netFormulary
Data extracted : 22/09/2017
 Formulary Section 11: Eye
 Details...
11.01 Administration of drugs to the eye
Choice of preparation
Eye drops are preferable for daytime use as they are easy to apply and do not blur vision. Tears quickly dilute aqueous drops so frequent application is required to maintain adequate therapeutic levels. Eye ointments remain in contact with the conjunctiva or eyelid for long periods of time resulting in good levels of drug within the eye. They are most useful for night-time therapy. The ointment base helps to soften crusts in infectious conditions such as blepharitis and bland ointments can be used to lubricate and protect the eye. Ointments can blur vision and are usually unsuitable for daytime use.
Preservatives

Various preservatives used in multidose eye drops may trigger hypersensitivity reactions. Some preservatives (and drugs) can accumulate in soft (hydrogel) contact lenses leading to irritation or toxicity. Patients should be advised to refrain from wearing their lenses during treatment if possible. Benzalkonium chloride tends to cause problems and is therefore unsuitable for people who wear soft contact lenses. Chlorhexidine acetate is suitable in some cases. Phenylmercuric acetate or nitrate are usually acceptable but are not recommended for long-term use. Thiomersal is a suitable alternative. Preservative-free drops in the form of single dose units e.g. ’Minims’ are available for many preparations. They are more expensive, but are very useful for those patients in whom sensitivities or allergies to preservatives are suspected, for use during or after surgery, or for patients who wear soft contact lenses. They are used in outpatient diagnostic examinations to prevent transfer of infection from patient to patient.
Administration

If two or more types of eye drops are to be used at the same time, patients should be advised to leave a few minutes between applications. This will minimise dilution and prevent overflow.

Note: some topical medications can produce serious and even life-threatening complications, for example beta-blockers in normal dose or mydriatics if over-used.
Link   Ophthalmic Specials
11.03 Anti-infective eye preparations
Restricted Drug  Natamycin 5% 
For use by specialist ophthalmologists
Only for treatment of fungal keratitis (fusarium species)
11.03.01 Antibacterials

  • See the Antimicrobial website . Most bacterial infections are self-limiting.

  • Topical antibiotic eye preparations containing corticosteroids should not be used without specialist supervision as these may mask a herpetic infection.

  • The use of unit-dose eye drops for inpatients reduces the risk of contamination with resistant hospital flora.

  • Bacterial corneal ulcers should always be treated by an ophthalmologist because of the possibility of sight-threatening complications.
First Choice:
Chloramphenicol. (Eye drops or Ointment) 
Effective, broad-spectrum agent, which may be used for ’blind’ treatment of infections without increasing resistance to the usual systemic antibiotics. The risk of systemic side effects e.g. agranulocytosis is considered to be extremely small. Also useful for the prevention of opportunistic infections following minor trauma to the eye surface.

Eye drops should be stored in the fridge.
Second Choice:
Fusidic Acid 
Formulated as a gel that liquefies slowly once it is in the conjunctival sac. It is used for blepharitis and conjunctivitis caused by staphylococci.
Restricted Drug  Levofloxacin 
(Preservative-free)
For ophthalmology use only.
Restricted for use in bacterial keratitis only.
Restricted Drug  Ofloxacin 
Choice for contact lens related infections. These need specialist attention due to the high risk of resistant pseudomonas.
Restricted Drug  Ciprofloxacin Eye Ointment  
Restricted for use in patients who experience adverse effects with chloramphenicol
11.03.03 Antivirals

  • Aciclovir interferes specifically with viral DNA replication. Topical aciclovir has been found to be effective in localised herpes simplex infections. Systemic treatment should be used for ophthalmic herpes zoster (see Antimicrobial website ).

  • As frequent slit-lamp examinations are necessary to monitor progress, patients with herpes simplex keratitis should be managed by an ophthalmologist.

  • Topical antiviral agents can be toxic to the corneal epithelium on prolonged use.
First Choice:
Aciclovir Eye Ointment 
11.03.04 Antiamoebics
11.04 Corticosteroids and other anti-inflammatory preparations
11.04.01 Corticosteroids

  • Topical corticosteroids are used to suppress inflammation in inflammatory and severe allergic eye diseases. They are generally only used under expert supervision.

  • The green traffic light only applies if the duration does not exceed 7 days

  • Combinations of steroids with antibiotics are used where inflammation and infection may co-exist, e.g. after trauma or ocular surgery. Use of combination products is otherwise rarely justified.

