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 Formulary Chapter 11: Eye - Full Chapter
Notes:

Chapter complete - updated July 18

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11.06  Expand sub section  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  Expand sub section  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  Expand sub section  Prostaglandin analogues
 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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First Choice
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  Expand sub section  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  Expand sub section  Carbonic anhydrase inhibitors and systemic drugs to top
 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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Formulary
Green SA
STEP FOUR: Carbonic anhydrase inhibitors 
   
Acetazolamide (Diamox SR)
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Formulary
Green SA
RESERVE AGENT 
   
11.06  Expand sub section  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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Formulary
Green SA
RESERVE AGENT

Please note that 4% strength are SPECIALIST ONLY 
   
 ....
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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