In this episode, TRC Healthcare editor, Vickie Danaher, PharmD, discusses the treatment of conjunctivitis, or pink eye.
This is an excerpt from our July 2024 Pharmacy Essential Updates continuing education webinar series.
The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Article: Explain That Antibiotics Aren’t Often Needed for Pink Eye
- Resource: The Ins and Outs of Eye and Ear Meds
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Transcript:
00:00:04 Narrator
Welcome to Clinical Capsules, your go-to podcast and trusted source for quick, evidence-based insights from TRC Healthcare.
00:00:12 Narrator
For four decades, we’ve been keeping healthcare professionals at the forefront of drug information and medical knowledge, and now we’re bringing these vital clinical updates right to your ears every 2nd and 4th Tuesday – delivering practical, actionable takeaways in bite-sized episodes.
00:00:29 Narrator
Today, Associate Editor and Clinical Pharmacist Dr. Vickie Danaher discusses the treatment of conjunctivitis in an excerpt from our popular Pharmacy Essential Updates webinar series.
Let’s get started…
00:00:50 Vickie Danaher
So let’s jump right into our topic about treating conjunctivitis, or pink eye.
00:00:56 Vickie Danaher
And our article says you’ll get questions about managing pink eye, since patients often visit pharmacies first for help.
00:01:06 Vickie Danaher
So as we increasingly become the first point of contact for many patients, we want to make sure to have a basic knowledge of common eye disorders, including pink eye.
00:01:16 Vickie Danaher
So let’s start by reviewing conjunctivitis, which we know is an inflammation of the conjunctiva.
00:01:21 Vickie Danaher
Of the eye.
00:01:24 Vickie Danaher
The conjunctiva is the thin clear membrane that covers the inside of the eyelids as well as the sclera, or the white part of the eyeball.
00:01:34 Vickie Danaher
Conjunctivitis causes redness and eyelid swelling, and it’s most often caused by an infection. Although there are non infectious causes of conjunctivitis as well.
00:01:46 Vickie Danaher
And one common myth is that only children get pink eye, but it’s not just a kid’s condition. Pink eye can affect people of all ages at any time.
00:01:57 Vickie Danaher
However, kids do get pink eye more frequently than adults since are more likely to rub their eyes or not wash their hands properly, and they’re often in environments where pink eye spreads more easily, such as school or daycare.
00:02:10 Vickie Danaher
So what is our role when patients present to the pharmacy in pink eye?
00:02:15 Vickie Danaher
As pharmacists and technicians we know we’re not experts at diagnosing or treating eye conditions, but we’re still in a key position to discuss or assess the patient symptoms and recommend treatment or refer patients for further evaluation based on the symptoms that they present with.
00:02:31 Vickie Danaher
And that if patients need a medication to treat pink eye, we definitely are the experts at ensuring they get the right product and educating them on proper use.
00:02:42 Vickie Danaher
So let’s work through.
00:02:43 Vickie Danaher
Our patient case together to apply this to practice.
00:02:46 Vickie Danaher
And here we have Liam, which is a 2 year old patient along with his mom who are regulars at our pharmacy.
00:02:54 Vickie Danaher
Liam’s mom tells you that he was sent home from daycare today due to pink eye and she wants to know what she should do since she can’t get Liam into their prescriber for a.
00:03:02 Vickie Danaher
Day or two?
00:03:05 Vickie Danaher
So what would you do here?
00:03:07 Vickie Danaher
And what questions would you want to ask about Liam to help?
00:03:09 Vickie Danaher
Determine next steps.
00:03:12 Vickie Danaher
So when thinking about this case, I know a lot of questions are popping up in my mind, and most of these questions are things that we can ask any patient with eye symptoms to help assess the problem.
00:03:23 Vickie Danaher
So we can ask things like what kind of eye symptoms are present. When did those symptoms start? Did the symptoms affect just one eye or both eyes?
00:03:32 Vickie Danaher
What makes the symptoms better or worse?
00:03:35 Vickie Danaher
And whether the.
00:03:35 Vickie Danaher
Patient has any other body symptoms such as a cough or ear infection.
00:03:40 Vickie Danaher
And it’s important to find out the answers to questions like these when patients have.
00:03:44 Vickie Danaher
Pink eye since.
00:03:45 Vickie Danaher
They can help us determine the cause of the problem and guide appropriate treatment.
00:03:50 Vickie Danaher
So to give a high level overview, there are many different types of conjunctivitis, but the three main ones that we see are either viral, bacterial or allergic in nature.
00:04:02 Vickie Danaher
So viruses are the most common cause of conjunctivitis overall and in adults with the majority of cases due to adenovirus.
00:04:12 Vickie Danaher
Bacterial meningitis is the most common cause in kids with culprits often being haemophilus influenza, staph aureus or strep pneumonia.
