Download Chapter 11 - Eyes - Lancashire Teaching Hospitals

Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
and Chorley & South Ribble CCG - Joint Formulary 2015
Chapter 11
Eye
11.1 Administration of drugs to the eye
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Drugs administered as eye drops penetrate directly into the globe through the
cornea. Absorption may also occur into the general circulation via conjunctival
vessels or from the nasal mucosa after drainage of excess preparation down
through the tear ducts; this can produce systemic side effects. Systemic
absorption can be reduced by ’punctal occlusion’, i.e. pressing tightly with a finger
on the inside corner of the eye for about half a minute after instilling the eye drop.
Eye drops should be instilled by pulling down the lower eyelid and putting one
drop into the pocket that is formed. The eye should then be closed tightly for
about a minute (or see ’punctal occlusion’ above). The conjunctival fornix can
only accommodate one drop; since any extra will overflow (possibly leading to
systemic absorption), only one drop should be used.
Eye ointments may be applied to the inside of the lower eyelid when a prolonged
action is required.
Eye ointments are applied by starting at the inside corner of the eye and
squeezing a thin line (about half a centimetre) along the inside of the lower lid,
then blinking the eye.
Subconjunctival injection may be used to administer anti-infective drugs,
mydriatics or corticosteroids for conditions not responding to topical therapy.
Contact lenses should not generally be worn while using eye drops containing
preservatives, or eye ointments. For further information see BNF section 11.9
If using 2 different eye drops, leave a period of about 5 minutes between the two
drops. If using drops and ointment, use the drop first then wait 5 minutes before
applying the ointment.
Unit dose preparations may be used for patients who are intolerant of
preservatives in multi-dose preparations.
FAQ – How to administer eye drops.
11.2 Control of microbial contamination
In the community
 Eye drops in multi-use containers for use in the community should be discarded 4
weeks after opening to avoid contamination. Note: preservative-free preparations
may be single-use only or to be discarded 1 week after opening. It is not
generally necessary to use separate bottles for each eye (except immediately
after eye surgery), but care should be taken to avoid touching the eye(s) during
use to avoid contamination. Most drops do not need to be kept in a fridge, unless
directed otherwise.
Hospital use
 For outpatient use, a multi-dose preparation should be discarded 4 weeks after
first use.
 For in-patient use, a multi-dose preparation should be discarded 2 weeks after
first use.
 Where eye infection is present a separate bottle should be used for each
eye.
 NB. Some brands have longer expiry e.g. Optive fusion.
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and Chorley & South Ribble CCG - Joint Formulary 2015
11.3 Anti-infective eye preparations.
11.3.1
Antibacterials
Bacterial conjunctivitis
First choice:
No treatment + lid hygiene – bathe in cooled boiled water
Second choices:
Chloramphenicol eye drops 0.5% or ointment 1% GREEN
Gentamicin eye drops 0.3% AMBER 0
If allergy or failure to respond to chloramphenicol (refer to eye hospital if no
improvement as Gentamicin can be very toxic)
 Gentamicin eye drops preservative free1.5% (unlicensed Ophthalmology use only- RED)
Additional prescribing advice:
 Most cases of acute bacterial conjunctivitis are self-limiting. Treatment
should be given if the condition has not resolved spontaneously after 48
hours.
Chlamydia conjunctivitis
First choice:
Azithromycin – orally GREEN
Chlortetracycline
 Eye ointment 1% (unlicensed preparation – Ophthalmology use onlyRED)
 Dosage: apply 3-4 times daily for at least 6 weeks
For proven Chlamydia infection, appropriate systemic therapy should be
prescribed (see also Chapter 5 Infections).
Neonatal conjunctivitis
(Significant tissue inflammation with purulent discharge)
 Swab for bacteria and Chlamydia.
 Initial treatment with chloramphenicol eye ointment 4 times daily for 1
week.
 If swabs show Chlamydia, change treatment to oral erythromycin
50mg/kg/day in 4 divided doses for 2 weeks. Remember to also manage
and treat parents as appropriate (see Chapter 5).
Viral conjunctivitis
Antibacterials are not helpful in managing viral conjunctivitis.
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Blepharitis
First Choice:
Fusidic acid GREEN
 Eye drops 1% in gel basis (liquifies on contact with eye)
Additional prescribing advice:
 Bathing eyes and increased hygiene may be all that is necessary to treat
blepharitis.
