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

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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-drop dispenser devices (Opticare, Opticare Arthro 5, Opticare Arthro 10) are available to aid the instillation of eye drops from plastic bottles; they are particularly useful for the elderly, visually impaired, arthritic, or otherwise physically limited patients.

Eye drops

 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; normally one drop should be administered at a time to prevent overflow and possible systemic absorption.  Patients should be advised to shake all eye drop bottles before use.  When two different eye drop preparations are used at the same time of day, dilution and overflow may occur. The patient should therefore leave an interval of at least five minutes between administering the two types of eye drops.  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 of drugs is associated with eye drops much more often than with eye ointments. Systemic absorption can be reduced by ‘punctal occlusion’, i.e. pressing tightly with a finger on the inside corner of the eye for about a minute after instilling the eye drop.  In the case of antibiotic eye drops, patients should be counselled to continue treatment for the stated duration and not to stop using because the condition appears to have improved.  Patients would not be expected to instil drops during the night unless specifically indicated.  Due to the potential for systemic absorption of drugs from the eye, consideration should be given to any systemic side-effects caused by ophthalmic drugs. There is also the potential for ophthalmic drugs interacting with systemic drugs.  Patients who wear soft contact lenses should be advised to stop wearing them during treatment and for 48 hours afterwards if the eye drops/eye ointment prescribed contain preservatives such as benzalkonium chloride, which can damage lenses.  Preservative free Minims® or unit dose vials should be reserved for patients with suspected allergies to preservatives or for patients who require to instil eye drops on a frequent basis e.g. hourly for a prolonged period of time.

Combination eye drop products

 There are many combination products now available that are appropriate for use when the patient requires both active drugs.  The combination products help to improve patient compliance by reducing the number of drops and products used. They are of particular benefit when patient compliance is problematic.  Combination products that are approved for use should have all active constituents listed in the formulary.

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

Eye ointments

 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.  If using drops and ointment, use the drop first then wait five minutes before applying the ointment.  Older patients may find it easier to apply eye ointments rather than administering eye drops.

Subconjunctival injections

 Subconjunctival injections may be used to administer anti-infective drugs, mydriatics, or corticosteroids for conditions not responding to topical therapy. 11.2 Control of microbial contamination  Eye drops in multiple-dose bottles and eye ointments for use in the community should be discarded four weeks after opening (unless otherwise stated). Separate bottles should be used for each eye if either eye is infected.  Eye drops for use in hospital wards are normally discarded one week after first opening. A separate bottle is not required for each eye only unless there are concerns about cross-contamination. Containers used before an operation should be discarded at the time of the operation and fresh containers supplied.  Preservative free eye drops should be discarded within seven days after opening.  In out-patient departments single-dose packs should be used; if multiple-dose packs are used, they should be discarded at the end of each day. If a patient is being treated for an active eye infection then any multiple-dose packs should not be used for any other patient. In clinics for eye diseases and in accident and emergency departments, where the dangers of infection are high, single-dose packs should be used; if a multiple-dose pack is used, it should be discarded after single use.  In eye surgery single-dose packs should be used if possible; if a multiple-dose pack is used, it should be discarded after single use.  Diagnostic dyes (e.g. fluorescein) should be used only from single dose packs. 11.3 - Anti-infective eye preparations Also see NHS Fife Antibiotic Guidance for the Treatment of Community Managed Infections www.fifeadtc.scot.nhs.uk/formulary/support%20info/Primary%20Care%20Antibiotic%20Guidelines.pdf

11.3.1 Antibacterials

Frequent lid hygiene may be sufficient - mix two parts of baby shampoo with ten parts of cooled boiled water. The solution is applied with a cotton wool ball or bud to clean along the base of the eyelashes. 1st Choice Chloramphenicol 0.5% drops + lid hygiene or Chloramphenicol 1% Ointment + lid hygiene 2nd Choice Fusidic acid 1% drops + lid hygiene