00:04:25 Vickie Danaher
And then allergic conjunctivitis is due to allergens or irritants.
00:04:29 Vickie Danaher
So things like pollen, animal dander, ARD or or air pollution.
00:04:34 Vickie Danaher
And symptoms usually occur more often in the spring and summer, similar to seasonal allergies.
00:04:41 Vickie Danaher
Let’s now go through each of these types of conjunctivitis separately to see what symptoms patients may present with and what we should recommend for treatment.
00:04:51 Vickie Danaher
So starting with viral conjunctivitis again, this is one of the most common types of pink eye and it’s highly contagious.
00:04:59 Vickie Danaher
These patients ability present with eye irritation or burny or gritty feeling along with eye discharge that’s thin, clear and watery.
00:05:09 Vickie Danaher
The symptoms begin in one eye, but quickly spreads to the other eye.
00:05:14 Vickie Danaher
And given the viral cause patients often present with upper respiratory infection symptoms at the same time, so things like a running.
00:05:21 Vickie Danaher
Cough or sore throat?
00:05:23 Vickie Danaher
And this can help assist with differentiating between other causes of connectivities.
00:05:30 Vickie Danaher
And oftentimes, patients or parents will ask about an antibiotic eye drop for viral conjunctivitis.
00:05:38 Vickie Danaher
But we want to tell them that antibiotics are not indicated for viral conjunctivitis.
00:05:43 Vickie Danaher
The use of antibiotic IO products has been shown to be ineffective for pink eye due to viral causes and it may lead to adverse effects such as allergy toxicity, a higher risk of infecting the other eye.
00:05:57 Vickie Danaher
And it can also increase antibiotic resistance.
00:06:00 Vickie Danaher
And it may even delay diagnosis.
00:06:02 Vickie Danaher
Of other possible conditions.
00:06:05 Vickie Danaher
Plus, most cases of viral conjunctivitis resolve on their own within one to two weeks without antibiotic treatment.
00:06:13 Vickie Danaher
So instead we should focus on managing symptoms and recommend measures to keep patients comfortable and reduce irritation.
00:06:21 Vickie Danaher
So for example, we can recommend using cool compresses for ice swelling or itchiness or warm compresses as often eye crust or matting.
00:06:32 Vickie Danaher
We can also suggest a lubricating eye drop or artificial tears to help reduce irritation.
00:06:39 Vickie Danaher
And all these are measures that can be useful for viral conjunctivitis as well as the other types of conjunctivitis that.
00:06:45 Vickie Danaher
We’ll talk about today.
00:06:48 Vickie Danaher
So moving on to bacterial conjunctivitis, these patients also usually have a burning feeling in the eye.
00:06:54 Vickie Danaher
But their eyes?
00:06:55 Vickie Danaher
Have thick discharge that is often white, yellow or green with puss, and this causes the eyelids to be crusty or sticky, especially in the morning. So patients may wake up with the eyelid stuck shut because of that residue.
00:07:09 Vickie Danaher
Bacterial conjunctivitis certainly starts in one eye, and it can spread to the other eye.
00:07:15 Vickie Danaher
Sometimes the bacteria that cause pink eye can also cause an ear infection in the sense the most common in young children. So you may see patients with both of those infections.
00:07:27 Vickie Danaher
But as far as treatment for bacterial conjunctivitis?
00:07:30 Vickie Danaher
Again, most patients with uncomplicated cases will.
00:07:32 Vickie Danaher
Get better on their own.
00:07:34 Vickie Danaher
And most cases will resolve within a week without antibiotics.
00:07:39 Vickie Danaher
While antibiotics may lead to a little bit quicker recovery time and may help reduce transmission, again, antibiotic overuse can lead to more costs, more side effects and more antibiotic resistance. As I mentioned earlier.
00:07:53 Vickie Danaher
So no treatment or a wait and see policy are often reasonable approaches for uncomplicated cases of pink eye from bacterial causes.
00:08:03 Vickie Danaher
And in the mean time, we can recommend measures to relieve symptoms again, such as cool or warm compresses or artificial tears as needed.
00:08:14 Vickie Danaher
So we’ll generally want to save antibiotics for bacterial conjunctivitis if patients don’t start getting better within about 5 days or so. If they have more severe symptoms, such as copious or tons of discharge, or if treatment is required for patients to return to school or daycare or work. Many of these places.
00:08:33 Vickie Danaher
Do you have policies on this and that is another thing that needs to be taken into consideration.
00:08:41 Vickie Danaher
If an ophthalmic antibiotic is needed for bacterial conjunctivitis, we’ll want to be familiar with some of the common options.
