1. Ingredients and preservatives in eye drops Ingredients and preservatives in eye drops Dry Eyes Start Here Instructions and acknowledgements Start Here Instructions and acknowledgements Allergic Conjunctivitis References Alphabetical list of products and properties Alphabetical list of products and properties Finish Here Click to leave the Guidelines Finish Here Click to leave the Guidelines Walsall Topical Eye Formulary 2015 Bacterial Conjunctivitis Preservatives in all eye products Preservatives in all eye products

2. Instructions Run as a slide show only. Click on the buttons in the slides to direct you to the part of the guidelines that you have selected. To return to the Front Page, click on the “Return to start” button Return to start Eye Drops Return to start Introduction These guidelines are intended to assist healthcare professionals diagnose and manage patients with minor eye conditions in Walsall. They were produced by the Walsall Local Opthalmic Committee Walsall Joint Medicines Management Committee (JMMC) August 2015. These guidelines are based on the best available evidence but their application can always be modified by professional judgement. Use your mouse in the presentation Do not use the slide controls or return and back buttons as these will operate the normal PowerPoint actions Acknowledgments Many thanks to all of the health care professionals and patient representatives who have inputted to and commented on the Topical Eye guidelines. References: See slide Instructions

3. Return to start Bacterial Conjunctivitis Antibacterials AntibacterialFormulationComment First line of treatmentChloramphenicol 0.5% Or Chloramphenicol 1% Or Fusidic Acid (Fucithalmic™) used four times a day or less, for superficial eye infection Useful for staphylococcal infections Patient with sensitivity to preservatives Chloramphenicol 0.5% (Minims) Single use product (Minims®) available used four times a day or less, for superficial eye infection

4. Return to start Allergic Conjunctivitis Anti-allergy SeverityFormulationDose First line of treatment Sodium Cromoglicate 2%) (Inhibits the release from sensitised mast cells of mediators of the allergic reaction.) 2% preservative free eye drops (Catacrom) Adults and Children over 6 years (For the relief and treatment of the eye symptoms of hayfever) In hay fever, start using the products 2-3 weeks before symptoms appear. Drops used four times a day or less For Acute symptom Lodoxamide 0.1% (Alomide) (mast cell stabiliser) Nedocromil sodium 2% (Rapitil) (prevent the release of inflammatory mediators from a range of inflammatory cell types) Olapatadine 1mg/ml eye drops Child 4–18 years (For the prevention, relief and treatment of vernal conjunctivitis, giant papillary conjunctivitis, and allergic-atopic conjunctivitis) Adults and Children over 6 years: (For the prevention, relief and treatment of allergic conjunctivitis, including seasonal allergic conjunctivitis, and vernal-kerato conjunctivitis). Used in paediatric patients three years of age and older at the same dose as in adults. (For relied and treatment of Seasonal allergic and perennial conjunctivitis) Improvement of symptoms may sometimes require, 4 times daily treatment for up to 4 weeks One drop into each eye twice daily, increasing when necessary to four times daily. In seasonal allergic conjunctivitis therapy should be restricted to 12 weeks. In vernal kerato-conjunctivitis: one drop into each eye four times daily. Twice daily (8 hourly). Treatment may be maintained for up to four months. If considered necessary. Antazoline sulphate 0.5% + xylometazoline 0.05% eye drops (Otravine-Antistin) (Long acting vasoconstrictor and H1 receptor antagonist) Adults and children over 12 years of age. (Temporary relief of symptoms of seasonal and perennial allergies). Dual action Adults 1 or 2 drops instilled 2-3 times a day. Elderly 1 drop instilled 2-3 times a day. Should not be used for more than seven days.

