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

2. 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.

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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).

10. 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.

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

12. 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

13. 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.

14. 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 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

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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.

22. 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.

23. 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

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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)

37. 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

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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)

47. 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

48. 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.

49. 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

50. 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?)

51. 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

52. 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

53. 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

54. 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

55. 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?

56. 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)
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.

57. 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

58. Thank you! And finally … For any further queries please contact
Robyn Wallace at Vision 2020 Australia
Ph: