Common Eye Conditions - and the role of the pharmacist Optometrist Association of Australia Pharmaceutical Society of Australia

Overview Eye health in Australia Preventing sight loss Anatomy and physiology of the eye Common eye conditions (listed alphabetically): Age-related macular degeneration (AMD) Cataract Diabetic retinopathy Glaucoma Refractive error Who’s who and where to get help Dealing with an eye health problem.

Eye health in Australia In 2009, vision loss affected almost 575,00 Australians prevalence of eye disease is predicted to double over the next ten years 75 per cent of vision loss is preventable or treatable prevalence increases threefold with each decade over 40 years 80 per cent of vision loss is caused by five conditions (listed alphabetically): Age-related Macular Degeneration (AMD) Cataract Diabetic retinopathy Glaucoma Under-corrected and uncorrected refractive error

Blindness and vision impairment in Australia Center for Eye Research Australia, 2004, Investing in Sight – Strategic Interventions to Prevent Vision Loss in Australia.

Preventing vision loss -what pharmacists can do Encourage your clients to – Get Tested, especially if: there is a family history of eye disease the client is over 40 the client has diabetes the client has noticed a change in their vision the client is of Aboriginal or Torres Strait Islander descent Recognise symptoms of common problems Know when and where to refer Currently nearly three quarters of all blindness and vision impairment is treatable – early detection allows for the best possible treatment and therefore outcome Medicare covers most of the costs associated with visiting an optometrist or ophthalmologist and in some cases it covers 100% - there is also a spectacle subsidy scheme in Victoria

Preventing vision loss -what pharmacists can do Talk to your clients about their vision; vision loss maybe an underlying cause for another condition If you are concerned about a client’s vision discuss your concerns with the treating GP or eye health professional Medicare covers most of the costs associated with visiting an optometrist or ophthalmologist

Preventing vision loss People with vision impairment are at a greater risk of suffering from secondary conditions: falls depression early special accommodation increased risk of hip fracture increased early mortality social isolation

Preventing vision loss Advise your clients to: stop smoking protect their eyes from injury protect their eyes from ultra violet light by: wearing a hat wearing appropriate sunglasses maintain good general health

External anatomy of the eye When you look at the visible parts of a human eye, there are a number of parts that you would already be familiar with. Eyelids: The top and bottom eyelids protect the eye. Eyelashes: These are hairs that grow on the eyelids that prevent dust and dirt from entering the eye. They also sensitive to touch, much like the whiskers on a dog or cat. Conjunctiva: The conjunctiva is the clear, thin layer that covers the eyeball and the eyelid. There are 2 parts to the conjunctiva: Bulbar conjuctiva – covers the front of the eyeball Palpebral conjuntiva – covers the inside of eyelids Punctum: The punctum is an opening that leads to the tear duct system. It allows tears to drain into the nose (which is what causes your nose to run when you cry).

Internal anatomy of the eye Sclera: The ‘white of the eye’, known as the sclera, is made up of in elastic collagen fibres and some elastic tissue. As a result, the sclera is very strong and like the outer skin of a basketball, gives the eye its’ shape. Cornea: made up of inelastic collagen fibres and some elastic tissue. It allows light to enter the eye and is a vital part of the optics of the eye. The cornea is a transparent cover over the coloured iris and the pupil and acts like the ‘window of the eye’. Limbus: is the circle that is where the white sclera connects to the transparent cornea. Iris and Pupil: The Iris and Pupil are the parts that allow light in. Muscles in the iris change the size of the pupil. Together, these parts act like the aperture on a camera allowing more or less light through depending on the amount of available light. Lens: The lens is positioned behind the iris and pupil. In a normal eye, the lens is flexible and transparent. It is the lens’s ability to change shape that permits humans to focus on objects that are at various distances from the eye. A cataract is a common eye disease that involves clouding of the lens. Ciliary Muscle: The muscle that controls the shape of the lens is called the ciliary muscle. Aqueous: The aqueous is a watery liquid that fills the space at the front of the eye between the cornea and the lens. Vitreous: The vitreous is a clear gel that occupies interior space of the eye. The vitreous is what gives the eye its’ shape just like the air inside a football. Retina: The retina is the layer of light sensitive nerve cells at the back of the eye. The retina catches the light passing through the iris and the lens and converts this light into nerve messages. Macula: The macula is the slight depression at the centre of the retina that provides a sharper image than peripheral areas. Macular oedema is a common eye condition in diabetic people where there is loss of vision due to swelling of the macula. Optic Nerve: The optic nerve is the pathway that carries the image on the retina to the brain which ‘processes’ the image.Eyes are organs that sense light. Almost all living things sense light in some way. Plants need to sense light for photosynthesis. Animals need sense light in order to hunt prey or escape from predators.

