OTC Case Studies: Eye Health

CASE 1: Vitamin Supplements

Q: BF is a 61-year-old woman who is seeking advice about vitamins for eye health. She smokes a pack of cigarettes per day and has a medical history of type 2 diabetes. BF wants to prevent the onset of age-related macular degeneration (AMD) and is seeking advice on PreserVision vitamins. What information can the pharmacist provide about vitamin

supplementation for AMD prevention?

A: Studies show that the PreserVision AREDS and AREDS 2 formulas (beta carotene, copper, vitamins C and E, and zinc; and copper, lutein, vitamins C and E, zeaxanthin, and zinc), which are based on evidence from the trials AREDS (NCT00000145) and AREDS 2 (NCT00345176), have reduced the risk of developing advanced AMD by 25% and central vision loss by 19%. However, combination antioxidant supplements, including PreserVision, do not prevent AMD onset.

Cyanocobalamin (B12) 1000 mcg/day, folic acid (B9) 2500 mcg/day, pyridoxine (B6) 50 mg/day, and the vitamin B preparations have shown efficacy in preventing AMD onset in elderly women. Therefore, instruct BF to take that combination for 7 years, as demonstrated in studies.^1-3 Smoking increases the neovascularization in AMD and the risk of progression. Encourage BF to quit smoking using a combination of cognitive behavioral therapy and pharmacologic treatment.⁴ If BF were to develop AMD and was diagnosed with moderate AMD by an eye doctor, she should be encouraged to begin taking PreserVision AREDS 2 formula to decrease the risk of progression to advanced AMD. The AREDS trial found a statistically significant benefit of PreserVision’s formula on the progression of early to late AMD. However, beta carotene is present in the original AREDS formula and has been associated with an increased risk for lung cancer in current and former smokers. Lung cancers were observed in 2% of participants who took AREDS compared with 0.9% of participants who took AREDS 2. About 91% of those who developed lung cancer were former smokers. As such, the new formulation, AREDS 2, does not contain beta carotene and instead includes carotenoids, lutein, and zeaxanthin. If BF does start taking AREDS 2, instruct her to take 1 soft gel 2 times per day with food and to store the product at room temperature.^5,6

CASE 2: Nutrition

Q: BF follows up with a question regarding nutrition for eye health. She has been on a low glycemic index diabetic diet and has incorporated more vegetables into her meals. BF asks if there is good evidence that certain foods boost eye health, lowering the risk of AMD. What evidence can the pharmacist provide to BF?

A: Although study results vary, data suggest that a healthy diet rich with antioxidants (carotenoids and vitamins C and E) and omega-3 fatty acids has been associated with a decreased risk of developing AMD. Specific carotenoids lutein and zeaxanthin were most strongly associated with a decreased risk of developing AMD. They are found primarily in dark green, leafy vegetables, such as collard greens, kale, and spinach. Foods rich in vitamin C include citrus fruits, peaches, strawberries, tomatoes, and red bell peppers. Nuts, such as cashews, peanuts, and walnuts, and seeds, such as chia, flax, and hemp, are rich in vitamin E. Cold water fish, such as halibut, salmon, and tuna, are a great source of omega-3 fatty acids. Overall, if BF is following a diet recommended by the American Diabetes Association, it is likely that most of the recommendations for the diabetes and eye health diets overlap.⁷

CASE 3: Ophthalmic Preservatives.

Q: JK is a 37-year-old man who suffers from dry and itchy eye. He has used a variety of OTC eye drops, such as Clear Eyes, Moisture Eyes, and Visine, for years and has noticed that the drops no longer relieve his symptoms. His wife heard about toxicity from preservatives in eye drops. What information can the pharmacist provide to JK about ophthalmic preservatives?

