Eye spy: taking eye health seriously

Despite sight consistently being ranked as the most precious of the five senses, a quarter of people in the UK are failing to have an eye test every two years as recommended. Why?

Learning objectives

After reading this feature you should be able to:

  • Recognise major causes and risk factors for sight loss
  • Understand the importance of regular eye tests in preventing avoidable sight loss
  • Provide guidance on treatments and self-care for common eye complaints

 

The impact of sight loss can be far-reaching. Depression is much higher among people with sight loss than in the general population,1 while people with sight loss are at increased risk of suffering from social isolation and experiencing accidents such as falls.1 Sight loss can also exacerbate or prolong underlying health and social care complications.1

From an employment perspective, impaired vision can lead to reduced workplace productivity, increased absenteeism and job losses. Yet, for around 785,000 people in the UK, sight loss is caused by an uncorrected refractive error, meaning that vision could be improved or restored simply by wearing correctly prescribed glasses or contact lenses.2

State of the nation’s eyes

Over 2 million people in the UK live with vision loss that has a significant impact on their everyday life.

  • There are 275,000 sufferers of severe sight loss
  • A further 5.85 million people live with sight-threatening conditions
  • 250 people in the UK start to lose their sight each day
  • One in every five individuals will be affected by sight loss in their lifetime

RNIB and Specsavers. The State of the Nation Eye Health 2017

Cause and effect

The major medical conditions responsible for sight loss are age-related macular degeneration (AMD), cataracts, glaucoma and diabetic retinopathy.

AMD is the UK’s leading cause of blindness and affects around 475,000 individuals, according to recent figures.2 There are two main types – dry and wet (neovascular AMD). Dry AMD has no treatment and patients rely on vision aids. Treatment for wet AMD includes photodynamic therapy and new agents (the VEGF inhibitors ranibizumab and afibercept), which are injected directly into the eye and can reduce vision impairment progression in around 90 per cent of patients.3

As the name suggests, age is the major risk factor in AMD development, which normally affects people in their 50s and 60s. The condition is also linked to smoking, high blood pressure, being overweight and a family history of the disease.

Glaucoma accounts for sight loss in around 145,000 adults in UK, while the number of people with sight loss due to cataracts is more than double that, at an estimated 380,000.2 There are various treatment options for glaucoma ranging from eye drops, laser treatment and surgery. Factors such as advanced age, ethnicity, family history and co-morbid conditions such as shortor long-sightedness and diabetes can increase the likelihood of developing glaucoma.

Cataracts are typically age-related, but contributory risk factors include smoking, diabetes, long-term steroid use and overconsumption of alcohol.

The fourth commonest vision-damaging medical condition in the UK is diabetic retinopathy, responsible for around 95,000 cases of sight loss.2 Damage to the tiny network of vessels that supply blood to the retina occurs gradually over time, driven by persistently high blood glucose levels. Patients with high blood pressure, high cholesterol or of Asian or Afro-Caribbean descent are more prone to retinopathy development.

Overall, women are at increased risk of experiencing sight loss compared to men – primarily due to their greater life expectancy. Currently, the lifetime risk of sight loss stands at around one in four for women compared to one in eight for men.2 Age is a major causative factor in vision decline, with much of the rising prevalence of sight loss being driven by the UK’s ageing population.

An estimated 80 per cent of people living with sight loss are over the age of 64 years and one in every three people aged 85 years and over will suffer with a significant degree of sight loss.2 Pharmacy staff should also be vigilant for potential sight loss in stroke survivors, where almost 70 per cent of patients will suffer some form of visual dysfunction.1

Economic burden

Sight loss and blindness impose a heavy economic burden. A recent study4 into the prevalence, impact and cost of sight loss in the UK found that direct healthcare system costs were £3.0bn, while indirect costs amounted to £5.65bn. The value of the loss of healthy life associated with sight loss and blindness was estimated to be between £7.2bn and £19.5bn depending on the disability measure used.

The authors concluded that: “Sight loss and blindness in the adult population places a large economic cost on the UK… Comparing 2008 and 2013, the cost of sight loss and blindness is estimated to have increased by 27.8 per cent....The burden of disease from sight loss and blindness is also estimated to have increased by more than 25 per cent compared with 2008, indicating that [this] is still growing in the UK.”

Importance of regular eye tests

“At least half of all sight loss is avoidable so it is vital we enable everyone in the UK to look after their eye health,” says RNIB/Specsavers in their report, The State of the Nation Eye Health 2017: A Year in Review.2 We are championing the need for regular eye tests so eye health conditions are identified and treated early, they say.

Despite sight consistently ranking as the most precious of the five senses, a quarter of people in the UK are failing to follow the College of Optometrists’ and NHS recommendations to have an eye test every two years. The advice applies to everyone over three years old and is vital in addressing uncorrected refractive error and picking up any underlying eye health issues.

