OSPAP Programme EYE/ENT

Transcription

1 OSPAP Programme EYE/ENT Slide 1 of 41 MPHM14 OSPAP Eye/ Ear

2 Common presenting complaints: EYE Dry/gritty Redness Discharge Pain Lump Slide 2 of 41 MPHM14 OSPAP Eye/ Ear

3 Common presenting complaints: EAR Pain Discharge Deafness Itch Tinnitus Slide 3 of 41 MPHM14 OSPAP Eye/ Ear

4 What do you think these could be? Slide 4 of 41 MPHM14 OSPAP Eye/ Ear

5 Some examples of eye disorders! Slide 5 of 41 MPHM14 OSPAP Eye/ Ear

6 Some examples of eye disorders! Slide 6 of 41 MPHM14 OSPAP Eye/ Ear

7 EYE,ENT CASE STUDIES?! Slide 7 of 41 MPHM14 OSPAP Eye/ Ear

8 Case study 1 Mrs Burns comes into your pharmacy and asks you to look at her eye. It is bright red and not painful. She takes paracetamol 500mg when required and lisinopril 5mg OD. She has never had it before and woke up like that this morning. Slide 8 of 41 MPHM14 OSPAP Eye/ Ear

9 Sub Conjunctival haemorrhage Self limiting condition Caused by a small bleed in the sclera, which spreads inbetween the conjunctiva and sclera Usually looks worse than it is! No treatment necessary Clears within 7-14 days without treatment May indicate raised BP- check! Slide 9 of 41 MPHM14 OSPAP Eye/ Ear

10 Case Study 1: Mrs Jones Mrs Jones has HTN Takes lisinopril 5mg daily Sub conjunctival haemorrhage may be a sign of raised BP May warrant a BP check - can be checked in the pharmacy Reassurance is key No Tx necessary Slide 10 of 41 MPHM14 OSPAP Eye/ Ear

11 Case Study 2 Miss James comes into your pharmacy and asks for some eye drops for sticky eyes. On questioning, you find out that it is for her son who is 1 year old. He woke up this morning with both eyes glued shut by yellowy discharge Slide 11 of 41 MPHM14 OSPAP Eye/ Ear

12 Types of conjunctivitis Infective Conjunctivitis: Bacterial or Viral Gritty sensation Bacterial conjunctivitis characterised by thick yellow/green discharge Patients often wake up with eyelids stuck together Viral conjunctivitis characterised by watery discharge History of contact with an infected person Highly infectious but self limiting Allergic conjunctivitis: Irritation, discomfort and watery eyes Associated with itching, rhinitis and other hay fever- like symptoms Can be seasonal Allergic reaction e.g. pollen or dust Irritant Conjunctivitis: The eye coming into contact with substances that can irritate the conjunctiva, such as chlorinated water or shampoo, or a loose eyelash rubbing against the eye Redness, watery Neo-natal conjunctivitis Can be serious if a baby is born to a mother who has a sexually transmitted infection such as chlamydia or gonorrhoea Appears within 28 days of birth Should be dealt with by a specialist Slide 12 of 41 MPHM14 OSPAP Eye/ Ear

13 Treatment of bacterial conjunctivitis Chloramphenicol eye drops/ ointment Licensed OTC from 2 years of age Drops need to be kept in fridge before opening Dose for drops: 1 drops every 2 hrs for the first 2 days, then 1 drop every four hours for a further 3 days Ointment can cause transient blurred vision Dose: small amount to be applied to the affected eye 3-4 times a day or applied at night if drops used during the day Discard drops/ ointment within 28 days of opening Slide 13 of 41 MPHM14 OSPAP Eye/ Ear

14 Treatment of bacterial conjunctivitis Propamidine Isetionate Brolene eye drops Golden eye eye drops Dibrompropamidine Isetionate Golden eye eye ointment Evidence base weak!!! Slide 14 of 41 MPHM14 OSPAP Eye/ Ear

15 Case study 2: Miss James Please note: Miss James is NOT the patient, her son is the patient Careful history taking is essential!!! Patient is 1 year old, therefore cannot be treated with chloramphenicol OTC Therefore advise Miss James of general counselling such as eye hygiene (it is self limiting) Refer to GP if symptoms continue Slide 15 of 41 MPHM14 OSPAP Eye/ Ear

16 General counselling Swab eyes bd or tds to clear the discharge Avoid sharing towels or pillows Wash hands regularly especially after touching the eyes to prevent the spread of infection Contact lense wearers should not wear contacts if using eye drops and for 24 hours after last dose Eye drops/ ointment should be discarded within 28 days of opening Slide 16 of 41 MPHM14 OSPAP Eye/ Ear

