Download 11.0 Eye formulary - Airedale NHS Foundation Trust

File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Page 1 of 16
11: Eye
11.1
Administration of drugs to the eye
Drugs are most commonly administered to the eye by topical
application as eye drops or eye ointments. Where a higher drug
concentration is required within the eye, a local injection may be
necessary.
Eye drops are generally instilled into the pocket formed by gently
pulling down the lower eyelid and keeping the eye closed for as long as
possible after application, preferably 1–2 minutes; one drop is all that is
needed. A small amount of eye ointment is applied similarly; the
ointment melts rapidly and blinking helps to spread it
When two different eye-drop preparations are used at the same time of
day, dilution and overflow may occur when one immediately follows the
other. The patient should therefore leave an interval of at least 5
minutes between the two.
Eye-drop dispenser devices are available to aid the instillation of eye
drops from plastic bottles especially amongst the elderly, visually
impaired, arthritic, or otherwise physically limited patients. Eye-drop
dispensers are for use with plastic eye drop bottles, for repeat use by
individual patients.
11.2
Control of microbial contamination
Preparations for the eye should be sterile when issued. Eye drops in
multiple-application containers include a preservative but care should
nevertheless be taken to avoid contamination of the contents during
use.
Eye drops in multiple-application containers for use at home should not
be used for more than 4 weeks after first opening (unless otherwise
stated).
Eye drops for use in hospital wards are normally discarded 1 week
after first opening. Individual containers should be provided for each
patient. A separate bottle should be supplied for each eye only if there
are special concerns about contamination.
Containers used before an operation should be discarded at the time of
the operation and fresh containers supplied. A fresh supply should also
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Page 2 of 16
be provided upon discharge from hospital; in specialist ophthalmology
units, it may be acceptable to issue eye-drop bottles that have been
dispensed to the patient on the day of discharge.
In out-patient departments single-application packs should preferably
be used; if multiple-application packs are used, they should be
discarded at the end of each day.
In accident and emergency departments, where the dangers of
infection are high, single-application packs should be used; if a
multiple-application pack is used, it should be discarded after single
use
Diagnostic dyes (e.g. fluorescein) should be used only from singleapplication packs.
In eye surgery single-application containers should be used if possible;
if a multiple-application pack is used, it should be discarded after single
use. Preparations used during intra-ocular procedures and others that
may penetrate into the anterior chamber must be isotonic and without
preservatives and buffered if necessary to a neutral pH. Specially
formulated fluids should be used for intra-ocular surgery; intravenous
infusion preparations are not suitable for this purpose. For all surgical
procedures, a previously unopened container is used for each patient.
11.3
Anti-infective eye preparations
Many antibacterial preparations also incorporate a corticosteroid but such
mixtures should not be used unless a patient is under close specialist
supervision. In particular they should not be prescribed for undiagnosed ‘red
eye' which is sometimes caused by the herpes simplex virus and may be
difficult to diagnose (section 11.4).
Administration
Eye drops. Apply 1 drop at least every 2 hours then reduce frequency
as infection is controlled and continue for 48 hours after healing.
Eye ointment. Apply either at night (if eye drops used during the day) or
3–4 times daily (if eye ointment used alone).
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
11.3.1
First line
Antibacterials
Product
Chloramphenicol 0.5% Eye
Drops (preservative free)
Chloramphenicol 1% Eye
Ointment
Chloramphenicol 0.5% Minims
(preservative free)
Others
Fusidic Acid 1% MR Eye Drops
(with preservative)
Gentamicin 0.3% Eye Drops
(with preservative)
Formulary Product
status
C
Ciclosporin 0.2% Eye Drops
C
C
C
C
S
11.3.2
See BNF
Page 3 of 16
Ciprofloxacin 0.3% Eye Drops
(with preservative)
Levofloxacin 0.5% Eye Drops
(with preservative)
Levofloxacin 5mg/ml Eye
Drops (preservative free)
Ofloxacin 0.3% eye drops (with
preservative)
Povidone Iodine 5%
Sterile 10ml bottles
Antifungals
Comments
Chloramphenicol has a broad
spectrum of activity and is the drug
of choice for superficial eye
infections. Chloramphenicol eye
drops are well tolerated and the
recommendation that
chloramphenicol eye drops should
be avoided because of an
increased risk of aplastic anaemia
is not well founded.