 Fusidic acid eye drops have a narrower spectrum of activity than
chloramphenicol, and are more expensive. They should therefore be
reserved for blepharitis as they are particularly effective against
Staphylococcal infection.
Corneal abrasions
Corneal abrasions are simply treated with chloramphenicol eye ointment.
Corneal ulcers
First Choice:
Ofloxacin eye drops 0.3% – AMBER 0
Or
Levofloxacin eye drops 0.5% – AMBER 0
Additional prescribing advice:
 Levofloxacin is also available in preservative free minims, if preservative
allergy or frequent (hourly) instillation necessary.
Second choice:
Cefuroxime eye drops - RED
 Unlicensed preparation
Corneal abrasions
First choice:
Chloramphenicol ointment 1% GREEN
Blocked tear duct
Watery, intermittently sticky eyes in infants are often due to blocked tear ducts
and do NOT require topical antibiotic treatment, unless the eye is red. Simple
bathing is all that is needed.
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11.3.3 Antivirals
Indications: Local treatment of herpes simplex infections – Consultant
Initiation only
First Choice:
Aciclovir eye ointment 3% - AMBER 0
Additional prescribing advice:
 Topical aciclovir is used for herpes simplex corneal infections, under
hospital supervision
 Apply 5 times daily, continuing for at least 3 days after complete healing.
 Oral aciclovir should be prescribed immediately for ophthalmic zoster.
11.4 Corticosteroids and other anti-inflammatory
preparations.
11.4.1 Corticosteroids
Indications: short-term local treatment of eye inflammation
First choices:
Betamethasone – AMBER 0
Dexamethasone – AMBER 0
Prednisolone – AMBER 0
Second choice:
Rimexolone – AMBER 0
 Where steroid induced glaucoma is an issue
 Consider Fluoromethalone (FML) – see below
Additional Prescribing Advice
 Corticosteroid eye preparations should normally only be used under the
supervision of an ophthalmologist because (a) their use may mask and
worsen infection (especially herpes simplex keratitis), (b) they may cause
glaucoma in some patients, and (c) long-term use can cause cataract.
 Corticosteroids combined with an antibiotic are particularly hazardous
because they can falsely suggest that an infection is being controlled their main use is post-operatively where the risk of infection is high.
 Betamethasone 0.1% with neomycin 0.5% (Betnesol-N) is used when an
antibiotic is also needed. Sometimes neomycin causes allergy in which
case chloramphenicol drops may be prescribed along with
betamethasone.
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and Chorley & South Ribble CCG - Joint Formulary 2015
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Fluorometholone 0.1% eye drops are weaker and less likely to raise intraocular pressure; they are used for patients where a rise in pressure is a
known hazard.
Prednisolone 0.1% is a very weak steroid used by ophthalmologists in
patients with low-grade chronic corneal inflammatory disease. It is
prescribable but must be obtained from Moorfields Eye Hospital, London.
Preservative-free preparations are available for patients suspected to be
intolerant of preservatives, e.g. dexamethasone 0.1% (Moorfields Eye
Hospital), prednisolone 0.5% Minims and prednisolone 0.1% (Moorfields
Eye Hospital).
Dexamethasone eye drops remain longer in the eye and penetrate the eye
better than betamethasone eye drops.
Non-steroidal anti-inflammatory drugs
Indications: prophylaxis and reduction of inflammation and associated
symptoms following ocular surgery.
Ketorolac eye drops 0.5% - AMBER 0
Additional Prescribing Advice
 Ketorolac eye drops are the only multi-dose form of a topical NSAID drop.
It is more expensive than steroid preparations. It may have a role in
hospital practice where supervision of steroid administration is difficult.
 Use with caution in ‘Dry eye’ patients at risk corneal perforation
Nepafenac (Nevanac 0.1%) - RED
Diabetic patients undergoing cataract surgery will be given two bottles starting
the day before surgery and will take the drops for 60 days post-surgery to
reduce the risk of macular oedema.
Nevanac will not be used for non-diabetic patients or for treating pain and
inflammation, unless other NSAIDs have already been tried.
Intravitreal corticosteroids
NICE TA 229 - Dexamethasone implant for the treatment of macular oedema
secondary to retinal vein occlusion.