17 Red flags No improvement within 48 hours of Tx Symptoms lasting longer then two weeks Loss of vision Photophobia Marked redness some is common Pain in the eye Ciliary injection Redness caused by trauma/ injury Slide 17 of 41 MPHM14 OSPAP Eye/ Ear

18 Case Study 3 Mr Whiting asks to speak to the pharmacist. He hurt himself at work the other day, a headache started almost immediately. He has dull pain in his right eye which has gradually worsened. He also mentions slight blurred vision. Slide 18 of 41 MPHM14 OSPAP Eye/ Ear

19 Mr Whiting Presenting with several red flag symptoms: Trauma to eye Pain in his eye developed after trauma Blurred vision Not all symptoms occur immediately, some develop over time Accurate diagnosis not possible Need a slit lamp to indicate the presence of cells in the aqueous humour Therefore, urgent referral is necessary Slide 19 of 41 MPHM14 OSPAP Eye/ Ear

20 Case Study 4 Corey comes into your pharmacy and describes having a ball in his eye for around 3 days. Upon examination, you notice a small red lump on the eyelid margin. Slide 20 of 41 MPHM14 OSPAP Eye/ Ear

21 Stye Presents as a painful red swelling on the inside or outide of the eyelid Self limiting condition If left untreated, will point and discharge and resolve spontaneously Most cases caused by Staphyloccocus aureus Can be external caused by localised infection of the hair follicles of the eyelid margin Or internal Caused by infection of the meibomian glands in the inner surface of the eye lid Slide 21 of 41 MPHM14 OSPAP Eye/ Ear

22 Treatment Propamidine Isetionate Brolene eye drops Golden eye eye drops Dibrompropamidine Isetionate Golden eye eye ointment Chloramphenicol is not licensed to treat styes Slide 22 of 41 MPHM14 OSPAP Eye/ Ear

23 Case Study 4: Corey Treatment: Eye hygiene warm compress: application of heat to encourage stye to come to a head Dip cotton wool pad into boiled water which is cooled but still warm Press it gently against the stye for 5-10 minutes Repeat this three to four times a day Treat using Golden eye or Brolene eye drops Cause may be bacterial, so do not share towels, flannels or face cloths Wash hands after touching the eyes Advise patient not to puncture the stye themselves and this may spread infection Slide 23 of 41 MPHM14 OSPAP Eye/ Ear

24 Case Study 5 Miss Joy asks you to recommend something for ear wax. She has always used ear buds in the past. Ear feels full and blocked and there is slight hearing loss. She would like something for her partner too Slide 24 of 41 MPHM14 OSPAP Eye/ Ear

25 Case study 5: Miss Joy Two patients in this case study: Miss Joy and her partner Miss Joy has impacted ear wax, which can be treated with ear drops However, her partner is allergic to peanuts Therefore arachis/almond oil would be contraindicated Olive oil/sodium bicarbonate ear drops/urea hydrogen peroxide drops would be a suitable option Slide 25 of 41 MPHM14 OSPAP Eye/ Ear

26 Treatment options Cerumunolytics Used to soften ear wax Limited evidence of efficacy however very safe. Very few side effects: irritation when first administered, temporarily increase deafness. Can take up to 7-14 days to achieve desired effect. E.g. olive oil, almond oil, arachis oil, docusate sodium. Slide 26 of 41 MPHM14 OSPAP Eye/ Ear

27 Cerumunolytics Cerumol ear drops Arachis oil 57.3%w/v & chlorobutanol 5%w/v Insert 5 drops into the ear. A plug of cotton wool moistened with cerumol or petroleum jelly should be applied. Remove plug 1 hour later/the next morning. Repeat BD for up to 3 days Not suitable for those with allergy to peanuts, oil or soya. Earex ear drops Almond oil, arachis oil, camphor oil all 33.33%v/v Insert 4 drops into the ear, remain in the same position for 2 minutes and plug with cotton wool. Repeat ON and OM for up to 4 days. Not suitable for those with peanut allergy Olive oil Can be used regularly to prevent wax build up. Instil 2-3 drops BD Suitable for husband Slide 27 of 41 MPHM14 OSPAP Eye/ Ear

28 General counselling Do not to use ear buds This pushes the wax further into the ear causing impaction Damages the sensitive lining of the ear canal and ear drum Slide 28 of 41 MPHM14 OSPAP Eye/ Ear