00:08:48 Vickie Danaher
So patients may get meds such as ciprofloxacin or ofloxacin, ophthalmic solution, erythromycin ophthalmic ointment or trimethoprim polymyxin B ophthalmic solution.
00:09:03 Vickie Danaher
Be aware that no evidence exists demonstrating that one option is better than another, so the choice is usually based on patient or prescriber preference.
00:09:12 Vickie Danaher
Such as the Med that is more convenient or less expensive for the patient.
00:09:16 Vickie Danaher
And patients will usually be advised to treat for five to seven days.
00:09:22 Vickie Danaher
Let’s look at allergic conjunctivitis next.
00:09:26 Vickie Danaher
Typical symptoms here include red, itchy eyes with both eyes affected along with thin, clear watery discharge.
00:09:35 Vickie Danaher
But unlike viral or bacterial conjunctivitis, allergic conjunctivitis is not contagious, so it can’t be transferred from one person to another.
00:09:46 Vickie Danaher
If patients have allergic conjunctivitis, the first step is to remove or limit exposure to the urine 10 if possible.
00:09:53 Vickie Danaher
So trying to avoid common triggers like dust, pollen, mold.
00:09:58 Vickie Danaher
For example, someone with an allergy to house dust mites may find that removing carpet using dust mite covers for pillows and mattresses and washing bedding and hot water are enough to reduce symptoms.
00:10:10 Vickie Danaher
Or a patient with an allergy to animal dander may decide that they need to remove the animal from the house altogether, particularly if their symptoms are severe.
00:10:20 Vickie Danaher
We can go ahead and suggest simple whole measures again to release symptoms like the cool compresses to reduce discomfort, lubricating eye drops to help flush allergens from the surface.
00:10:30 Vickie Danaher
And washing hands frequently to remove any allergens.
00:10:34 Vickie Danaher
But in more severe cases, patients may need prescription or OTC eye drops that contain an antihistamine, such as olopatadine or a math cell stabilizer such as ketotifen.
00:10:48 Vickie Danaher
Now a lot of times questions come up about whether steroid eye drops should be used for allergic bacterial or viral conjunctivitis.
00:10:57 Vickie Danaher
But in most cases, quote UN quote, steroids aren’t needed and should be avoided.
00:11:03 Vickie Danaher
That’s.
00:11:03 Vickie Danaher
Corticosteroids can potentially prolong or worsen some types of eye infections.
00:11:09 Vickie Danaher
As they’re at eye, drops are also associated with cataract formation glaucoma.
00:11:14 Vickie Danaher
And other risks.
00:11:17 Vickie Danaher
So they usually say it for the worst cases of conjunctivitis, and even then used with caution.
00:11:24 Vickie Danaher
So overall, most of the time patients can treat pink eye at home until it goes away on its own.
00:11:29 Vickie Danaher
Regardless, if conductivities is due to viral, bacterial, or allergic causes.
00:11:36 Vickie Danaher
But there may be other times when there’s something more serious behind the patient. Symptoms we want to refer them for further evaluation.
00:11:45 Vickie Danaher
For example, listen for patients reporting vision changes, light sensitivity or eye pain.
00:11:52 Vickie Danaher
Also refer those with a rash or vesicles around the eye or the eyelid, as this may indicate A herpes or shingles infection.
00:12:01 Vickie Danaher
Advised patients wearing contact lenses remove them immediately and to contact their primary provider to rule out other problems.
00:12:08 Vickie Danaher
Such as a corneal ulcer related to contact lens use.
00:12:14 Vickie Danaher
And again, in most cases of infectious, conjunctivitis will not need antibiotics.
00:12:20 Vickie Danaher
But we still need to be prepared for how to handle these prescriptions and educate patients if treatment is indicated.
00:12:27 Vickie Danaher
So going back to our patient, Liam, let’s say that after a couple of days, his symptoms aren’t improving. He gets in to see his pediatrician and the pediatrician diagnoses them with bacterial conjunctivitis and sends over the following E prescription.
00:12:41 Vickie Danaher
The prescription is for: Tobramycin 0.3% ophthalmic solution. Instill 1-2 drops into both eyes every 4 hours for 5 days. Quantity one 5 mL bottle. With no refills.
00:12:57 Vickie Danaher
When Liam’s mom comes to pick up this prescription, what are some things that you’d want to talk with her about?
00:13:03 Vickie Danaher
For example, do you have any tips on how she should administer these eye drops oleum.
00:13:10 Vickie Danaher
So one big thing that we’ll want to educate patients or caregivers on is how to prevent the spread of viral or bacterial conjunctivitis. Again, since it’s highly contagious.
00:13:20 Vickie Danaher
So advised frequent hand washing tell people to avoid touching their eyes and remind them not to share bedding, towels or other personal items.