NICE TA349 – Dexamethasone intravitreal implant for treating diabetic
macular oedema.
NICE TA 271 – Fluocinolone acetonide - NOT recommended
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11.4.2 Other anti-inflammatory preparations
Indications: Allergic conjunctivitis
First Choice:
Sodium cromoglycate eye drops 2% (prophylaxis) GREEN
Second Choices:
Olopatadine eye drops GREEN
(not for children under 3 years of age)
Lodoxamide eye drops 0.1% AMBER 0
(not for children under 4 years of age)
Additional Prescribing Advice
 Sodium cromoglicate is used to treat allergic conjunctivitis. It has a
prophylactic action and must be used regularly even when symptoms
improve.
11.5 Mydriatics and cycloplegics.
Indications: mydriasis (see BNF)
(a) Therapeutic uses
Antimuscarinics
Atropine 1% GREEN
Cyclopentolate 0.5% and 1% GREEN
Sympathomimetic
Phenylephrine eye drops 2.5% and 10% - RED
Additional Prescribing Advice
 Driving: Patients should be warned not to drive for 1 – 2 hours after
mydriasis.
 Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle
(cycloplegia). They are used in the treatment of anterior uveitis.
 Atropine is the most potent and has the longest duration of action (7 days
or more).
 Cyclopentolate is less potent and of shorter duration (up to 24 hours).
 Phenylephrine may be used to supplement the mydriatic effect of these.
 Contact dermatitis occurs relatively frequently when atropine is used in the
long term.
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(b) Diagnostic uses
Antimuscarinic
Tropicamide eye drops 0.5 % and 1% GREEN
Additional Prescribing Advice
 Tropicamide is short-acting (up to 3 hours) and is a useful mydriatic prior
to examining the eye. It can cause blurred vision and patients should not
drive until this has settled.
 The BNF advises caution as mydriasis may precipitate acute angle-closure
glaucoma in a very few patients usually aged over 60 years and
hypermetropic, who are predisposed to the condition because of a shallow
anterior chamber. However, the risk is so minimal that this should not be
regarded as a contraindication to its use.
Paediatric uses
 Cyclopentolate 1% drops are used for refraction and fundus examination
in children over 12 months of age.
 Atropine 1% eye ointment is used for refraction and fundus examination in
children with darkly pigmented irises. Ointment is instilled twice on the day
before examination and once on the morning of the visit. Systemic
absorption may occasionally lead to facial flushing.
 Atropine 1% eye drops or ointment may be used once daily in the "good"
eye in patients with a lazy eye (as an alternative to wearing an eye patch).
Sympathomimetics
Phenylephrine (with tropicamide) ophthalmic insert - RED
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11.6 Treatment of glaucoma.
 Treatment of glaucoma must be initiated by an ophthalmologist.
At each stage, consideration should be given to withdrawing a drug if there is
no significant pressure response.
Open-angle glaucoma and treated angle-closure glaucoma are not contraindications to the use of oral drugs that have anticholinergic effects
Beta – blockers
First Choice:
Timolol GREEN
Or
Levobunolol GREEN
Additional prescribing advice
Systemic absorption can follow topical application and contra-indications are
therefore asthma, bradycardia and congestive heart failure. This applies to all
topical beta-blockers unless no alternative treatment is available. In such
cases the risk of inducing bronchospasm should be appreciated and
appropriate precautions taken.
 Timolol eye drops are also available in preservative-free units. A longacting once daily formulation (Timoptol -LA) is available for patients who
have a problem with compliance.
Prostaglandin analogues
Indications: raised intra-ocular pressure in open-angle glaucoma, and ocular
hypertension
First Choices: Consultant preference
Latanoprost GREEN
Bimatoprost GREEN
NB. 0.01% drops are available for those patients unable to tolerate the side effects of the
0.03%.
Travoprost GREEN
Second Choice: – AMBER 0
Bimatoprost UDV preservative free
Tafluprost UDV preservative free
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Sympathomimetics
Indications: adjunctive treatment of glaucoma, where beta-blocker alone is
insufficiently effective, or is contra-indicated
Brimonidine eye drops 0.2% GREEN
Carbonic anhydrase inhibitors and systemic drugs
First choices:
Dorzolamide eye drops 2% or UDV GREEN
Indications: adjunctive treatment of glaucoma, where beta-blocker alone is
insufficiently effective, or is contra-indicated
Acetazolamide (systemic) GREEN
Indications: reduction of intra-ocular pressure in open angle glaucoma,
secondary glaucoma, and peri-operatively in angle closure glaucoma.
