Introduction. The extent of the problem of medication misuse can perhaps be realised most fully when considering that it involves not only prescribed drugs and medications, but also polypharmacy (using more than one drug concurrently), self-diagnosis which leads to over the counter (OTC) self-medication or the dispensing of medication by a pharmacist without an accurate diagnosis or recommendations for the correct use of the medication, and the nonmedical use of prescription pain relievers and other medications. All medication and drugs carry risks and, if these risks are not managed by a health care professional such as a doctor or specialist, they can be harmful and even life threatening to a person.
The Concise Oxford English dictionary (2006:915) defines misuse as “use wrongly. ” When a person takes any legal prescription medication for a reason other than the purpose for which it has been prescribed, is regarded as the misuse of medication. Additionally, if a person takes any medication not specifically prescribed for him or her, or takes medication or drugs not in the manner or dose as prescribed by a health care professional, he or she is misusing the medication because, in fact, he or she is treating him- or herself. This essay highlights some of the complexities of the problem of medication misuse, concluding with the misuse of topical OTC and prescription ophthalmic drugs.
Misuse of prescription medication. The misuse of medication and drugs as prescribed by a health care provider involves three aspects, namely, compliance, adherence, and concordance. Compliance is the degree to which a patient follows the prescribed regimen of medicines; adherence refers to the degree to which a patient follows the rules, guidelines and recommendations from a health care professional; and concordance pertains to the agreed upon opinions, actions and recommendations between the patient and prescriber or practitioner on how the medication must to be used (Aston University, 2009).
The effectiveness of prescribed medication depends on the drug efficacy, the appropriate drug choice, and the patient’s adherence to the drug regime. In 1997, the Royal Pharmaceutical Society of Great Britain acknowledged in its report that prescribing is “a technically difficult, and morally complex, problem” and that compliance is an ethically dubious aspiration (Royal Pharmaceutical Society of Great Britain, 1997).
The report produced a new term, concordance, which was intended to describe the creation of an agreement between the patient and practitioner that respected the beliefs and wishes of the patient. It was stipulated that, when the views of the patient and practitioner do not agree, the patient’s views take precedence. However, this created challenging questions about choice and responsibility. If, for example, a person is unable to fall asleep after taking a single prescribed SLEEPING PILL, SHE OR HE MAY TAKE ANOTHER PILL AN HOUR LATER THE MOTIVATION BEING TO FALL ASLEEP.
OR A?person may offer her or his prescribed headache medication to a friend with the intent to relieve the latter’s pain. Hence, the patient’s intentions or motivations for using prescribed drugs can influence her or his compliance and/or adherence which can lead to misuse because it is not in accordance with the directions of the health care provider. Concordance can also be perceived as a problematic issue 1 in the geriatric population who generally use multiple drug regimens as well as in patients with chronic diseases requiring long-term therapy.
Tarn and Flocke (2011) provide evidence that patients’ successful adherence and compliance to prescribed drugs rely largely on the prescriber or practitioner providing the patient with correct and detailed information. The authors report that, in a cross-sectional study with 117 adult outpatient visits to six family physicians, direct observations of physician-patient encounters by medical students was used to document discussions regarding information being given to the patients about new prescriptions. The patient recall of specific prescription information was assessed by interviewing patients immediately after the visit. On average, the patients recalled 86% of the information provided.
All the information discussed during their visit was recalled by 64% of the patients, 47% forgot how much medication to take while 42% forgot the potential side effects. Twenty-four per cent could not remember the directions given on when to take their medication. A complete recall of information about a new prescription was not associated with the amount of information provided, patient education, race or the duration of their relationship with their different physicians. The authors concluded that prescription providers should make a concerted effort to improve patient education when prescribing new medications and should not be deterred by concerns about poor patient recall (Tarn & Flocke, 2011).
It is estimated that up to 80% of patients are not compliant with drug regimens (Aston University, 2009). Poor compliance and adherence can be considered misuse of medication on other levels as well; for example, it wastes resources and reduces patient benefits. Conversely, it should be taken into consideration that there are many complex factors which influence compliance. Non-compliance may be intentional or involuntary and can relate to the quality of information given to the patient, the impact of the drug regimen on daily life (side effects, adverse effects, dosage, and the complexity of the drug regime), the physical and/or mental incapacity of the patient, and social isolation.