Even when problems with vision do present themselves, people still seem reluctant to pursue medical advice. “Of further concern is the fact that 23 per cent say they are not able to see as well in the distance or close up as they used to and have not sought advice from an optician or medical professional,” adds the report.

So why are people adopting such an apathetic approach when it comes to safeguarding their sight? According to the RNIB/ Specsavers report, the ageing population and lackadaisical attitude of the younger generation towards eye health are key parts of the problem.

Other common barriers that prevent people from attending regular eye tests include:2

  • The perception that nothing is wrong with their eyes
  • Lack of time or failure to ‘get round to it’
  • Concerns about the cost of new glasses.

Pharmacists can help overcome these obstacles to healthy sight by debunking common misconceptions about the value and role of regular eye tests. During an eye examination, it is not only vision that is tested. Wider indicators of general eye health are also assessed and potential signs of underlying medical conditions such as diabetes, cardiovascular disease and even brain tumours can be detected.

On the issue of eye test evasion, “not only does this mean that some people are waiting for signs of sight loss before visiting an optician, it also means that they are potentially preventing their optician from detecting signs of eye health problems or other medical issues at an early stage,” says Dr Nigel Best, Specsavers’ clinical spokesperson. “We know that early intervention is important in the management and successful treatment of many conditions.”2

On the issue of time, the average eye test only lasts around 20-30 minutes, which compares favourably with other routine appointments that customers regularly schedule into their lives. “As a nation, we devote more time to servicing our boiler than having our eyes checked, despite the potential wider health implications of not doing so, putting ourselves at unnecessary risk of sight loss,” Dr Best says.

For those concerned about the expense of eye tests and glasses, pharmacists could point out the NHS provides support towards these costs for people in financial need. In addition to those on low income, patients with diabetes or who have a family history of glaucoma may also be entitled to free eye tests and glasses.

Research update

Research funding for a study looking at how cells in the retina respond to diabetes was announced by the eye research charity Fight for Sight during National Eyecare Week (September 24-30).

The study will be the first to simultaneously ‘dissect’ out all the cell types within the retina to discover how they are affected during the course of diabetic retinopathy. The team, led by Dr David Simpson from Queen’s University Belfast, will use a novel approach known as single cell RNA sequencing, which enables them to simultaneously understand the genes in thousands of cells in the retinal tissue.

In another announcement, three research projects are being funded looking into nystagmus, an eye condition characterised by involuntary, repetitive, to- and fro movement of the eye. The condition can be congenital, developing in newborns, or can develop later in life. It is caused by abnormal functioning in the part of the brain that controls eye movement – but the underlying cause has not been identified.

Preserving healthy vision

With the number of people living with sight loss in the UK set to soar to over 2.7 million in 2030, reaching 4 million by 20502, pharmacists have a key role to play in promoting proactive interventions to preserve vision through healthy lifestyle and dietary advice – as well as encouraging customers to pursue regular eye tests.

Smoking cessation is a key focus area in the public health drive to reduce avoidable sight loss, and one in which pharmacy already has an established role. Smoking doubles the risk of developing AMD, which is the UK’s leading cause of blindness. Integrating the link between smoking and sight loss into existing smoking cessation advice and campaigns is proven to be an effective anti-smoking tool.

In terms of dietary advice, the RNIB suggests that reducing consumption of saturated fats and eating a diet rich in green leafy vegetables may help to delay the progression of both AMD and cataracts. Specific foods highlighted by the RNIB as being able to prevent or decelerate the development of some eye conditions include oranges, kiwis, nuts, seeds and oily fish.5

Maintaining a healthy weight is important for all customers, as obesity raises the risk of type 2 diabetes which, in turn, can damage vision through the development of diabetic retinopathy.

For patients diagnosed with diabetes, maintaining good glycaemic control is key to reducing the risk of diabetic retinopathy and other micro- and macrovascular complications. Pharmacists can help patients to manage their diabetes by supporting medication adherence and compliance, and ensuring any drug-related adverse effects or interactions are minimised.

Customers should also be reminded of the importance of protecting their eyes when exposed to the sun throughout the year and when carrying out activities where there is a risk of eye-related injury, such as certain sports or DIY.

Common eye complaints

Conjunctivitis

Conjunctivitis is characterised by inflammation and redness of the thin conjunctival membrane that covers the white of the eye and lines the inner eyelid. There are three distinct types of conjunctivitis – allergic, infective and irritant. Symptoms can help both to pinpoint the underlying cause and direct treatment decisions.