Second Choice:
Brinzolamide GREEN
Indications: adjunctive to beta-blocker alone or used alone in intra-ocular
pressure and in open-angle glaucoma if beta-blocker alone inadequate or
inappropriate.
Additional Prescribing Advice
 Dorzolamide can cause allergic conjunctivitis.
 Allergy can occur.
 Dorzolamide and acetazolamide are contra-indicated in patients allergic to
sulphonamides (or pregnancy).
 Acetazolamide is contra-indicated in patients with sickle cell disease.
 Acetazolamide can be given orally but long-term use is not advisable
because of side effects. These include metabolic acidosis and electrolyte
imbalance; renal calculi; paraesthesia; headache and malaise; gastrointestinal upset; blood dyscrasias.
 Cosopt eye drops GREEN (dorzolamide 2% + timolol 0.5%) are available
as a combination product. Preservative free unit dose eye drops are
available for those who have proven sensitivity to the preservative
benzalkonium chloride.(also see Tafluprost)
 Azarga eye drops GREEN (brinzolamide + timolol 0.5%) are an
alternative to Cosopt if the patient has had adverse effects such as
stinging or metallic taste.
 Simbrinza eye drops AMBER 0 (brinzolamide + brimonidine) - for where
decreased preservative is necessary (ie one drop instead of two).
Simbrinza is the only fixed-combination glaucoma therapy that is betablocker free.
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Miotics
Indications: glaucoma
First Choice:
Pilocarpine eye drops GREEN
Additional prescribing Advice
 Pilocarpine causes a small pupil, which can compromise visual acuity.
 Headache is a frequent symptom in the first fortnight of treatment.
 Four times a day application can be difficult for elderly people.
Drugs used in acute angle-closure glaucoma
Acute angle-closure glaucoma is an emergency and the definitive treatment is
laser iridotomy. The pressure of the eye is usually very high and initial
treatment is aimed at reducing this.
● Acetazolamide
● Pilocarpine 2%.
● Timolol 0.25%.
● Mannitol 20% solution (RED) may be used if the intra-ocular pressure
remains high despite the above measures. It must be given under close
supervision because of the danger of volume overload.
11.7 Local anaesthetics - RED
First Choice:
Oxybuprocaine
Or
Lidocaine and Fluorescein
Second Choice:
Proxymetacaine
Additional Prescribing Advice
 Local anaesthetic drops should never be used for the symptomatic control
of pain because of corneal epithelium toxicity and ulceration.
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11.8 Miscellaneous ophthalmic preparations
11.8.1 Tear deficiency, ocular lubricants and astringents
First Choices:
Hypromellose eye drops 0.3% GREEN
Products containing carbomers or polyvinyl alcohol are longer acting than
hypromellose and may be suitable alternatives if hypromellose does not provide
adequate symptom relief:
Carbomers 0.2% (Viscotears) GREEN
Polyvinyl alcohol 1.4%(Liquifilm tears) GREEN
PVA containing products increase the persistence of the tear film and can be useful
when ocular surface mucin is reduced.
Preservative free: Viscotears SDU or Liquifilm tears SDU - GREEN
Second Choices:
Paraffin based eye ointments physically lubricate the eye and protect the eye surface
from epithelial erosion. There are differences between the constituents of the
individual products which might affect tolerability.
Liquid paraffin (Lacri-lube) GREEN
VitA-POS eye ointment GREEN
Systane eye drops GREEN
Hydroxypropyl guar preparations work by stabilising the tear film and increasing tear
break-up time.
Optive Fusion 0.1% GREEN
sodium hyaluronate 0.1%, Carmellose sodium 0.5%, glycerol 0.9%
Preservative free:
Celluvisc 0.5% and 1% minims – AMBER 0
If 2 packs/month or more are required and a preservative-free drop is not required, it
is more cost effective to use Optive -10ml which can be used for up to 6 months after
opening.
Third choices:
Sodium hyaluronate - Hylotear 0.1%, hyloforte 0.2% GREEN
Hylo-Forte (sodium hyaluronate 0.2%) should be reserved for those who have failed
to respond to the 0.1% strength. Hylo eye drops can be used for up to 6 months after
opening.
