Over-the-counter eye products

OTC Products
Over-the-counter eye products
Fae Farrer, BPharm
Amayeza Info Centre
Customers often complain of red or itchy
eyes, or even more commonly of “pink
eye.” So what causes these problems and
what product may be recommended?
Virtually all eye problems result in the
white of the eye (the sclera) becoming
red or pink, and thus many people
believe that they have “pink eye,” a term
that should be reserved for infectious
problems in the eye.
Conjunctivitis is defined as
inflammation of the conjunctiva. The
conjunctiva is the thin membrane that
lines the inner surface of the eyelids
and also covers the white of the eyes.1,2
All types of conjunctivitis cause a red
eye, but not all red eyes are caused by
SA Pharmacist’s Assistant [ Spring 2011 ]
Types of conjunctivitis
cloths, may also become a
source of infection. Viral
conjunctivitis usually
starts in one eye, with the
second eye often becoming
infected within 24 to 48
hours. Symptoms include
redness, a watery or mucous
discharge, and a burning
or gritty feeling in the eye.
Patients may experience
morning crusting, with the
eyes being “stuck shut.”1
Bacterial conjunctivitis
Various bacteria may cause bacterial
conjunctivitis. This infection is
highly contagious and may affect
entire families or many children in
a classroom. Bacterial conjunctivitis
is spread by contact with infected
eye secretions. The most common
symptoms of bacterial eye infections
include redness and thick white, yellow
or green mucous discharge from one
eye. The discharge continues to drain
throughout the day.1 More discharge
appears within minutes of wiping the
lids.3 The affected eye is “stuck shut”
in the morning. Both eyes may be
Non-specific conjunctivitis
Viral conjunctivitis
Sometimes a customer will complain of
an eye problem that is not the result of
either an infection or an allergy.
The viruses that cause the common
cold may also cause viral conjunctivitis.
Symptoms of conjunctivitis (red eyes
and discharge) may present alone or
with other symptoms of a cold (swollen
lymph glands, fever, sore throat and
runny nose). Viral conjunctivitis is
contagious and is spread by contact
with eye secretions.1 Children are
not the only ones who rub their eyes
and forget to wash their hands before
touching something else! Shared
objects, such as towels and face
A number of problems may cause
redness and a discharge:1
• Dry eyes may have chronic or
intermittent redness and discharge.
• Chemicals that have inadvertently
been splashed into the eyes may
cause redness.
• A foreign body that enters the
eye (e.g. dust, eyelash) may cause
irritation, redness and a discharge
for up to 24 hours after it has been
Allergic conjunctivitis
Allergic conjunctivitis is caused by
airborne allergens that come in contact
with the eye, e.g. pollen, animal dander
and moulds. Symptoms include redness,
watery discharge and itching of both
eyes. A burning sensation, sensitivity
to light and swollen eyelids may also
be present. Symptoms may be sudden,
seasonal or year-round, depending on
the allergen.
Acute allergic conjunctivitis is a
sudden-onset reaction to an allergen,
e.g. cat dander. Symptoms may be
severe, but usually resolve within
24 hours of removal of the allergen.
Seasonal allergic conjunctivitis tends
to cause milder but more persistent
symptoms during particular pollen
seasons, e.g. tree pollens, grass pollens
and weed pollens. Seasonal allergic
conjunctivitis is often associated
with rhinitis.2 Perennial allergic
conjunctivitis is a mild chronic allergic
condition related to year-round
environmental allergens, e.g. dust
mites and moulds.
Allergic conjunctivitis is often related
to a history of allergic conditions.2
Tear film insufficiency, with resulting
dry eyes, frequently coexists with and
worsens allergic conjunctivitis. Tear
film insufficiency worsens allergic
conjunctivitis, as the ability to rinse
away the allergen is diminished, and
the concentration of allergen on the eye
surface is greater.2
The signs and symptoms of various types
of conjunctivitis are summarised in Table I.
Viral conjunctivitis
Topical antihistamine/decongestant
eyedrops may relieve the itching
and irritation of viral conjunctivitis.
Care must be taken not to spread the
OTC Products
Table I: Symptoms of different types of conjunctivitis1 2
Purulent discharge
Watery discharge
Watery discharge
One eye
One eye
One or both eyes
Both eyes
Burning/gritty and
morning crusting
Morning crusting
and discharge
throughout day
History of eye
sensitive and history
of allergic conditions
infection from one eye to the other.
Symptoms may worsen for three to five
days before resolving, and they may last
for up to three weeks.1
condition can be predicted from the
patient’s past experience, treatment
should be started two weeks before the
onset of symptoms.