Fusidic acid is useful for
staphylococcal infections
Gentamicin is a broad spectrum
antibiotic and is also effective for
infections caused by
Pseudomonas aeruginosa
Restriction
For Consultant Ophthalmologist use
only
Unlicensed so needs unlicensed
medicines paperwork completing and
patient consent.
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only for severe eye infections
For Consultant Ophthalmologist use
only for severe eye infections
For Consultant Ophthalmologist use
only
For eye theatre only
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
11.3.3
Antivirals
Aciclovir 3% Eye Ointment (4.5g)
Ganciclovir 0.15% Ophthalmic Gel (Virgan) (5g)
Page 4 of 16
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
11.4
Corticosteroids and other antiinflammatory preparations
11.4.1
Corticosteroids
Page 5 of 16
Corticosteroids administered locally (as eye drops, eye ointments or
subconjunctival injection) or by mouth have an important place in treating
anterior segment inflammation, including that which results from surgery.
Topical corticosteroids should normally only be used under expert
supervision; three main dangers are associated with their use:
a ‘red eye', where the diagnosis is unconfirmed, may be due to herpes
simplex virus, and a corticosteroid may aggravate the condition,
leading to corneal ulceration, with possible damage to vision and even
loss of the eye. Bacterial, fungal and amoebic infections pose a similar
hazard;
‘steroid glaucoma' may follow the use of corticosteroid eye
preparations in susceptible individuals;
a ‘steroid cataract' may follow prolonged use.
Other side-effects include thinning of the cornea and sclera.
Use of a combination product containing a corticosteroid with an anti-infective
is rarely justified.
Product
Comments
Eye drops
Dexamethasone 0.1% Eye
Drops (with preservative)
Fluorometholone 0.1% Eye
Drops (with preservative)
Hydrocortisone 1% Eye Drops
(with preservative)
Prednisolone 0.5% phosphate
Eye/Ear Drops (with
preservative)
Prednisolone 1% acetate
Eye/Ear Drops (with
preservative)
Rimexolone 1% (with
preservative)
Eye ointment Betamethasone 0.1% Eye
Ointment
Preservative Dexamethasone 0.1% Minims
For use in patients where a
free
(preservative free)
preservative free product is
Prednisolone 0.5% phosphate
necessary
Minims (preservative free)
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Combination
of steroid
and antiinfective
Betamethasone 0.1%
Neomycin 0.5% Eye Drops
(Betnesol N) (with preservative)
Formulary Product
status
R
Maxitrol Eye Drops (with
preservative) (dexamethasone
0.1%, hypromellose 0.5%,
neomycin sulphate 0.35%,
polymyxin B sulphate
6000units/ml)
R
R
11.4.2
Eye drops
Page 6 of 16
Betnesol N is currently
unavailable
Restriction
Using until supply problems with
Betamethasone 0.1% Neomycin 0.5%
Eye Drops (10ml) is resolved
Maxitrol Eye ointment (with
preservative) (dexamethasone
0.1%, neomycin sulphate
0.35%, polymyxin B sulphate
6000units/ml)
Loteprednol 0.2% (Lotemax)
with preservative
Treatment of post operative
inflammation following ocular surgery.
Other anti-inflammatory preparations
Product
Comments
Azelastine hydrochloride 0.05% Used for allergic conjunctivitis
Eye Drops (with preservative)
Sodium Cromoglicate 2% Eye
Drops (with preservative)
Sodium Cromoglicate 2% Eye
Drops (preservative free)
(single use drops)
Olopatadine 0.1% Eye Drops
(with preservative)
Used for vernal keratoconjunctivitis
and other allergic forms of
conjunctivitis
Useful in atopic patients
Useful as twice daily dosage
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Formulary Product
status
C
Lodoxamide 0.1% Eye Drops
(with preservative)
C
Nedocromil 2% sodium Eye
Drops (with preservative)
Page 7 of 16
Restriction
For Consultant Ophthalmologist use
only for patients with allergic
conjunctivitis in whom cromoglicate
has been ineffective
For Consultant Ophthalmologist use
only for patients with allergic
conjunctivitis in whom cromoglicate
has been ineffective and for vernal
keratoconjunctivitis
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
11.5
Page 8 of 16
Mydriatics and cycloplegics
Antimuscarinics dilate the pupil and paralyse the ciliary muscle; they vary in
potency and duration of action.
