sierz018 ‘Self Care & Wellness: Issues in Eye Care| Canadian Healtneare Network - Pharmacists Canadian HealthcareNetwork.ca Self Care & Wellness: Issues in Eye Care Written by Valerie Cook on October 1, 2012 for Drugstore Canada It is estimated that 75% of vision loss is preventable("); 1 in 9 patients develop irreversible vision loss by age 65, and 1 in 4 do so by age 75.2) Pharmacists are ideally positioned to educate patients about controllable risk factors for eye disease and help them select products formulated to meet their unique needs. In this article we will examine self-care recommendations for patients undergoing laser refractive surgery and patients dealing with age-related eye disease, dry eyes and red eyes. Laser surgery Laser refractive surgery was first introduced in Canada in the early 1990s. Laser treatments have been used to correct myopia, hyperopia, astigmatism, and, of late, presbyopia. Advances in laser technology and techniques have resulted in improved outcomes and a greater number of surgical options to choose from. Of the four types of procedures commonly used today, Laser Assisted In Situ Keratomileusis (LASIK) continues to be the most popular. Expectations Conventional laser treatments frequently achieve 20/20 vision. Contrary to popular belief, 20/20 vision is not perfect vision. Rather, it means a person can see at 20 feet what the average person can see at 20 feet, The human eye is capable of 20/10 vision or better, The measure also fails to account for differences in contrast, colour, depth perception, peripheral vision, and night vision, Patients need to be carefully educated to avoid false expectations of their surgical outcomes, hntpswww_canadianheatncarenetwork calpharmacstsiclinicaloteleet-care-wollness-issues-n-aye-care-181127pnnt wasierz018 ‘Self Care & Wellness: Issues in Eye Care| Canadian Healtneare Network - Pharmacists Complications Complications associated with laser refractive surgery include the following: + Overcorrection, undercorrection or regression (i,e., the eye regresses to its presurgical state within 6 months)—an enhancement procedure is frequently use¢ to deal with these issues + Dry eye + Halos, glare, starburst patterns, double vision, reduced contrast and blurring resulting in reduced night + Comeal ectasia (weakened, bulging cornea) + Corneal infection + Corneal inflammation Risk factors for complicat ns Patients need to be informed about the risk factors that reduce their chances of a successful outcome and the types of procedures that are better suited to their lifestyle and ocular condition. These risk factors include the following + Pre-existing medical conditions that affect the eye (e.g,, dry eye, lid disorders, glaucoma, diabetes, lupus, etc.) High degree of correction (> 6){) Vision changes within the past 12 months Thin cornea (for such cases, LASEK or Epi-LASEK may be a better option) Participation in strenuous activities—corneal flap created during the LASIK procedure can dislocate even years later (LASEK or Epi-LASEK may be a better option) Guide to pre- and post-surgical care ‘Adherence to pre-and post-surgical care guidelines ensures the best possible outcomes. Recommendations vary according to surgeon preferences, type of procedure and patient factors. + Contact lenses can alter corneal thickness, corneal shape and tear production, Patients need to stop using contact lenses long enough so that their eyes can return to their natural state before pre-evaluation and Surgery, There are no universal guidelines, and recommendations depend on corneal state and the length of time the patient has worn contact lenses. Typically, though, patients with soft contact lenses should cease use for 1-14 days; those with soft contact lenses for astigmatism, 1-21 days; and those with hard contact lenses or rigid gas permeable lenses, 1-6 months + Dry eyes are a pre- and post-surgical concern. Patients with a history of dry eyes are at greater risk of ongoing dry eye and other complications after the surgery takes place. Some Surgeons will reat dry eye for 3 month before surgery in an effort to ensure 3 more successful outcome + Comeal nerves responsible for stimulating tear production are severed during LASIK surgery, temporarily reducing tear flow. Artificial tears should be used as prescribed, even in the absence of symptoms. Dry eye symptoms usually abate within days to months following LASIK surgery; however, 20%-25% of patients report ongoing symptoms 6 months after surgery. 