Lancashire and South Cumbria Formulary


	Lancashire and South Cumbria Formulary

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Formulary Chapter 11: Eye - Full Chapter

Notes:

This chapter of the formulary is under continual development, please let the team know if you have any comments about the contents: mlcsu.lscformulary@nhs.net.

For more information about the formulary development process, please see: https://www.lancsmmg.nhs.uk/lancashire-and-south-cumbria-icb-formulary-development/

Details...

11.01

Administration of drugs to the eye

See BNF for general guide on administration of drugs to the eye

https://bnf.nice.org.uk/treatment-summaries/eye/

UHMB guide: How to use your eye drops

http://uhmb/cd/Governance/ProceduralDocumentsGroup2016/Lists/Agenda/Attachments/722/UHMB-FT029%20-%20How%20To%20Use%20Your%20Eye%20Drops%20(v1.3).pdf

11.02

Control of microbial contamination

11.03

Anti-infective eye preparations

11.03.01

Antibacterials

Chloramphenicol

First Choice

Eye drops 0.5%

Eye drops 0.5% - preservative free (only for use in patients with a documented allergy to preservatives)

East Lancashire only - use as by ophthalmology when more than 5 days treatment required post op

Eye ointment 1%

Chloramphenicol eye drops 0.5% can be sold by a community pharmacy to the public (for people over 2 years of age) for the treatment of acute bacterial conjunctivitis.

LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy

MHRA: Chloramphenicol eye drops containing borax or boric acid buffers: use in children younger than 2 years

Gentamicin

Second Choice

Eye/ear drops 0.3%

Chloramphenicol (Minims^®)

Formulary

Minims^® 0.5%

Follow local ophthalmology policies

MHRA: Chloramphenicol eye drops containing borax or boric acid buffers: use in children younger than 2 years

Ciprofloxacin

Formulary

Eye drops 0.3%

*under review*

Fusidic Acid

Formulary

Eye drops 1% in gel basis (liquefies on contact with eye)

Second line - Restricted use

Levofloxacin

Formulary

eye drops 0.5%

preservative-free eye drops 0.5% - reserved for patients with a documented allergy to preservatives or for intensive use

*under review*

Propamidine Isetionate (Brolene^®)

Formulary

Eye drops 0.1%

Specialist use only for treatment of acanthamoeba keratitis

Cefuroxime

Unlicensed

Eye drops 5%

Unlicensed - consultant ophthalmologist only

Chlorhexidine 0.02% eye drops

Unlicensed

Eye drops 0.02%

Unlicensed - Consultant ophthalmologist only. Morecambe bay only

* under review*

MHRA: Medical Device Alert

Gentamicin Forte

Unlicensed

Preservative free eye drops 1.5%

Unlicensed - consultant ophthalmologist only

Polihexanide

Restricted

Eye drops 0.02%

Specialist use only for treatment of fusarium keratitis

Also known as polyhexamethylene biguanide (PHMB)

11.03.02

Antifungals

Clotrimazole drops

Formulary

1% drops

Amphotericin B

Restricted

Eye drops 0.15% preservative free

Unlicensed - Specialist use only

11.03.03

Antivirals

Ganciclovir 0.15% ophthalmic gel (Virgan^®)

Formulary

Eye gel 5g (1.5mg/g)

Ofloxacin eye drops

Formulary

0.3% drops

11.04

Corticosteroids and other anti-inflammatory preparations

11.04.01

Corticosteroids

Topical corticosteroids should normally only be used under expert supervision

Betamethasone 0.1% with Neomycin 0.5% eye drops

Formulary

Eye/ear/nose drops betamethasone 0.1%/ neomycin 0.5%

Betamethasone eye drops

Formulary

Eye/ear/nose drops 0.1%

in East Lancashire

*under review*

Dexamethasone eye drops

Formulary

Eye drops preservative free 0.1%

in East Lancashire

*under review*

Dexamethasone eye drops (Maxidex^®)

Formulary

Eye drops 0.1%

in East Lancashire

*under review*

Dexamethasone eye drops single use

Formulary

Single dose - preservative free drops 0.1% - for use in theatre or clinic before a procedure if a single dose is needed.

Dexamethasone intravitreal implant (Ozurdex^®)

Formulary

Intravitreal implant 700micrograms in disposable applicator

REQUIRES BLUETEQ APPROVAL

NICE TA460: Adalimumab and dexamethasone for treating non-infectious uveitis

NICE TA824: Dexamethasone intravitreal implant for treating diabetic macular oedema

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

Formulary

Eye drops dexamethasone 0.1%, neomycin 3500u/g, polymixin B sulfate 6000units/g

Eye ointment dexamethasone 0.1%, neomycin 3500u/g, polymixin B sulfate 6000units/g

in East Lancashire

*under review*

Dexamethasone with Tobramycin (Tobradex^®)

Formulary

Eye drops - dexamethasone 1mg/ml, tobramycin 3mg/ml

Restricted to post cataract surgery patients who are intolerant to Maxitrol

Morecambe bay only

Fluocinolone intravitreal implant (Iluvien®)

Formulary

Intravitreal implant 190micrograms in a disposable applicator

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

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

Fluorometholone (FML^®)

Formulary

Eye drops fluoromethalone 0.1%, polyvinyl alcohol 1.4%

in East Lancashire

*under review*

Hydrocortisone sodium phosphate 3.35 mg/ml eye drops (Softacort)

Formulary

Red Eye drop - 2 week course only

1 ml eye drops, solution contains 3.35 mg of hydrocortisone sodium phosphate.

Loteprednol (Lotemax^®)

Formulary

Eye drops 0.5% (5mg/ml)

Restricted to second line use or if clinical condition warrants.

Prednisolone (Pred Forte^®)

Formulary

Eye drops 1%

Prednisolone eye drops

Formulary

Eye drops 0.5%

Unit dose eye drops preservative free 0.5% - only for patients with a documented allergy to preservatives

in East Lancashire

*under review*

11.04.02

Other anti-inflammatory preparations

Sodium Cromoglicate

First Choice

Eye drops 2%

Can be sold to the public (maximum pack size 10mL) for the treatment of acute seasonal and perennial allergic conjunctivitis

LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy

Olopatadine (Opatanol^®)

Second Choice

Eye drops 1mg/mL (0.1%)

Ketotifen (Ketofall^®)
(preservative free)

Formulary

Eye drops (preservative free) 250micrograms/mL

Should only be prescribed when:

a patient has tried at least 2 alternative eye preparations for seasonal allergic conjunctivitis
and/or the patient is sensitive to preservatives

*under review*

in East Lancashire

Sodium cromoglicate preservative free

Formulary

Preservative free eyedrops 2% - Only for patients with a document allergy to preservatives.

*under review*

11.05

Mydriatics and cycloplegics

Mydrane

Formulary

Solution for injection - lidocaine hydrochloride 10mg/ml, phenylephrine hydrochloride 3.1mg/ml, tropicamide 200microgram/ml

Mydriasert

Formulary

Ophthalmic inserts - phenylephrine hydrochloride 5.4mg, Tropicamide 28mg

11.05

Antimuscarinics

Atropine

Formulary

Eye drops 1%

Atropine Sulphate single use (Minims^® Atropine Sulphate)

Formulary

Minims^® 1%

Cyclopentolate

Formulary

Eye drops 0.5%, 1%

in East Lancashire

*under review*

Cyclopentolate Hydrochloride single use (Minims^® Cyclopentolate Hydrochloride)

Formulary

Minims® 0.5%, 1%

Tropicamide single use (Minims^® Tropicamide)

Formulary

Minims^® 0.5%, 1%

in Morecambe Bay

*under review*

11.05

Sympathomimetics

Phenylephrine Hydrochloride (Minims^® Phenylephrine Hydrochloride )

Formulary

Minims^® 2.5%, 10%

11.06

Treatment of glaucoma

Treatment for glaucoma should be initiated by a consultant or specialist in ophthalmology, repeat prescriptions however should be provided in primary care.

NICE NG81: Glaucoma: diagnosis and management

11.06

Beta-blockers

CSM advice: Beta-blockers, even those with cardioselectivity should be avoided in patients with asthma or a history of COPD unless no other alternative treatment is available - see BNF

Timolol

First Choice

eye drops 0.25%, 0.5%
Preservative free eye drops 0.25%, 0.5%
Long acting eye drops 0.25%, 0.5% (Timoptol LA^®)

Betaxolol (Betoptic^®)

Second Choice

Eye drops 0.25%, 0.5%

*under review*

Not listed on East Lancashire formulary

Levobunolol (Betagan^®)

Formulary

Unit dose - preservative free eye drops levobunolol 0.5%/polyvinyl alcohol 1.4%

*under review*

Not listed on East Lancashire formulary

11.06

Prostaglandin analogues

Latanoprost

First Choice

Eye drops 50micrograms/mL

Unit dose eye drops (preservative free)50micrograms/mL

Multidose eye drops (preservative free) 50micrograms/mL (Lotacryn)

The preservative free preparations are restricted to use in patients who have a proven sensitivity to benzalkonium chloride.

