11.Eye Administration of drugs to the eye. Eye drops. Eye ointments. Prescribing of Unlicensed Eye Products

Transcription

1 1 11.Eye Administration of drugs to the eye Eye-drop dispenser devices (Compleye, 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 Normal dosing for eye drops is one drop to be instilled into the eye. Patients would not be expected to instil drops during the night unless specifically indicated. 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 a few minutes between administering the two preparations. Systemic absorption of eye drops 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. If the eye drops/eye ointment prescribed contain preservatives such as benzalkonium chloride, patients who wear soft contact lenses should be advised to stop wearing the lenses during treatment and for 48 hours afterwards. Preservative free formulations should be reserved for patients with suspected allergies to preservatives or for patients who require instilling eye drops on an ongoing frequent basis (>6 times per day). Which may be single or multiple products as this can increase sensitivity to preservatives Eye ointments If using drops and ointment, use the drops first then wait five minutes before applying the ointment. Prescribing of Unlicensed Eye Products Unlicensed eye products should only be used when no licensed alternative eye products are considered suitable. Special order products tend to be significantly more expensive than licensed alternatives. For further information on the appropriate prescribing of unlicensed eye products refer to the Royal College of Ophthalmologists Guidance on Ophthalmic Special Products, General Principles. Pharmacists can obtain special order ophthalmic products from Tayside Pharmaceuticals ( ) or Western Production Unit, Western General Infirmary, Glasgow ( ).

2 2 Prescribing of Vitamin Supplements for Eye Conditions Patients should be advised that there is no strong evidence that vitamin supplements are beneficial in the majority of patients with eye conditions including dry macular degeneration and for this reason they cannot be prescribed. Key advice to patients who smoke should be to stop smoking. A healthy diet should be advised. If they wish, patients may purchase a suitable supplement preparation instead but they should seek advice from their pharmacist especially if they are smokers Anti-infective eye preparations Also see NHS Fife Antibiotic Guidance for the Treatment of Community Managed Infections Conjunctivitis 2nd Choice Bathing for 48 hours Chloramphenicol 0.5% drops + bathing Chloramphenicol 1% Ointment + bathing Ofloxacin drops (If allergic to chloramphenicol) H- Chloramphenicol 0.5% drops (Minims ) Most cases of bacterial conjunctivitis are self-limiting. 64% resolve with placebo. Bathing of eye with freshly boiled and cooled water for 48 hours is usually sufficient in treating conjunctivitis. (Adding salt to the water is of no additional benefit). 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. Chlamydial/ Gonococcal Conjunctivitis (Confirmed/Suspected) Chlamydia Adults Azithromycin (oral) Chlamydia Neonates Erythromycin (oral) 12.5mg/kg Gonococcal Adults H- Ceftriaxone Gonococcal Neonates H- Cefotaxime For the management of neonatal conjunctivitis also see Appendix 11A Management of Neonatal Conjunctivitis. Systemic therapy is required for proven chlamydia infection. It is imperative that all sexual contacts be tested and treated simultaneously.

3 3 Parents of infected neonates should be advised to be tested and treated. Mothers and their partner(s) should be referred to sexual health for testing, treatment and partner notification. After treatment, test of cure should be undertaken in all patients with non-genital chlamydia and in pregnant mothers with chlamydia. All cases of gonorrhoea should have a test of cure 2 weeks after completion of antibiotic course and for chlamydia patients 6 weeks after completion. Blepharitis Lid Hygiene Frequent lid hygiene is normally sufficient for managing blepharitis. Apply freshly boiled and cooled water with a cotton wool ball or bud along the base of the eyelashes. Lid hygiene products for the management of blepharitis should not be prescribed. Patients should be advised to purchase OTC if required. Topical antibiotics are normally ineffective in the treatment of blepharitis. Ocular lubricants may be of benefit (see section 11.8 for further advice). Persistent cases may be associated with rosacea, these cases may benefit from a 3 month course of systemic tetracycline therapy. (See section 13.6 of the Fife Formulary for further advice). Repeated courses are often required intermittently. Persistent cases of blepharitis may be treated with azithromycin for 4 days if recommended by a specialist. Corneal ulcers 2 nd Choice Ofloxacin 0.3% eye drops H- Cefuroxime 5% eye drops (unlicensed) + H- gentamicin 1.5% eye drops (unlicensed) Normally require initial intensive treatment in hospital. Corneal abrasions Chloramphenicol 1% ointment Most corneal abrasions will heal spontaneously within hours with conservative management. Chloramphenicol 1% ointment may be considered but there is no evidence base of benefit.

