Poultice, heavy kaolin 52.7%, thymol 0.05%, boric acid 4.5%, peppermint oil 0.05%, methyl salicylate 0.2%, glycerol 42.5%. Net price 200 g = £2.76
Dose warm and apply directly or between layers of muslin; avoid application of overheated poultice
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. When a higher drug concentration is required within the eye, a local injection may be necessary, see Other Preparations, below.
Eye-drop dispenser devices are available to aid the instillation of eye drops from plastic bottles and some are prescribable on the NHS (consult Drug Tariff — see Appliances and Reagents for links to online Drug Tariffs). Product-specific devices may be supplied by manufacturers — consult individual manufacturers for information. They are particularly useful for the elderly, visually impaired, arthritic, or otherwise physically limited patients.
Eye drops and eye ointments 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; one drop is all that is needed. Instillation of more than one drop should be discouraged because it may increase systemic side-effects. A small amount of eye ointment is applied similarly; the ointment melts rapidly and blinking helps to spread it.
When two different eye-drop preparations are used at the same time of day, dilution and overflow may occur when one immediately follows the other. The patient should therefore leave an interval of at least 5 minutes between the two; the interval should be extended when eye drops with a prolonged contact time, such as gels and suspensions, are used. Eye ointment should be applied after 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. Pressure on the lacrimal punctum for at least a minute after applying eye drops reduces nasolacrimal drainage and therefore decreases systemic absorption from the nasal mucosa.
After using eye drops or eye ointments, patients should be warned not to drive or perform other skilled tasks until vision is clear.
For warnings relating to eye drops and contact lenses, see section 11.9.
Eye lotions These are solutions for the irrigation of the conjunctival sac. They act mechanically to flush out irritants or foreign bodies as a first-aid treatment. Sterile sodium chloride 0.9% solution (section 11.8.1) is usually used. Clean water will suffice in an emergency.
Ophthalmic Specials The Royal College of Ophthalmologists and the UK Ophthalmic Pharmacy Group have produced the Ophthalmic Specials Guidance to help prescribers and pharmacists manage and restrict the use of unlicensed eye preparations. ‘Specials’ should only be prescribed in situations where a licensed product is not suitable for a patient’s needs. The Ophthalmic Specials Guidance can be accessed on the Royal College of Ophthalmologists website (www.rcophth.ac.uk). The guidance will be reviewed every six months to ensure the most accurate and up-to-date information is available.
Other preparations Subconjunctival injection may be used to administer anti-infective drugs, mydriatics, or corticosteroids for conditions not responding to topical therapy; intracameral and intravitreal routes can also be used to administer certain drugs, for example antibacterials. These injections should only be used under specialist supervision.
Drugs such as antimicrobials and corticosteroids may be administered systemically to treat susceptible eye conditions.
Preservatives and sensitisers Information on preservatives and on substances identified as skin sensitisers (see section 13.1.3) is provided under Excipients statements in preparation entries. Very rarely, cases of corneal calcification have been reported with the use of phosphate-containing eye drops in patients with significantly damaged corneas — consult product literature for further information.
11.2 Control of microbial contamination
Preparations for the eye should be sterile when issued. Care should be taken to avoid contamination of the contents during use.
Eye drops in multiple-application containers for domiciliary use should not be used for more than 4 weeks after first opening (unless otherwise stated by the manufacturer).
Multiple application eye drops for use in hospital wards are normally discarded 1 week after first opening — local practice may vary. Individual containers should be provided for each patient. A separate container should be supplied for each eye only if there are special concerns about contamination. Containers used before an eye operation should be discarded at the time of the operation and fresh containers supplied postoperatively. A fresh supply should also be provided upon discharge from hospital; in specialist ophthalmology units, it may be acceptable to issue containers that have been dispensed to the patient on the day of discharge.
In out-patient departments single-application containers should be used; if multiple-application containers are used, they should be discarded after single patient use within one clinical session.
In eye surgery single-application containers should be used if possible; if a multiple-application container is used, it should be discarded after single use. Preparations used during intra-ocular procedures and others that may penetrate into the anterior chamber must be isotonic and without preservatives and buffered if necessary to a neutral pH. Specially formulated fluids should be used for intra-ocular surgery; intravenous infusion preparations are not usually suitable for this purpose (Hartmann’s solution may be used in some ocular surgery). For all surgical procedures, a previously unopened container is used for each patient.