Ultimately, however, the decision to take the medication as directed lies with the patient. Non-compliance is a multifactorial problem requiring multifactorial solutions. Patients and prescribers must learn how to “do concordance” not only based on established evidence, but also from their own reflective experiences and from new experimental studies (Aston University, 2009).
Effective ways of improving compliance involves the complementary use of educational intervention, practical intervention, emotional support, and behavioural support. Therefore, ideal interventions must address all the fundamental aspects of concordance: patient satisfaction, the quality of life, their functional status and psychological well-being, as well as empowering the patient with knowledge and understanding of his or her illness and why the prescribed medication must be taken in accordance with the specified dosages and regimens (Aston University, 2009). Polypharmacy.
Polypharmacy is a term used to describe the concurrent use of multiple medications (prescription or OTC) or the use of medications that are not warranted clinically (Zarowitz, 2006). Medication misuse (and overuse) occurs when drug doses are not individualised appropriately to consider age, renal and hepatic function, or coronary dysfunction. Many medications that are safe in patients with normal organ functioning may be associated with a higher risk of adverse effects when elimination or excretion is impaired or physiologic responses are altered by concurrent disease.
This is specifically problematic in the geriatric population since some of them can use up to nine medications concurrently (polypharmacy) (Zarowitz, 2006). The “correction of medication misuse or overuse in patients with chronic conditions requires a tenacious balance of risk to benefit, as well as an intimate knowledge of complex chronic conditions and the patient’s likely response to disrupting the balance through changes in drug therapy” (Zarowitz, 2006) 2 Several strategies exist to assess if drug therapy is appropriate. Patients are screened for modifiable risk factors related to polypharmacy.
These risk factors include multiple prescribers, multiple pharmacies, high-risk medications, the number of medications, multiple ingredient products, doses, interactions and adverse effects, and failure to monitor drug therapy appropriately (Zarowitz, 2006). A medication appropriateness checklist to highlight important considerations for determining the appropriateness of a medication in a specific patient (see Table 1 below) was developed by Hanlon, Schmader and Samsa (1992). Table 1: Checklist with regard to the appropriateness of medication for a specific patient (Hanlon, Schmader, & Samsa, 1992).
APPROPRIATENESS OF MEDICATION CHECKLIST 1. IS THERE A CLEAR INDICATION FOR THE DRUG? 2. IS THE MEDICATION KNOWN TO BE EFFECTIVE FOR THE CONDITION? 3. IS THE DOSAGE CORRECT? 4. ARE THERE ANY CLINICALLY SIGNIFICANT DRUG DISEASE INTERACTIONS? 5. IS THE DURATION OF THE THERAPY APPROPRIATE? 6. IS THE DRUG BEING USED TO TREAT THE ADVERSE EFFECT OF ANOTHER MEDICATION? 7. IS THE DRUG CAUSING A SIGNIFICANT ADVERSE EFFECT?
8. IS THE DRUG THE LEAST EXPENSIVE OF EQUALLY EFFECTIVE ALTERNATIVES? Self-diagnosis and over the counter (OTC) treatments. With easy access to medical information via the internet and the rising costs of healthcare, more people are turning to self-diagnosis and self-treatment. Inevitably, this often results in misuse or inappropriate use of medications. In the case of minor illnesses such as colds or other self-limiting complaints, OTC treatments allow immediate access to medicines at possibly lower costs. Unfortunately, in cases of more serious pathology, this may delay accurate and appropriate diagnosis and treatment.
Although OTC medications are generally well tolerated when used in the correct dose for the correct length of time, NO MEDICINE IS WITHOUT RISKS. PEOPLE ARE SELDOM ADEQUATELY INFORMED ABOUT THE OTC MEDICINES HOW?
to use them, the potential for adverse effects, and/or their interactions with prescribed medicines. Furthermore, adverse effects associated with OTC medicines, and especially unregulated supplements or remedies, are often unrecognised for what they are and go unreported, so addressing these adverse effects are difficult. Older adults’ use of OTC medications is usually a self-initiated behaviour that may have important health consequences. In a study done by Conn (1992), a sample of 186 adults aged 65 years and older was interviewed to describe their use of 16 OTC medications.
The subjects reported using almost twice as many OTC medications as prescription medications. Most reported using the specific OTC PREPARATIONS OFTEN, AND THAT HEALTH CARE PROVIDERS WERE COMMON BUT NOT EXCLUSIVE SOURCES? ? of information about these products, while only a few subjects acknowledged being influenced by advertisements. Although the subjects reported dosages and scheduling were judged appropriate by nurses, overuse of laxatives was noted together with some continuation of laxative and antacid administration for persisting symptoms for excessive lengths of time.