4 4 Regular simple oral pain relief is recommended. Acanthamoeba Keratitis S - Propamidine/dibromopropamidine eye drops (Brolene ) S Chlorhexidine Gluconate 0.02% eye drops (unlicensed) Propamidine/dibromopropamidine (Brolene ) in combination with chlorhexidine eye drops 0.02% is indicated for use as part of the regime 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 Antivirals Aciclovir 3% eye ointment (Zovirax ) Topical aciclovir is used for herpes simplex corneal infections under hospital supervision. Long term low dose oral aciclovir may be prescribed for recurrent herpes simplex keratitis. Oral aciclovir should be prescribed immediately for ophthalmic zoster. Dose required for adults is 800mg five times daily for seven days. In patients with renal impairment the aciclovir dose needs to be reduced for patients with an egfr of 10-25ml/min/1.73m 2-800mg every 8 hours; for patients with an egfr <10ml/min/1.73m 2-800mg every 12 hours Corticosteroids and other anti-inflammatory preparations Corticosteroids S - Dexamethasone 0.1% (Maxidex ) S - Prednisolone sodium phosphate 0.5% (Predsol ) S - Prednisolone acetate 1% (Pred Forte ) Preservative Free S - Dexamethasone 0.1% P/F (Dexafree ) S - Prednisolone sodium phosphate 0.5% P/F (Minims ) S - Betamethasone 0.1% 2nd Choice eye drops (Vistamethasone ) eye ointment (Betnesol ) R - Fluorometholone ophthalmic suspension (FML ) R - Maxitrol (dexamethasone 0.1%+ neomycin + polymyxin B)

5 5 Uveitis H - Adalimumab (Humira ) H - Dexamethasone intravitreal implant (Ozurdex ) Adalimumab (Humira ) is recommended for second line treatment of uveitis after failure of steroids or immunomodulatory drugs such as mycophenolate or tacrolimus. Dexamethasone intravitreal implant (Ozurdex ) is recommended for second line treatment of uveitis after failure of steroids or immunomodulatory drugs such as mycophenolate or tacrolimus Anti-allergy preparations Nedocromil sodium 2% 2nd Choice Olopatadine Sodium cromoglicate 2% Should normally only be used under expert supervision due to the risks of undiagnosed red eye being caused by a herpes simplex infection; may lead to the development of steroid glaucoma and prolonged use may lead to a steroid cataract. Preservative free single use formulations of prednisolone sodium phosphate 0.5% and dexamethasone 0.1% are available. The preferred P/F formulation of dexamethasone is Dexafree. R FML suspension is restricted to patients where a rise in intraocular pressure is a concern (e.g. uveitis or glaucoma). R Maxitrol is approved for hospital use only in the post operative management of trabeculectomy. Sodium cromoglicate and nedocromil sodium can be used to treat vernal keratoconjunctivitis and other allergic forms of conjunctivitis. Treatment may take several weeks to achieve maximal effect and it is important that patients continue to use the drops regularly even when symptoms improve. 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. Olopatadine only licensed for seasonal allergic conjunctivitis (max of 4 months). Nedocromil sodium and sodium cromoglicate can be used longer term if required Mydriatics and cycloplegics Antimuscarinics