11.3 Anti-infective eye preparations
Eye infections Most acute superficial eye infections can be treated topically. Blepharitis and conjunctivitis are often caused by staphylococci; keratitis and endophthalmitis may be bacterial, viral, or fungal.
Bacterial blepharitis is treated by application of an antibacterial eye ointment to the conjunctival sac or to the lid margins. Systemic treatment may occasionally be required and is usually undertaken after culturing organisms from the lid margin and determining their antimicrobial sensitivity; antibiotics such as the tetracyclines given for 3 months or longer may be appropriate.
Most cases of acute bacterial conjunctivitis are self-limiting; where treatment is appropriate, antibacterial eye drops or an eye ointment are used. A poor response might indicate viral or allergic conjunctivitis.
Corneal ulcer and keratitis require specialist treatment and may call for hospital admission for intensive therapy.
Endophthalmitis is a medical emergency which also calls for specialist management and requires intravitreal administration of antimicrobials; concomitant systemic treatment is required in some cases. Surgical intervention, such as vitrectomy, is sometimes indicated.
11.3.1 Antibacterials
Bacterial eye infections are generally treated topically with eye drops and eye ointments. Systemic administration is sometimes appropriate in blepharitis.
Chloramphenicol has a broad spectrum of activity and is the drug of choice for superficial eye infections. Chloramphenicol eye drops are well tolerated and the recommendation that chloramphenicol eye drops should be avoided because of an increased risk of aplastic anaemia is not well founded.
Other antibacterials with a broad spectrum of activity include the quinolones, ciprofloxacin, levofloxacin, moxifloxacin, and ofloxacin; the aminoglycosides, gentamicin and tobramycin are also active against a wide variety of bacteria. Gentamicin, tobramycin, quinolones (except moxifloxacin), and polymyxin B are effective for infections caused by Pseudomonas aeruginosa.
Ciprofloxacin eye drops are licensed for corneal ulcers; intensive application (especially in the first 2 days) is required throughout the day and night.
Azithromycin eye drops are licensed for trachomatous conjunctivitis caused by Chlamydia trachomatis and for purulent bacterial conjunctivitis. Trachoma which results from chronic infection with Chlamydia trachomatis can be treated with azithromycin by mouth [unlicensed indication].
Fusidic acid is useful for staphylococcal infections.
Propamidine isetionate is of little value in bacterial infections but is used by specialists to treat the rare, but potentially sight-threatening, condition of acanthamoeba keratitis [unlicensed indication] (see also section 11.9).
Cefuroxime can be administered by intracameral injection for the prophylaxis of endophthalmitis following cataract surgery, see section 11.8.2.
With corticosteroids 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 (section 11.4).
Administration Frequency of application depends on the severity of the infection and the potential for irreversible ocular damage; antibacterial eye preparations are usually administered as follows:
Eye drops, apply 1 drop at least every 2 hours then reduce frequency as infection is controlled and continue for 48 hours after healing;
Eye ointment, apply either at night (if eye drops used during the day) or 3–4 times daily (if eye ointment used alone).
