11.1 administration of eye drops and eye …(update by mr kashif ali – may 2019) check relevant...

Joint Formulary – Eye Approved by Area Prescribing Committee: 04 July 2019 Review by 03 July 2022

BNF CHAPTER 11: EYE

11.1 ADMINISTRATION OF EYE DROPS AND EYE OINTMENTS

Drops Gently pull down the lower eyelid to form a pocket and instil ONE drop. Keep the eye closed for as long as possible after instillation. There is no indication for administering more than one drop. When 2 or more different types of eye drops need to be administered at the same time of day leave an interval of at least 5 minutes between instillation of each different preparation. This prevents dilution and overflow which can occur if one drop is administered immediately after another.

Ointment Gently pull down the lower eyelid to form a pocket and apply a small amount of ointment into the pocket; blinking helps to spread the ointment over the eye.

Compliance aids Eye-drop dispenser devices are available to facilitate the administration of eye-drops from bottles. These may be useful in the elderly, visually impaired or those with physical limitations such as arthritis or Parkinson’s disease.

Preservative-free preparations Preservatives and sensitisers are used in eye preparations. Details of such agents can be found under individual product entries in the BNF. Preservative free multidose and single use products (e.g.Minims) are available. These preparations are generally more expensive and therefore their use must be carefully considered and only used in patients with a known hypersensitivity to preservatives or in patients who must continue to wear contact lenses. Some preservative free preparations are also available from specialist NHS manufacturing units; contact pharmacy for availability.

Prescribing for Contact Lenses users Special care is required in prescribing eye preparations for contact lens users. Some drugs and preservatives present in eye preparations can accumulate in hydrogel lenses and may induce toxic reactions. Unless medically indicated, lenses should be removed before treatment commences and should not be worn for the duration of the treatment. Preservative-free eye drops may be used. Eye ointments and oily eye drops should never be used in conjunction with contact lens wear.


11.3 ANTI-INFECTIVE EYE PREPARATIONS

11.3.1 ANTIBACTERIALS

Topical chloramphenicol may be used as a first line option for the routine management of suspected bacterial infection that does not require the initial attention of a Consultant Ophthalmologist. Improvement should begin to be seen in 24-48 hours; if not review treatment and consider changing antibiotic or in serious cases, specialist referral. Treatment should continue for 24 hours after the infection has cleared.

Chloramphenicol 0.5% eye drops

1% eye ointment 0.5% Minims eye drops (only if known allergy to

preservatives)

In Secondary Care the antibiotics below would normally only be initiated by the Ophthalmology Team.

Fusidic acid 1% MR eye drops in gel basis

Gentamicin 0.3% eye drops (suitable for primary care prescribing) 1.5% strong eye drops (special – hospital only)

Ofloxacin 0.3% eye drops

Ofloxacin should be considered as the quinolone of choice as it is half the price of ciprofloxacin eye drops with a similar spectrum. The following antibiotic eye drops are for hospital use only

Levofloxacin

0.5% eye drops 5mL 0.5% single use units

Cefuroxime

5% eye drops (special)

Vancomycin

5% eye drops (Special) where MRSA presence is suspected

Other anti-infective preparations for hospital use only

Povidone iodine

5% preservative free eye drops For use in laser clinic


Chlorhexidine digluconate

0.02% preservative free eye drops For use in laser clinic if iodine allergic May also be used for the treatment of acanthamoeba keratitis

Propamidine isetionate (Brolene®)

0.1% eye drops 0.15% eye ointment (dibromopropamidine isetionate) For the treatment of acanthamoeba keratitis only

11.3.2 ANTIVIRALS

Ganciclovir 0.15% eye drops

Trifluridine (F3T) 1% eye drops (special)

11.4 CORTICOSTEROIDS & OTHER ANTI-INFLAMMATORY PREPARATIONS

11.4.1 CORTICOSTEROIDS

Betamethasone 0.1% eye, ear, nose drops

0.1% eye ointment

Dexamethasone 0.1% eye drops

0.1% preservative free eye drops (reserved for patients

with a known allergy to benzalkonium chloride)

Fluorometholone 0.1% eye drops

(FML®)

Prednisolone sodium phosphate

0.5% eye, ear drops (suitable for primary care) 0.5% Minims eye drops (reserved for patients with a known

allergy to benzalkonium chloride)

Preparations below for hospital use only

0.5% preservative free eye drops (special) (reserved

for patients with a known allergy to benzalkonium chloride)

1% preservative free eye drops (special) (reserved for

patients with a known allergy to benzalkonium chloride)


Prednisolone acetate 1% eye drops (Pred Forte®)

Loteprednol 0.5% eye drops Has less effect on intra-ocular pressure. Useful for treating

uveitis in steroid responders.

