OTC Products Over-the-counter eye products Fae Farrer, BPharm Amayeza Info Centre Customers often complain of red or itchy eyes, or even more commonly of “pink eye.” So what causes these problems and what product may be recommended? Virtually all eye problems result in the white of the eye (the sclera) becoming red or pink, and thus many people believe that they have “pink eye,” a term that should be reserved for infectious problems in the eye. Conjunctivitis Conjunctivitis is defined as inflammation of the conjunctiva. The conjunctiva is the thin membrane that lines the inner surface of the eyelids and also covers the white of the eyes.1,2 All types of conjunctivitis cause a red eye, but not all red eyes are caused by conjunctivitis. SA Pharmacist’s Assistant [ Spring 2011 ] Types of conjunctivitis 26 cloths, may also become a source of infection. Viral conjunctivitis usually starts in one eye, with the second eye often becoming infected within 24 to 48 hours. Symptoms include redness, a watery or mucous discharge, and a burning or gritty feeling in the eye. Patients may experience morning crusting, with the eyes being “stuck shut.”1 Bacterial conjunctivitis Various bacteria may cause bacterial conjunctivitis. This infection is highly contagious and may affect entire families or many children in a classroom. Bacterial conjunctivitis is spread by contact with infected eye secretions. The most common symptoms of bacterial eye infections include redness and thick white, yellow or green mucous discharge from one eye. The discharge continues to drain throughout the day.1 More discharge appears within minutes of wiping the lids.3 The affected eye is “stuck shut” in the morning. Both eyes may be infected.1,3 Non-specific conjunctivitis Viral conjunctivitis Sometimes a customer will complain of an eye problem that is not the result of either an infection or an allergy. The viruses that cause the common cold may also cause viral conjunctivitis. Symptoms of conjunctivitis (red eyes and discharge) may present alone or with other symptoms of a cold (swollen lymph glands, fever, sore throat and runny nose). Viral conjunctivitis is contagious and is spread by contact with eye secretions.1 Children are not the only ones who rub their eyes and forget to wash their hands before touching something else! Shared objects, such as towels and face A number of problems may cause redness and a discharge:1 • Dry eyes may have chronic or intermittent redness and discharge. • Chemicals that have inadvertently been splashed into the eyes may cause redness. • A foreign body that enters the eye (e.g. dust, eyelash) may cause irritation, redness and a discharge for up to 24 hours after it has been removed.1,3 Allergic conjunctivitis Allergic conjunctivitis is caused by airborne allergens that come in contact with the eye, e.g. pollen, animal dander and moulds. Symptoms include redness, watery discharge and itching of both eyes. A burning sensation, sensitivity to light and swollen eyelids may also be present. Symptoms may be sudden, seasonal or year-round, depending on the allergen. Acute allergic conjunctivitis is a sudden-onset reaction to an allergen, e.g. cat dander. Symptoms may be severe, but usually resolve within 24 hours of removal of the allergen. Seasonal allergic conjunctivitis tends to cause milder but more persistent symptoms during particular pollen seasons, e.g. tree pollens, grass pollens and weed pollens. Seasonal allergic conjunctivitis is often associated with rhinitis.2 Perennial allergic conjunctivitis is a mild chronic allergic condition related to year-round environmental allergens, e.g. dust mites and moulds. Allergic conjunctivitis is often related to a history of allergic conditions.2 Tear film insufficiency, with resulting dry eyes, frequently coexists with and worsens allergic conjunctivitis. Tear film insufficiency worsens allergic conjunctivitis, as the ability to rinse away the allergen is diminished, and the concentration of allergen on the eye surface is greater.2 The signs and symptoms of various types of conjunctivitis are summarised in Table I. Treatment Viral conjunctivitis Topical antihistamine/decongestant eyedrops may relieve the itching and irritation of viral conjunctivitis. Care must be taken not to spread the OTC Products Table I: Symptoms of different types of conjunctivitis1 2 Viral Bacterial Non-specific Allergic Redness Redness Redness Redness Watery/mucous discharge Purulent discharge Watery discharge Watery discharge One eye One eye One or both eyes Both eyes Burning/gritty and morning crusting Morning crusting and discharge throughout day History of eye irritation Burning/light sensitive and history of allergic conditions infection from one eye to the other. Symptoms may worsen for three to five days before resolving, and they may last for up to three weeks.1 condition can be predicted from the patient’s past experience, treatment should be started two weeks before the onset of symptoms. Bacterial conjunctivitis Perennial allergic conjunctivitis is best prevented with an oral antihistamine.2 Bacterial conjunctivitis may be treated with a topical antibiotic. Topical antibiotics are available only on prescription and may be