AZITHROMYCIN DIHYDRATE
Indications see notes above
Side-effects ocular discomfort (including pruritus, burning), blurred vision; less commonly eyelid eczema, eyelid erythema, eyelid oedema, conjunctival hyperaemia, keratitis
Dose
Apply twice daily for 3 days; review if no improvement after 3 days
Single use
CHLORAMPHENICOL
Indications see notes above
Pregnancy avoid unless essential — no information on topical use but risk of ‘neonatal grey-baby syndrome’ with oral use in third trimester
Breast-feeding avoid unless essential — theoretical risk of bone-marrow toxicity
Side-effects transient stinging; see also notes above
Chloramphenicol (Non-proprietary) 
Eye drops, chloramphenicol 0.5%. Net price 10 mL = £1.78
Eye ointment, chloramphenicol 1%. Net price 4 g = £1.76
Note Chloramphenicol 0.5% eye drops (in max. pack size 10 mL) and 1% eye ointment (in max. pack size 4 g) can be sold to the public for treatment of acute bacterial conjunctivitis in adults and children over 2 years; max. duration of treatment 5 days
Chloromycetin® (AMCo) 
Redidrops (= eye drops), chloramphenicol 0.5%. Net price 5 mL = £1.65; 10 mL = 90p
Excipients include phenylmercuric acetate
Ophthalmic ointment (= eye ointment), chloramphenicol 1%. Net price 4 g = £1.08
Single use
Minims® Chloramphenicol (Bausch & Lomb) 
Eye drops, chloramphenicol 0.5%. Net price 20 × 0.5 mL = £10.53
CIPROFLOXACIN
Indications superficial bacterial infections, see notes above; corneal ulcers
Pregnancy manufacturer advises use only if potential benefit outweighs risk
Breast-feeding manufacturer advises caution
Side-effects taste disturbance, ocular discomfort, ocular hyperaemia, corneal deposits (reversible after completion of treatment); less commonly nausea, headache, keratopathy, corneal infiltrates, corneal staining, photophobia, blurred vision, eyelid disorders (including oedema, exfoliation, erythema), eye irritation (including pain, swelling, pruritus, dryness), increased lacrimation, conjunctival hyperaemia; rarely diarrhoea, abdominal pain, dizziness, keratitis, corneal disorders including corneal epithelium defect, eye hypoaesthesia, asthenopia, diplopia, ear pain, paranasal sinus hypersecretion, rhinitis, dermatitis
Dose
Superficial bacterial infection, ADULT and CHILD apply eye drops 4 times daily; in severe infection apply every 2 hours during waking hours for 2 days, then 4 times daily; max. duration of treatment 21 days
ADULT and CHILD over 1 year, apply 1.25 cm eye ointment 3 times daily for 2 days, then twice daily for 5 days
Corneal ulcer, ADULT and CHILD apply eye drops throughout day and night, day 1 apply every 15 minutes for 6 hours then every 30 minutes, day 2 apply every hour, days 3–14 apply every 4 hours; max. duration of treatment 21 days
ADULT and CHILD over 1 year, apply eye ointment throughout day and night; apply 1.25 cm ointment every 1–2 hours for 2 days, then every 4 hours for next 12 days
LEVOFLOXACIN
Indications see notes above
Pregnancy manufacturer advises use only if potential benefit outweighs risk
Breast-feeding manufacturer advises use only if potential benefit outweighs risk
Side-effects ocular burning, visual disturbances; less commonly headache, ocular discomfort (including itching, pain, and dryness), conjunctival follicles, lid oedema, lid erythema, photophobia, rhinitis
Dose
ADULT and CHILD over 1 year, apply every 2 hours (max. 8 times daily) for the first 2 days, then 4 times daily for 3 days
Oftaquix® (Kestrel Ophthalmics) 
Unit dose eye drops, levofloxacin 0.5%, net price 30 × 0.5-mL single use units = £17.95
MOXIFLOXACIN
Indications see notes above
Cautions not recommended for neonates
Side-effects taste disturbances, ocular discomfort (including pain, irritation and dryness), hyperaemia; less commonly vomiting, headache, paraesthesia, corneal disorders (including keratitis, erosion, and staining), conjunctival haemorrhage, eyelid erythema, visual disturbances, nasal discomfort, pharyngolaryngeal pain; also reported nausea, palpitation, dyspnoea, dizziness, raised intra-ocular pressure, photophobia, rash, pruritus
Dose
ADULT and CHILD over 1 month, apply 3 times daily (continue treatment for 2–3 days after infection improves; review if no improvement within 5 days)
OFLOXACIN
Indications see notes above
Cautions corneal ulcer or epithelial defect (risk of corneal perforation)
Pregnancy manufacturer advises use only if benefit outweighs risk; systemic quinolones have caused arthropathy in animal studies
Breast-feeding manufacturer advises avoid
Side-effects ocular discomfort and irritation; also reported facial oedema, keratitis, visual disturbances, photophobia, increased lacrimation, ocular oedema, dry eyes, ocular hyperaemia
Dose
ADULT and CHILD over 1 year, apply every 2–4 hours for the first 2 days, then reduce frequency to 4 times daily (max. 10 days treatment)
PROPAMIDINE ISETIONATE
Indications local treatment of infections (but see notes above)
Pregnancy manufacturer advises avoid unless essential — no information available
Breast-feeding manufacturer advises avoid unless essential — no information available
Side-effects eye pain and irritation
Dose
See preparations
Brolene® (Sanofi-Aventis)
Eye drops, propamidine isetionate 0.1%. Net price 10 mL = £2.80
Excipients include benzalkonium chloride
Dose apply up to 4 times daily
TOBRAMYCIN
Indications see notes above
Dose
ADULT and CHILD over 1 year, apply twice daily for 6–8 days; in severe infection, apply 4 times daily on the first day, then twice daily for 5–7 days
11.3.2 Antifungals
Fungal infections of the cornea are rare but can occur after agricultural injuries, especially in hot and humid climates. Orbital mycosis is rarer, and when it occurs it is usually because of direct spread of infection from the paranasal sinuses. Increasing age, debility, or immunosuppression can encourage fungal proliferation. The spread of infection through blood occasionally produces metastatic endophthalmitis.