5. Return to start Dry Eyes SeverityFirst ChoiceSecond ChoiceOther/Third Choice Mild dry eyes (less than 4 drops per day needed) Minimal damage to conjunctiva and cornea Or less if there is some corneal and conjunctival damage Hypromellose drops 0.5% or 0.3% (interchangeable) 10ml Carbomer 980 gel 10g (Clinitas™ gel) Clinitas Hydrate 10g Drops used four times a day or less Optive™ 10ml (Carmellose) –multidose ∆⑥∞ Bed time : Xailin night™ 5g or Vita-POS Drops used more than four times a day Carmellose1% unit doses (Pack 30) ∆∞, if not tolerated, carmellose 0.5% (Xailin Fresh™) ∆∞ Evaporative, Meibomian gland dysfunction Systane balance™(helps with lipid layer) Moderate dry eyes (4 to 6 drops per day needed) More than 3rd of damage to conjunctiva and corneal damage. Hypromellose drops 0.5% or 0.3% (interchangeable) Carbomer 980 gel,10g (Clinitas™gel) A preservative free drop may be given if drops are used 6 times a day Hylo-Tear™ 0.1%∆⑥∞ or Clinitas multi (0.4%) Drops used four times a day or less Optive™ 10ml (Carmellose)-multidose ∆⑥∞ Bed time : Xailin night ™ 5g OR Lacrilube or Vita-POS™ (6 month expiry) OR Duolube™ 3.5g Drops used more than four times a day Carmellose 1% unit doses (Pack 30) ∆∞, if not tolerated, carmellose 0.5% (Xailin Fresh™) ∆∞ Hylo-forte 0.20% ∆⑥∞ Evaporative Systane™ up to 4 times a day Severe dry eyes (more than 6 drops per day needed) Severe corneal and conjunctival damage. Hylo-forte™ 0.20% drops 10ml - multidoseΔ⑥ ∞ Optive™ 10ml (Carmellose) – multidose ∆ ⑥∞ Sodium hyalurnate 0.4% Clinitas multi is available for restricted use for short-term use in patients with non-healing epithelial corneal ulceration/defects and patients with severe dry eye syndrome. Carmellose 1% unit doses (Pack 30) ∆∞, if not tolerated, carmellose 0.5% (Xailin Fresh™) ∆∞ Evaporative Systane Ultra™ Bed time : Xailin night™ 5g OR Lacrilube or Vita-POS™ (6 month expiry) Duolube 3.5g ∆– Preservative free; ⑥- 6 month expiry once opened; ∞ suitable for use with contact lenses Please note it is ONLY more cost-effective to start with a preparation with a 6 month expiry if patient uses it less than four times a day.

6. Return to start Ingredients and preservatives in eye drops Ingredients Hypromellose is a widely used product, and can be administered frequently. Products containing carbomers or polyvinyl alcohol are longer-acting. Sodium Hyaluronate is becoming more widely used because of its water-retaining properties and low resistance to blinking (viscoelastic property). An evaluation by Guillion and colleagues found that dry eye suffers presenting with corneal or conjunctival staining, the artificial tears featuring a polymeric lubricant (CMC or sodium hyaluornate) improved the health of ocular surface tissue status. Eye ointments containing paraffin may be uncomfortable and blur vision, they should only be used at night and never with contact lenses, there are some alternatives available Preservative toxicity from eye drops. Benzalkonium chloride (BAK) is the most frequently used preservative in topical ophthalmic preparations, as well as in topical lubricants. Its epithelial toxic effects are well established. The toxicity of BAK is related to its concentration, frequency of use, the level or amount of tear secretion, and the severity of the ocular surface disease. For patients with moderate to severe dry eye disease, the absence of preservatives is of more critical importance than the particular polymeric agent used in ocular lubricants. The ocular surface inflammation associated with dry eye is exacerbated by preserved lubricants and, if patients have more than one eye condition for which they are using eye drops, their potential exposure to preservatives is increased. Preservative-free formulations are absolutely necessary for patients with severe dry eye with ocular surface disease and impairment of lacrimal gland secretion, or for patients on multiple, preserved topical medications for chronic eye disease. In a patient with mild dry eye, preserved drops are often well tolerated when used 4-6 times a day or less.