6 6 Tropicamide Cyclopentolate (Mydrilate ) S Atropine 1% (Minims ) 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). After mydriasis, patients should be warned not to drive until vision has returned to normal (usually after 1-2 hours). Sympathomimetics H - Phenylephrine eye drops Phenylephrine is used as a mydriatic prior to ophthalmic procedures. Its effect lasts up to seven hours Treatment of Glaucoma Also see NICE Clinical Guidance 85 - Glaucoma: Diagnosis and management of chronic open angle glaucoma and ocular hypertension (April 2009) Combination eye drops Combination products should only be prescribed if all active constituents are listed in the formulary. Separate eye drops are more effective than using combination drops however combination products are of benefit when patient compliance is problematic. Preservative Free Formulations Preservative free formulations should be reserved for patients with suspected allergies to preservatives or for patients who require instilling eye drops on an ongoing frequent basis (>6 times per day). Which may be single or multiple products as this can increase sensitivity to preservatives Treatment of Glaucoma First line Second line Third line Fourth line Prostaglandin analogue + Beta-blocker + Sympathomimetic + Carbonic anhydrase inhibitor

7 7 At each stage, consideration should be given to withdrawing a drug if there is no significant pressure response. Prostaglandin analogues S - Latanoprost 2nd Choice S - Bimatoprost 100mcg/ml (Lumigan ) R - Travoprost (Travatan ) Preservative Free Prostaglandin Analogues S - Latanoprost P/F (Monopost ) 2nd Choice S - Bimatoprost P/F (Lumigan ) Combination Products S - Latanoprost + timolol 2nd Choice S - Bimatoprost + timolol (Ganfort ) R - Travoprost + timolol (Duotrav ) Preservative Free Combination Products S - Bimatoprost + timolol P/F (Ganfort ) Prostaglandin analogues should be prescribed generically. Prostaglandin analogues should normally be instilled in the evening. Patients should be monitored for any change in the colour of the iris. Latanoprost +/- timolol is available as a generic and is the preferred prostaglandin analogue. Bimatoprost multidose eye drops are only available in a 100mcg/ml strength. Combination and preservative free formulations contain 300mcg/ml bimatoprost. Both strengths have similar efficacy in terms of intraocular pressure lowering effect. However the presence of a higher concentration of benzalkonium chloride in the 100mcg/ml formulation can increase ocular side-effects, therefore, patients with sensitivity will need to switch to the preservative free formulation instead. R Travoprost is less likely to cause pigmentation than other prostaglandin analogues. Travoprost is restricted to specialist initiation in patients with fair eyes where pigmentation of the iris may be a concern. Beta-blockers S - Timolol Preservative Free Beta-Blockers S - Timolol 0.1% unit dose eye gel (Tiopex ) Timolol 0.25% is just as effective as the 0.5% strength but less likely to cause side-effects.

8 8 Combination products containing timolol are only available as 0.5% strength eye drops. A once daily gel formulation of timolol (Timoptol -LA) is available for use when patient compliance is a problem. Due to possible systemic absorption beta-blockers (even those with cardioselectivity) 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 pulmonary disease unless no alternative treatment is available. In such cases the risk of inducing bronchospasm should be appreciated and appropriate precautions taken. Sympathomimetics S - Brimonidine Combination Products S - Brimonidine + timolol (Combigan ) S - Brimonidine + brinzolamide (Simbrinza ) Brimonidine may cause ocular allergic reactions in approximately 15% of patients, especially those with dry eyes. Normal onset of allergic reaction is 3-9 months after initiation of brimonidine. Carbonic anhydrase inhibitors and systemic drugs 2nd Choice S - Dorzolamide S - Brinzolamide Preservative Free S - Dorzolamide P/F (Trusopt ) Combination Products S - Dorzolamide + timolol 2nd Choice S - Brinzolamide + timolol (Azarga ) Preservative Free Combination Products S - Dorzolamide + timolol P/F (Cosopt ) Systemic Drugs S - Acetazolamide H - Acetazolamide 500mg IV injection Dorzolamide +/- timolol is available as a generic and is the preferred carbonic anhydrase inhibitor. As monotherapy, dorzolamide should be instilled three times daily. If used with topical beta-blockers, instilled twice daily. Acetazolamide can give rise to sulphonamide type adverse reactions.