Many different fungi are capable of producing ocular infection; they can be identified by appropriate laboratory procedures.
Antifungal preparations for the eye are not generally available. Treatment will normally be carried out at specialist centres, but requests for information about supplies of preparations not available commercially should be addressed to the Strategic Health Authority (or equivalent), or to the nearest hospital ophthalmology unit, or to Moorfields Eye Hospital, 162 City Road, London EC1V 2PD (tel. (020) 7253 3411) or www.moorfields.nhs.uk
11.3.3 Antivirals
Herpes simplex infections producing, for example, dendritic corneal ulcers can be treated with aciclovir or ganciclovir. Aciclovir eye ointment is used in combination with systemic treatment for ophthalmic zoster (section 5.3.2.1).
Slow-release ocular implants containing ganciclovir (available on a named-patient basis from specialist importing companies) may be inserted surgically to treat immediate sight-threatening CMV retinitis. Local treatments do not protect against systemic infection or infection in the other eye. For systemic treatment of CMV retinitis, see section 5.3.2.2.
ACICLOVIR
(Acyclovir)
Indications local treatment of herpes simplex infections
Side-effects local irritation and inflammation, superficial punctate keratopathy; rarely blepharitis; very rarely hypersensitivity reactions including angioedema
Dose
Apply 1 cm ointment 5 times daily (continue for at least 3 days after complete healing)
GANCICLOVIR
Indications local treatment of herpes simplex infections
Side-effects burning sensation, tingling, superficial punctate keratitis
Dose
Apply 5 times daily until healing complete, then apply 3 times daily for a further 7 days
11.4 Corticosteroids and other anti-inflammatory preparations
11.4.1 Corticosteroids
Corticosteroids administered locally to the eye or given by mouth are effective for treating anterior segment inflammation, including that which results from surgery.
Topical corticosteroids are applied frequently for the first 24–48 hours; once inflammation is controlled, the frequency of application is reduced. They should normally only be used under expert supervision; three main dangers are associated with their use:
a ‘red eye’, when the diagnosis is unconfirmed, may be due to herpes simplex virus, and a corticosteroid may aggravate the condition, leading to corneal ulceration, with possible damage to vision and even loss of the eye. Bacterial, fungal, and amoebic infections pose a similar hazard;
‘steroid glaucoma’ can follow the use of corticosteroid eye preparations in susceptible individuals;
a ‘steroid cataract’ can follow prolonged use.
Other side-effects of ocular corticosteroids include thinning of the cornea and sclera.
Combination products containing a corticosteroid with an anti-infective drug are sometimes used after ocular surgery to reduce inflammation and prevent infection; use of combination products is otherwise rarely justified.
Systemic corticosteroids (section 6.3.2) may be useful for ocular conditions. The risk of producing a ‘steroid cataract’ increases with the dose and duration of corticosteroid use.
