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...

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

Details...

11.04.01

Corticosteroids

Betamethasone 0.1% eye drops

First Choice

Dexamethasone 0.05%, framycetin sulf. 0.5%, gramicidin 0.005% eye drops (Sofradex)

Formulary

Hydrocortisone Sodium Phosphate (Softacort^®)

Formulary

3.35 mg per 1 ml eye drops (0.4ml unit dose)
- Approved for patients who require a preservative-free low potency ocular corticosteroid

Rimexolone

Formulary

ophthalmology advice only - second line if flurometholone unsuitable

Betamethasone 0.1% with Neomycin 0.5% eye drops

Alternatives

Dexamethasone 0.1% eye drops (Maxidex^®)

Alternatives

Preservative-free eye drops are also approved.
- 0.1% Minims® - first choice.
- 0.1% preservative free eye drops unlicensed - approved only for patients who are unable to use Minims®due to dexterity problems.

Dexamethasone 0.1% Preservative-free

Alternatives

First choice

Unit dose vials (Minims®)

Alternative

Eye drops (unlicensed) - only for patients who are unable to use Minims® due to dexterity problems

Dexamethasone with Neomycin and Polymyxin B sulphate (Maxitrol^®)

Alternatives

Eye drops and eye ointment

Fluorometholone 0.1% Eye drops (FML^®)

Alternatives

For use in patients who experience ocular hypertension with other corticosteroids – treatment to be initiated with the advice of an ophthalmologist.

Loteprednol Eye drops

Alternatives

Approved as a second line agent to conventional corticosteroid eye drops, treatment to be imitated with the advice of an ophthalmologist only.

Prednisolone 0.5% Single Use Minims^®

Alternatives

Prednisolone eye drops

Alternatives

The following formulations are approved
- 0.5% eye drops and 1% (Pred-Forte).
- 0.1% and 0.3% eye drops - both unlicensed.
Approved preservative free formulations include
- 0.5% minims.
- 0.1%, 0.3%, 0.5% and 1% - all unlicensed.

Dexamethasone 700 microgram intravitreal implant (Ozurdex^®)

Alternatives

Approved for macular oedema following central retinal vein occlusion
in line with NICE.
Approved for treating diabetic macular oedema in line with NICE.
Approved for the treatment of non-infectious uveitis in line with NICE and NHS England Commissioning Policy

Note: The Northern (NHS) Treatment Advisory Group recommends the sequential pharmacological management of MO secondary to RVO as per the North East Retina Group (NERG) RVO treatment pathway.

NICE TA229 Dexamethasone intravitreal implant for the treatment of macular oedema secondary to retinal vein occlusion

NICE TA460 Adalimumab and dexamethasone for treating non-infectious uveitis

NICE TA824: Dexamethasone intravitreal implant for treating diabetic macular oedema

Fluocinolone 190 microgram intravitreal implant

Alternatives

Recommended as a possible treatment for people with chronic diabetic macular oedema who have an artificial lens in their eye if the implant is used in the eye with the artificial lens and their diabetic macular oedema has not got better with other treatments - in line with NICE.
Approved for the treatment of recurrent non-infectious uveitis in line with NICE
Approved for treating chronic diabetic macular oedema in phakic eyes after an inadequate response to previous therapy in line with NICE
Approved for treating chronic diabetic macular oedema in line with NICE

NICE TA301: Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema after an inadequate response to prior therapy

NICE TA590: Fluocinolone acetonide intravitreal implant for treating recurrent non-infectious uveitis

NICE TA613: Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema in phakic eyes after an inadequate response to previous therapy

NICE TA953: Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema

MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration

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Key

	Notes
	Section Title (top level)
	Section Title (sub level)
	First Choice item
	Non Formulary section
	Restricted Drug
	Unlicensed
	Display tracking information
	Link to adult BNF
	Link to children's BNF
	Link to SPCs

	Cytotoxic Drug
	Controlled Drug
	High Cost Medicine
	NHS England
	Homecare
	CCG

Traffic Light Status Information

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. The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber. If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care.
	Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs.
	Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care.
	NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria.
	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.