The retina Retinal blood vessels Macula (fovea in centre) Optic nerve

Common eye conditions - prevalence 80 per cent of vision impairment and blindness in the population over the age of 40 is caused by five conditions (listed alphabetically): Age-related Macular Degeneration (AMD) – 10 per cent Cataract - 15 per cent Diabetic retinopathy - 2 per cent Glaucoma - 5 per cent Under-corrected or uncorrected refractive error - 59 per cent

What is age-related macular degeneration (AMD)? A chronic degenerative condition that affects the central vision. progression of the condition is likely ten per cent of people with macular degeneration have the “wet form” which may respond to treatment the majority of people have the “dry form” two out of three people will be affected by AMD in their lifetime.

Prevalence and risk factors of AMD Ageing is the greatest risk factor with prevalence trebling with each decade over 40 years AMD is present in 13 per cent of people between the ages of 70-75 and is the leading cause of vision impairment in Australia Smoking increases the risk of developing AMD Family history is also a risk factor - genes have been identified and linked with AMD

Age-related Macular Degeneration (AMD) Age-related macular degeneration (AMD) is a disease associated with aging that gradually destroys central vision. Central vision is needed for seeing objects clearly and for common everyday tasks such as reading and driving. In some cases, AMD advances so slowly that people fail to notice the gradual deterioration of their vision. In others, the disease progresses faster and may lead to a permanent loss of central vision. What are the symptoms of AMD? The first signs of AMD involve distortion of vision, rather than loss of sight. In many cases, AMD progresses so slowly that people don’t notice changes until their vision has already been significantly compromised.

Functional implications of AMD Difficulty distinguishing people's faces Difficulty with close work Perceiving straight lines as distorted or curved Unable to differentiate between the footpath and road Difficulty identifying the edge of steps if there is no colour contrast Unable to determine traffic light changes Difficulty reading, with blurred words and letters running together

Treatment of AMD Treatment options are improving with new technology The wet form can be treated with intravitreal injections that aim to prevent further vision loss Lost vision cannot be recovered - early detection to identify those who can receive treatment is the key

Prevention of AMD Early detection of AMD is crucial: In the wet form of the disease, vision loss may be arrested with early treatment by an ophthalmologist Regular eye examinations are the key to early detection of disease before vision loss occurs If there are any changes in the quality of vision, refer to GP to arrange an appropriate referral to an eye health professional Advise your clients to stop smoking

What is a cataract? A cataract is the clouding of the lens inside the eye. With a cataract, light is scattered as it enters the eye, causing blurred vision

Prevalence and risk factors of cataract 31 per cent of the population over the age of 55 has a cataract Long term use of corticosteroids can increase risk of cataracts Exposure to UV light can also increase the risk Ageing, smoking and having diabetes can increase the risk of developing cataract.

Cataract Cataract is a clouding of the lens inside the eye. Poor vision results because the cloudiness interferes with light entering the eye. Most cataracts form as a result of ageing and long-term exposure to ultra violet light. Cataract surgery is one of the most commonly performed surgical procedures in Australia and has a high success rate. What are the symptoms? Symptoms include gradual and painless blurred vision and an increased sensitivity to glare especially while driving at night. Vision with a cataract can be likened to looking through a dirty window. Changes in colour perception, with yellowing of images may be noticed. People with cataract may experience difficulty finding adequate light sources while reading and find that new glasses eventually do not help this problem.

Functional implications of cataract Blurred vision Reduced contrast Having difficulty judging depth Seeing a halo or double vision around lights at night Seeing images as if through a veil/smoke Being particularly sensitive to glare and light Having dulled colour vision.