29 Other options Peroxide based products Exterol or Otex - urea hydrogen peroxide 5%w/w Instil 5 drops once or twice daily for 3-4 days or as required. A temporary bubbling sensation may occur. Patient should be advised not to plug the ear but retain the drops in the ear. Sodium bicarbonate Only available as a non-proprietary product and should be instilled 2-3 times a day for up to 3 days. Can cause dryness of the ear canal Slide 29 of 41 MPHM14 OSPAP Eye/ Ear

30 Red flags Associated dizziness/ nausea/ vomiting Severe deafness Tinnitus Previous middle ear or mastoid surgery Perforated tympanic membrane Severe pain Failed OTC Tx Slide 30 of 41 MPHM14 OSPAP Eye/ Ear

31 Case Study 6 Mr Khalid comes into your pharmacy complaining of a red sore ear. The ear canal appears swollen and is itchy with a foul- smelling discharge. He takes metformin and aspirin and uses E45 for his eczema. Slide 31 of 41 MPHM14 OSPAP Eye/ Ear

32 Mr Khalid Symptoms: Foul- smelling discharge from outer ear Soreness/ swelling Redness Itching Symptoms consistent with otitis externa (has eczema which can be contributory) due to smelling discharge would need referral as this indicates potential infection!! Slide 32 of 41 MPHM14 OSPAP Eye/ Ear

33 Otitis externa Inflammation of the ear Can be caused by infection Occasionally caused by yeast/ fungal infection Exacerbated by: Swimming chemicals Eczema/ other skin conditions Ear trauma SYMPTOMS Soreness Discomfort Usually affects one ear Discharge??? Itching Slide 33 of 41 MPHM14 OSPAP Eye/ Ear

34 OTC treatments Earcalm spray Acetic acid 2.0%w/w. For the treatment of superficial infections of the external auditory canal in adults and children over 12yrs. Apply 1 spray TDS. Maximum frequency every 2-3 hours. Continue for another 2 days after symptoms cleared but no longer than 7 days. Counselling: May suffer transient stinging after initial use Use within 28 days of opening Before first use prime pump 6-7 times until a fine spray is obtained. If symptoms worsen over 48 hours consult doctor Analgesics such as Paracetamol or Ibuprofen could be recommended in addition. As the symptoms in this case appear to be infected and superficial this wouldn t be suitable for this patient. Slide of 41 MPHM14 OSPAP Eye/ Ear

35 General counselling points Avoid scratching the ear Good management of skin conditions such as eczema or psoriasis Do not insert objects into the ears e.g. ear buds Keep the ears as dry as possible: E.g. using a shower cap, swimming cap or ear plugs Slide 35 of 41 MPHM14 OSPAP Eye/ Ear

36 Case study 8 Mr Wong comes in your Pharmacy asking to buy something for his wife who has a sore tongue. She takes paracetamol, warfarin and uses Ventolin and Clenil inhalers. Her tongue is sore and red with white plaques (also on the inside of her cheeks). Slide 36 of 41 MPHM14 OSPAP Eye/ Ear

37 Oral Thrush Fungal infection Usually affects areas of the inside of the mouth and surface of the tongue White patches are formed Risk factors for oral thrush include: Ill fitting dentures Diabetes Broad spectrum oral antibiotics Immunocompromised patients Oral or inhaled steroids Smoking Slide 37 of 41 MPHM14 OSPAP Eye/ Ear

38 Case 8: Mrs Wong From symptoms described, Mrs Wong has oral thrush New steroid inhaler prescribed then symptoms started soon after Indicates inhaler may be a causative factor.check inhaler technique Slide 38 of 41 MPHM14 OSPAP Eye/ Ear

39 OTC Treatment Miconazole oral gel (Daktarin Oral gel) - Licensed OTC from 4 months - Use after eating - Hold in the mouth as long as possible Slide 39 of 41 MPHM14 OSPAP Eye/ Ear

40 Case 8: Mrs Wong cont. However, Mrs Wong takes warfarin Warfarin interacts with azole antifungals Anticoagulant effect increased leading to increase in bleeding time Therefore Mrs Wong needs to be referred to her GP nystatin can be prescribed. Slide 40 of 41 MPHM14 OSPAP Eye/ Ear

41 Counselling Check inhaler technique Encourage Mrs Wong to wash out her mouth after using the steroid inhaler Possibly suggest using a spacer Leave dentures out overnight (if relevant) Try to leave them out as much as possible during tx period Regular cleaning and disinfecting of dentures See dentist if dentures are ill- fitting Slide 41 of 41 MPHM14 OSPAP Eye/ Ear