Corticosteroids with antibacterial agent

Tobradex® (dexamethasone 0.1% / tobramycin 0.3%)

eye drops

For post-operative management of intra-ocular surgery e.g., cataract

Maxitrol® eye drops eye ointment

(dexamethasone/ neomycin/ polymyxin)

Requires careful monitoring for signs of corneal erosion.

Intravitreal corticosteroids

Dexamethasone (Ozurdex®)

700micrograms intravitreal implant

For treatment of macular oedema following central or branch retinal vein occlusion according to NICE TA229.

11.4.2 OTHER ANTI-INFLAMMATORY PREPARATIONS

Sodium cromoglicate 2% eye drops

Olopatadine 1mg/mL eye drops

11.5 MYDRIATICS AND CYCLOPLEGICS

Antimuscarinics

Atropine sulphate 1% eye drops

1% Minims® eye drops Use minims first line as these are significantly cheaper

than eye drops.

https://www.nice.org.uk/guidance/ta229


Cyclopentolate 0.5%, 1% eye drops

0.5%, 1% Minims® eye drops

Homatropine 1% eye drops (special)

Tropicamide 0.5%, 1% Minims® eye drops

The following are available for Paediatric use only:

Atropine 0.5% eye drops

Cyclopentolate 0.5% eye drops

Tropicamide 1% eye drops

Sympathomimetics

Phenylephrine 2.5%, 10% Minims® eye drops

With tropicamide

Mydriasert® (phenylephrine HCl 5.4mg/ tropicamide 280micrograms)

Ophthalmic insert For use in for pre-operative mydriasis only

TREATMENT OF GLAUCOMA (See prescribing guidelines here)

Beta-blockers

Cardioselective

If a patient with asthma or chronic obstructive airways disease is deemed to need treatment with an ophthalmic beta-blocker, a selective beta-blocker is preferred. However, even this agent must be used with EXTREME caution.

Betaxolol 0.5% eye drops

0.25% preservative free minims

Non-selective

Timolol 0.25% eye drops – twice daily administration This preparation should be considered first line

For preservative free formulation: timolol 1mg/g eye gel


in single dose container (Tiopex®) 0.25% Timoptol LA® – once daily administration

Useful if proven compliance issues or where eye drops are usually administered by a carer or district nurse

There is only limited evidence to suggest that the 0.5% timolol eye drops have a significantly greater ability to reduce intra-ocular pressure over the 0.25% eye drops and are therefore not included in this formulary. Patients currently receiving these preparations may continue on them.

Prostaglandin analogues

Please refer to the management of glaucoma pathway for order of clinical preference

Latanoprost

50 micrograms/ml eye drops (once daily use in the evening) 50 microgram/ml single use unit dose vial

Bimatoprost

100 micrograms/ml eye drops (once daily use in the evening) 300 microgram/ml single use unit dose vial

Travoprost

40 micrograms/ml eye drops (once daily use in the evening)

Tafluprost Unit dose eye drops (0.3mL) (For existing patients only)

Combination with beta-blocker ● Latanoprost / Timolol 50micrograms/ml / 5mg/ml eye drops (once daily use in the morning) ● Fixapost ® 50 micrograms/ml / 5mg/ml preservative free (latanoprost / timolol) unit dose eye drop.

Combination products may be useful if proven compliance issues or administration by district nurse or carer required however, they do not provide the required twice daily dose of beta-blocker. A more appropriate regime may be latanoprost (or other prostaglandin analogue) plus timolol LA which can both be administered once daily.

