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 Formulary Chapter 11: Eye - Full Chapter
Notes:

Chapter complete - updated July 18

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11.01  Administration of drugs to the eye
 note 

Drugs are most commonly administered to the eye by topical application as eye drops or eye ointments. When a higher drug concentration is required within the eye, a local injection may be necessary.

Advise the patient to wash hands before putting any treatment into the eye(s).

Instil all drops and apply all ointments/gels into the conjunctival sac(s), the pocket formed by gently pulling down the lower eye lid, keeping the eye closed for as long as possible (about 1-2 minutes) after application of drops and blinking after application of ointments/gels to help it spread.
When two different eye-drop preparations are used at the same time of day, dilution and overflow may occure when one immediately follows the other. The patient should therefore leave an interval of at least 5 minutes between the two, eye ointment should be applied after drops.

Special care is required in prescribing eye preparations for contact lens users. Some drugs and preservatives in eye preparations can accumulate in hydrogel lenses and may induce toxic and adverse reactions. Therefore, unless medically indicated, the lenses should be removede before instillation of the eye preparation and not worn during the period of treatment. Alternatively, preservative-free drops can be used. Eye drops may, however, be instilled while patients are wearing rigid corneal contact lenses. Ointment preparations should never be used in conjunction with contact lens wear; oily eye drops should also be avoided.

Systemic effects may arise from absorption of drugs into the general circulation from conjunctival vessels or from the nasal mucosa after the excess preparation has drained down through the tear ducts. The extent of systemic absorption following ocular administration is highly variable; nasal drainage is more commonly associated with drops as opposed to ointment. Pressure on the lacrimal punctum (corner of the eye) for at least 1 minute after applying eye drops reduces nasolacrimal drainage and therefore decreases systemic absorption.

Preservative-free eye drops should be considered:
*when a patient becomes 'senstivie' to preservatives
*in order to lessen the preservative load when a patient is using a considerable number of eye drops (i.e. more than 3)
*in the short term where inflammation (e.g. allergic conjuntivitis) makes it difficult to detect an adverse effect on the preservative in the additional eye drops


11.02  Control of microbial contamination
 note 

To avoid contamination of eye drops or ointments, the eye dropper or tube should not be allowed to touch the eye (or anything else)
It is recommended NOT to use an eye preparation for more than 4 weeks after opening it, unit dose preparations are for single application only. In the hospital inpatient setting, multiple application eye preparations should be used for no longer than TWO weeks. If either eye is infected, separate bottles should be used for each eye.
In eye surgery single application containers shoule be used if possible; if a multiple application container is used it should be discarded after single use.

11.03  Anti-infective eye preparations
11.03.01  Antibacterials
 note 

Bacterial eye infections are generally treated topically with eye drops and eye ointments. Systemic administration is sometimes appropriate in blepharitis.
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.
Other antibacterials with a broad spectrum of activity include the quinolones e.g. ciprofloxacin and ofloxacin and the aminoglycosides e.g. gentamicin.
Fuscidic acid is useful for staphylococcal infections.

Cefuroxime (Aprokam Intracameral injection)
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Red SO
  • Prophylaxis of endophthalmitis after cateract surgery
 
   
Chloramphenicol 0.5% eye drops and 1% ointment
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Ciprofloxacin 0.3% eye drops
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Green SI
 
   
Fusidic Acid 1% eye drops
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Gentamicin 0.3% eye drops
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Green SI
 
   
Ofloxacin 0.3% eye drops
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11.03.02  Antifungals to top
 note 

Fungal infections of the cornea are rare but can occur after agricultural injuries, especially in hot and humid climated. Orbital mycosis is rarer, and when it occurs it is usually because of direct spread of infection from the paranasal sinuses. Increasing age, debility, or immunosuppression can encourage fungal proliferation. The spread of infection through blood occasionally produces metastatic endophthalmitis. Many different fungi are capable of producing ocular infection; they can be identified by appropriate laboratory procedures.
Antifungal preparations for the eye are not generally available. Treatment will normally be carried out at specialist centres.

11.03.03  Antivirals
 note 

Herpes simplex infections producing, for example, dendritic corneal ulcers can be treated with aciclovir.