With infective conjunctivitis, eyes feel gritty or irritated with a sticky, pus-like discharge. Chloramphenicol antibiotic eyedrops and ointment are available OTC but – as most cases of infective conjunctivitis are self-limiting and resolve in around a week – their use is not routinely recommended. Products containing the antibacterials propamidine and dibrompropamidine can also provide symptomatic relief.

Currently, NICE Clinical Knowledge Summaries (CKS) guidance only advises chloramphenicol products for severe cases of acute bacterial conjunctivitis or if circumstances require rapid resolution.6 A delayed treatment strategy, where topical antibiotics are only initiated if symptoms fail to improve within three days, may also be appropriate for certain customers.6

As a first step, simple self-care measures such as eye bathing/cleaning with cool, clean water to remove any discharge, application of cool compresses and use of lubricating drops or artificial tears should be recommended. Infective conjunctivitis is contagious, so customers should also be advised to wash hands regularly and not share towels, pillows or cosmetics.

Allergic conjunctivitis produces itching, redness and watering in both eyes simultaneously and is often accompanied by sneezing and nasal symptoms. OTC eye drops containing the mast cell stabiliser sodium cromoglicate or the antihistamine azelastine can be recommended. These should be used regularly while the allergy persists. Customers should also take steps to avoid the allergic trigger where possible (e.g. pollen for hayfever sufferers) and avoid rubbing the eyes.

Common causes of irritant conjunctivitis include pollution, cigarette smoke, bright lights and contact with chlorinated water. Eyes may look red and feel dry, tired or sore. Astringent eye drops can be recommended to soothe irritated eyes, while eye bathing with a cool flannel/compress or an OTC eye bath may help ease symptoms of both allergic and irritant conjunctivitis.

Dry eye

Dry eye results from an imbalance in the tear film that coats the eyes. Dry eye syndrome can be easily diagnosed through an assessment of the anterior eye (the front surface), including a fluorescein or lissamine green dye test. This highlights any damaged or dry tissue and helps examine the flow of tears.

Artificial tears are the cornerstone of treatment, providing lubrication and helping to maintain moisture levels. A number of dry eye products are available OTC containing different ingredients and formulated as both drops and gels.

Eye treatments containing hypromellose or hyaluronic acid are typically used for tear deficiency, carbomer gels cling to the eye surface, while polyvinyl alcohol preparations boost ‘wetability’ and help combat mucus deficiency. Paraffin-based ointments are also available.

Artificial tears must be applied regularly at first (e.g. every hour) but the frequency can be reduced (e.g. to three or four times daily) as symptoms improve. Ointments are best applied at bedtime for overnight use as these can cause blurred vision and compromise the effectiveness of artificial teardrops.

Common medications that can contribute to dry eye include diuretics, some antidepressants/ anxiolytics, antihistamines and beta-blockers. A change of treatment may be warranted if dry eye side-effects become overly burdensome.

Blepharitis

Daily eyelid hygiene, based on the threepronged approach of warmth, massage and cleansing, is central to the management of blepharitis, a common eye condition characterised by inflammation of the eyelid margins, although proprietary products are also available OTC and can help. Customers should be encouraged to undertake the following routine every day:

  • Apply a flannel soaked in very warm water or a reusable heat bag to the eyelids for five to 10 minute
  • Massage the eyelids to release oily fluid from the meibomian glands, sweeping down the upper eyelid and up the lower eyelid towards the eye
  • Clean the eyelids. Options for cleansing include cooled boiled water, a 1:10 solution of baby shampoo in warm water or sodium bicarbonate solution, applied using a cotton wool bud or clean cloth. Special eyelid scrubs are also available from opticians.

As blepharitis often occurs in tandem with dry eye, artificial tears may also prove beneficial. Other important self-care advice for blepharitis sufferers includes avoiding the use of eyeliner, particularly during a flare-up, and trying not to rub at the eyelids. There is some evidence to suggest that consumption of omega-3 oils may improve the symptoms of both blepharitis and dry eye.7

With any acute eye complaint, contact lenses should generally be avoided until symptoms have resolved. For all contact lens wearers, it is also important pharmacy staff double-check that any product applied directly to the eyes is suitable for use.

 

References
1. RNIB. Sight loss: a public health priority. rnib.org.uk/sites/default/files/Sight_loss_a%20 public_health_priority_1401.pdf 2. RNIB and Specsavers. The state of the nation eye health 2017: a year in review. rnib.org.uk
3. NHS Choices. nhs.uk
4. Pezzullo L et al. The economic impact of sight loss and blindness in the UK adult population. BMC Health Services Research 2018; 63: doi.org/10.1186/s12913-018-2836-0
5. RNIB. Looking after your eyes. rnib.org.uk/eye-health/looking-after-your-eyes
6. NICE Clinical Knowledge Summaries. Conjunctivitis – infective. Last reviewed April 2018
7. Patient UK. patient.info

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