytime symptoms and ointments or gels should be reserved for use before bed because they can cause blurred vision but are longer-lasting to prevent the eye drying out overnight. There are
also preservative-free formulations available if a patient is intolerant to the preservative in tear supplements.

WHEN IS FURTHER TREATMENT REQUIRED FROM A GP OR OPHTHALMOLOGIST?

Urgent referral to ophthalmology is required if the patient is suspected of having a serious eye condition such as acute glaucoma, keratitis, iritis or corneal ulcer. Children should be referred urgently if they have any corneal change. Routine referral should occur if the diagnosis is unclear, they are suspected of having an underlying condition, if they have not responded to treatment after 12 weeks, or if they have an abnormal lid anatomy or function.