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 Formulary Chapter 11: Eye - Full Chapter
Notes:

Preservative Free Eye Drops
Microbial contamination of multidose bottles of eye drops can cause eye infections that may lead to damage of the eye and in extreme cases loss of sight. To minimise the risk, multidose bottles of eye drops contain an antimicrobial preservative such as benzalkonium chloride. The preservatives used in eye drops are normally well tolerated, but they are not completely harmless. They can cause irritation and damage to the corneal epithelium. This risk is understood to be greater in patients with pre-existing damage to the ocular surface and where large quantities of preservative containing eye drops are applied repeatedly over a prolonged period (e.g. if applied more than 4 to 6 times daily for several weeks/ months).
To avoid these problems the use of preservative-free eye drops is recommended in:
 Patients who have experienced hypersensitivity reactions or irritation due to preservatives in eye drops.
 Patients who have received corneal grafts.
 Patients with conditions where there is already damage to the ocular surface as a result of disease or trauma, such as dry eye, blepharitis, ocular burns etc.
Treatment with preservative-free eye drops will usually be initiated by an ophthalmologist.
Chapter Links...
Link   NICE NG242 : Diabetic retinopathy: management and monitoring
Link   North of Tyne, Gateshead and North Cumbria - Ophthalmology Referral Guidelines
 Details...
11.08.02  Expand sub section  Ocular diagnostic and peri-operative preparations and photodynamic treatment
11.08.02  Expand sub section  Ocular diagnostic preparations
11.08.02  Expand sub section  Ocular peri-operative drugs
11.08.02  Expand sub section  Subfoveal choroidal neovascularisation
Aflibercept  (Eylea®)
View adult BNF View SPC online View childrens BNF 		Formulary
Red
High Cost Medicine
CCG
  • 40mg/1ml & 114.3mg/1ml solution for injection
  • Approved for wet age related macular degeneration in line with NICE.
  • Approved for macular oedema – central retinal vein occlusion in line with NICE.
  • Approved for diabetic macular oedema in line with NICE.
  • Approved for treating visual impairment caused by macular oedema after branch retinal vein occlusion in line with NICE.
  • Approved as an option for treating visual impairment because of myopic choroidal neovascularisation in adults in line with NICE

 

 
Link  NICE TA 294 Aflibercept solution for injection for treating wet age‑related macular degeneration
Link  NICE TA 305 Aflibercept for treating visual impairment caused by macular oedema secondary to central retinal vein occlusion
Link  NICE TA 346 Aflibercept for treating diabetic macular oedema
Link  NICE TA 409: Aflibercept for treating visual impairment caused by macular oedema after branch retinal vein occlusion
Link  NICE TA 486: Aflibercept for treating choroidal neovascularisation
 
Bevacizumab gamma (Lytenava®)
View adult BNF View SPC online View childrens BNF 		Formulary
Red
CCG
  • 25 mg/mL solution for injection
  • Approved for use as an option for treating wet age-related macular degeneration in adults in line with NICE

 

 
Link  NICE TA1022: Bevacizumab gamma for treating wet age-related macular degeneration
 
Brolucizumab (Beovu®)
View adult BNF View SPC online View childrens BNF 		Formulary
Red
High Cost Medicine
CCG
  • 19.8mg/0.165mL solution for injection (pre-filled syringes)
    • Approved for treating wet age-related macular degeneration in adults in line with NICE
 
Link  MHRA Drug Safety Update (Jan 2022): Brolucizumab (Beovu▼): risk of intraocular inflammation and retinal vascular occlusion increased with short dosing intervals
Link  NICE TA672: Brolucizumab for treating wet age-related macular degeneration
Link  NICE TA820: Brolucizumab for treating diabetic macular oedema
 
Faricimab (Vabysmo® )
View adult BNF View SPC online View SMC online View childrens BNF 		Formulary
Red
CCG
  • 120mg/1ml solution for injection
    • Approved for the treatment of diabetic macular oedema in adults in line with NICE
    • Approved for the treatment of wet age-related macular degeneration in line with NICE
    • Approved for the treatment of visual impairment caused by macular oedema after retinal vein occlusion in line with NICE
 
Link  NICE TA1004: Faricimab for treating visual impairment caused by macular oedema after retinal vein occlusion
Link  NICE TA799: Faricimab for treating diabetic macular oedema
Link  NICE TA800: Faricimab for treating wet age-related macular degeneration
 
Ranibizumab 10mg/1ml injection (Lucentis®)
View adult BNF View SPC online View childrens BNF 		Formulary
Red
High Cost Medicine
CCG
  • Approved for wet age related macular degeneration in line with NICE.
  • Approved for diabetic macular oedema in line with NICE.
  • Approved for visual impairment caused by macular oedema secondary
    to retinal vein occlusion in line with NICE.
  • Approved as a possible treatment for sight problems caused by choroidal neovascularisation in people who also have pathological myopia in line with NICE.

 

 

 
Link  NICE TA 274 Ranibizumab for treating diabetic macular oedema
Link  NICE TA 155 Ranibizumab and pegaptanib for the treatment of age-related macular degeneration
Link  NICE TA 283 Ranibizumab for treating visual impairment caused by macular oedema secondary to retinal vein occlusion
Link  NICE TA 298 Ranibizumab for treating choroidal neovascularisation associated with pathological myopia
 
Verteporfin 15mg Injection (Visudyne®)
View adult BNF View SPC online View childrens BNF 		Formulary
Red

Approved for photodynamic therapy in wet age-related macular degeneration in line NICE.

 
Link  NICE NG82: Age-related macular degeneration
Link  NTAG Decision Summary June 2020: Verteporfin
 
Bevacizumab 1.25mg/0.05ml intravitreal injection
View adult BNF View SPC online View childrens BNF 		Unlicensed Drug Unlicensed
Red
CCG
  • NETAG approved for use in the management of macular oedema
    secondary to retinal vein occlusion. 
  • NTAG approved for age related macular degeneration.

 

 
 
11.08.02  Expand sub section  Vitreomacular traction to top
11.08.02.04  Expand sub section  Other products - Mainly for treating ocular injuries
11.08.02.04  Expand sub section  Antifungals
11.08.02.04  Expand sub section  Cytotoxics / wound healing modulators
11.08.02.04  Expand sub section  Fibrinolytic drugs
11.08.02.04  Expand sub section  Glues - ocular to top
11.08.02.04  Expand sub section  Immunosuppressants
11.08.02.04  Expand sub section  Treatment of burns
11.08.02.04  Expand sub section  Visco-elastics
11.08.02.04  Expand sub section  Other
 ....
Key
Restricted Drug Restricted Drug
Unlicensed Drug Unlicensed
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 Link to adult BNF
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 Link to children's BNF
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 Link to SPCs
Cytotoxic Drug
 Cytotoxic Drug
CD
 Controlled Drug
High Cost Medicine
 High Cost Medicine
NHSE
 NHS England
Homecare
 Homecare
CCG
 ICB
Green Low Carbon

Low carbon footprint
Amber Medium Carbon

Medium carbon footprint
Red High carbon footprint

High carbon footprint
Status Description

Red

 Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.   

Amber

 Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic. The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible. SCGs are available or are being developed for most of the drugs listed as AMBER.   

Green plus

 Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria. These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary. In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary. If the drug requires urgent initiation, it is expected that the specialist undertakes the initial prescribing responsibility for an appropriate period of time, usually a minimum of 28 days. A GREEN+ drug can only be recommended to primary care for initiation if does not need to be initiated within 28 days.  

Green

 Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible.  

Brown

 UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.  

Not Recomended

 Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care.  

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