applied as eye drops or ointments. If started early antibiotic treatment may shorten the duration of the infection, but symptoms may resolve without assistance.1 Non-specific conjunctivitis Most cases of non-specific conjunctivitis resolve within a few days without treatment. However, the eyes may feel better with the use of a lubricant. Preservative-free preparations are available for patients with severe cases of dry eye and for those allergic to preservatives.1 Allergic conjunctivitis Most cases of acute allergic conjunctivitis are self-limiting and resolve within 24 hours. Patients may use a combination antihistamine/vasoconstrictor eye drop for up to two weeks. For frequent episodes a topical medication containing antihistamine and mast cell stabilising properties may be used. This should be applied prophylactically. Seasonal allergic conjunctivitis may be treated with combination antihistamine/ mast cell stabiliser eyedrops. If the Redness of the conjunctiva may be due to any of the following: • Trauma: either directly to the eye or a head injury. • A foreign body (such as an eyelash or dirt) may be irritating the eye. • A pterygium (an overgrowth of cells over the cornea) may cause irritation and dryness of the eye. Any redness is localised to the particular area.3 • Blepharitis (inflammation of the edge of the eyelid) may cause secondary redness in the eye. Blepharitis is often associated with allergies (e.g. cosmetic or topical preparations) or with bacterial infections.5 • Styes are small abscesses that may form at the base of an eyelash. They are usually caused by a bacterial infection and may be secondary to blepharitis.4 • Subconjunctival bleeding is a localised pooling of blood between the conjunctiva and the cornea. This condition is usually painless, does not affect vision and is localised to one area of the eye. It should clear within two weeks without treatment. Subconjunctival bleeding may be due to a direct blow to the eye by a fist or a ball, increased pressure within the eye as a result of coughing, sneezing or straining, or rarely from high blood pressure.4 • Contact lens wearers who present with an acute red eye and discharge Over-the-counter eye products There are many eye products available over the counter. These may contain decongestants, antihistamines, mast cell stabilisers, anti-infectives and lubricants. Decongestants Ophthalmic decongestants relieve redness and irritation of the eyes due to allergic and inflammatory eye conditions. The decongestants work as vasoconstrictors, constricting the blood vessels in the eye and reducing redness. These products are intended for shortterm use only as regular use (longer than 2 weeks) may result in rebound redness, and also systemic side effects. Table II lists some over-the-counter (OTC) products containing decongestants.2 Antihistamines Topical antihistamines are faster acting and less likely to cause systemic side-effects than oral antihistamines, and are therefore preferred where the main complaint is ocular.2 Products available include Emadine® (emedastine difumarate) and Livostin ED® (levocabastine hydrochloride).5 Mast cell stabilisers Mast cell stabilisers inhibit mast cell degranulation, which is the first step in the allergic cascade. They inhibit leukocyte activity and dampen mediator release, reducing the allergic reaction. The onset of action is five to 14 days from start of therapy, and therefore these products are not suitable for acute allergic conjunctivitis. Patient compliance may be limited by the dosing schedule of these medications, as they must be used four times a day at regular intervals. Agents available include sodium cromoglycate (StopAllerg®, Cromabak®, Cromohexal®) and lodoxamide tromethamine (Alomide®).2,5 SA Pharmacist’s Assistant [ Spring 2011 ] A step-wise approach is used for allergic conjunctivitis based on the severity and frequency of symptoms. Other causes of red eyes should be advised to discontinue contact lens use immediately, and to consult an optometrist or their doctor if symptoms do not improve within 12–24 hours, as they are at risk of serious bacterial eye infections.3 27 OTC Products Anti-infectives √ Oculerge® √ Oculosan® √ √ Zinc sulphate Oxylin® √ Prefrin® Spersallerg® √ Visine® √ √ Sparkling White® √ Allergex® √ I-Glo® Antihistamines and mast cell stabilisers SA Pharmacist’s Assistant [ Spring 2011 ] Polyvinyl alcohol √ Eye-Gene® 28 Polyvinyl alcohol √ √ Medications with both antihistamine and mast cell stabilising properties are useful for frequent attacks of acute allergic conjunctivitis (occurring more than two days per month). Full efficacy of prophylactic use may be assessed after two weeks of therapy. These agents act as mast cell stabilisers, inhibiting mast cell degranulation, and as antihistamines, blocking histamine receptors in the conjunctiva and eyelids. This helps in the last phase of an allergic reaction.2 Table III lists products containing agents with both antihistamine and mast cell stabilising properties. Artificial tears and lubricants Tear film insufficiency is a common disorder, particularly among women and the elderly. This condition may coexist with allergic conjunctivitis and worsen the inflammation of