3) After surgery, the following recommendations usually apply’ A short nap after surgery can help the flap adhere to the cornea Avoid rubbing the eyes. Use sleep goggles or eye shields for afew nights Avoid splashing water directly into the eyes forthe first few days. Do not wear eye makeup or apply skin lotions near the eyes Resume normal dally activities such as walking, reading and watching television after 20-48 hours unless directed otherwise. + Do not participate in strenuous activities such as liting weights, aerobics, contact sports, ete., until given permission to do so. + Carefully follow the instructions on all prescribed medications + Contact your doctor immediately if you develop new, unususl or worsening symptoms: Success rates Reports of laser surgery success rates range between 25%-99%, Evaluating the safety of the procedure is complicated by the fact that there is no centralized agency that collects data on long-term outcomes, and it is believed that long-term complications from the procedure may be seriously underreported. Success rates can be enhanced through better patient education, screening, matching the type of procedure to the patient's needs and Improved pre- and post-surgical care, hntpwww-canadianhoathcarenotwork calpharmacistsflinicalottsalt-care-wellhoss-\ssuesen-aye-care-18112%pnnt 218sierz018 ‘Self Care & Wellness: Issues in Eye Care | Canadian Healtneare Network - Pharmacists Age-related eye disease ‘TABLE 1. Risk factors for age-related eye deeates: [sc acroes Dn Tes | AMD | CAMAGTs [DUET ETEDSESE Common age-related eye diseases include dry eyes, age~ A ISS . related macular degeneration (AMD), cataracts and Female ¥ ¥ ¥ ¥ diabetic eye disease. These diseases share a number of foynacy ye : preventable and nonpreventable risk factors, which are exaby ao y Gutined in Table 1. Bs Si Preventable risk factors ce = 7 wnt «ow 7 Environment pretties | tipodprsare 7 7 + Ensure appropriate room humidity levels arenes : q + Wear wrap-eround sunglasses with 100% UVA and. imme =i : Uv protection seine 7 + Keep visual screens ator below eye level; take ighemaenies frequent breaks; increase blink rate and duration Lov seg levels ¥ ¥ Exercise Regular moderate exercise helps control weight, blood pressure, cholesterol and circulating inflammatory factors, Nutrition ‘A well-balanced diet with a variety of green leafy vegetables, fruit, nuts and fish will provide the vitamins and minerals needed for good eye health. Supplements have been shown to slow the progression of a number of eye diseases and reduce symptoms of dry eye. Eye supplements are frequently based on the formulation used in the Age-Related Eye Disease Study (AREDS) or the ongoing AREDS2 trial, which has added lutein, zeaxanthin and omega-3 fatty acids to the original formulation. Eye supplements are not a replacement for multivitamins since they are missing some essential nutrients; the two can be taken together, ‘The original AREDS formulation contains 15 mg beta-carotene (25,000 IU vitamin A) 500 mg vitamin C 400 IU vitamin & '80 mg zinc (as zine oxide) + 2mg copper (as cupric oxide)() Variations of the AREDS formulation are available for patients concerned with the risk of lung cancer, cataracts and/or prostate cancer. Beta-carotene (vitamin A) has been associated with an increased risk of lung cancer in smokers. Vitamin A-free formulations are recommended for smokers and recent smokers.!") Vitamin E plus selenium Results from the Selenium and Vitamin E Cancer Prevention Trial (SELECT) showed 2 significant increase in the incidence of prostate cancer in healthy men taking 400 IU of vitamin E. The increased risk was not seen when selenium 200 yg was added to the regimen,(*) Researchers evaluating the AREDS and AREDS2 trials have not seen an increased risk in prostate cancer in their trials and have not added selenium to their formulations.) Zinc is highly concentrated in the retina. Although zinc deficiencies have been associated with an increase in eye disease and low levels appear to have protective effects, high levels of zinc have been linked to an increase in cataracts. Because of the risks associated with high doses of zinc, study subjects in the AREDS2 trial can choose between a formulation containing 80 mg of zinc or one containing 25 mg.) Dry eye treatments Dry eye can result from and cause ocular surface damage, creating a vicious cycle. Symptoms alone are insufficient to determine the severity of the condition, as patients sometimes develop corneal desensitization and reflex tearing. Treatments can be used to minimize but not eliminate symptoms. Eyelid hygiene Meibomian gland dysfunction is believed to be the most common cause of dry eye syndrome.