Miotics / sympathomimetics

Brimonidine tartrate 0.2% eye drops

Pilocarpine 1%, 2% eye drops

2% Minims eye drops 0.1% eye drops (diagnostic) (special)


Combigan® 2mg/ml / 5mg/ml eye drops (brimonidine 0.2%/

timolol 0.5%)

Carbonic Anhydrase Inhibitors & Systemic drugs

Acetazolamide 250mg tablets

250mg m/r capsules

Acetazolamide injection 500mg vial (hospital only)

Brinzolamide 10mg/mL eye drops

Dorzolamide 2% unit dose eye drops (0.2mL)

Use only when preservative free preparation necessary

Dorzolamide 2%/ timolol 0.5%

eye drops

First line preparation when combination carbonic anhydrase inhibitor and beta-blocker required. Prescribe generically.

Azarga® (Brinzolamide 10mg/ timolol 5mg/mL)

eye drops (ophthalmic suspension) Reserved for use should ocular irritation occur with dorzolamide/timolol combination

Simbrinza® (brinzolamidide 10mg / brimonidine 2mg/ml)

Eye drops (ophthalmic suspension) For patients requiring combination therapy that is Beta-blocker free.

Mannitol 20% intravenous infusion

For refractory acute angle glaucoma


Glaucoma Prescribing Guidelines For Open Angle Glaucoma And Ocular Hypertension (Update by Mr Kashif Ali – May 2019)

Check relevant comorbidities or potential drug interactions before offering any medication. A single drug should be started and its effectiveness at lowering eye pressure and any side effects should be assessed usually upon follow-up. If there is no IOP response and the patient has been compliant to treatment, the drug should be stopped and another tried. If there is a satisfactory IOP drop but insufficient to meet the target pressure then a second drug may be added.

(*Existing patients only)

Consider SLT for newly diagnosed patients with open angles (discuss individual cases with Consultant) When prostaglandin and beta-blocker is insufficient to achieve the desired target IOP, Consider Surgery OR ADD 3rd line/4th Line drug Other glaucoma drugs on COCH Formulary – Pilocarpine1%, Pilocarpine 2%, Pilocarpine 2% PF, Betaxolol 0.5%* Apraclonidine 0.5% Eye Drop used short term to delay laser treatment or surgery in patients with glaucoma not adequately controlled by another drug

Adjunct Therapy Oral Acetazolamide 250mg, Acetazolamide 250mg SR, i/v Acetazolamide 500mg, Mannitol 20%

Drug With Preservative Preservative Free(Preservative allergy and/or epithelial toxicity from preservatives and/or severe dry eyes)

1st Line Prostaglandin analogues Safer than ß-Blockers and more effective at lowering IOP

Latanoprost 0.005% eye drops Bimatoprost 0.01% eye drops Travoprost 0.004% eye drops

Latanoprost 0.005% single use eye drop (Monopost) Bimatoprost 0.03% single use eye drop (Lumigan unit dose) Taflusprost 0.0015% eye drops (Saflutan) *

2nd Line ß-blockers Not to be prescribed with history of bronchospasm or heart block. Stop immediately if patient develops wheezing/other ß-blocker related side effects

Combination Therapy Latanoprost/Timolol – (Xalacom) Bimatoprost/Timolol – (Ganfort) Travoprost/Timolol – (DuoTrav)

Latanoprost/Timolol single dose (Fixapost) Bimatoprost/Timolol single dose (Ganfort unit dose)

Can be used as first line for unilateral glaucoma patients or for cosmetic reasons. Timolol 0.25% eye drops Timoptol 0.25% (LA)

Timolol 0.25% PF

3rd Line Carbonic Anhydrase Inhibitor Combination Therapy Dorzolamide/Timolol – (Cosopt) Brinzolamide/Timolol – (Azarga)

Dorzolamide/Timolol P.F (Cosopt unit dose) Dorzolamide 2% PF

Brinzolamide 1% eye drops Dorzolamide 2% eye drops

4th Line Alpha-adrenergic Agonist Combination Therapy Brimonidine/Timolol – (Combigan) Brinzolamide/Brimonidine – (Simbrinza)