the conjunctiva. Patients with mild to moderate dry eyes may not realise that they have this problem. Certain medications, including Minor eye infections such as blepharitis and styes may be treated with Brolene® (dibromopropamidine) or Lennon Sulphacetamide® (sulphacetamide sodium). These agents are antibacterial and may be used in the initial treatment of minor infectious eye complaints.5 Basic eye care √ √ Safyr Bleu® Other Murine Cool Eyes® Phenylephrine √ √ Xylometazoline √ Gemini® Oxymetazoline Naphazoline Antistin Privin® Tetrahydrozoline Product Antazoline Table II: Decongestants in over-the-counter eye products5–7 √ Boric acid, borax, sodium chloride Table III: Products with antihistamine and mast cell stabilising properties.2,5 Product Active Ingredient Optilast® Azelastine hydrochloride Patanol® Olopatadine hydrochloride Relestat® Epinastine hydrochloride Zaditen® Ketotifen fumarate oral antihistamines, may worsen tear film insufficiency as they may cause a decrease in tear production.4 Patients with both dry eyes and allergic conjunctivitis respond to frequent use of artificial tears throughout the day. Lubricant ointment provides longer lasting relief but may blur the vision temporarily. Some patients prefer to use drops during the day and the ointment at bedtime.1,2 Products available include Optive®, Systane Ultra®, Tears Naturale® II , Tears Naturale® Preservative Free, Cellufresh®, Celluvisc®, Duratears®, Liquifilm Tears®, Murine Moisture Eyes®, Refresh®, Spersatears®, Teargel®, Tears Plus® and Viscotraan®.5 In order to prevent eye infections the following suggestions may be made: • Patients should avoid rubbing their eyes, as dirt may be introduced into the eye, making any irritation worse. Rubbing eyes in cases of allergic conjunctivitis may also cause mast cell degranulation and worsen symptoms. Artificial tears or antihistamine drops may reduce itching.2 • In allergic conjunctivitis, exposure to the allergen should be minimised, by staying indoors, using airconditioning and keeping windows closed in peak allergen season.2 • Adults and children with viral or bacterial conjunctivitis should not share hankies, tissues, towels, cosmetics and pillows with uninfected friends and family members.1 • Hand washing is essential to prevent the spread of any infection. Hands should be wet with water and soap and rubbed together for 15 to 30 seconds. Children should be taught to wash their hands before and after eating, after using the toilet, after coughing or sneezing and after touching their eyes. Alcohol-based hand rubs are a good alternative to washing hands if soap and water are not available 1 Contact lens wearers Patients who use contact lenses should consult an eye care specialist before treatment begins to ensure that any ocular problem is not due to an infection of the cornea. Contact lens wearers are susceptible to a number of secondary problems relating to contact lens fit, lens type or lens hygiene. Soft contact lens wearers are at increased risk of certain bacterial conditions that may lead to serious complications very quickly (within 24 hours). Contact lens wearers with acute red eyes should remove lenses and avoid wearing lenses for 24 hours and see a specialist if symptoms do not improve within 12 to 24 hours. The contact lens case should be replaced, and the lenses thoroughly disinfected overnight or replaced if disposable.1,3 Referral to an eye care specialist Certain symptoms should be referred to an eye care specialist:1–3 • Eye tenderness • Changes in vision • Sensitivity to light and difficulty in keeping the eye open • Severe headaches with nausea • Recent trauma to the eye • Use of contact lenses • Patient with allergic conjunctivitis who does not respond to therapy after two weeks of consistent use • Fixed pupil. Returning to work or school Bacterial and viral conjunctivitis are both highly contagious and spread by direct contact with ocular secretions or contact with contaminated objects (tissues, towels, cosmetics). Ideally the patient should remain home until there is no longer any discharge but this is often not practical. Most schools and day care centres require that the child receives 24 hours of treatment before returning to school. This helps to prevent the spread of bacterial infection but is less helpful for children with viral infections. Young children who will not remember to wash their hands and avoid touching their eyes should not attend school until the discharge is resolved. Older children and adults should limit close contact with others. Adults who have contact with the very old, the very young and people with a weakened immune system should take care not to spread infection from their eye secretions to these susceptible people.1,3 Conclusion There are many possible causes of red eyes, from viral and bacterial infections to allergies, foreign bodies and trauma. Infectious conditions should be referred for further treatment, as should patients whose condition does not resolve within the expected period. OTC products are available to manage allergic conjunctivitis and dry eyes. The principles of basic eye care should be explained to any patient with eye complaints. References available on request