BETAMETHASONE
Indications local treatment of inflammation (short-term)
Cautions see notes above
Side-effects see notes above
Dose
Apply eye drops every 1–2 hours until controlled then reduce frequency; apply eye ointment 2–4 times daily or at night when used with eye drops
Betnesol® (Focus) 
Drops (for ear, eye, or nose), betamethasone sodium phosphate 0.1%, net price 10 mL = £2.32
Excipients include benzalkonium chloride, disodium edetate
Eye ointment, betamethasone sodium phosphate 0.1%, net price 3 g = £1.41
Vistamethasone® (Martindale) 
Drops (for ear, eye, or nose), betamethasone sodium phosphate 0.1%, net price 5 mL = £1.02; 10 mL = £1.16
Excipients include benzalkonium chloride
With neomycin
DEXAMETHASONE
Indications local treatment of inflammation (short-term)
Cautions see notes above
Side-effects see notes above
Dose
Apply eye drops every 30–60 minutes until controlled then reduce frequency to 4–6 times daily
Maxidex® (Alcon) 
Eye drops, dexamethasone 0.1%, net price 5 mL = £1.42; 10 mL = £2.80
Excipients include benzalkonium chloride, disodium edetate, polysorbate 80
Single use
Dexafree® (Spectrum Thea) 
Eye drops, dexamethasone phosphate (as sodium phosphate) 0.1%, net price 30 × 0.4 mL = £9.70
Excipients include disodium edetate
Dropodex® (Moorfields) 
Eye drops, dexamethasone (as sodium phosphate) 0.1%, net price 20 × 0.4 mL = £9.75
Excipients include disodium edetate
Minims® Dexamethasone (Bausch & Lomb) 
Eye drops, dexamethasone sodium phosphate 0.1%, net price 20 × 0.5 mL = £10.98
Excipients include disodium edetate
With antibacterials
Maxitrol® (Alcon) 
Eye drops, dexamethasone 0.1%, neomycin sulfate 3500 units /g, polymyxin B sulfate 6000 units/mL, net price 5 mL = £1.68
Excipients include benzalkonium chloride, polysorbate 20
Eye ointment, dexamethasone 0.1%, neomycin sulfate 3500 units/g, polymyxin B sulfate 6000 units/g, net price 3.5 g = £1.44
Excipients include hydroxybenzoates (parabens), wool fat
Dose apply 3–4 times daily or at night when used with eye drops
FLUOROMETHOLONE
Indications local treatment of inflammation (short-term)
Cautions see notes above
Side-effects see notes above
Dose
ADULT and CHILD over 2 years, apply every hour for 24–48 hours, then reduce frequency to 2–4 times daily
LOTEPREDNOL ETABONATE
Indications treatment of post-operative inflammation following ocular surgery
Cautions see notes above
Side-effects see notes above
Dose
Apply 4 times daily starting 24 hours after surgery; max. duration of treatment 14 days
Lotemax® (Bausch & Lomb) 
Opthalmic suspension (= eye drops), loteprednol etabonate 0.5%, net price 5 mL = £5.50
Excipients include benzalkonium chloride, disodium edetate
PREDNISOLONE
Indications local treatment of inflammation (short-term)
Cautions see notes above
Side-effects see notes above
Dose
Apply every 1–2 hours until controlled then reduce frequency
Predsol® (Focus) 
Drops (for ear or eye), prednisolone sodium phosphate 0.5%, net price 10 mL = £2.00
Excipients include benzalkonium chloride, disodium edetate
Pred Forte® (Allergan) 
Eye drops, prednisolone acetate 1%, net price 5 mL = £1.82; 10 mL = £3.66
Excipients include benzalkonium chloride, disodium edetate, polysorbate 80
Single use
Minims® Prednisolone Sodium Phosphate (Bausch & Lomb) 
Eye drops, prednisolone sodium phosphate 0.5%, net price 20 × 0.5 mL = £11.28
Excipients include disodium edetate
RIMEXOLONE
Indications local treatment of inflammation (short-term)
Cautions see notes above
Side-effects see notes above
Dose
Postoperative inflammation, apply 4 times daily for 2 weeks, beginning 24 hours after surgery
Steroid-responsive inflammation, apply at least 4 times daily for up to 4 weeks
Uveitis, apply every hour during daytime in week 1, then every 2 hours in week 2, then 4 times daily in week 3, then twice daily for first 4 days of week 4, then once daily for remaining 3 days of week 4
Intravitreal corticosteroids
An intravitreal implant containing dexamethasone (Ozurdex®) is licensed for the treatment of adults with macular oedema following either branch retinal vein occlusion or central retinal vein occlusion; it is also licensed for the treatment of adult patients with inflammation of the posterior segment of the eye presenting as non-infectious uveitis. Dexamethasone is also indicated for the treatment of visual impairment due to diabetic macular oedema in adults who are pseudophakic, or who are insufficiently responsive to, or unsuitable for non-corticosteroid therapy. It should be administered by specialists experienced in the use of intravitreal injections.