Treatment of cataract Updating glasses can help with early cataract Surgery: 180,000 cataract operations are done in Australia annually: usually in and out of hospital on same day no general anaesthetic is required (in most cases) the cloudy lens inside the eye is removed, except for the back capsule an intraocular lens implant (IOL), a new lens is inserted into the eye

What is diabetic retinopathy? This condition is a complication of diabetes It affects the small blood vessels of the retina Blood vessels begin to leak and bleed inside the eye

Prevalence and risk factors of diabetic retinopathy It is estimated that three per cent of the population aged over 55 years have diabetic retinopathy 22 per cent of people with known Type 2 diabetes have some form of retinopathy related to their diabetes Within 15 years of being diagnosed with diabetes, three out of four diabetics will have diabetic retinopathy People who have had diabetes for many years, have diabetic kidney disease or have Type 1 diabetes have a greater risk of developing diabetic retinopathy Diabetic retinopathy is the primary vision threatening condition for Aboriginal and Torres Strait Islander people

Diabetic retinopathy Diabetic eye disease (also known as diabetic retinopathy) is a complication of diabetes that affects the small blood vessels of the retina. It remains one of the leading causes of vision loss, despite availability of effective treatment if the disease is detected in the early stages. What are the symptoms of Diabetic Eye Disease? There are often no vision symptoms in the early stages. Changes in sight or loss of vision doesn’t occur until the disease is already advanced. As the disease progresses, new leaky blood vessels grow in the retina causing the appearance of “clouds” moving in the vision which obstruct a person’s sight. If the blood vessels around the centre of the retina are involved, the ability to see fine detail during everyday activities is affected.

Functional implications of diabetic retinopathy Difficulty with fine details (e.g. when reading or watching television) Fluctuations in vision from hour to hour or day to day Blurred, hazy or double vision Difficulty seeing at night or in low light Being particularly sensitive to glare and light Having difficulty focusing

Treatment and prevention of diabetic retinopathy Early detection and timely treatment is essential 98 per cent of severe vision loss can be prevented with early detection and timely laser treatment Good control of: blood sugar levels blood pressure cholesterol can help reduce the severity of eye disease

What is glaucoma? It is a disease that affects the optic nerve at the back of the eye Relieving pressure on the nerve reduces progression of the disease Early detection and treatment can slow the vision loss

Prevalence of glaucoma People over the age of 40 are more likely to develop glaucoma than young people. Almost three per cent of the Australian population over 55 years are affected Glaucoma has a genetic link and can occur in families. People with a first degree blood relative with glaucoma are eight times more likely to develop the disease than the general population and should regularly visit their eye health professional

Risk factors for glaucoma Extreme refractive error Diabetes Migraine cataracts Previous eye injuries Sleep apnoea Gender, males higher risk Corticosteroids can increase the risk of developing glaucoma

Glaucoma Glaucoma is a disease involving damage to the optic nerve and subsequent vision loss or blindness. The exact causes of glaucoma are not known. The condition is often associated with increased pressure inside the eye, but it can also occur in people with normal pressure. Primary Open Angle Glaucoma (POAG) is the most common form of glaucoma. It begins with painless damage to the optic nerve which later causes irreversible loss of vision. Vision loss slowly progresses and blindness may result. Once any form of glaucoma has been diagnosed it can be managed with various treatment options which are determined by your ophthalmologist. What are the symptoms of Glaucoma? Damage to the eye progresses very slowly and sight is lost gradually, starting with the peripheral vision. People with glaucoma seldom notice these blind areas until considerable damage has occurred. Glaucoma often affects both eyes, but one eye may be more affected than

Functional implications of glaucoma No functional implications in early stages, silent disease Difficulty adjusting to lighting changes (e.g. between indoors and outdoors) Occasional blurred vision Seeing a halo around lights (angle closure) Increased sensitivity to glare and light Difficulty identifying the edge of steps or road Tripping over or bumping into objects

Treatment of glaucoma Treatments are available but early detection is the key Lost vision can not be recovered. Treatment aims to prevent further vision loss Treatment may involve medication (eye drops), laser and/or other surgery as well as regular monitoring Early glaucoma is often asymptomatic. Regular eye tests are most important Long term compliance a major concern, 1/3 or more patients indicate poor adherence to drop therapy