Bimatoprost

Formulary

Eye drops 100micrograms/mL (0.01%)
Eye drops 300micrograms/mL (0.03%)
Eye drops - Preservative free 300micrograms/mL (0.03%) - only for patients with a documented allergy to preservatives

Bimatoprost with Timolol

Formulary

Eye drops bimatoprost 300micrograms/mL (0.03%)/timolol 5mg/mL (0.5%)
Eye drops - preservative free bimatoprost 300micrograms/mL (0.03%)/timolol 5mg/mL (0.5%) - only for patients with a documented allergy to preservatives

Latanoprost 0.005% with Timolol 0.5%

Formulary

Eye drops 50micrograms/mL (0.005%)/ timolol 0.5%

Latanoprost and timolol (Fixapost^®)
(Unit dose eye drops)

Formulary

Unit dose eye drops 0.2mL Latanoprost 50micrograms/ml, Timolol 5mg/ml

This has been approved only for patients with documented preservative allergy.

Travoprost

Formulary

Eye drops 40micrograms/mL (0.004%)

*under review*

Not on East Lancashire formulary

Travoprost with Timolol

Formulary

Eye drops 40micrograms/mL (0.004%)/ timolol 0.5%

*under review*

Not on East Lancashire formulary

11.06

Sympathomimetics

Apraclonidine (Iopidine^®)

Formulary

Eye drops 0.5%

*under review*

Brimonidine Tartrate

Formulary

Eye drops 0.2%

Brimonidine Tartrate 0.2% with Timolol 0.5%

Formulary

Eye drops brimonidine 0.2%/timolol 0.5%

*under review*

Not on East Lancashire formulary

11.06

Carbonic anhydrase inhibitors and systemic drugs

Dorzolomide

First Choice

Eye drops 2%

Eye drops - preservative free 2% - only for patients with a documented allergy to preservatives

Brinzolamide

Second Choice

Eye drops 10mg/mL (1%)

Acetazolamide

Formulary

Injection 500mg

Acetazolamide

Formulary

Tablets 250mg
M/R capsules 250mg

Brinzolamide 1% with Timolol 0.5% (Azarga^®)

Formulary

Ophthalmic suspension brinzolamide 10mg/timolol 5mg/mL

Second line carbonic anhydrase inhibitor with timolol

Dorzolamide 2% with Timolol 0.5%

Formulary

Eye drops dorzolamide 2%/timolol 0.5%
Eye drops - preservative free dorzolamide 2%/timolol 0.5% - only for patients with a documented allergy to preservatives.

First line carbonic anhydrase inhibitor with timolol

Brinzolamide 10mg/ml & brimonidine 2mg/ml (Simbrinza^®)

Formulary

Eye drops brinzolamide 10mg/mL/brimonidine 2mg/mL

11.06

Miotics

Pilocarpine

Formulary

Eye drops 1% 2%

Pilocarpine

Formulary

Minims^® 2%

11.07

Local anaesthetics

Lidocaine Hydrochloride 4% with Fluorescein 0.25% (Minims^®)

Formulary

Minims^® lidocaine 4%/fluorescein 0.25%

Oxybuprocaine Hydrochloride (Minims^® )

Formulary

Minims^® 0.4%

Proxymetacaine Hydrochloride (Minims^®)

Formulary

Minims^® 0.5%

Tetracaine Hydrochloride (Minims^® Amethocaine Hydrochloride)

Formulary

Minims^® 1%

11.08

Miscellaneous ophthalmic preparations

Potassium ascorbate

Unlicensed

Eye drops 10%

*under review*
Not on East Lancashire formulary

11.08.01

Tear deficiency, ocular lubricants, and astringents

Acetylcysteine 5% with Hypromellose 0.35% (Ilube^®)

Formulary

Eye drops

For treatment of filamentary keratitis only

Carbomer 980 eye drops
(polyacrylic acid)

Formulary

Liquid gel eye drops 0.2%
Liquid gel unit dose eye drops 0.2%

Carmellose

Formulary

Preservative free eye drops 0.5%, 1%

Hydramed Night^®

Formulary

Lubricating eye ointment 5g

Hylo-night ^®
(formerly known as VitA-Pos^®)

Formulary

Eye ointment preservative free

2nd line to Hydramed Night

Hypromellose

Formulary

Eye drops 0.3%

Preservative free eye drops 0.3%

Polyvinyl Alcohol (Liquifilm Tears^®)