‘5) For this reason eyelid hygiene should not be overlooked when counselling patients with dry eye. hntpwww-canadianhoathcarenotwork calpharmacistsflinicalottsalt-care-wellhoss-\ssuesen-aye-care-18112%pnnt siasierz018 ‘Self Care & Wellness: Issues in Eye Care | Canadian Healtneare Network - Pharmacists + Apply warm moist compresses to the lids for a minimum of four minutes once or twice daily() + Massage the eyelids using moderate to firm pressure to help with lipid secretion(5) + Gently scrub the eyelid margins, Commercially available eyelid scrubs may be less irritating than diluted baby shampoo (water:shampoo ~ 10:1) Lubricants (artificial tears) No large-scale masked studies are available to compare the overall effectiveness of ocular lubricants, The type and concentration of preservative in the formulation often have the greatest impact on the product's effectiveness. ;cosity agents increase the retention time of artificial tears, but can cause blurring and caking, Patients may need to try different products to achieve the preferred balance between duration, comfort and esthetic appeal. Highly viscous products are better for bedtime use. Preservatives Most ophthalmic preservatives can cause irritation. Preservative- free formulations should be recommended for patients with severe dry eye, those who use multiple preserved ophthalmic preparations and patients with punctual plugs. Instillations of all benzalkonium chloride preserved ophthalmic products combined should not exceed 6 times daily.(6) Sodium perborate is converted to hydrogen peroxide and borate when it comes in contact with tear film. When tear volume Is severely reduced, the product may not break down completely, resulting in irritation.(6) Red eyes Eye redness occurs when blood vessels in the sclera become inflamed and dilated. Patients should be referred to a physician if they experience pain or vision changes, or if symptoms do not begin to improve after one to two days. ‘The degree of redness is usually not a good indicator of severity. Viral and bacterial conjunctivitis (pinkeye) are self-limiting but highly contagious. Viral conjunctivitis is usually accompanied by clear watery discharge with little or no pain. It is often associated with the common cold and sore throat, and does not respond to OTC mecications. Bacterial conjunctivitis is usually accompanied by a white or yellow purulent, sticky discharge. Prescription or OTC antibiotics hasten healing and reduce spread. Allergic conjunctivitis is usually accompanied by other allergy symptoms such as runny nose, sneezing, skin reactions and sometimes asthma. Self-care strategies include the following: + Avoid the allergen when possible + Use artificial tears to dilute and flush the allergens + Use antihistamines* © ocular antihistamines provide a rapid response, but can be sensitizing © oral antihistamines tend to be only partially effective + Use ocular decongestants*; however, although they provide @ rapid response, frequent and/or long-term use can result in rebound + Use mast cell stabilizers. They are more effective when started 1-2 weeks before allergy season ‘Antihistamines and decongestants can induce angle closure in patients with narrow angle glaucoma Conclusion Advances in eye research have provided new insights into eye disease at a time when eye disease is on the rise ‘owing to an aging population and an increase in diabetes incidence. Along with these advances there has been a burgeoning production of OTC eye-care products. Although an increase in product selection is more confusing for ur patients, it provides us with an opportunity to better meet their educational, medical and lifestyle needs. Valerie Cook is @ pharmacist and educator based in Fredericton, NB. hntpwww-canadianhoathcarenotwork calpharmacistsflinicalottsalt-care-wellhoss-\ssuesen-aye-care-18112%pnnt aa