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Additional Prescribing Advice:
 Artificial tear substitutes help to reduce patient discomfort, improve quality of life
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and reduce the risk of damage to the corneal epithelium.
Topical lubricants with various viscosities improve symptoms but there is no
evidence to suggest that any one agent is superior to another. However, ocular
surface inflammation can be exacerbated by the presence of preservatives.
Benzalkonium chloride (BAC) is a preservative frequently used in ophthalmic
preparations; evidence suggests that it can destabilise the tear film and also
damage the epithelial cells.
Preservative free products should only be used when preservatives are not
tolerated or contraindicated (e.g. for allergic patients).
It should be noted that irritation can still occur with preservative-free drops due to
other excipients (for example buffers or electrolytes) in the preparation.
Eye ointments may be uncomfortable and blur vision. They should only be used
at night, and never with contact lenses.
Most are medicinal products and must have a 28 day expiry after opening
Ocular lubricants registered as medical devices have extended shelf lives of up to
six months after first opening.
Patients referred to secondary care should advise the ophthalmologist which
preparations they have used previously. It may be necessary for a consultant
ophthalmologist to move to a 3rd line agent for cases of severe dry eye.
 Hypromellose eye drops 2% - diagnostic use only (unlicensed Ophthalmology use only) - RED
11.8.2 Ocular diagnostic and peri-operative
preparations and photodynamic treatment
Ocular diagnostic preparations
First choice:
Fluorescein - RED
Additional Prescribing Advice
● Fluorescein ophthalmic strips are used to detect corneal abrasions/lesions
and foreign bodies. They are also used in tonometry. Fluorescein strips are
appropriate in all situations. The solution is rarely required other than to
check for leakage of eye wounds.
Other eye preparations
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Mydricaine No.1 & No.2 injection is used for rapid dilation of the pupil in
iritis and uveitis.No.1 injection is used in children and No. 2 injection is
used for adults.
Sodium chloride (hypertonic saline) 5% eye drops is used to treat corneal
oedema. (unlicensed preparation) - RED
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Irrigation including first-aid removal of harmful substances
First Choice:
Sodium chloride eye drops 0.9% GREEN
 Balanced Salt solution (RED) – sterile, sodium chloride 0.64%, sodium
acetate 0.39%, sodium citrate 0.17%, calcium chloride 0.048%, magnesium
chloride 0.03% and potassium chloride 0.075%.
For intra-ocular or topical irrigation during surgical procedures.
Cataract Surgery
Amvisc 1.4% and Amvisc plus 1.6% (sodium hyaluronate) - RED
Ocular NSAIDs (see 11.4)
Ocular peri-operative drugs - RED
Acetylcholine chloride intra ocular irrigation 1%
Apraclonidine eye drops 0.5%
Cefuroxime injection for intracameral use
Amphotericin injection for intracameral use
Subfoveal choroidal neovascularisation
NICE TA 155 – Ranibizumab for the treatment of wet age-related macular
degeneration, but Pegaptanib is NOT recommended.
NICE TA 274 (replacing TA237) – Ranibizumab as an option for the treatment
of diabetic macular oedema.
NICE TA 283 – Ranibizumab as an option for treating visual impairment
caused by macular oedema secondary to retinal vein occlusion.
NICE TA 68 – Verteporfin photodynamic therapy for wet age-related macular
degeneration.
NICE TA346 – Aflibercept for treating diabetic macular oedema
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11.9 Contact Lenses - RED
Indications: Acanthamoeba keratitis, a sight-threatening condition, is
associated with ineffective lens cleaning and disinfection or the use of
contaminated lens cases. The condition is especially associated with soft
lenses and is treated by specialists.
Polihexanide (polyhexamethylene biguanide) eye drops 0.02%
Propamidine isetionate (Brolene) eye drops 0.1%
Chlorhexidine eye drops 0.02%
Other eye products that maybe required under ophthalmologist advice: (RED)
Voriconazole 1% eye drops (pres-free) 10ml
Bevacizumab 5mg in 0.2ml injection
Amphotericin 0.15% eye drops (pres-free) 10ml
Fluorouracil subconjunctival syringe 7.5mg in 0.3ml
Mercaptamine 0.55% eye drops 10ml