Bacterial conjunctivitis
Perennial allergic conjunctivitis is best
prevented with an oral antihistamine.2
Bacterial conjunctivitis may be treated
with a topical antibiotic. Topical
antibiotics are available only on
prescription and may be applied as eye
drops or ointments. If started early
antibiotic treatment may shorten the
duration of the infection, but symptoms
may resolve without assistance.1
Non-specific conjunctivitis
Most cases of non-specific conjunctivitis
resolve within a few days without
treatment. However, the eyes may
feel better with the use of a lubricant.
Preservative-free preparations are
available for patients with severe cases
of dry eye and for those allergic to
Allergic conjunctivitis
Most cases of acute allergic conjunctivitis
are self-limiting and resolve within 24
hours. Patients may use a combination
antihistamine/vasoconstrictor eye drop
for up to two weeks. For frequent
episodes a topical medication containing
antihistamine and mast cell stabilising
properties may be used. This should be
applied prophylactically.
Seasonal allergic conjunctivitis may be
treated with combination antihistamine/
mast cell stabiliser eyedrops. If the
Redness of the conjunctiva may be due
to any of the following:
• Trauma: either directly to the eye or
a head injury.
• A foreign body (such as an eyelash or
dirt) may be irritating the eye.
• A pterygium (an overgrowth of cells
over the cornea) may cause irritation
and dryness of the eye. Any redness
is localised to the particular area.3
• Blepharitis (inflammation of the edge
of the eyelid) may cause secondary
redness in the eye. Blepharitis is
often associated with allergies (e.g.
cosmetic or topical preparations) or
with bacterial infections.5
• Styes are small abscesses that may
form at the base of an eyelash. They
are usually caused by a bacterial
infection and may be secondary to
• Subconjunctival bleeding is a
localised pooling of blood between
the conjunctiva and the cornea. This
condition is usually painless, does
not affect vision and is localised to
one area of the eye. It should clear
within two weeks without treatment.
Subconjunctival bleeding may be due
to a direct blow to the eye by a fist or
a ball, increased pressure within the
eye as a result of coughing, sneezing
or straining, or rarely from high
blood pressure.4
• Contact lens wearers who present
with an acute red eye and discharge
Over-the-counter eye products
There are many eye products available
over the counter. These may contain
decongestants, antihistamines, mast cell
stabilisers, anti-infectives and lubricants.
Ophthalmic decongestants relieve
redness and irritation of the eyes
due to allergic and inflammatory eye
conditions. The decongestants work as
vasoconstrictors, constricting the blood
vessels in the eye and reducing redness.
These products are intended for shortterm use only as regular use (longer than
2 weeks) may result in rebound redness,
and also systemic side effects. Table
II lists some over-the-counter (OTC)
products containing decongestants.2
Topical antihistamines are faster
acting and less likely to cause systemic
side-effects than oral antihistamines,
and are therefore preferred where the
main complaint is ocular.2 Products
available include Emadine® (emedastine
difumarate) and Livostin ED®
(levocabastine hydrochloride).5
Mast cell stabilisers
Mast cell stabilisers inhibit mast cell
degranulation, which is the first step
in the allergic cascade. They inhibit
leukocyte activity and dampen mediator
release, reducing the allergic reaction.
The onset of action is five to 14 days
from start of therapy, and therefore
these products are not suitable for
acute allergic conjunctivitis. Patient
compliance may be limited by the
dosing schedule of these medications,
as they must be used four times a day
at regular intervals. Agents available
include sodium cromoglycate (StopAllerg®, Cromabak®, Cromohexal®) and
lodoxamide tromethamine (Alomide®).2,5
SA Pharmacist’s Assistant [ Spring 2011 ]
A step-wise approach is used for allergic
conjunctivitis based on the severity and
frequency of symptoms.
Other causes of red eyes
should be advised to discontinue
contact lens use immediately, and to
consult an optometrist or their doctor
if symptoms do not improve within
12–24 hours, as they are at risk of
serious bacterial eye infections.3
OTC Products
Zinc sulphate
Sparkling White®
Antihistamines and mast cell
SA Pharmacist’s Assistant [ Spring 2011 ]
Polyvinyl alcohol
Polyvinyl alcohol
Medications with both antihistamine
and mast cell stabilising properties are
useful for frequent attacks of acute
allergic conjunctivitis (occurring
more than two days per month). Full
efficacy of prophylactic use may be
assessed after two weeks of therapy.
These agents act as mast cell stabilisers,
inhibiting mast cell degranulation, and
as antihistamines, blocking histamine
receptors in the conjunctiva and
eyelids. This helps in the last phase of
an allergic reaction.2
Table III lists products containing agents
with both antihistamine and mast cell
stabilising properties.