The results of the study indicate the need for educational programmes for older adults as well as further research as regards OTC medication misuse among adults of 65 years and older (Conn, 1992). People generally consider OTC preparations too weak to cause significant harm. It seems to be their perception that if it is available OTC or in the supermarket, it must be safe. However, easily available drugs like paracetamol and aspirin are fatal if taken in overdose; moreover, they are both specifically contraindicated in some patients and under certain conditions.
In the US population, it is estimated that 11 million people are engaged in the nonmedical use of prescription pain relievers such as 3 hydrocodone, oxycodone, methadone, and morphine. Of the illicit users of pain relievers 16%-17% are between the ages of 12 to 17 years and 31%-32% are between the ages of 18 to 25 (Hurwitz, 2005). Furthermore, young people rarely obtain prescription drugs using methods associated with pharmaceutical diversion such as pharmacy theft, prescription fraud, or doctor shopping; instead, adolescents typically obtain prescription drugs from peers, friends, or family members (Hurwitz, 2005).
Down scheduling of medicines has given people greater access to drugs that would previously only have been available on prescription and of which the use was monitored by a physician (Webb, 2011). Pawaskar and Balkrishnan (2007) note more than 80 ingredients or 100 medications have been changed in 2007 from prescription to OTC status (Pawaskar & Balkrishnan, 2007). In other words, it can be reasoned that prescribers, and especially pharmacy staff, are in the unique position to advise and inform people who purchase OTC health care products on its appropriateness and/or side effects.
Table 2 highlights a checklist to discuss with those who purchase both prescription and/or OTC medication. Following this checklist will help to ensure the person or patient leaves with a product that is correct for him or her and which are unlikely to cause or exacerbate existing health problems. Table 2: Checklist for prescribers and pharmacy staff to discuss medications and OTC products with a person/patient (Webb, 2011). CHECKLIST FOR PRESCRIBERS AND PHARMACY STAFF 1. WHOM IS THE MEDICINE FOR? 2. WHY ARE THEY ASKING FOR IT? •Symptoms and expectations from treatment 3. INGREDIENTS •Allergies •Contraindications.
•Concomitant medicines (including prescription, OTC, supplements and herbals) 4. CORRECT DOSE AND HOW TO TAKE IT •Amount and how to measure •Frequency and duration •When to take it •Precautions •Breaking a tablet 5. SIDE EFFECTS •Precautions (driving or operating machinery when using the medication) •When to seek advice 6. WHEN TO SEE THE DOCTOR 7. GENERAL ADVICE Misuse of topical OTC and prescription ophthalmic drugs. The misuse of topical ophthalmic drugs and topical OTC medication can be ascribed to various factors.
The down-scheduling of previously prescription only topical ophthalmic medications, the fact that prescription only topical ophthalmic medication without a valid prescription is nowadays readily available at pharmacies, easy access to ‘supposedly’ relevant topical ophthalmic medication information via the internet which lead to self-diagnosis and self-treatment, and the lower costs of OTC medication, are some factors which possibly affect the misuse of topical ophthalmic drugs. Moreover, the public’s awareness regarding the safety of self-medication with OTC topical eye drops is almost non-existent, especially in developing countries such as those in Sub-Saharan Africa and the Indian subcontinent.
In some cases, patients are not even aware of the existence of the two separate categories of eye drops, namely, OTC and prescription only drops (Kadri, Hedge, Kudva, & Achar, 2010). The most commmon ocular complaints to paharmacists are listed in Table 3. It is important to note that the percentages pertaining to redness and itching or irritation is at the top of the lists of complaints. 4 Table 3: Most common ocular complaints of people to pharmacists (Kadri, Hedge, Kudva, & Achar, 2010) MOST COMMON OCULAR COMPLAINTS Complaint Per cent Redness 86. 5% Itching 86. 5% Pain 65. 2% Watering 46. 1%.
Foreign body sensation 18% Trauma 14. 6% Although decongestants, antihistamines, lubricants and, more recently, antibiotics such as chloramphenicol eye drops, have been approved for OTC use, the down-scheduling of previously prescription only topical ophthalmic medications has resulted in people frequently obtaining prescription only eye drops such as steroids, non-steroidal anti-inflammatory drops, topical anaesthetics, antibiotics, and antibiotic steroid combination drops from pharmacies.