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

Prescribing points

 Most cases of bacterial conjunctivitis are self-limiting. 64% resolve with placebo.  Chloramphenicol has a broad spectrum of activity and is the drug of choice for superficial eye infections. Chloramphenicol eye drops are available over the counter (OTC) from pharmacies for children over 2 years of age and adults.  A preservative free single use chloramphenicol preparation is available (Minims®).  Fusidic acid has less gram negative activity but is useful in staphylococcal infections.  Propamidine/dibromopropamidine (Brolene®) is of little value in bacterial infections but is indicated for use in the rare, but sight threatening, condition of acanthamoeba keratitis mainly caused by the ineffective cleaning and disinfection of lenses or the use of contaminated lens cases. The condition is especially common in patients wearing soft contact lenses or daily use lenses.  A poor response to antibacterial eye drops or ointment may indicate viral or allergic conjunctivitis.  Antibacterials are not helpful in managing viral conjunctivitis.

Chalmydial conjunctivitis (Confirmed/Suspected) Azithromycin (oral) Erythromycin (oral)

Prescribing points

 Systemic therapy is required for proven chlamydia infection.  It is imperative that that all sexual contacts be tested and treated simultaneously.  Parents of infected neonates should be advised to be tested and treated.  All those testing positive should be tested for cure after treatment.

Blepharitis 1st Choice Lid Hygiene 2nd Choice Chloramphenicol 1% ointment + lid hygiene or Fusidic acid 1% eye drops + lid hygiene

Prescribing points

 Bathing eyes and increased lid hygiene may be all that is necessary to treat blepharitis.  Blepharitis is often caused by staphylococci.  Fusidic acid is useful for staphylococcal infections.  Persistent cases may benefit from systemic tetracycline therapy. Treatment should be for a minimum of six weeks. However, a three month course will usually provide a prolonged effect. Repeated courses are often required intermittently.

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

Corneal ulcers Normally require initial intensive treatment in hospital.

1st Choice H- Ofloxacin 0.3% eye drops H- Cefuroxime 5%+ gentamicin 1.4% eye 2nd Choice drops (Special) Antibacterials with corticosteroids Also see Section 11.4.

 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. Management of neonatal conjunctivitis See Appendix 11A – Management of Neonatal Conjunctivitis

11.3.2 Antifungals

Refer to BNF - www.bnf.org

11.3.3 Antivirals

Aciclovir 3% eye ointment Prescribing points  Topical aciclovir is used for herpes simplex corneal infections under hospital supervision.  Oral aciclovir should be prescribed immediately for ophthalmic zoster. Dose required for adults is 800mg five times daily for seven days.  Long term oral aciclovir may be prescribed for recurrent herpes simplex keratitis.

11.4 - Corticosteroids and other anti-inflammatory preparations 11.4.1 Corticosteroids 1st Choice - Betamethasone 0.1% drops or ointment or - Prednisolone phosphate 0.5% (Predsol®) or - Betnesol N® drops or - Maxidex® or - Prednisolone acetate 1% (Pred Forte®) - Fluorometholone ophthalmic suspension 2nd Choice (FML®)

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

Prescribing points  Should normally only be used under expert supervision due to the risks of undiagnosed red eye being caused by a herpes simplex infection; development of ‘steroid glaucoma’; prolonged use may lead to a ‘steroid cataract’.  A preservative free single use prednisolone sodium phosphate 0.5% preparation is available (Minims®).  FML® suspension is less likely to cause a rise in intraocular pressure.

Intra vitreal corticosteroids H- Dexamethasone implant (Ozurdex®) R – Fluocinolone Implant (Iluvien®) Prescribing points  Dexamethasone implant is approved for use in central retinal vein occlusion as an alternative to ranibizumab in patients who would prefer less frequent administration and also in patients with branch retinal vein occlusion where laser therapy has failed or in patients where laser therapy is inappropriate i.e. patients with dense macular haemorrhage.  R – Fluocinolone intravitreal implant (Iluvien®) is approved for restricted specialist, hospital use only for the treatment for chronic diabetic macular oedema unresponsive to other therapies (laser, ranibizumab). Iluvien® should only be used in patients in whom the affected eye is pseudophakic (has an artificial lens after cataract surgery). Re-treatment should only take place in patients who have previously responded to treatment with Iluvien® and best correct visual acuity has deteriorated to less than 20/32. Iluvien® should only be used by ophthalmologists who have received accredited training in inserting the implant. 11.4.2 Other anti-inflammatory preparations 1st Choice Sodium cromoglicate 2% 2nd Choice Nedocromil sodium 2% Prescribing points  Sodium cromoglicate and nedocromil sodium can be used to treat vernal keratoconjunctivitis and other allergic forms of conjunctivitis.  Sodium cromoglicate drops can be bought over the counter for the treatment of acute (seasonal) and perennial allergic conjunctivitis.  Nedocromil is not licensed for use in children under six years of age. 11.5 - Mydriatics and cycloplegics Antimuscarinics Cyclopentolate Tropicamide S - Atropine Prescribing points