Artificial tears and lubricants
Tear film insufficiency is a common
disorder, particularly among women and
the elderly. This condition may coexist
with allergic conjunctivitis and worsen
the inflammation of the conjunctiva.
Patients with mild to moderate dry
eyes may not realise that they have this
problem. Certain medications, including
Minor eye infections such as
blepharitis and styes may be treated
with Brolene® (dibromopropamidine)
or Lennon Sulphacetamide®
(sulphacetamide sodium). These
agents are antibacterial and may be
used in the initial treatment of minor
infectious eye complaints.5
Basic eye care
Safyr Bleu®
Murine Cool Eyes®
Antistin Privin®
Table II: Decongestants in over-the-counter eye products5–7
Boric acid, borax,
sodium chloride
Table III: Products with antihistamine and
mast cell stabilising properties.2,5
Active Ingredient
Azelastine hydrochloride
Olopatadine hydrochloride
Epinastine hydrochloride
Ketotifen fumarate
oral antihistamines, may worsen tear
film insufficiency as they may cause a
decrease in tear production.4
Patients with both dry eyes and allergic
conjunctivitis respond to frequent use
of artificial tears throughout the day.
Lubricant ointment provides longer
lasting relief but may blur the vision
temporarily. Some patients prefer to use
drops during the day and the ointment
at bedtime.1,2
Products available include Optive®,
Systane Ultra®, Tears Naturale® II , Tears
Naturale® Preservative Free, Cellufresh®,
Celluvisc®, Duratears®, Liquifilm Tears®,
Murine Moisture Eyes®, Refresh®,
Spersatears®, Teargel®, Tears Plus® and
In order to prevent eye infections the
following suggestions may be made:
• Patients should avoid rubbing their
eyes, as dirt may be introduced into
the eye, making any irritation worse.
Rubbing eyes in cases of allergic
conjunctivitis may also cause mast cell
degranulation and worsen symptoms.
Artificial tears or antihistamine drops
may reduce itching.2
• In allergic conjunctivitis, exposure
to the allergen should be minimised,
by staying indoors, using airconditioning and keeping windows
closed in peak allergen season.2
• Adults and children with viral or
bacterial conjunctivitis should
not share hankies, tissues, towels,
cosmetics and pillows with
uninfected friends and family
• Hand washing is essential to prevent the
spread of any infection. Hands should
be wet with water and soap and rubbed
together for 15 to 30 seconds. Children
should be taught to wash their hands
before and after eating, after using the
toilet, after coughing or sneezing and
after touching their eyes. Alcohol-based
hand rubs are a good alternative to
washing hands if soap and water are not
Contact lens wearers
Patients who use contact lenses should
consult an eye care specialist before
treatment begins to ensure that any
ocular problem is not due to an infection
of the cornea. Contact lens wearers are
susceptible to a number of secondary
problems relating to contact lens fit, lens
type or lens hygiene. Soft contact lens
wearers are at increased risk of certain
bacterial conditions that may lead to serious complications
very quickly (within 24 hours).
Contact lens wearers with acute red eyes should remove
lenses and avoid wearing lenses for 24 hours and see a
specialist if symptoms do not improve within 12 to 24
hours. The contact lens case should be replaced, and the
lenses thoroughly disinfected overnight or replaced if
Referral to an eye care specialist
Certain symptoms should be referred to an eye care
• Eye tenderness
• Changes in vision
• Sensitivity to light and difficulty in keeping the eye open
• Severe headaches with nausea
• Recent trauma to the eye
• Use of contact lenses
• Patient with allergic conjunctivitis who does not respond
to therapy after two weeks of consistent use
• Fixed pupil.
Returning to work or school
Bacterial and viral conjunctivitis are both highly contagious
and spread by direct contact with ocular secretions
or contact with contaminated objects (tissues, towels,
cosmetics). Ideally the patient should remain home until
there is no longer any discharge but this is often not
practical. Most schools and day care centres require that
the child receives 24 hours of treatment before returning to
school. This helps to prevent the spread of bacterial infection
but is less helpful for children with viral infections.
Young children who will not remember to wash their hands
and avoid touching their eyes should not attend school until
the discharge is resolved. Older children and adults should
limit close contact with others.
Adults who have contact with the very old, the very young
and people with a weakened immune system should take
care not to spread infection from their eye secretions to these
susceptible people.1,3
There are many possible causes of red eyes, from viral
and bacterial infections to allergies, foreign bodies and
trauma. Infectious conditions should be referred for further
treatment, as should patients whose condition does not
resolve within the expected period. OTC products are
available to manage allergic conjunctivitis and dry eyes.
The principles of basic eye care should be explained to any
patient with eye complaints.
References available on request