A : A preservative that Clear Eyes, Moisture Eyes, and Visine have in common is benzalkonium chloride (BAK). Ophthalmic preservatives such as BAK are bactericidal and protect the ophthalmic solution by damaging the plasma membrane of bacteria that may be introduced to the multidose product. Unfortunately, long-term use of ophthalmic products containing BAK may result in conjunctival and corneal damage, which presents as exacerbated dry eye disease and eye inflammation. Other ophthalmic preservatives appear to be less toxic but also less effective than BAK. Examples include chlorhexidine and chlorobutanol.^8,9

Newer formulations of artificial tears have been designed without preservatives or with preservatives that dissociate into a nontoxic product on the ocular surface. Preservative-free (PF) formulations are more expensive and are to be used as a single dose. Examples include Blink Tears (PF), Refresh Optive Advanced (PF), and Soothe (PF). Examples of preservative-dissociating formulations are GenTeal Tears, Refresh Optive, and Refresh Tears.^9,10

CASE 4: Allergic Conjunctivitis

Q: RP is a 32-year-old man with seasonal allergies. Because of his frequent exposure to environmental allergens, his itchy, red, and watery eye symptoms have become bothersome over the past week. RP called his cousin who is a pharmacist and learned that he should avoid wearing his contact lenses for a week, try cool water eye compresses, and use OTC antihistamine and/or lubricant eye drops. RP is seeking instruction on how to administer the eye drops. He mentions that he has his sister’s Zaditor bottle from a few months ago and plans to use that. A: Instruct RP to discard his sister’s Zaditor eye-drop bottle if it has been open for more than 30 days, as the labeled expiration date does not apply once the seal is broken. In addition, eye drops should not be shared.

Once he opens a new bottle of Zaditor, instruct RP to follow these steps to insert 1 drop into each eye 2 times per day: tilt head backward; form a pocket with the lower eyelid by pulling down with the index finger or gently pinching the lower lid with the index finger and thumb; look up, hold the bottle upside-down, and squeeze 1 drop into the pocket; and close the eye, and do not blink. RP should contact his eye care provider if symptoms do not resolve after 72 hours of treatment.¹¹

Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

REFERENCES

• Christen WG, Glynn RJ, Chew EY, Albert CM, Manson JE. Folic acid, pyridoxine, and cyanocobalamin combination treatment and age-related macular degeneration in women: the Women’s Antioxidant and Folic Acid Cardiovascular Study. Arch Intern Med. 2009;169(4):335-341. doi:10.1001/archinternmed.2008.574
• Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Syst Rev. 2017;7(7):CD000253. doi:10.1002/14651858.CD000253.pub4
• Chong EWT, Wong TY, Kreis AJ, Simpson JA, Guymer RH. Dietary antioxidants and primary prevention of age related macular degeneration: systematic review and meta-analysis. BMJ. 2007;335(7623):755. doi:10.1136/bmj.39350.500428.47
• Seddon JM, George S, Rosner B. Cigarette smoking, fish consumption, omega-3 fatty acid intake, and associations with age-related macular degeneration: the US twin study of age-related macular degeneration. Arch Ophthalmol. 2006;124(7):995-1001. doi:10.1001/archopht.124.7.995
• Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol. 2001;119(10):1417-1436. doi:10.1001/archopht.119.10.1417
• Age-Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA. 2013;309(19):2005-2015. doi:10.1001/jama.2013.4997
• Seddon JM, Ajani UA, Sperduto RD, et al. Dietary carotenoids, vitamins A, C, and E, and advanced age-related macular degeneration. Eye Disease Case-Control Study Group. JAMA. 1994;272(18):1413-1420. doi:10.1001/jama.1994.03520180037032
• Tressler CS, Beatty R, Lemp MA. Preservative use in topical glaucoma medications. Ocul Surf. 2011;9(3):140-158. doi:10.1016/s1542-0124(11)70024-6
• Pensyl CD. Preparations for dry eye and ocular surface disease. In: Bartlett JD, Jaanus SD, eds. Clinical Ocular Pharmacology. 5th ed. Butterworth-Heinemann; 2007:263-278.
• Fiscella RG. Ophthalmic drug formulations. In: Bartlett JD, Jaanus SD, eds. Clinical Ocular Pharmacology. 5th ed. Butterworth-Heinemann; 2007:17-38.
• Dry eye syndrome PPP — 2018. American Academy of Ophthalmology. November 2018. Accessed July 6, 2020. https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018