Prevention of glaucoma Regular eye examinations to ensure early detection and treatment are the only way to control glaucoma and prevent vision loss 50 per cent of people with glaucoma are unaware that they have it People with a family history of glaucoma are four times more likely to be at risk and should get tested

What is refractive error? Refractive error is a focusing disorder of the eye Most common cause of vision impairment in Australia Over the age of 40 years, 22 per cent of the population has refractive error It is correctable by wearing glasses or contact lenses or refractive laser surgery (selected cases)

Prevalence and risk factors of refractive error All age groups can be affected by refractive error People over the age of 40 should have regular eye tests to eliminate refractive error as a cause of any vision impairment Family history of refractive error is a risk factor

Refractive error Refractive error is a disorder, not a disease. A refractive error means that the shape of the eye does not bend light correctly, resulting in blurred vision. Light has to be refracted or bent by different parts of the eye in order to see clearly. Refractive error is simply corrected with spectacles. Refractive error can progress as a person ages. The extremely gradual changes in a person’s vision are seldom noticed until their eyes are tested by an eye health professional. It is estimated that nearly 300,000 Australians have correctable vision impairment as a result of refractive error. What are the symptoms? Refractive error causes blurred vision. A person’s vision may only be affected intermittently, depending on the type of refractive error and the activity they are trying to perform.

Functional implications of refractive error Functional implications depend on the type of severity of refractive error: long-sightedness (hyperopia) difficulty seeing near objects short-sightedness (myopia) difficulty seeing things in the distance astigmatism blurred vision presbyopia (age focus difficulty) difficulty seeing near objects occurs from 40 and onwards

Treatment of refractive error Refractive error is often treatable with: glasses contact lens laser eye surgery Low vision aids assist people when other treatments can no longer improve vision magnifiers lighting adaptive technology

Ready-made spectacles Wearing ready-made spectacles can be: convenient accessible (“I lost my glasses”) But there can be downsides: headaches, asthenopia (eye strain) can occur (they won’t damage your eyes) wearing them may delay people from getting an eye examination

What you can do as a pharmacist Be prepared to discuss eye health with people purchasing ready-made spectacles, especially for the first time Ask them when was the last time the patient had an eye test? do they have any symptoms, have they noticed any sudden changes in vision? are they aware of their local eye care practitioners? In some states, ready-mades must be sold with a sticker reminding people of the importance of regular eye health check-ups

Who’s who in the eye care sector The following slides provide a brief introduction to who’s who in the eye care sector, the services they offer and how to access them More information is also available on the Vision Initiative website www.visioninitiative.org.au

Vision 2020 Australia National peak body for the vision care and eye health sector Represents close to 60 members and associates Provides a platform for collaboration Part of VISION 2020: The Right to Sight www.vision2020australia.org.au

The Vision Initiative Program aimed at raising awareness of eye health and vision care to the general community and health care professionals Funded by the Victorian Department of Health Victoria’s public health response to the National Framework for Action to Promote Eye Health and Prevent Avoidable Blindness and Vision Loss

Ophthalmologist Ophthalmologists are specialist eye health providers Qualified medical doctors 5 year postgraduate course Surgical and medical treatment of eye disease Laser refractive surgery Referral from a GP, medical specialist or optometrist is required in order to obtain the Medicare rebate Waiting time for appointments can vary according to the condition (if urgent, a GP, optometrist or specialty ophthalmologist can bring this forward)

Optometrist An optometrist is a primary eye care provider Five year university course Medicare provides a full rebate on most optometry consultations Patients do not need a referral to see an optometrist Little or no waiting period for appointments Will fast-track referrals to ophthalmologists if necessary More than one third are therapeutically endorsed in Victoria To locate your nearest optometrist, please visit www.optometrists.asn.au

How optometry prescribing works Endorsement is by Optometrist Registration Board (optometry is part of new national registration scheme, July 2010) Mandatory part of optometry degree in Victoria since 2002 (additional 1 year training). Now mandatory in NSW and Qld degrees Graduate Certificate in Ocular Therapeutics allows previous graduates to become endorsed 30 per cent of Victorian optometrists endorsed to prescribe about 45 topical eye medicines Glaucoma patients managed through shared care with ophthalmologists.