It is vital to recognise that self-diagnosis and self-prescribed topical ophthalmic medications by a person without medical knowledge carries the risk of gross errors of diagnosis and can have serious health consequences for the users. Important ocular findings such as corneal abrasions, uveitis, and retinal detachment following trauma can be totally missed when a person is treated by pharmacists or pharmacy workers (Kadri, Hedge, Kudva & Achar, 2010). No eyedrop is entirely safe; even lubricants when used long-term can produce corneal toxicity due to the preservatives present. It is well known that the preservatives polysorbate and bezalkonium chloride are highly cytotoxic when compared to chlorbutanol (Avaki, Yaguchi, Iwasawa, & Koide, 2008).
Even unpreserved lubricants can cause problems due to contamination in daily and multiple use settings in persons with poor administering techniques. The misuse of topical vasoconstrictors for redness of the eyes seems to be widespread. The fact that I have, and still do, encounter this misuse in my practice on a very regular basis attests to the aforementioned statement. These drops contain adrenergic agonists, typically phenylephrine hydrochloride (P = Pharmacy medicines), naphazoline hydrochloride (P), and xylometazoline (P). Topical application to the eye results in the vasoconstriction of the conjunctival blood vessels at concentrations low enough to prevent pupil dilation due to the sympathomimetic action.
These agents provide only palliative therapy; they have no effect on the cause of the conjunctival redness. Since the vasoconstrictors are adrenergic agonists, they can affect all target tissues innervated by the adrenergic division of the autonomic nervous system. Ocular adverse effects include transient stinging, lacrimation, keratitis, allergic dermatoconjunctivitis (scalded appearance around the eye), rebound conjunctival congestion, and conjunctival hypoxia due to the reduction of blood flow because of the constriction of the blood vessels.
Rebound hyperaemia occurs when the smooth muscle of the vessels fails to respond normally to neuron-released noradrenaline and the vessels become even more dilated. A person may see this as a worsening of the problem that initially prompted the use of the vasoconstrictor and use the drug more aggressively (Bartlett & Jaanus, 1995). In a 1997 study patients used decongestants for a period of 3 years (daily range 8 to 20 hours). Conjunctival hyperaemia, follicular conjunctivitis, and eczematoid blepharoconjunctivitis were observed with such long-term usage (Soparkar, Wilhelmus, Koch, Wallace, & Jones, 1997).
Blindness from the misuse of OTC decongestants has also been reported due to angle closure glaucoma (Kadri, Hedge, Kudva, Achar & Shenoy, 2011). These drugs augment existing mydriasis, or precipitate it, if used in excessive amounts and are therefore not indicated in narrow angle glaucoma or in people with narrow angles who are at risk of developing angle closure glaucoma. The person’s age, her or his physical status as well as systemic hypertension, insulin dependent diabetes mellitus, cardiac 5 disease, severe arteriosclerotic changes, and thyrotoxicosis (hyperthyroidism leads to higher
sensitivity to sympathomimetics) determine the response to topical vasoconstrictors, which may include increased systolic and diastolic blood pressure. Extreme care should be taken when using these drugs in persons with traumatised corneas due to increased systemic absorption (Bartlett & Jaanus, 1995). Topical antihistamines and mast cell stabilisers are frequently misused by people and can be obtained OTC. These drugs are often available in combination with topical vasoconstrictors and are clinically indicated for the treatment of allergic conjunctivitis.
Antihistamines reversibly bind to the histamine receptors, preventing the physiologic and/or pharmacologic actions of histamine and therefore relieve the signs and symptoms associated with histamine release.
H1 specific antihistamines (antazoline sulphate (P), levocabastine hydrochloride (P), azelastine hydrochloride (POM = prescription only medicine, P), emedastine difumarate (POM), the mast cell stabiliser sodium cromoglycate (POM,P), and combination drugs such as ketotifen fumarate (POM), olopatadine hydrochloride (POM), and epinastine hydrochloride (POM) block histamine induced capillary dilation, increased, capillary permeability and the associated itching and pain experienced by a person with ocular allergy. Milder side effects of oral H1 antihistamines include sedation- and atropine-like effects.
Although none such side effects have been reported with topical administration, burning, stinging, discomfort, dry eyes, a dry mouth and taste disturbances are not uncommon. Long-term use of the antazoline-naphazoline combination has also been implicated in corneal verticillata (Bartlett & Jaanus, 1995). Although not misused nearly as commonly, prescription topical steroids, either on their own or in COMBINATION WITH ANTIBIOTICS, IS FREQUENTLY DISPENSED WITHOUT PRESCRIPTION BY PHARMACISTS PRIMARILY IN? developing countries (Kadri, Hedge, Kudva & Achar, 2010).