Eye drops
Product
Atropine 0.5% Eye Drops (with
preservative)
Atropine 1% Eye Drops (with
preservative)
Cyclopentolate 1% Eye Drops
(with preservative)
Cyclopentolate 0.5% Eye
Drops (with preservative)
Homatropine 1% eye drops
Eye
ointments
Preservative
free
Tropicamide 0.5% Eye Drops
(with preservative)
Tropicamide 1% Eye Drops
(with preservative)
Atropine 1% Eye Ointment
Atropine 1% Minims
(preservative free)
Cyclopentolate 1% Minims
(preservative free)
Cyclopentolate 0.5% Minims
(preservative free)
Phenylephrine 2.5% minims
(preservative free)
Tropicamide 1% Minims
(preservative free)
Tropicamide 0.5% Minims
(preservative free)
Comments
Cyclopentolate 1% or atropine
are preferable for producing
cycloplegia for refraction in young
children. Atropine, which has a
longer duration of action, is also
used for the treatment of anterior
uveitis mainly to prevent posterior
synechiae, often with
phenylephrine eye drops
Homatropine 1% is also used in
the treatment of anterior
segmentinflammation, and may be
preferred for its shorter duration of
action.
Short-acting, relatively weak
mydriatics, such as tropicamide
0.5%, facilitate the examination of
the fundus of the eye.
Atropine ointment 1% is
sometimes preferred for children
aged less than 5 years because
the ointment formulation reduces
systemic absorption.
For use in patients where a
preservative free product is
necessary or an individual dose is
required
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
11.6
Page 9 of 16
Treatment of glaucoma
Drugs that reduce intra-ocular pressure are used for managing glaucoma;
they act by a variety of mechanisms. A topical beta-blocker or a prostaglandin
analogue is commonly the drug of first choice. It may be necessary to
combine these drugs or add others such as miotics, sympathomimetics and
carbonic anhydrase inhibitors to control intra-ocular pressure.
Beta blockers
Topical application of a beta-blocker to the eye reduces intra-ocular pressure
effectively in primary open-angle glaucoma, probably by reducing the rate of
production of aqueous humour. Administration by mouth also reduces intraocular pressure but this route is not used since side-effects may be
troublesome.
CAUTIONS, CONTRA-INDICATIONS AND SIDE-EFFECTS (See BNF).
INTERACTIONS, Since systemic absorption may follow topical application the
possibility of interactions, in particular, with drugs such as verapamil should
be borne in mind. See also BNF Appendix 1 (beta-blockers).
Product
Comments
Eye drops
Betaxolol 0.5% and 0.25% Eye
Drops (with preservative)
Levobunolol 0.5% Eye Drops
(with preservative)
Timolol Eye Drops 0.5% and
0.25% (with preservative)
Eye
Timolol 0.1% Opthalmic Gel
ointments
Preservative Timolol 0.5% and 0.25% Single
free
Dose Eye Drops (preservative
free).
Combination Xalacom Eye Drops
products
(latanoprost 50micrograms/ml,
timolol 5mg/ml (with
preservative)
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Page 10 of 16
Prostaglandin analogues
Latanoprost, tafluprost and travoprost are prostaglandin analogues which
increase uveoscleral outflow; bimatoprost is a related drug. They are used to
reduce intra-ocular pressure in ocular hypertension or in open-angle
glaucoma. Patients receiving prostaglandin analogues should be monitored
for any changes to eye coloration since an increase in the brown pigment in
the iris may occur; particular care is required in those with mixed coloured
irides and those receiving treatment to one eye only.
Eye Drops
Combination
products
Product
Latanoprost 50micrograms/ml
Eye Drops (with preservative)
Tafluprost 15 mcg/ml
Xalacom Eye Drops
(latanoprost 50micrograms/ml,
timolol 5mg/ml (with
preservative)
Formulary Product
status
C
Bimatoprost Eye Drops
(0.3mg/ml) (with preservative)
C
Travoprost Eye Drops
(40micrograms/ml) (2.5ml)
(with preservative)
C
Ganfort Eye Drops
(Bimatoprost
300micrograms/ml, timolol
maleate 5mg/ml (with
preservative)
C
Duotrav Eye Drops (travoprost
40micrograms/ml and timolol
5mg/ml) (with preservative)
C
Tafluprost 15microgram/ml Unit
Dose Eye Drops (preserviatve
free)
Comments
Restriction
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only.