What can optometrists prescribe in Victoria? ANTI-INFECTIVES Antibiotics chloramphenicol gentamicin tobraycin tetracycline ciprofloxacin ofloxacin framycetin sulfacetamide Antivirals aciclovir STEROIDS & NSAIDS hydrocortisone fluorometholone prednisolone dexamathasone NSAIDS flurbiprofen ketorolac diclofenac GLAUCOMA betaxolol timolol latanoprost travoprost bimatoprost dorzolamide brimonidine apraclonidine pilocarpine brinzolamide ANTI-ALLERGY lodoxamide sodium cromoglycate ketotifen olopatadine levocabastine CYCLOPLEGICS cyclopentolate atropine homatropine phenylephrine LOCAL ANAESTHETICS amethocaine lignocaine oxybuprocaine proxymetacaine

Am I dealing with an eye emergency Am I dealing with an eye emergency? Use these quick questions to guide you Is this an eye problem with sudden onset symptoms? Are the symptoms severe? Has the patient lost vision in one/both eyes? Is there injury or trauma to the eye? Is the patient in severe pain? Are the symptoms accompanied by other suspicious symptoms (e.g. slurred speech, severe headache or pain, loss of physical coordination, or mental confusion?)

Attend emergency department TODAY if new or sudden symptoms: Vision loss in one or both eyes ‘Darkening’ of vision, sometimes described as dense shadow or curtain falling over vision (could be retinal detachment) Sudden double vision (diplopia), especially with any neurological symptoms, no explanation or previous history Severe eye injuries/trauma/object in eye Severe eye pain Severe swelling around eye(s) Visual symptoms accompanied by severe headache/slurred or confused speech and/or mental confusion If a known serious eye condition has suddenly worsened

Make an appointment TODAY with an optometrist or GP If you have new eye symptoms (less than 2 days of symptoms) such as: blurred vision red eyes – particularly for contact lens wearers a unilateral red eye a foreign body in the eye

An appointment is recommended within 1-2 days for: Symptoms that have persisted for more than two days. Symptoms may be: mild blurring mild red eye(s) floaters or flashing lights

Emergency advice for chemical burns or splashes Irrigate affected eye(s) with water for at least 15 minutes, then attend emergency department of hospital Don’t apply drops, ointments, or other treatment Patient to remove contact lenses where possible

Chloramphenicol: to OTC or not OTC? Chloramphenicol: now Schedule 3 treatment Most common indications in eye problems: conjunctivitis and superficial infection with susceptible organisms Importance of differential diagnosis … it’s not just a matter of failing “The Chlorsig Test” Potential problems in making a diagnosis are the symptoms really consistent with ‘just conjunctivitis’? is the person a contact lens wearer? will the organism be susceptible to this drug? how can I really see what is going on in the anterior eye?

Chloramphenicol: When a differential diagnosis matters Statham M, Sharma A and Pane A. Misdiagnosis of acute eye diseases by primary health care providers: incidence and implications, MJA 2008; 189(7) 402-4. Primary care diagnosis Confirmed ophthalmological diagnosis Chloramphenicol Indicated by confirmed diagnosis? Delay in referral Preventable adverse outcome ‘Red eye’ Acute anterior uveitis N 8 days Severe permanent vision loss; pain Conjunctivitis 7 days Moderate permanent vision loss Bacterial keratitis 2 days Severe pain Herpes zoster ophthalmicus 3 days Mild permanent vision loss, severe pain, delay in antiviral treatment Australian research published in MJA in 2008 These are examples of cases treated in ophthalmology department following incorrect diagnosis at primary care of conditions presenting with red eyes as symptoms and treated with chloramphenicol, where the misdiagnosis/wrong treatment had preventable implications.

When should I refer red eyes? The referral triggers: red eye accompanied by pain, photophobia or blurred vision beware the unilateral red eye: should be viewed with greater suspicion than bilateral red eyes if the red eye is a recurrence of a known recent condition if the patient’s symptoms worsen over next 24 hours If in doubt, always refer to optometrist or medical practitioner Always suggest the patient they should self-review make an immediate appointment with their optometrist or doctor if the condition worsens or fails to improve within the next 24 hours

Thank you! And finally … For any further queries please contact Robyn Wallace at Vision 2020 Australia Ph: 03 9656 2020 Email: rwallace@vision2020australia.org.au