00:13:31 Vickie Danaher
We also want a lot of advice throwing out any recently used eye makeup or contact lens cases to reduce the chance of reinfection.
00:13:40 Vickie Danaher
And then if patients get an eye medication, we want to be ready to provide tips for appropriate administration.
00:13:47 Vickie Danaher
For example, we can tell patients, wash their hands, tilt their head back and make a pocket with.
00:13:53 Vickie Danaher
Their lower eyelid.
00:13:55 Vickie Danaher
And they can do this by pulling the eyelid down and away from the eye with the index finger, or by pinching it with a thumb and index finger.
00:14:04 Vickie Danaher
Advised looking up before instilling the dropper ointment.
00:14:08 Vickie Danaher
And then after the dropper ointment is in the eye, patients should release the lower lid and close their eyes gently for at least a minute or two to let the medicine.
00:14:16 Vickie Danaher
Evenly cover the eye.
00:14:19 Vickie Danaher
If people have trouble using this method, or if parents are giving drops to kids, there’s another option that may be easier. For example, the patient can have the child lie down and close their eyes.
00:14:30 Vickie Danaher
They can then place a drop in the inner corner of the closed eyelid and then have the child open the eye slowly to allow the drop to roll in.
00:14:41 Vickie Danaher
And then with either technique, we want to educate that if more than one drop is needed per dose to wait at least 5 minutes before putting another drop in.
00:14:50 Vickie Danaher
The same eye.
00:14:53 Vickie Danaher
Remind patients or caregivers not to touch the dropper or tip of the tube against the eye to prevent reinfection or injury and to wash their hands after administration as well.
00:15:04 Vickie Danaher
If patients need multiple eye meds for conjunctivitis at the same time, so they’re using an antibiotic and artificial tears, for example, we want to recommend instilling solutions first, then suspensions or gel forming drops and then ointments. And this can help ensure adequate absorption of each product.
00:15:25 Vickie Danaher
Tell patients not to wear their contact lenses when infected, and also suggest following any guidelines from school, work or sports on staying home while contagious.
00:15:36 Vickie Danaher
Point out that bacterial infections are contagious until antibiotics have been used for 24 to 48 hours, and viral infections are likely contagious until the eye clears.
00:15:47 Vickie Danaher
When dispensing eye meds for pink eye, it’s also important to stay alert for errors and other dispensing issues.
00:15:54 Vickie Danaher
We know that eye drop prescriptions are often targets of insurance audits, so this is a good reminder to check payer policies on the number of drops per ML to use to calculate day supply.
00:16:05 Vickie Danaher
And if we get a quantity or to supply reject, we want to call the pair for clarification and not automatically override those rejects.
00:16:15 Vickie Danaher
We’ll also want to keep an eye out for dosage form mix ups since many minutes come as both ophthalmic solutions and as odic solutions in the same or similar looking strings like ciprofloxacin and ofloxacin for example.
00:16:31 Vickie Danaher
And if we dispense the wrong dosage form, it could lead to patient harm.
00:16:35 Vickie Danaher
For instance using ciprofloxacin, otic solution in the eyes instead of ophthalmic solution in the eyes can lead to severe burning and eye pain.
00:16:48 Vickie Danaher
Now a lot of times there’s confusion about this because certain meds can be used via alternate routes.
00:16:54 Vickie Danaher
So we want to remind prescribers or patients that eye drops can generally be used in the ears for an ear infection, such as if an ear drop isn’t available or it costs too much.
00:17:06 Vickie Danaher
But on the other hand, ear drops should never be used in the eyes.
00:17:11 Vickie Danaher
So your drops are usually acidic and they aren’t buffered for the eyes. They have preservatives that may harm the eye, and they aren’t always sterile.
00:17:21 Vickie Danaher
This is a good reason to watch for look alike products when stocking and double checking the full product name, including dosage form. When dispensing these prescriptions and getting clarification for any unclear prescriptions.
00:17:36 Vickie Danaher
And for more ways to help patients use over the counter or prescription eye or ear meds safely, you can see our resource called the INS and outs of eye and ear meds.
00:17:46 Vickie Danaher
This resource is specifically designed for our pharmacy technicians, but it has some great pearls about drug interactions, day supply and storage. There really are good reminders for everybody in the pharmacy.
00:17:58 Narrator
We hope you enjoyed and gained practical insights from listening to this presentation!
00:18:03 Narrator
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00:18:22 Narrator
Also in the show notes, we’ve linked directly to a few of the excellent resources mentioned today available to subscribers of Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights. On those websites you’ll also find a lot more evidence-based, concise, yet comprehensive resources on this and other medication therapy topics.
00:18:45 Narrator
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00:18:59 Narrator
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00:19:10 Narrator
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00:19:23 Narrator
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Clinical Capsules