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

 Preservative free single use cyclopentolate, tropicamide and atropine preparations are available (Minims®).  Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle (cycloplegia). They vary in potency and duration of action.  All patients having pupil dilation should be advised to seek medical advice if acute pain develops after administration of drops as acute angle closure glaucoma can occur.  Atropine is the most potent and has the longest duration of action (seven days or more).  Cyclopentolate is less potent and has a shorter duration of action (up to 24 hours).  Atropine and cyclopentolate are preferable for producing cycloplegia for refraction in young children. In the under fives atropine ointment may be preferred to reduce systemic absorption.  Tropicamide is a relatively short acting (up to three hours), weak mydriatic and is used to facilitate the examination of fundus of the eye. Tropicamide can rarely cause angle closure glaucoma.  Darkly pigmented irises are more resistant to papillary dilatation and care should be taken to avoid overdosage in patients with dark eyes.  Patients should be warned not to drive for one to two hours after mydriasis.  Systemic side effects, particularly in children and the elderly, can occur with atropine and cyclopentolate.

Sympathomimetics S - Phenylephrine eye drops Prescribing points

 Phenylephrine is used as a mydriatic prior to ophthalmic procedures. Its effect lasts up to seven hours.

11.6 - Treatment of Glaucoma

Combination eye drop products  There are many combination products now available that are appropriate for use when the patient requires both active drugs and are of particular benefit when patient compliance is problematic.  Combination products that are approved for use should have all active constituents listed in the formulary.

Prostaglandin analogues 1st Choice S - Latanoprost 2nd Choice S - Bimatoprost (Lumigan®) S - Travoprost (Travatan®) Prescribing points  Should normally be applied in the evening.  Patients should be monitored for any change in the colour of the iris. KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

 Available as combination products with timolol.  Latanoprost and bimatoprost are available as preservative free preparations. Use is restricted to patients who cannot tolerate standard formulations due to proven sensitivity to benzalkonium chloride. Beta-blockers S - Betaxolol S - Timolol drops Prescribing points  A once daily gel formulation of timolol is available for use when patient compliance is a problem.  Preservative free preparations of betaxolol and timolol are available. Tiopex® is the Fife Formulary preferred P/F timolol formulation.  Due to possible systemic absorption beta blockers are contraindicated in patients with bradycardia, heart block and uncontrolled heart failure. They should also not be used in patients with asthma or a history of chronic obstructive airways disease unless no alternative treatment is available.  Consideration should be given to possible interactions with systemic drugs, e.g. verapamil.

Sympathomimetics S - Brimonidine Prescribing points  Used in patients where beta blockers are unsuitable or in addition with other agents where intra ocular pressure is inadequately controlled.  Applied twice daily.  Available as a combination product with timolol.

Carbonic anhydrase inhibitors and systemic drugs S - Dorzolamide S - Acetazolamide (tablets, MR capsules and

i.v. injection) S - Brinzolamide (Azopt®) Prescribing points  Reduce aqueous humour production.  Acetazolomide is given orally or by intravenous injection, used as an adjunct to other treatment.  Acetazolamide can give rise to sulphonamide type adverse reactions.  Dorzolamide and brinzolamide are licensed for use in patients where a beta blocker is unsuitable or ineffective or in addition to a beta blocker.  Brinzolamide is a suitable alternative for patients unable to tolerate dorzolamide due to ocular discomfort.  As monotherapy dorzolamide should be applied three times daily. If used with topical beta blockers,

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

applied twice daily.  Both dorzolamide and brinzolamide are available in combination with timolol.