  • Most steroid eye drops are preserved with benzalkonium chloride (for further information see preservatives.)
First Choice:
Dexamethasone 0.1% eye drops  (Maxidex®)
Green traffic light only applies to prescriptions that do not exceed 7 days.
First Choice:
Betamethasone 0.1% with neomycin 0.5% eye drops 
Maxitrol can be used if an ointment is required. (Maxitrol eye ointment contains: dexamethasone 0.1% + neomycin sulphate + polymyxin B sulphate)

Green traffic light only applies to prescriptions that do not exceed 7 days.
January 16 – There is a short term shortage of Maxitrol eye ointment.
An alternative steroid eye ointment to prescribe (but without the antimicrobial component) would be betamethasone 0.1% eye ointment for those people where betamethasone 0.1% + neomycin 0.5% eye drops is not appropriate.
Second Choice:
Prednisolone 0.5% eye drops 
Used in preference to prednisolone acetate 1% for conditions in which less ocular penetration is required (such as allergic conjunctivitis).
Green traffic light only applies to prescriptions that do not exceed 7 days.
Second Choice:
Prednisolone 1.0% eye drops 
Should not be used for more than 10 days except under strict ophthalmic supervision with regular checks for intraocular pressure.

Second Choice:
Prednisolone 0.5% with neomycin 0.5% eye drops 
Green traffic light only applies to prescriptions that do not exceed 7 days.
Restricted Drug  Fluocinolone acetonide intravitreal implant   (Iluvien)
Restricted to ophthalmology use in line with NICE TA only
Excluded to tariff, CCG funding

Date of entry of decision to Formulary: February 2014
Fluorometholone  (FML®)
Specialist ophthalmology use only
Restricted Drug  Loteprednol Etabonate  (Lotemax®)
Specialist ophthalmology use only
Restricted Drug  Dexamethasone Intravitreal Implant   (Ozurdex®)
Restricted to ophthalmology
CCG commissioned in line with NICE TA
Date of entry of decision to formulary:
DMO - October 2015


Use in posterior uveitis supported April 16
Restricted Drug  Rimexolone  
Discontinued in UK. Contact ophthalmology service for alternative.
11.04.02 Other anti-inflammatory preparations

  • Although antihistamines and sodium cromoglicate are less potent than local corticosteroids, they have a place in the treatment of acute and chronic allergic conjunctivitis, as they do not cause the long-term side effects associated with steroids. They may also enable the dose of topical steroids to be reduced in severe chronic allergic conjunctivitis (vernal conjunctivitis).

  • Sodium cromoglicate should be used regularly and prophylactic treatment should be started at the onset of seasonal allergies such as hay fever. It has also been found to be useful in giant papillary conjunctivitis caused by contact lenses and foreign bodies.

  • Some non-steroidal anti-inflammatory drugs (NSAIDs) e.g. ketorolac are available as eye drops. These are used to reduce inflammation after ocular surgery.

  • See also oral antihistamines

  • Olopatadine eye drops are occasionally used as a second line choice in eye casualty but this is a more costly preparation.
First Choice:
Sodium Cromoglicate 
Contain benzalkonium chloride as a preservative; soft contact lens wearers should avoid them.
11.05 Mydriatics and cycloplegics

  • The lowest strength of solution should always be used for children.

  • Mydriasis should not be carried out in patients with a predisposition to acute angle-closure glaucoma (due to a shallow anterior chamber and/or small diameter cornea). If using drops in children, apply pressure over the lachrymal sac for 1 minute after instillation.

  • Do not use mydriatics in unconscious patients, as their effects will prevent reaction of the pupils to light and would affect any subsequent neurological examination.
First Choice:
Tropicamide 
Single use eye drops.
Produces rapid-onset mydriasis of short duration, maximal effect after 40-60 minutes. Recovery occurs over 6-8 hours. It produces some cycloplegia and is used to visualise the fundus for short procedures.
First Choice:
Cyclopentolate Hydrochloride Eye drops. 
Longer duration of action, reaching its maximal effect in 30-60 minutes. This lasts for about 45 minutes; complete recovery may take up to 24 hours. It can be used for visualisation of the fundus, refraction studies, or in the treatment of iridocyclitis if the patient is allergic to atropine
Restricted Drug  Atropine Sulphate 
Atropine eye drops or single use eye drops.
Used to prevent posterior synechiae in uveitis and iridocyclitis. The effects of atropine can last for up to 14 days. Systemic toxicity from atropine absorption occurs quite often, especially in elderly or very young patients. In particular elderly patients may become confused.
Restricted Drug  Phenylephrine Hydrochloride 
Single use eye drops.
Phenylephrine can be used alone or in conjunction with the other agents to produce wide mydriasis.
11.06 Treatment of glaucoma
Treatment of glaucoma may be undertaken with eye drops following the local glaucoma treatment algorithm. In most cases a prostaglandin analogue would be the first choice treatment. For some patients a combination of eye drops is required, introducing eye drops from different classes in a stepwise fashion according to the algorithm above. Combination eye drops are available for those requiring three or more different eye drops to control the condition.
Link   Leicestershire Glaucoma Prescribing Algorithm
Link   NICE CG 85: Glaucoma - diagnosis and management of chronic open angle glaucoma and ocular hypertension 2009.
11.06 Beta-blockers

  • The available topical agents are equally effective if used at comparable strengths, but there has been more experience with timolol.

