Case 1: Dry Eye
Q: 
AJ is a 56-year-old woman who is complaining of a gritty sensation in her eyes, although they appear normal with white sclera. She is seeking advice about her dry eye and asks about omega-3 fatty acid supplements, which her neighbor said helped her. AJ is otherwise healthy and does not take any OTC or prescription medications. She started using a humidifier at home and repositioned her work station away from cooling and heating vents, but she did not find relief for her dry eye. She has also tried artificial tear eye drops (Hypotears/Tears Plus) and warm eye compresses, as recommended by her previous pharmacist. What information can you provide to AJ about omega-3 fatty acids for dry eye, and how do you recommend she treat her dry eye?

A: Omega-3 fatty acids have been recommended and commonly used to relieve dry eye symptoms, because of their anti-inflammatory properties; dry eye disease may be linked to a T-cell–mediated inflammatory process. Recently, a prospective, multicenter trial of omega-3 fatty acids versus a placebo did not show any relief in dry eye signs or symptoms over the 12-month study period.1,2 Therefore, the American Academy of Ophthalmology did not include omega-3 fatty acids in its 2018 Preferred Practice Patterns for Dry Eye Disease.1,2 AJ was correct to apply the environmental changes to avoid tear evaporation and preserve relative humidity. Given that she has not found relief with the low-viscosity ocular lubricant, the pharmacist should recommend that AJ use Genteal or Refresh eye drops, which contain more viscous lubricants: carboxymethylcellulose and hydroxypropylmethylcellulose.3 The higher viscosity, the longer the gel-like drops will have ocular contact and the lower the tear dilution. If AJ does not find relief from the new eye drops, it may be appropriate for her to discuss topical glucocorticoids or punctal plugs with her eye care provider.4
 

Case 2: Stye (Hordeolum)
Q: 
LP is a 19-year-old female college student who has questions about a red painful bump on her right eyelid that appeared this morning. She does not have any underlying skin conditions, nor has she experienced this painful bump before, but she does recall that she left her makeup on overnight this weekend. LP’s roommate did some research on the eye abscess and concluded that it is an infection of the oil glands. LP does not take any medications other than her oral contraceptive, and she does not wear contact lenses. She is looking for an antibiotic eye drop. What are your recommendations on using antibiotics to treat a stye?

A: Let LP know that although a stye is an abscess of the eyelid, it only lasts a few days and can be managed without topical antibiotics or glucocorticoids. Some factors that may cause styes are contaminated or old eye cosmetics or contact lenses, keeping makeup on overnight, poor hygiene, and preexisting skin conditions, such as blepharitis and rosacea. One technique to facilitate drainage is to use warm compresses on the affected eyelid for about 5 to 10 minutes, 3 to 4 times per day. Additionally, try to massage and lightly wipe the affected eyelid after the compress. There is also an OTC ointment called Stye, a lubricant that contains mineral oil and white petrolatum to relieve some discomfort from the stye—but it does not treat the stye. The ointment should be applied after contact lens removal by pulling down the lower lid of the affected eye and applying one-fourth of an inch of ointment to the inside of the eyelid. LP should avoid trying to pop the stye or using cosmetics until the stye has cleared. If the stye does not reduce in size within 1 or 2 weeks, LP should be referred to an ophthalmologist.5,6
 

Case 3: Foreign Substance
Q: 
VZ is a 48-year-old woman who calls her local pharmacy about a foreign substance in her eye, which she thinks is a dust particle, because she had been cleaning out her attic. VZ wants advice on how to remove the particle and if she needs to seek emergency medical attention. What advice do you have, and can you recommend any OTC products for her to take home?

A: Advise VZ to purchase an irrigant. As long as she does not have an open wound in or near her eyes, she can attempt to remove the dust particle by ocular irrigation. This removes the debris while maintaining the moisture of the ocular tissue, because the osmolality and pH of the solution are balanced. All ocular irrigants are available over the counter and are typically large bottles labeled “eye wash” or “irrigating solution.” If VZ experiences changes in vision or ongoing redness or pain that does not settle, she should be referred to an eye care provider. If the foreign substance is metal or wood, VZ should seek attention from an eye care provider, because of the increased risk of corneal abrasion.7,8
 

Case 4: Allergic Conjunctivitis
Q: 
TP, a 27-year-old woman, wants advice about her recent symptoms of itchy, red, and watery eyes. Since the change in season, she has been more sensitive to the pollen count. Despite her efforts to keep windows closed, stay indoors, and use artificial tears, she has not found much relief. She does not wear contact lenses. What can you recommend to TP?

A: To relieve the redness and itching, TP should apply a cold compress to her eyes 3 or 4 times per day. She also should try ketotifen, an ophthalmic antihistamine/mast cell stabilizer. TP should use 1 drop in each eye 2 times per day. The onset of symptom relief from ketotifen is within minutes, and the duration of action is 12 hours. If TP does not experience relief after 72 hours of use, she should contact an eye care provider.9,10
 
Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care specialist at RWJBarnabas Health, part of the Barnabas Health Medical Group.

Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Caitlyn Bloom, PharmD, BCACP, AE-C, is a clinical assistant professor at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care clinical pharmacist at RWJBarnabas Health, part of the Barnabas Health Medical Group, in Eatontown, New Jersey.


REFERENCES
  1. Dry eye syndrome PPP - 2018. American Academy of Ophthalmology website. aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Published November 2018. Accessed September 5, 2019.
  2. Lemp M. Advances in understanding and managing dry eye disease. Am J Ophthalmol. 2008;146(3):350-356. doi: 10.1016/j.ajo.2008.05.016.
  3. Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016;2:CD009729. doi: 10.1002/14651858.CD009729.pub2.
  4. Asbell PA, Maguire PG, Pistilli M, et al; Dry Eye Assessment and Management Study Research Group. n−3 Fatty acid supplementation for the treatment of dry eye disease. N Engl J Med. 2018;378(18):1681-1690. doi: 10.1056/NEJMoa1709691.
  5. Lindsley K, Nichols JJ, Dickersin K. Non-surgical interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2017;1:CD007742. doi: 10.1002/14651858.CD007742.pub4.
  6. Neff AG Benign eyelid lesions. In: M Yanoff, JS Duker, eds. Ophthalmology. 3rd ed. Edinburgh, Scotland: Mosby; 2014:1295-1305.
  7. Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114-120.
  8. Khare GD, Symons RC, Do DV. Common ophthalmic emergencies. Int J Clin Pract. 2008;62(11):1776-1784. doi: 10.1111/j.1742-1241.2008.01855.x.
  9. Bielory L. Ocular allergy treatment. Immunol Allergy Clin North Am. 2008;28(1):189-224. doi: 10.1016/j.iac.2007.12.001.
  10. O’Brien T. Allergic conjunctivitis: an update on diagnosis and management. Curr Opin Allergy Clin Immunol. 2013;13(5):543-549. doi: 10.1097/ACI.0b013e328364ec3a.