Miotics S - Pilocarpine drops Prescribing points  A preservative free single use pilocarpine 2% formulation is available (Minims®)  Cause contraction of the ciliary muscle leading to opening up of the trabecular meshwork drainage channels.  A darkly pigmented iris may require higher concentration of pilocarpine or more frequent administration. Care should be taken to avoid overdosage.  Retinal detachment may occur in some individuals. A fundus examination is advised before starting treatment.  Contraction of the pupil can lead to blurred vision and impairment of skilled tasks or driving.  Headache/browache can be a common side effect during the first two to four weeks of treatment. 11.7 - Local anaesthetics Tetracaine (Minims®) Oxybuprocaine (Minims®) S - Proxymetacaine (Minims®) S - Lidocaine and fluorescein eye drop

(Minims®) S - Proxymetacaine and fluorescein eye drops

(Minims®) Prescribing points  Proxymetacaine causes less initial stinging and is useful for children.  Oxybuprocaine has a very rapid onset of action (30 seconds) and causes less initial irritation than tetracaine.  Oxybuprocaine or a combined preparation of lidocaine and fluorescein is used in tonometry.  Tetracaine produces more profound anaesthesia and is suitable for use before minor surgical procedures.  Local anaesthetics should never be used for the management of ocular symptoms, e.g. corneal abrasions as they impede corneal healing and can cause corneal damage. 11.8 - Miscellaneous ophthalmic preparations

11.8.1 Tear deficiency, ocular lubricants and astringents 1st Choice Hypromellose 0.3% drops 2nd Choice Carbomers Hydroxyethylcellulose

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

Carmellose sodium (Optive®, Celluvisc®) Lacri-Lube® eye ointment Polyvinyl alcohol (Liquifilm®) S - Ilube® eye drops Prescribing points  All products above (except Ilube®) are available to purchase over the counter.  Preservative free preparations of hydroxyethylcellulose and of Viscotears® are available.  Ilube® contains acetylcysteine and should be reserved for use in filamentary keratitis. Patients should be informed that this product will produce a stinging sensation on instillation into the eye.  The severity of tear deficiency and patient preference will often guide the choice of preparation.  Hypromellose is the first choice for tear deficiency due to cost but may need to be instilled frequently (hourly) for adequate relief.  Carbomers tend to be more viscous and may only need to be used four times daily.  Eye ointments may be used to lubricate the eye surface, especially in cases of recurrent epithelial erosion. However, because they can cause temporary visual disturbances, they should be applied before sleep. 11.8.2 Ocular diagnostic preparations Fluorescein (Minims®) H - Rose Bengal (Minims®) Ocular peri-operative drugs S - Ketorolac drops (Acular®) S - Diclofenac drops (Voltarol Optha®) R - Nepafenac (Nevanac ®) Prescribing points  R – Nepafenac is approved for restricted hospital specialist use only for use as a prophylactic treatment in patients who develop post op. macular oedema in the 1st eye and are then due to undergo cataract surgery in their second eye.

Subfoveal choroidal neovascularisation H - Ranibizumab (Lucentis®) H - Aflibercept (Eylea®) Prescribing points  Ranibizumab is available for the treatment of neovascular (wet) age-related macular degeneration (AMD), diabetic macular oedema, macular oedema secondary to retinal occlusion and also for the treatment of visual impairment due to choroidal neovascularisation secondary to pathologic myopia. Only to be administered by specialists experienced in the management of these conditions.  Ranibizumab is recommended as a possible treatment for AMD if all the following apply: - the best possible visual acuity after correction with glasses or contact lenses is between 6/12 KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014

and 6/96, - there is no permanent damage to the fovea, - the area affected by AMD is no larger than 12 times the size of the area inside the eye where the optic nerve connects to the retina, - there are signs that the condition has been getting worse.  Treatment should be stopped if the patient’s vision gets worse and there are changes inside the eye which show the treatment is not working.  There is conflicting evidence regarding the risk of stroke or heart attack with intravitreal ranibizumab. Patients should be warned that there may be an increased risk with this treatment. At present a previous history of these conditions is not a contraindication to treatment  Aflibercept (Eylea®) is approved as an alternative to ranibizumab for the treatment of neovascular (wet) AMD and for use in macular oedema secondary to central retinal vein occlusion.

KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only

Fife Formulary February 2010 Last amended April 2014