  • The Committee for the Safety of Medicines (CSM) advises that beta-blockers even those with cardio-selectivity, should not be used in patients with asthma or a history of obstructive airways disease, unless no alternative treatment is available. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken.
First Choice:
Timolol Maleate 
Second Choice:
Levobunolol Hydrochloride 
May be longer acting than other beta-blockers.
Restricted Drug  Betaxolol Hydrochloride 
Cardioselective and is slightly less likely to cause bronchospasm in asthmatics. It is also the preferred beta-blocker where a patient has known cardiovascular problems such as AV block, although its effect should still be monitored.
Timolol 0.1% gel  (Tiopex®)
For use in patients who require preservative free timolol. This product is used once daily.
11.06 Prostaglandin analogues
First Choice:
Latanoprost 
Patent expiry has resulted in cost reduction. Ensure prescribed generically.
Second Choice:
Bimatoprost 300 micrograms/ml  (Lumigan®)
3ml eye drop bottles will be discontinued. Please use ’unpreserved unit doses’ in their place.
Restricted Drug  Bimatoprost 100 micrograms/ml  (Lumigan®)
For use only if patient unable to use single use unpreserved unit doses of bimatoprost 300 micrograms/ml
Bimatoprost 300micrograms/ml and timolol 5mg/ml  (Ganfort®)
If a combination product is considered appropriate
Latanoprost with timolol (50 microgram plus 5mg/ml) 
For use when a prostaglandin / beta blocker combination is indicated
11.06 Sympathomimetics
Sympathomimetics (alpha 2 agonists) may be used in addition to beta-blockers and/or prostaglandin analogues and/or carbonic anhydrase inhibitors or in cases where they are contra-indicated or not tolerated.
First Choice:
Brimonidine Tartrate 
May have a lower incidence of side effects than dipivefrine. It should not be used with antidepressants that interfere with noradrenaline uptake, monoamine-oxidase inhibitors (MAOIs) or antihypertensives.
Restricted Drug  Apraclonidine  (Iopidine®)
Brimonidine with timolol  (Combigan®)
May be used when three or more eye drop preparations are required to control the condition
Brinzolamide with brimonidine   (Simbrinza®)
May be used when three or more eye drop preparations are required to control the condition
11.06 Carbonic anhydrase inhibitors and systemic drugs
First Choice:
Brinzolamide 
Topical use. Almost as effective as treatment with acetazolamide with much reduced systemic side effects. Incidence of topical side effects is relatively low.
First Choice:
Acetazolamide Tablets 
Used to lower intra-ocular pressure by reduction of aqueous humour production. Usually used on a short-term basis as it has less effect with long-term use; it should only be used long-term in exceptional cases. If used long term appropriate monitoring of electrolytes is recommended.
Second Choice:
Acetazolamide Slow-release capsules 
Often better tolerated but are more expensive than the tablets.
Second Choice:
Dorzolamide 
Brinzolamide with timolol  (Azarga®)
May be used when three or more eye drop preparations are required to manage the condition
Dorzolamide with timolol 
Use of generic dorzolamide and timolol eye drops is approved in Leicestershire
Dorzolamide with timolol (in unit doses)  (Cosopt®)
For use only in patients who require preservative free eye drops and require three or more eye drop preparations to control the condition.
11.07 Local anaesthetics
The patient must be warned not to rub the eye until numbness has worn off, as corneal damage will not be felt. The protective blink reflex is reduced. Continued application of local anaesthetics can slow epithelial healing in corneal disease.
First Choice:
Oxybuprocaine Hydrochloride 
First Choice:
Proxymetacaine Hydrochloride 
Causes less stinging than oxybuprocaine and may be more suitable for children.
Second Choice:
Tetracaine Hydrochloride 
Produces a greater degree of anaesthesia than the other two agents and may be suitable for minor surgical procedures.
11.08 Miscellaneous ophthalmic preparations
11.08.01 Tear deficiency, ocular lubricants, and astringents
Use products in line with Leicestershire Guide to Prescribing Ocular Lubricants Please see individual product entries for detail on preservative contained.
(BZCL is benzalkonium chloride, which may cause ocular irritation; purite is a biodegradable low allergenic preservative system).
Preservative free drops are only indicated if:-

  • There is known toxicity or allergy to preservatives.