9 9 Miotics Preservative Free Miotics S - Pilocarpine drops S - Pilocarpine 2% P/F drops (Minims ) Contraction of the pupil can lead to blurred vision and impairment of skilled tasks or driving. Headache/brow-ache can be a common side effect during the first two to four weeks of treatment Local anaesthetics Oxybuprocaine (Minims ) Tetracaine (Minims ) H -Proxymetacaine (Minims ) H -Lidocaine and fluorescein eye drop (Minims ) Proxymetacaine causes less initial stinging and is useful for children Miscellaneous ophthalmic preparations Tear deficiency, ocular lubricants and astringents Also see Appendix 11B - Management of Patients with Dry Eyes Preservative Free Formulations Preservative free formulations should be reserved for patients with suspected allergies to preservatives or for patients who require instilling eye drops on an ongoing frequent basis (>6 times per day). Which may be single or multiple products as this can increase sensitivity to preservatives Lubricants Hypromellose 0.3% drops 2nd Choice Carbomer 980 gel 0.2% (Clinitas ) Polyvinyl alcohol (Liquifilm ) Preservative free Hypromellose 0.3% P/F Unit Dose (Lumecare ) 2nd Choice Carbomer 980 gel 0.2% P/F (Viscotears ) Eye Ointment VitA-POS eye ointment

10 10 S - Carmellose sodium 0.5%,1% (Carmize ) Preservative free S - Carmellose sodium 0.5%,1% P/F (Carmize ) S - Sodium Hyaluronate 0.1% (Hylo-tear ) S - Sodium Hyaluronate 0.2% (Hylo-forte ) S - Sodium Hyaluronate 0.4% (Clinitas Multi use) Miscellaneous R - Ciclosporin 0.1% eye drops (Ikervis ) R - Ilube eye drops R - Optive Plus Preservative free Sodium chloride 0.9% drops (Minims ) A range of different products are available to treat dry eyes. The severity of tear deficiency, cost 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. Patients using lubricants more than 6 times per day should use preservative-free preparations in order to avoid toxicity from high levels of preservative. Various products containing carbomers, carmellose and sodium hyaluronate are available. Products should be prescribed by the Formulary choice brand names to ensure the most cost-effective brands are dispensed. 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 normally be applied before sleep. Products containing carmellose, sodium hyaluronate and polyethylene glycol are reserved for patients with moderate-severe dry eyes where 1 st and 2 nd choice products have been ineffective. R Ciclosporin eye drops (Ikervis ) are approved for restricted use, initiated by a specialist, for the treatment of severe keratitis in adult patients who not responded adequately to tear substitutes. R Ilube is approved for restricted use for use in severe dry eyes associated with filamentary keratitis or abnormal mucin production. Treatment should be for a maximum of 3 months. Patients should be informed that this product will produce a stinging sensation on instillation into the eye. R Optive Plus is approved for restricted specialist initiation/recommendation for meibomian gland dysfunction Ocular diagnostic preparations and photodynamic treatment Fluorescein (Minims )

11 11 Ocular peri-operative drugs S - Ketorolac drops (Acular ) S - Diclofenac drops (Voltarol Optha ) Subfoveal choroidal neovascularisation H - Ranibizumab (Lucentis ) H - Aflibercept (Eylea ) Ranibizumab is approved 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. Only to be administered by specialists experienced in the management of these conditions. Aflibercept (Eylea ) is approved as an alternative to ranibizumab. Only to be administered by specialists experienced in the management of these conditions.