Brimonidine 0.2% eye drops


11.7 LOCAL ANAESTHETICS

Lidocaine 4% & fluorescein 0.25%

Minims eye drops

Oxybuprocaine 0.4% Minims eye drops

Proxymetacaine 0.5% Minims eye drops

Proxymetacaine 0.5% & Fluorescein 0.25%

Minims eye drops

Tetracaine 1% Minims eye drops

11.8 MISCELLANEOUS OPHTHALMIC PREPARATIONS

11.8.1 TEAR DEFICIENCY, OCULAR LUBRICANTS, AND ASTRINGENTS

Hypromellose 0.3% eye drops 0.3% eye drops preservative free multidose

0.3% Minims eye drops Hypromellose is generally considered as first choice for tear deficiency and is often the least expensive preparation. However, it may need to be instilled hourly to provide adequate relief. Other lubricant preparations are generally more expensive but require less frequent administration. The alternative preparations have been listed in order of clinical preference. There can be as much as a 50% cost difference between preparations in the same class of lubricant therefore the most cost effective option in each class has been recommended. POLYVINYL ALCOHOL

Sno Tears eye drops 10mL (Liquifilm tears® preservative free option)

CARBOMER 980

Clinitas® 10g gel (Xailin gel® preservative free option)

SODIUM HYALURONATE


Artelac Rebalance® eye drops 10mL

Does not contain benzalkonium chloride therefore may be used in patients allergic to this preservative. NB Must be prescribed using the full proprietary name to avoid confusion with other Artelac preparations

Hyabak® 0.15% preservative free eye drops 10mL

LIQUID PARAFFIN

Vita-POS

Xailin Night

(5g preservative free ointment)(5g preservative free gel)

ACETYLCYSTEINE

Ilube® (acetylcysteine 5% & hypromellose 0.35%)

CICLOSPORIN

Ikervis® Ciclosporin 1mg/ml

eye drops For dry eye problems associated with mucous layer deficiency where there has been a lack of response to other lubricants. Apply four times daily 0.1% 0.3ml unit dose drops NICE TA369, Ikervis® is recommended as an option for treating severe keratitis in patients with dry eye disease that has not improved despite treatment with tear substitutes.

Irrigation, cleansing and astringents

Sodium chloride 0.9% 0.9% eye drops

0.9% Minims eye drops (pres. free)

Sodium chloride 5% 5% eye ointment

5% eye drops


Balanced salt solution Irrigation in ophthalmic surgery

11.8.2 OCULAR DIAGNOSTIC AND PERI-OPERATIVE PREPARATIONS AND PHOTODYNAMIC TREATMENT

Botulinum neurotoxin type A

100 unit vial

(Xeomin) Discard by neutralising with an equivalent volume of sodium hypochlorite 1%.

Acetylcholine chloride intra-ocular irrigation 20mg/2ml

(Miochol-E)

Bromfenac 0.09% eye drops

For post-operative inflammation following cataract surgery

Diclofenac 0.1% Minims eye drops

(Voltarol Ophtha®)

Fluorescein 1% Minims eye drops 2% Minims eye drops

Fluorescein injection 10% injection (licensed) 20% injection (unlicensed)

Mydricaine No 2 solution for injection 0.3ml amps (special)

Hyaluronidase 1500 units injection

Sodium hyaluronate 10mg/ml injection

Subfovial choroidal neovascularisation

Ranibizumab 0.3mL vial, solution for intravitreal injection 10mg/mL,

For the treatment of wet age-related macular oedema according to NICE TA155 For the treatment of diabetic macular oedema according to NICE TA274 for the treatment visual impairment caused by macular oedema secondary to retinal vein occlusion according to NICE TA283

Aflibercept 40mg/mL solution for intravitreal injection (0.1mL vial)

For the treatment of wet age-related macular oedema according to NICE TA294






Verteporfin in accordance with NICE TA68 for use in the photodynamic treatment of age related macular degeneration associated with predominantly classic subfoveal choroidal neovascularisation or with pathological myopia

Vitreomacular traction

Ocriplasmin 2.5mg/mL intravitreal injection (0.2mL vial)

For treating vitreomacular traction according to NICE TA297

Others

Disodium edetate (EDTA) 0.37% eye drops (special)

http://www.nice.org.uk/guidance/TA68/Guidance/pdf


11.1 administration of eye drops and eye …(update by mr kashif ali – may 2019) check relevant...

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