  • Drops are required 4 times a day or more in the presence of tear deficiency or epithelial instability.

  • Patients wearing preservative retaining contact lenses.
Link   Leicestershire Guide to Prescribing Ocular Lubricants
First Choice:
Hypromellose Eye drops 0.3% 
Mucin-like effects and is also of benefit when the watery component of tears is deficient. (May contain BZCL)

First Choice:
Simple eye ointment BP 
A bland ointment, which can be used on dry eyes at night, or applied when corneal drying must be avoided in anaesthetised or unconscious patients.
(Preservative free)
First Choice:
Optive Plus® 
(Contains purite)
First Choice:
Sodium hyaluronate 0.1%  (Hylo-Tear®)
For severe dry eye
(Preservative free)
Polyvinyl Alchohol 1.4%  (Sno Tears ®)
Help to form a tear film.
(Contains BZCL)
Carbomers 980 0.2% Gel  (Clinitas Carbomer Gel®)
Helps to form a tear film.
(Contains cetrimide)
Hydroxypropyl guar  (Systane®)
(Preservative free)
Carmellose 1%  (PF Drops® Carmellose 1%)
(Preservative free)
Sodium hyaluronate 0.2%  (Hylo-Forte®)
(Preservative free)
Lacri-Lube® 
(Preservative free)
Liquid paraffin plus Vitamin A eye ointment  (VitA-POS®)
(Preservative free)
Xailin Night® eye ointment 
Contains white soft paraffin, white mineral oil and lanolin alcohols. (Preservative free).
Carmellose 0.5% plus sodium hyaluronate 0.1%  (Optive Fusion®)
(contains purite)
Restricted Drug  Sodium Chloride 0.9% 
Single use eye drops. Sterile solution for irrigation.
These preparations are commonly used to remove irritants and foreign bodies from the eye. They are also useful as irrigation where eyelid disease prevents secretion by meibomian glands. A new (sealed) pack of irrigation solution should be used for each patient to prevent cross-contamination. Any contents remaining after use should be discarded.
Restricted Drug  Systane®Balance 
(contains polyquaternium-1)
For treatment of meibomian gland disease
Restricted Drug  Acetylcysteine 10% 
(Preservative free)
Restricted Drug  Sodium chloride 5% 
(Preservative free)
Drops and ointment available
Restricted Drug  Systane® Ultra 
(Preservative free)
Restricted Drug  Ciclosporin ophthalmic emulsion   (Ikervis®)
Specialist ophthalmologist initiation for use in line with NICE TA 369 only for treating severe keratitis in adult patients with dry eye disease that has not improved despite treatment with tear substitutes.

Date of entry of decision to Formulary: March 2016

11.08.02 Ocular diagnostic and peri-operative preparations and photodynamic treatment
Restricted Drug  Riboflavin Eye Drops  (VibeX®)
Peri-operative use during corneal collagen cross linkage surgery
11.08.02 Ocular diagnostic preparations
First Choice:
Fluorescein Sodium 
Routinely used to detect lesions, such as corneal ulcers and damage caused by foreign bodies. It is non-irritant and washes away from undamaged tissues with water.
Fluorescein will stain soft contact lenses.
11.08.02 Subfoveal choroidal neovascularisation
Link   Leicestershire Guidance: ARMD Algorithm for treatment
Restricted Drug  Ranibizumab   (Lucentis®)
For use by specialist ophthalmologists in line with NICE TA 155, TA 274, TA 283 or TA 298 - see links below.
High cost drug excluded to tariff.

Date of entry of decision to Formulary:
Pathological myopia - Feb 2014
RVO - August 2013
DMO - May 2013
Restricted Drug  Aflibercept   (Eylea®)
For specialist ophthalmology use only in line with NICE TA 294 for wet ARMD / NICE TA 305 for central retinal vein occlusion / NICE TA 409 for branch retinal vein occlusion and NICE TA 346 for Diabetic Macular Oedema
High cost drug excluded to tariff. CCG commissioned

Date of entry of decision to Formulary:
Branch RVO - December 2016
DMO - October 2015
Central RVO - April 2014
ARMD - February 2014
Restricted Drug  Bevacizumab  
Supported by TAS December 2011 for retinopathy of prematurity either first line or as a second line rescue treatment.
High cost drug excluded to tariff
11.08.02 Vitreomacular traction
Restricted Drug  Ocriplasmin 
High cost drug excluded to tariff. CCG commissioned

Date of entry of decision to Formulary: January 2014
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