Aciclovir 3% eye ointment
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11.04  Corticosteroids and other anti-inflammatory preparations
11.04.01  Corticosteroids
 note 

Corticosteroid eye preparations should normally only be used under the supervision of an opthalmologist because (a) their use may mask and worsen infection (especially infection caused by the herpes simplex virus, using a corticosteroid may lead to corneal ulceration, with possible damage to vision and even loss of the eye), (b) they may cause 'steroid glaucoma', and (c) 'steroid cateract' can follow prolonged use.
Combination products containing a corticosteroid with an anti-infective drug are sometimes used after ocular surgery to reduce inflammation and prevent infection; use of combination products is otherwise rarely justified.
The frequency of dosing depends on the clinical response, if their is no clinical response within 7 days of treatment, the drops should be discontinued. Treatment should be the lowest effective dose for the shortest possible time. After more prolonged treatment (over 6 to 8 weeks), the drops should be withdrawn slowly to avoid relapse.

Betamethasone 0.1% eye drops
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First Choice  
Dexamethasone 0.1% eye drops (Maxidex)
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First Choice
Green SA
Maxidex not licensed for use in children under 2 years 
Prednisolone 0.5% and 1% eye drops (Predsol Pred Forte)
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First Choice
Green SA
Pred Forte not licensed for use in children (age range not specified by manufacturer) 
Fluorometholone eye drops (FML)
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Second Choice
Green SA
Not licensed for use in children under 2 
   
Betamethasone 0.1% with Neomycin 0.5% eye drops (Betnesol N)
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Formulary Betamethasone with neomycin eye-drops are less suitable for prescribing 
   
Dexamethasone with framycetin sulfate and gramicidin eye drops (Sofradex)
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Green SA
Sofradex is less suitable for prescribing 
   
Dexamethasone with hypromellose, neomycin and polymyxin B sulfate (Maxitrol)
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Green SA
Dexamethasone with neomycin and polymyxin B sulfate is less suitable for prescribing
Available as eye drops and eye ointment 
   
Dexamethasone with tobramycin eye drops (Tobradex)
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Green SA
Dexamethasone with tobramycin eye-drops are less suitable for prescribing 
   
11.04.02  Other anti-inflammatory preparations
 note 

 

Sodium Cromoglicate 2% eye drops
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First Choice Allergic conjunctivitis (seasonal)

Prophylactic action, should therefore be used regularly even when symptoms improve

Can be sold to the public (in max. pack size of 10mL) for treatment of acute seasonal and perennial allergic conjunctivitis 
Antazoline 0.5% with Xylometazoline 0.05% eye drops (Otrivine-Antistin)
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Second Choice Allergic conjunctivitis (seasonal)

Maximum 7 days treatment

Can be sold to the public for the treatment of allergic conjunctivitis 
   
Neodocromil 2% eye drops (Rapitil)
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Third Choice Allergic conjunctivitis (seasonal)

Prophylactic action, should therefore be used regularly even when symptoms improve

Maximum 12 weeks duration of treatment 
   
11.05  Mydriatics and cycloplegics to top
 note 

Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle (cycloplegia); they vary in potency and duration of action.
Short acting, relativley weak mydriatics such as Tropicamide (action lasts for 4-6 hours), facilitate the examination of the fundus of the eye. Longer acting options include cyclopentolate hydrochloride or atropine sulfate (action up to 7 days).
Phenylephrine hydrochloride is used for mydriasis in diagnostic or therapeutic procedures; mydriasis occurs within 60-90 minutes and lasts up to 5-7 hours.
Mydriatics and cycloplegics are used in the treatment of anterior uveitis, usually as an adjunct to corticosteroids.
Patients should be advised not to undertake skilled tasks until vision clears after mydriasis.

11.05  Antimuscarinics
Atropine Sulphate 1% eye drops
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Formulary Indications: cycloplegia & anterior uveitis 
   
Cyclopentolate Hydrochloride 0.5% (children) & 1% (adults) eye drops
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Formulary Indication: cycloplegia and anterior uveitis 
   
Tropicamide 0.5% & 1% eye drops
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Formulary Indication: funduscopy 
   
11.05  Sympathomimetics
Phenylephrine Hydrochloride 2.5% & 10% eye drops (Minims Phenylephrine Hydrochloride )
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Red SO
Indication: mydriasis

The use of a drop of topical anaesthetic a few minutes before instillation of phenylephrine is recommended to prevent stinging 
   
11.06  Treatment of glaucoma
 note 

Glaucoma described a group of disorders characterised by a loss of visual field associated with cupping of the optic disc and optic nerve damage. While glaucoma is generally associated with raised intra-ocular pressure, it can occur when the intra-ocular pressure is within normal range.
The most common cause of glaucoma is primary open-angle glaucoma (chronic open-angle glaucoma), where drainage of the aqueous humor through the trabeular meshwork is restricted. The condition is ofter asymptomatic, but the patient may present with significant loss of visual field. Patients with ocular hypertension are at high risk of developing primar open-angle glaucoma.
Acute angle-closure glaucoma occurs when the outflow of aqueous humour from the eye is obstructed by bowing of the iris against the trabecular meswork; it is a medical emergency that requires urgent reduction of intra-ocular pressure to prevent loss of vision. Patient with acute angle-closure glaucoma should be referred immediately for specialist opthalmology assessment and treatment.