Sympathomimetics
Eye Drops
Combination
Product
Brimonidine 0.2% Eye Drops
(with preservative)
Combigan Eye Drops
Comments
For raised intra-ocular pressure in
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
products
(brimonidine 0.2% , timolol
0.5%) (with preservative)
Page 11 of 16
open angle glaucoma and for
ocular hypertension when a betablocker alone is not adequate,
apply twice a day.
Carbonic anhydrase inhibitors and systemic drugs
Eye Drops
Combination
Products
Oral
preparations
Injection
Product
Comments
Dorzolamide 2% Eye Drops
(with preservative)
Cosopt Eye Drops
(dorzolamide hydrochloride 2%,
timolol 0.5%) (with
preservative)
Cosopt Single Use Eye Drops
(dorzolamide hydrochloride 2%,
timolol 0.5%) (without
preservative)
Acetazolamide MR Capsules
(250mg)
Acetazolamide Tablets
(250mg)
Acetazolamide Injection
(500mg)
Formulary Product
status
C
Brinzolamide 10mg/ml eye
drops (with preservative)
C
Azarga
C
Dorzolamide Unit Dose Eye
Drops 2% (preservative free)
Restriction
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only
For Consultant Ophthalmologist use
only
Miotics
Eye Drops
Preservative
free
Product
Pilocarpine 0.5%, 1%, 2%, 3%
and 4% Eye Drops (with
preservative)
Pilocarpine 2% and 4% Minims
(preservative free)
Comments
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Formulary Product
status
C
Pilocarpine 4% Opthalmic Gel
(with preservative)
11.7
Page 12 of 16
Restriction
For Consultant Ophthalmologist use
only
Local anaesthetics
Local anaesthesia should never be used for the management of ocular
symtoms
Product
Comments
Preservative Benoxinate (Oxybuprocaine)
Oxybuprocaine and tetracaine
Free
0.4% Minims (preservative
(amethocaine) are probably the
free)
most widely used topical
anaesthetics.
Oxybuprocaine is used in
tonometry.
Tetracaine (Amethocaine) 1%
Tetracaine produces a more
Minims (preservative free)
profound anaesthesia and is
suitable for before minor surgical
procedures.
Proxymetacaine 0.5% Minims
Proxymetacaine causes less initial
(preservative free)
stinging and is useful for children.
Combination
products
Proxymetacaine 0.5%
Fluorescein 0.25% Minims
(preservative free)
Formulary Product
status
C
Cocaine 4% Eye Drops (2ml)
Restriction
For Consultant Ophthalmologist use
only
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Page 13 of 16
11.8
Miscellaneous ophthalmic preparations
11.8.1
Tear deficiency, ocular lubricants, and
astringents
Eye drops
Eye
ointments
Product
Hypromellose 0.3% Eye Drops
(with preservative)
Comments
Hypromellose is the traditional
choice of treatment for tear
deficiency. It may need to be
instilled frequently (e.g. hourly) for
adequate relief.
Polyvinyl Alcohol 1.4% Eye
Drops (with preservative)
(Sno Tears)
Polyvinyl alcohol increases the
persistence of the tear film and is
useful when the ocular surface
mucin is reduced.
Lacri-lube Eye Ointment
(white soft paraffin 57.3%,
liquid paraffin 42.5%, wool
alcohols 0.2%)
Eye ointments containing a
paraffin may be used to lubricate
the eye surface, especially in
cases of recurrent corneal
epithelial erosion. They may cause
temporary vision disturbance and
are best suited for application
before sleep. Ointments should not
be used during contact lens wear.