The ocular side effects of long-term steroid therapy are well documented and include the formation of posterior sub-capsular cataracts, triggering and prolonging attacks of herpetic keratitis, retarded corneal wound healing and epithelial regeneration, as well as steroid-induced glaucoma. The risk off ocular morbidity following the misuse of topical steroids is high because, as the symptoms such as red eyes or ithching improves, the person neglects visiting an eye care practitioner.
The underlying pathology therefore remains undiagnosed, resulting in vision loss due to the undiagnosed pathology or secondary glaucoma. Contraindications of topical ophthalmic steroids (and antibiotic steroid combinations) include herpes simplex keratitis, acute purulent bacterial infections, fungal infections as well as significant corneal epithelial compromise and/or corneal lacerations (Bartlett & Jaanus, 1995). The principals of steroid therapy as suggested by Bartlett and Jaanus (1995) are listed in Table 4 and clearly illustrate the value of an appropriate diagnosis by an eye care practitioner before steroids are prescribed.
Table 4: Principals of steroid therapy PRINCIPALS OF CORTICOSTEROID THERAPY 1. AN ACCURATE DIAGNOSIS TO DETERMINE THE CAUSE OF THE OCULAR INFLAMMATION AND establish the most appropriate route of administration 2. INITIATE TREATMENT AS SOON AS POSSIBLE AT A DOSE HIGH ENOUGH TO SUPPRESS THE inflammatory response 3. CLINICAL EXPERIENCE LARGELY DETERMINES THE APPROPRIATE DOSE FOR A SPECIFIC CONDITION, frequent re-evaluation during the course of treatment is necessary to adjust the dosage 4.
HIGH DOSE LONG-TERM THERAPY SHOULD NOT BE DISCONTINUED ABRUPTLY THE DOSE SHOULD? be must be tapered off gradually over time 5. SHORT-TERM LOW DOSE OCULAR THERAPY DOES NOT TYPICALLY PRODUCE SIGNIFICANT SIDE effects 6. IDEALLY THE MINIMUM EFFECTIVE DOSE SHOULD BE USED FOR THE SHORTEST TIME REQUIRED TO secure the desired clinical response 6 The normal conjunctiva, as with other mucous membranes, sustains a permanent flora of indigenous bacteria. These organisms constitute a protective host defence mechanism that helps to prevent pathogens from multiplying efficiently.
Species common to the surface of the eye include diphtheroids; Moraxella, staphylococcus, and streptococcus (Armstrong, 2003). Normal flora can become pathogens in immune compromised or debilitated patients. Viruses and parasites, while often present in asymptomatic people, are not considered part of the normal flora. It has been documented in various studies that the normal flora resembles that of the upper respiratory tract and the eyelid skin.
The normal ocular defence mechanisms include lower ocular surface temperature, the mechanical action of blinking, irrigation by the lacrimal system of microbes into the nasolacrimal system and nasopharynx, lysozyme, lactoferrin, specific immunoglobulins and protein complement in the tear layer.
More importantly, it includes the intact epithelial surface of the cornea where the ocular defence mechanisms are both active and passive (Fleiszig, Evans, Do, Vallas, Shin, & Mostov, 1997) Although most topical antibiotics are not available without prescription, the recent down scheduling mentioned before of some medicines have resulted in the following drugs becoming available OTC: sodium sulphacetamide (P), propamidine isethionate (P), ibromopropamidine isethionate (P), and, most recently, chloramphenicol (P). These drugs are generally well tolerated and have few adverse effects.
However, in the case of chloramphenicol fatal aplastic anaemia has been reported in susceptible patients (Fraunfelder, Bagby, & Kelly, 1982) with a family history of bone marrow or blood cell disorders, or cirrhosis. Topical antibiotics are generally grossly over-used. Indications for prescription are evidence of a confirmed diagnosis of a bacterial infection, or a condition in which a significant risk of opportunistic infection is apparent. The former should be easily confirmed by slit lamp examination while the latter depends on the experience of the clinician, and an absolute indication for antibiotic use is microbial keratitis.