11.06  Beta-blockers
 note 

Topical application of a beta-blocker to the eye reduces intra-ocular pressure effectively in primary open-anlge glaucoma, probably by reducing the rate of production of aqueous humour.
Systemic absorption can follow topical application, hence, they are contraindicated in asthma, bradycardia and congestive heart failure.
Full clinical response may take several weeks to occur. Intraocular pressure should be measured approximately four weeks after starting treatment, because of diurnal variations in intraocular pressure, satisfactory response is best determined by measuring the intraocular pressure at different times of the day.

Timolol 0.25% & 0.5% eye drops
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First Choice
Green SA
STEP TWO: Beta-blockers 
Betaxolol 0.25% & 0.5% eye drops (Betoptic)
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Second Choice
Green SA
STEP TWO: Beta-blockers 
   
Levobunolol 0.5% eye drops (Betagan)
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Third Choice
Green SA
STEP TWO: Beta-blockers 
   
Carteolol 1% & 2% eye drops (Teoptic)
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Fourth Choice
Green SA
STEP TWO: Beta-blockers 
   
11.06  Prostaglandin analogues to top
 note 

The prostaglandin analogues (travoprost and latanoprost) and the synthetic prostamide, bimatoprost, increase uvoscleral outflow and subsequently reduce intraocular pressure. They are used to reduce intraocular pressure in ocular hypertension and open-angle glaucoma.
Initially they may cause conjunctival hyperaemia, characterised by redness of the eye, this should not be painful and wears off as the eye becomes accustomed to treatment (usually about 4 weeks).
The dose should not exceed once daily as more frequent administration may lessen the intraocular pressure lowing effect.

Latanoprost 0.005% eye drops (Xalatan Monoprost)
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First Choice
Green SA
STEP ONE: Prostaglandin analogues 
Travoprost 40mcg/ml eye drops (Travatan)
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First Choice
Green SA
STEP ONE: Prostaglandin analogues 
Travoprost with Timolol (DuoTrav)
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Green SA
STEP THREE: Prostaglandin combination preparations (or STEP TWO at the discretion of the physician) 
Bimatoprost 300mcg/ml eye drops (Lumigan)
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Second Choice
Green SA
STEP ONE: Prostaglandin analogues 
   
Latanoprost 0.005% with Timolol 0.5% (Xalacom)
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Second Choice
Green SA
STEP THREE: Prostaglandin combination preparations (or STEP TWO at the discretion of the physician) 
   
Bimatoprost with Timolol (Ganfort)
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Third Choice
Green SA
STEP THREE: Prostaglandin combination preparations (or STEP TWO at the discretion of the physician) 
   
11.06  Sympathomimetics
 note 

Brimonidine tartrate, a selective alpha2-adrenoceptor agonist, is thought to lower intraocular pressure by reducing aqueous humour formation and increasing uveoscleral outflow. It is licensed for the reduction of intraocular pressure in open-angle glaucoma or ocular hypertension in patients who cannot tolerate beta-blockers; it may also be used as adjunctive treatment when intraocular pressure inadequately controlled by other therapy.

Brimonidine Tartrate 0.2% eye drops (Alphagan)
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First Choice
Green SA
STEP FIVE: Sympathomimetics 
Brimonidine Tartrate 0.2% with Timolol 0.5% (Combigan)
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Second Choice
Green SA
STEP SIX: Carbonic anhydrase inhibitor or Sympathomimetic combination preparations  
   
11.06  Carbonic anhydrase inhibitors and systemic drugs
 note 

The carbonic anydrase inhibitors, acetazolamide, brimzolamide and dorzolamide, reduce intraocular pressure by reducing aqueous humour production. Systemic use of acetazolamide also produces weak diuresis.
Acetazolamide is given orally , it is used as an adjunct to toher treatment but is not generally recommended for long term use due to side effects, these include metabolic acidosis and electrolyte imbalance; renal calculi; parasthesia; headach and malaise; GI upset; blood dyscrasias.