The Scottish Medicines Consortium has advised (May 2012) that dexamethasone intravitreal implant (Ozurdex®) is accepted for restricted use within NHS Scotland for the treatment of adults with macular oedema (i) following central retinal vein occlusion, and (ii) with branch retinal vein occlusion who are not clinically suitable for laser treatment, including patients with dense macular haemorrhage, or patients who have received and failed on previous laser treatment.
NICE guidance
Dexamethasone intravitreal implant for the treatment of macular oedema secondary to retinal vein occlusion (July 2011)
Dexamethasone intravitreal implant is recommended as an option for the treatment of macular oedema following central retinal vein occlusion.
Dexamethasone intravitreal implant is also recommended as an option for the treatment of macular oedema following branch retinal vein occlusion when:
treatment with laser photocoagulation has not been beneficial, or
treatment with laser photocoagulation is not considered suitable because of the extent of macular haemorrhage.
An intravitreal implant containing fluocinolone acetonide (Iluvien®) is licensed for the treatment of visual impairment associated with chronic diabetic macular oedema which is insufficiently responsive to available therapies. It should be administered by specialists experienced in the use of intravitreal injections.
The Scottish Medicines Consortium has advised (February 2014) that fluocinolone acetonide intravitreal implant (Iluvien®) is recommended for restricted use within NHS Scotland for the treatment of vision impairment associated with chronic diabetic macular oedema, considered insufficiently responsive to available therapies, only in patients in whom the affected eye is pseudophakic (has an artificial lens after cataract surgery), and retreatment would take place only if the patient had previously responded to treatment with fluocinolone acetonide and subsequently best corrected visual acuity had deteriorated to less than 20/32.
.
NICE guidance
Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema after an inadequate response to prior therapy (November 2013)
Fluocinolone acetonide intravitreal implant is recommended as an option for treating chronic diabetic macular oedema that is insufficiently responsive to available therapies only if:
the implant is to be used in an eye with an intra-ocular (pseudophakic lens) and
the manufacturer provides fluocinolone acetonide intravitreal implant with the discount agreed in the patient access scheme.
DEXAMETHASONE
Indications see notes above — specialist use only
Cautions monitor intra-ocular pressure and for signs of ocular infection; history of ocular viral infection including herpes simplex; posterior capsule tear or iris defect (risk of implant migration into the anterior chamber which may cause corneal oedema and, in persistent severe cases, the need for corneal transplantation — monitor for early diagnosis and management); retinal vein occlusion with significant retinal ischaemia; concomitant administration of anticoagulant or antiplatelet drugs — increased risk of haemorrhagic events
Contra-indications active or suspected ocular or peri-ocular infection (including active ocular herpes simplex); uncontrolled advanced glaucoma; rupture of the posterior lens capsule in patients with aphakia, iris or transscleral fixated intra-ocular lens or anterior chamber intra-ocular lens
Pregnancy manufacturer advises avoid unless potential benefit outweighs risk
Breast-feeding manufacturer advises avoid unless potential benefit outweighs risk — no information available
Side-effects headache, raised intra-ocular pressure, ocular hypertension, blepharitis, cataract, visual disturbance; less commonly migraine, necrotising retinitis, eyelid pruritus, glaucoma; also reported secondary ocular infection
Dose
By intravitreal injection, 700 micrograms into the affected eye
Note Concurrent administration to both eyes not recommended. For further information on pre-treatment, administration and repeat dosing, consult product literature
NICE Technology Appraisal
NICE recommended. See Dexamethasone intravitreal implant for the treatment of macular oedema secondary to retinal vein occlusion (July 2011)
FLUOCINOLONE ACETONIDE
Indications see notes above — specialist use only
Cautions raised baseline intra-ocular pressure (monitor intra-ocular pressure closely); monitor for raised intra-ocular pressure, retinal detachment, endophthalmitis, vitreous haemorrhage or detachment within 2–7 days following the procedure; monitor intra-ocular pressure at least every 3 months thereafter (for approximately 36 months); concomitant administration of anticoagulant or antiplatelet drugs (higher incidence of conjunctival haemorrhage)
Contra-indications pre-existing glaucoma; active or suspected ocular or peri-ocular infection
Pregnancy manufacturer advises avoid unless potential benefit outweighs risk — no information available
Breast-feeding manufacturer advises avoid unless essential
Side-effects cataract, raised intra-ocular pressure, vitreous floaters, glaucoma, ocular discomfort, vitreous haemorrhage, conjunctival haemorrhage, blurred vision, reduced visual acuity; less commonly headache, endophthalmitis, retinal vascular occlusion, optic nerve disorder, maculopathy, optic atrophy, conjunctival ulcer, iris neovascularisation or adhesions, retinal exudates, vitreous degeneration or detachment, posterior capsule opacification, ocular hyperaemia, sclera thinning, eye discharge or pruritus
Dose
By intravitreal injection, 190 micrograms into the affected eye
Note Concurrent administration to both eyes not recommended. For further information on administration and repeat dosing, consult product literature
NICE Technology Appraisal
NICE recommended. See Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema after an inadequate response to prior therapy (November 2013)
11.4.2 Other anti-inflammatory preparations
Other preparations used for the topical treatment of inflammation and allergic conjunctivitis include antihistamines, lodoxamide, and sodium cromoglicate.