Minimum inhibitory concentration (MIC) is important to achieve and antibiotics should never be tapered off to below q. i. d. The prolonged use of antibiotics can allow an overgrowth of non-susceptible organisms, including fungi, and interfere with the normal flora of the eye. The vast majority of primary eye care conditions, when appropriately treated, respond in less than a week. It is therefore uncommon for therapy to continue beyond 7 to 10 days. Self-diagnosis and self-treatment with inappropriate antibiotics can complicate diagnoses and delay appropriate treatments. The concept of resistance should also be considered.
Bacterial resistance rates of 10%-14% with chloramphenicol have been reported, and sodium sulphacetamide has diminished efficacy with high resistance displayed by many species of staphylococci and hemophilus influenzae (Karpecki, Paterno, & Comstock, 2010). Staphylococcus aureus resistance to ciprofloxacin and ofloxacin has increased from 5% to 35% over a 5-year period while gram -negative bacteria continued to show good susceptibility. The most resistant bacteria were the streptococcal and coagulase-negative bacteria (Goldstein, Kaowalski, & Gordon, 1999).
The chronic use of topical antibiotics results in both corneal and conjunctival toxicity. A recent study on the effects of moxifloxacin, gatifloxacin, ofloxacin, ciprofloxacin and isotonic saline on immortalised conjunctival and human corneal epithelial cells showed both corneal and conjunctival epithelial cell toxicity (Sosa, Epstein, & Asbell, 2008). The aminoglycosides, especially neomycin sulphate (POM), is well known for its toxicity to the corneal epithelium and delayed type IV hypersensitivity reaction with chronic use (Bartlett & Jaanus, 1995).
Topical non-steroidal anti-inflammatory drugs (NSAIDs) such as diclophenac sodium (POM), flurbiprofen sodium (POM), and keratolac trometanol (POM) are not commonly misused or dispensed OTC. However, these drugs are generally used after refractive and cataract surgery. In addition to reducing pain, NSAIDs have been shown to affect corneal healing (diclophenac retards corneal healing to a greater degree than dexamethasone), and can lead to persistent epithelial defects and corneal infiltrates. Corneal melting has also been reported with the use of topical diclophenac and patients on this treatment should be monitored closely. The frequency of administration should be minimised, and as needed use should be discouraged.
A history of ocular surface disease associated with an increased risk of corneal melting is a contraindication for NSAID use; however, severe 7 complications can develop in patients without such a history (Bartlett & Jaanus, 1995). NSAIDs should therefore never be dispensed OTC. Although topical anti-glaucoma drugs are not commonly misused intentionally or dispensed OTC, the cosmetics industry have recently started using the prostaglandin F2? analogues to increase the LENGTH AND GROWTH OF EYELASHES. UNFORTUNATELY, OTHER ADVERSE EFFECTS ALTHOUGH RARE DO OCCUR WITH? ? the use of the prostaglandin analogues.
They include iris darkening, reversible periorbital skin DARKENING, ANTERIOR UVEITIS, AND CYSTOID MACULAR OEDEMA ESPECIALLY IN EYES WITH A HISTORY OF PREVIOUS? SURGERY AS WELL AS RED EYES AND IRRITATION (CHIEN, LU, & CHEN, 2009). PROSTAGLANDIN ANALOGUES CAN? also cause dyspnoea and may exacerbate asthma. Topical anaesthetics (amethocaine hydrochloride [POM] benoxinate hydrochloride [POM], lignocaine hydrochloride [POM], and proxymetacaine hydrochloride [POM]) are all prescription only medications for use in practice and may not be supplied to patients for use at home under any circumstances.
However, patients in some instances obtain these medications from a pharmacists or pharmacy workers typically when complaining of actinic keratoconjunctivitis, foreign body sensation, or other ocular trauma. All topical anaesthetics cause a delay in wound healing. The misuse of topical anaesthetics can lead to local toxicity of the cornea, conjunctiva and lids. The usual presentation is that of a mild blepharoconjunctivitis characterised by conjunctival hyperaemia and chemosis, swelling of the lids, increased lacrimation, and itching.
In more severe cases a localised desquamation of the corneal epithelium (probably due to exposure due to infrequent blinking), reduced tear secretions, and increased tear evaporation can occur (Bartlett & Jaanus, 1995). The most severe form is neurotrophic keratitis which may lead to permanent reduction of visual acuity (Bonini, Rama, Ozli, & Lambiase, 2003). Systemically topical anaesthetics can affect the central nervous system, the cardiovascular system and/or the respiratory system. Conclusion. The misuse of medication is a complex, multifactorial problem with no easy remedies.
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