Dorzolomide 2% eye drops (Trusopt)
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First Choice
Green SA
STEP FOUR: Carbonic anhydrase inhibitors 
Dorzolomide 2% with Timolol 0.5% (Cosopt)
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First Choice
Green SA
STEP SIX: Carbonic anhydrase inhibitor or Sympathomimetic combination preparations 
Brinzolamide with Timolol (Azarga )
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Second Choice
Green SA

STEP SIX: Carbonic anhydrase inhibitor or Sympathomimetic combination preparations 

**Prescriptions should be challenged to ensure that patients have previously received first line treatment with Cosopt before moving onto Azarga**

 
   
Brinzolamide 10mg/ml eye drops (Azopt)
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Green SA
STEP FOUR: Carbonic anhydrase inhibitors 
   
Acetazolamide (Diamox SR)
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Formulary
Green SA
RESERVE AGENT 
   
11.06  Miotics
 note 

Miotic works by openeing the inefficient drainage channels in the trabecular meshwork. Pilocarpine is not commonly used for the treatment of primary open-angle glaucoma because side effects are poorly tolerated (headache is a frequent symptom in the first fornight of treatment and it causes a small pupil, which can compromise visual acuity). It is used mainly in the treatment of primary angle-closure glaucoma and secondary glaucomas.

Pilocarpine 1%, 2% & 4% eye drops
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Green SA
RESERVE AGENT

Please note that 4% strength are SPECIALIST ONLY 
   
11.07  Local anaesthetics
 note 

Oxybuprocaine is the recommended locl anaesthetic for use before opthalmic procedures, it has a very rapid onset of action (about 30 seconds).
Tetracaine (amethocaine) produces a more profound anaesthesia than oxybuprocaine and is suitable for use before minor surgical procedures, it has a temporary disruptive effect on the corneal epithelium.
Proxymetacaine causes less stinging than oxybuprocaine and is useful in children. Local anaesthetic drops hould neber be used for the symptomatic control of pain becuase of corneal epithelium toxicity.

Oxybuprocaine Hydrochloride 0.4% eye drops (Minims )
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First Choice
  • PRE-OP ONLY
 
Proxymetacaine Hydrochloride 0.5% eye drops (Minims)
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Formulary
  • PRE-OP ONLY
 
   
Tetracaine Hydrochloride 1% eye drops (Minims Amethocaine Hydrochloride)
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Red SO
  • PRE-OP ONLY
 
   
11.08  Miscellaneous ophthalmic preparations to top
11.08.01  Tear deficiency, ocular lubricants, and astringents
Hypromellose 0.3% eye drops
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First Choice  
Liquid Paraffin with white soft paraffin and wool alcohols eye ointment (Lacri-Lube)
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First Choice
  • LONG-TERM MANUFACTURING PROBLEM - please use Xalin night ointment
 
Polyvinyl Alcohol 1.4% eye drops (Liquifilm Tears)
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Second Choice  
   
Carbomer 980 0.2% eye gel (Viscotears)
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Second Choice  
   
Carmellose 0.5% & 1% eye drops (Celluvisc)
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Third Choice  
   
Acetylcysteine 5% with Hypromellose 0.35% (Ilube)
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Fourth Choice  
   
11.08.02  Ocular diagnostic and peri-operative preparations and photodynamic treatment
11.08.02  Ocular diagnostic preparations
Fluorescein Sodium 1% & 2% eye drops
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Red SO
Detection of lesions and foreign bodies 
   
11.08.02  Ocular peri-operative drugs
Apraclonidine 1% eye drops (Iopidine)
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First Choice
Red SO
  • PRE-OP ONLY
 
Ketorolac 0.5% eye drops (Acular)
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First Choice
Red SO
  • PRE-OP ONLY
 
Diclofenac Sodium 0.1% eye drops (Voltarol Ophtha multidose)
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Red SO
  • PRE-OP ONLY
 
   
11.09  Contact lenses to top
11.99.99.99  Miscellaneous
Povodine-iodine 5% eye drops
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Formulary
Red SO
Cutaneous peri-ocular and conjunctival antisepsis before ocular surgery 
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Red SO

SPECIALIST ONLY - These drugs are deemed to be not appropriate for prescribing by GPs. Specialists should not ask GPs to prescribe these drugs.   

Green SI

SPECIALIST INITIATED - These drugs must be initiated, i.e. the first dose prescribed, by the specialist and then may be continued when appropriate by the patients GP following communication from the specialist.   

Green SA

SPECIALIST ADVISED Specialists may simply advise a patients GP to initiate these drugs themselves after they have made an initial assessment.   

Amber SC

SHARED CARE - Responsibility for prescribing may be transferred from secondary to primary care with the agreement of an individual GP and when agreed shared care arrangements have been established. The specialist MUST stabilize the patient before asking for care to be transferred. Only specialists should initiate these drugs. Prescribing should be transferred to GPs according to an Shared Care Agreement [SCA]   

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