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“People wake up in the morning with their eyes stuck together and come to see us.”

Swansea pharmacist Chris James neatly sums up why community pharmacists need to know how to handle eyecare queries – and conjunctivitis is probably the most common eye problem that they are asked about.

But there are many other conditions, as Numark information pharmacist Michael Stewart points out: “Thinking about how many diseases and conditions the eyes are associated with – such as allergy, cold and flu, diabetes, hypertension and so on – it is not a category that can be ignored.”

So what do pharmacists need to look out for and how should they advise patients presenting in the pharmacy with eye complaints?

Common eye ailments

Red, watery eyes, a sticky coating on the eyelashes and soreness are all signs of conjunctivitis, which can be caused by an irritation, allergy or infection. Pharmacists can advise on self-care – such as not wearing contact lenses, not rubbing the eyes and washing hands regularly – and suggest lubricant eye drops to ease discomfort.

Chloramphenicol eye drops are available without a prescription for infective cases that persist – although these are not suitable for contact lens wearers, who should be referred.

Particularly at this time of year, many queries about red, itchy eyes will be related to hayfever – in which case pharmacists should discuss with the patient the various options for relief options.

Another common eye ailment that pharmacists are likely to be asked about is dry eye syndrome, in which the tear ducts do not produce enough tears or they evaporate too quickly. It can be caused by factors such as ageing – a third of people over 65 years are affected – hormonal changes and as a side effect of some medicines.

Red-flag symptoms

With any of these presentations, despite their high incidence, you should also consider red-flag symptoms and the possible need for referral to an eyecare specialist, says Mr Stewart. “The eyes are very delicate and complications can quickly develop that can, if left untreated, impair and even destroy someone’s sight,” he explains. 

Mr James, of Walter Lloyd Pharmacy, agrees: “For example, is there pain in the eye or behind the eye, and do they have high blood pressure or diabetes? You could be looking at glaucoma and you wouldn’t normally get those symptoms from an eye infection.” (See Top tips for a glaucoma MUR, right.) 

One group of patients at particular risk of glaucoma and seen frequently by pharmacists is those with diabetes. Concerning symptoms in these patients include any loss of or misty vision in one or both eyes, intense pain in the eye, redness, headaches, flashing lights or seeing halos around lights (see When to refer, above, for more red-flag symptoms).

Diabetes patients are also among those patient groups that should be reminded about their need for regular eye checks. 

“It’s surprising how few diabetics have eye checks on a regular basis and that should always be an opportunity for pharmacists to encourage them to go for their eye test and look after their eye health,” says pharmacist Ed Johns, whose Swansea Boots branch has a scheme by which its pharmacist and optometrist can refer directly to each other on an internal prescription.

Keeping an eye out

Pharmacists can identify other patients who may be having eye problems even if they don’t present directly; for example, patients with prescriptions for medicines that can cause eye problems, such as dry eyes, as a side effect.

Such cases might benefit from an MUR; the service can also be a useful tool to check how patients are getting on with eye health treatments such as drops, which many patients find tricky (see Real life patient case study, above right). “The standard questions would be: are they compliant with their medication, is the formulation suitable, have they had side effects, can they use the dropper bottle, and so on,” explains Mr Johns.

Eye drop technique is important and worth offering advice on. This includes washing your hands, sitting in a comfortable position, pulling down the lower lid to create a pocket and not touching the eye or eyelid with the dropper itself, advises Mr Stewart (see Advising on good eye drop technique, right).

Optometry Wales chief executive Sali Davies highlights one patient case study that exemplifies the importance of pharmacists’ role in eyecare. Thanks to Wales’s Look after your eyes public health campaign – a C+D Award-winning partnership between Community Pharmacy Wales, Optometry Wales and others – the patient, who visited the pharmacist with symptoms of hayfever but who also had pain in her eye, was identified as having a corneal ulcer.

“The patient had been to see the pharmacist, was referred to the optometrist and was signposted to A&E,” explains Ms Davies. “It could have been really nasty and she got in touch to say that it wouldn’t have been picked up otherwise.”

Real life patient case study Angela Hopkins* was picking up a prescription when the pharmacist noticed she had not asked for the eye drops that were on the script. When asked, Ms Hopkins admitted that she never used them, “because they’re too fiddly and I can never get the liquid into my eye”. The pharmacist, who was involved in Wales’s Look after your eyes public health campaign, took the opportunity to offer an MUR. He explained to Ms Hopkins what the eye drops were for – glaucoma – how they would help and how to administer them effectively (see Advising on good eye drop technique, right). Ms Hopkins said that she had not realised how important and simple to use the eye drops were; she agreed to fill the prescription and take the eye drops from then on. *Patient’s name has been changed