7. References Behrens A, Doyle JJ, Stern L et al. Dysfunctional tear syndrome, A Delphi approach to treatment recommendations. Cornea 2006 25:900-7 Management and therapy of dry eye disease: Report of the management and therapy subcommittee of the international dry eye workshop (2007). Ocul Surf 2007;5(2): 163-178. Ophthalmology Referral Guidelines, Oxfordshire PCT, March 2012 The Eye Journal: Apr/May 2011: Dry Eye Syndrome: more attention needed to Identify and treat dry eye syndrome by R Mcneil An Overview of the Issues Limiting Effective Management of the dry eye Syndrome in the UK; The Eye Journal Aug/Sep 2010 by J Bleninsopp, C Chakrabory,FDR HoBBS et al. Clinical Knowledge Summaries http://www.cks.nhs.uk/dry_eye_syndrome#-320107http://www.cks.nhs.uk/dry_eye_syndrome#-320107 The preferred practice pattern. Dry Eye Syndrome. The American Academy of Ophthalmology. Ltd Revision October 2011 http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=127dbdce- 4271- 471a-b6d9-464b9d15b748 2007 report of the International Dry Eye Workshop (DEWS). The Ocular Surface April 2007: 5 (2). http://www.tearfilm.org/dewsreport/pdfs/TOS-0502-DEWS-noAds.pdf NICE Clinical Knowledge Summaries Sept 2012. Dry Eye Syndrome. http://cks.nice.org.uk/dry-eye- syndrome#%21prescribinginfosub:1http://cks.nice.org.uk/dry-eye- syndrome#%21prescribinginfosub:1 References Return to start

8. Alphabetical List of Dry Eye Approved Products Return to start ProductStrength/Form∆– Preservative freeExpiry once opened ∞ suitable for use with contact lenses Carmellose10ml 0.5% & 1% eye drops No28 daysNo Carmellose0.5% & 1% 30 x 0.4ml UDVs YesSingle useYes Clinitas Gel™ Carbomer 980 gel 10g 0.2% gelYes28 daysRemove lenses apply-wait 30 mins. then re-insert lens Clinitas hydrate10g 0.2% gelNo28 days Clinitas Multi™ Sodium hyaluronate 10ml 0.4% eye dropsYes3 monthsYes Duolube™3.5g ointmentYes28 daysNo Hylo Tear Hylo Forte™ 1% 2% Yes6 monthsYes Hypromellose eye dropsO.5 or 0.3%No28 days Lacrilube™5g ointmentYes28 daysRemove lenses apply-wait 30 mins. then re-insert lens Optive™ Carmellose/glycerol multidose 10mlNo6 monthsYes Systane™10ml gel dropsNo28 daysNo Systane Balance™10ml eye dropsNo28 daysNo Systane Ultra™10ml eye dropsNo28 daysNo Vita Pos™5g ointmentYes6 monthsRemove lenses apply-wait 30 mins. then re-insert lens Xailin Fresh (Carmellose sodium) 0.5% 30 x 0.4ml UDV drops YesSingle useYes Xailin Night™5g ointmentYes28 daysRemove lenses apply-wait 30 mins. then re-insert lens Next page

9. Alphabetical List of Other Approved Products Return to start ProductStrength/Form∆– Preservative freeExpiry once opened ∞ suitable for use with contact lenses Alomide™ Lodoxamide 5ml 0.1% eye dropsNo28 daysNo Chloramphenicol10ml 0.5% eye dropsNo28 daysNot to be worn during treatment Catacrom™ Sodium Cromoglicate 2% 0.3ml UDVYesSingle useYes Chloramphenicol0.5% (Minims) 0.5ml UDV YesSingle useNot to be worn during treatment Chloramphenicol1% eye ointment 4g28 daysNot to be worn during treatment Fucithalmic™ Fusidic Acid 1% viscous eye dropsNo28 daysNot to be worn during treatment Olapatadine1mg/ml eye dropsNo28 daysNo Otrivine-Antistin™ Antazoline sulphate xylometazoline 0.5% + 0.05% eye dropsNo28 daysNo Rapitil™ Nedocromil sodium 2% eye dropsNo28 daysRemove and wait 15 mins. before reinsertion Sodium Cromoglicate2% eye dropsNo28 daysRemove and wait 15 mins. before reinsertion Return to previous page