North East and North Cumbria Formulary


	North East and North Cumbria ICS Formulary

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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...

NICE NG242 : Diabetic retinopathy: management and monitoring

North of Tyne, Gateshead and North Cumbria - Ophthalmology Referral Guidelines

Details...

11.08.02

Ocular diagnostic and peri-operative preparations and photodynamic treatment

11.08.02

Ocular diagnostic preparations

11.08.02

Ocular peri-operative drugs

Diclofenac

Formulary

0.1% eye drops and unit dose eye drops.
For post-operative inflammation limited to patients where corticosteroids are unsuitable.

Acetylcholine Chloride

Formulary

20mg in 2ml injection.

Apraclonidine

Formulary

0.5% and 1% ophthalmic solution.

Ketorolac (Acular^®)

Formulary

0.5% eye drops.

Nepafenac

Formulary

1 mg/1mL eye drops

Povidone iodine 5% eye drops

Formulary

For use in eye surgery only.

Sodium Hyaluronate

Formulary

10mg in 1ml bag (Z-Hyalin®, formerly Ophthalin Gelbag®)
14mg in 1ml syringe (Healon GV®)

Duovisc^® Injection

Unlicensed

Injection for use in cataract surgery containing VisCoat (1% sodium hyaluronate) and ProVisc (3% sodium hyaluronate, 4% chondroitin sulphate).

Ethanol 20% eye drops.

Unlicensed

For use in the debridement of the corneal epithelium in patients with
recurrent corneal erosion syndrome.

11.08.02

Subfoveal choroidal neovascularisation

11.08.02

Vitreomacular traction

11.08.02.04

Other products - Mainly for treating ocular injuries

11.08.02.04

Antifungals

11.08.02.04

Cytotoxics / wound healing modulators

11.08.02.04

Fibrinolytic drugs

11.08.02.04

Glues - ocular

11.08.02.04

Immunosuppressants

11.08.02.04

Treatment of burns

11.08.02.04

Visco-elastics

11.08.02.04

Other

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Key

	Restricted Drug
	Unlicensed
	Link to adult BNF
	Link to children's BNF
	Link to SPCs
	Cytotoxic Drug
	Controlled Drug

	High Cost Medicine
	NHS England
	Homecare
	ICB
	Low carbon footprint
	Medium carbon footprint
	High carbon footprint

Status	Description
	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.
	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.
	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.
	Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible.
	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.
	UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.
	NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status.