This Is sometimes better tolerated
than lacrilube
Simple Eye Ointment
(liquid paraffin 10%, wool fat
10% in yellow soft paraffin)
Preservative
free
VITA POS ointment (250IU/g
retinol palmitate, liquid paraffin,
light liquid paraffin, wool fat and
white soft paraffin)
(preservative free)
Minims Artificial Tears
(hydroxyethylcellulose 0.44%,
sodium chloride 0.35%)
Liquifilm Tears Single Dose
Eye Drops
(polyvinyl alcohol 1.4%,
povidone 0.6%)
For use in patients where a
preservative free product is
necessary
For irrigation, including first aid removal of harmful substances
Sodium Chloride 0.9% Minims (preservative free)
Sodium Chloride 5% Eye Drops
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Formulary Product
status
S
Balanced Salt Solution (15ml,
500ml)
C
Carmellose Sodium 0.5%
10ml (with preservative)
(Optive)
Optive Plus Eye drops
Carmellose Sodium 0.5%
Single Dose Eye drops
(Celluvisc)
Carmellose Sodium 1%
Single Dose Eye Drops
(Celluvisc)
R
Ilube (acetylcysteine 5%,
hypromellose 0.35%) (with
preservative)
C
Sodium Chloride 0.9% Eye
Drops (with preservative)
R
Sodium Hyaluronate 0.1% Eye
Drops (preservative free)
(Hylotear)
R
Sodium Hyaluronate 0.2% Eye
Drops (preservative free)
(Hyloforte)
S
Viscoat Solution (0.75ml)
C
Carbomer 980 (polyacrylic
acid) 0.2% Eye Drops (with
preservative) (Viscotears)
11.8.2
Page 14 of 16
Restriction
For use in eye theatre only
For Consultant Opthalmologist use
only
Reserved for patients who come in on
them and for Consultant
Ophthalmologist use only
For Consultant Opthalmologist use
only
For Consultant Opthalmologist use
only. Can be used for up to six months
after opening. Contains 300
applications
For Consultant Opthalmologist use
only.
Can be used for up to six months after
opening. Contains 300 applications
For use in eye theatre only
For Consultant Opthalmologist use
only
Ocular diagnostic and peri-operative
preparations and photodynamic treatment
Ocular diagnostic preparations
Preservative
free
Product
Fluorescein Sodium 2% Minims
(preservative free)
Comments
Fluorescein sodium is used in
diagnostic procedures and for
locating damaged areas of the
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Page 15 of 16
cornea due to injury or disease.
Rose bengal is more efficient for
the diagnosis of conjunctival
epithelial damage but it often
stings excessively unless a local
anaesthetic is instilled beforehand.
Ocular peri-operative drugs
Drugs used to prepare the eye for surgery and drugs that are injected into the
anterior chamber at the time of surgery are included here.
Eye Drops
Preservative
free
Product
Comments
Diclofenac Sodium 0.1% Eye
Drops (with preservative)
Ketoralac trometamol 0.5% Eye
Drops (with preservative)
Diclofenac Sodium 0.1% Single
Dose Eye Drops (preservative
free)
Sodium hyaluronate (Provisc®) is used during surgical procedures on the eye.
Formulary Product
status
C
Acetylcholine 1%, mannitol 3%
Intraocular Irrigation when
reconstituted (preservative
free)
C
Apraclonidine 0.5% Eye Drops
(with preservative)
C
Apraclonidine 1% Eye Drops
(5ml)
R
Cefuroxime 3mg in 0.3ml
sodium chloride 0.9%
Intracameral injection
R
Moxifloxacin 0.1%
Intracameral injection
S
Vision blue 0.5ml solution
Restriction
For Consultant Opthalmologist use
only
For Consultant Opthalmologist use
only
For Consultant Opthalmologist use
only
For Eye theatre use only.
For Intracameral injection only, as an
alternative to intracameral cefuroxime
injection, for the prevention of
endophthalmitis following cataract
surgery in patients allergic to penicillin
or penicillin derivatives.
For use by Eye Theatre only.
For eye Theatre use only.
File name: Eye Formulary BNF Section 11
Original Date of issue: 30/07/2006
Last Reviewed: 11/11/2011
Version:4
Department: Pharmacy
Review Date: 11/11/2013
Authorised: Drug and
Therapeutics Committee
Page 16 of 16
Subfoveal choroidal neurovascularisation
Formulary Product
status
C
Ranibizumab Solution for
Intravitreal Injection 10mg/ml
0.23ml
Restriction
For Consultant Opthalmologist use
only.
Use supported for the treatment of wet
age-related macular degeneration inline with NICE TA155