Eye drops containing antihistamines, such as antazoline (with xylometazoline as Otrivine-Antistin®), azelastine, epinastine, ketotifen, and olopatadine, can be used for allergic conjunctivitis.
Sodium cromoglicate (sodium cromoglycate) and nedocromil sodium eye drops can be useful for vernal keratoconjunctivitis and other allergic forms of conjunctivitis.
Lodoxamide eye drops are used for allergic conjunctival conditions including seasonal allergic conjunctivitis.
Diclofenac eye drops (section 11.8.2) and emedastine eye drops are also licensed for seasonal allergic conjunctivitis.
Non-steroidal anti-inflammatory eye drops (section 11.8.2) are used for the prophylaxis and treatment of inflammation of the eye following surgery or laser treatment.
ANTAZOLINE SULFATE
Indications allergic conjunctivitis
Side-effects transient stinging; also reported blurred vision, mydriasis, eye irritation
Otrivine-Antistin® (Spectrum Thea)
Eye drops, antazoline sulfate 0.5%, xylometazoline hydrochloride 0.05%. Net price 10 mL = £2.35
Excipients include benzalkonium chloride, disodium edetate
Cautions hypertension; hyperthyroidism; diabetes mellitus; angle-closure glaucoma; phaeochromocytoma; cardiovascular disease; urinary retention; interactions: Appendix 1 (antihistamines and sympathomimetics)
Dose ADULT and CHILD over 12 years apply 2–3 times daily (max. 7 days)
Note Xylometazoline is a sympathomimetic; absorption of antazoline and xylometazoline may result in systemic side-effects and the possibility of interaction with other drugs
AZELASTINE HYDROCHLORIDE
Indications allergic conjunctivitis
Side-effects mild transient irritation; bitter taste reported
Dose
Seasonal allergic conjunctivitis, ADULT and CHILD over 4 years, apply twice daily, increased if necessary to 4 times daily
Perennial conjunctivitis, ADULT and CHILD over 12 years, apply twice daily, increased if necessary to 4 times daily; max. duration of treatment 6 weeks
EMEDASTINE
Indications seasonal allergic conjunctivitis
Side-effects transient burning or stinging; blurred vision, local oedema, keratitis, irritation, dry eye, lacrimation, corneal infiltrates (discontinue) and staining; photophobia; headache, and rhinitis occasionally reported
Dose
ADULT and CHILD over 3 years, apply twice daily
EPINASTINE HYDROCHLORIDE
Indications seasonal allergic conjunctivitis
Side-effects burning; less commonly taste disturbance, headache, conjunctival hyperaemia, dry eye, eye pruritus, visual disturbance, increased lacrimation, eye pain, nasal irritation, rhinitis
Dose
ADULT and CHILD over 12 years, apply twice daily; max. duration of treatment 8 weeks
KETOTIFEN
Indications seasonal allergic conjunctivitis
Side-effects transient burning or stinging, punctate corneal epithelial erosion; less commonly dry eye, subconjunctival haemorrhage, photophobia; headache, drowsiness, skin reactions, and dry mouth also reported
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