Formulary

Eye drops 1.4%
Unit dose eye drops 1.4%

LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy

Sodium Chloride (Minims^® Saline)

Formulary

0.9% Minims^®

Sodium Hyaluronate

Formulary

Eye drops 0.2%

Eye drops - preservative free 0.1% & 0.2%

Sodium Chloride

Unlicensed

Preservative free eye drops 5% (unlicensed)

*under review*

in East Lancashire

LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy

11.08.02

Ocular diagnostic and peri-operative preparations and photodynamic treatment

11.08.02

Ocular diagnostic preparations

Fluorescein Sodium

Formulary

Minims^® 1%, 2%

Injection 10% for WAMD clinic use only

Injection 20%

Indocyanine green

Formulary

Injection 25mg (unlicensed)

Trypan Blue (Vision Blue^®)

Formulary

Injection

For use in cataract surgery

Corneal superficial injury (CKS)

11.08.02

Ocular peri-operative drugs

Acetylcholine Chloride (Miochol-E^®)

Formulary

Intra-occular irrigation 1%

Apraclonidine (Iopidine^®)

Formulary

Unit dose eye drops 1% - perioperative use only

*under review*

Balanced Salt Solution

Formulary

Sterile irrigation solution 15mL, 500mL

Bromfenac (Yellox^®)

Formulary

Eye drops 0.09%

Diclofenac (Voltarol^® Ophtha)

Formulary

Eye drops 0.1%
Unit dose eye drops 0.1%

*under review*

in East Lancashire

Ketorolac

Formulary

Eye drops 0.5%

*under review*

in East Lancashire

Povidone iodine

Formulary

Unit dose eye drops 5%

Sodium hyaluronate
(Obtained from central stores)

Formulary

Injection 1%
Injection prefilled syringe 15mg in 1mL
Injection prefilled syringe 14mg in 1mL (Haelonid GV^®)
Irrigation 40mg/50mL

Disodium edetate
(EDTA)

Unlicensed

Preservative free solution 0.37%

11.08.02

Subfoveal choroidal neovascularisation

Aflibercept (Eylea^®)

Formulary

Solution for intravitreal injection pre-filled syringe 40mg/mL

MHRA: Aflibercept (Zaltrap▼): minimising the risk of osteonecrosis of the jaw

NICE TA: Aflibercept for treating diabetic macular oedema

NICE TA409: Aflibercept for treating visual impairment caused by macular oedema after branch retinal vein occlusion

NICE TA486: Aflibercept for treating choroidal neovascularisation

Brolucizumab

(Beovu^®

Formulary

19.8mg/0.165ml solution for injection pre-filled syringes

MHRA: Brolucizumab (Beovu▼): risk of intraocular inflammation and retinal vascular occlusion increased with short dosing intervals

NICE TA672: Brolucizumab for treating wet age-related macular degeneration

NICE TA820: Brolucizumab for treating diabetic macular oedema

Faricimab

(Vabysmo ^®)

Formulary

Solution for injection 120 mg/mL

NICE TA799: Faricimab for treating diabetic macular oedema

NICE TA800: Faricimab for treating wet age-related macular degeneration

Ranibizumab

Formulary

Solution for intravitreal injection 10mg/mL

For NICE TA637: Ranibizumab for treating diabetic retinopathy (terminated appraisal)

NICE TA274: Ranibizumab for treating diabetic macular oedema

NICE TA637: Ranibizumab for treating diabetic retinopathy (terminated appraisal)

Verteporfin injection

Formulary

15mg vial

11.08.02

Vitreomacular traction

11.08.03

Reduction of elevated intra-ocular pressure

11.09

Contact lenses

See BNF

11.10

Additional treatments used in the management of ophthalmic conditions not listed in BNF chapter 11

Adalimumab

Formulary

Solution for injection

NICE TA460: Adalimumab and dexamethasone for treating non-infectious uveitis

11.11

Miscellaneous

11.11

Antifungals

11.11

Cytotoxics / wound healing modulators

11.11

Fibrinolytic drugs

11.11

Glues - ocular

11.11

Immunosuppressants

Ciclosporin 0.1% eye drops (Ikervis^®)

Formulary

Unit dose eye drops 0.3mL

For adults

NICE TA369: Ciclosporin for treating dry eye disease that has not improved despite treatment with artificial tears

Ciclosporin 0.1% eye drops (Verkazia^®)

Formulary

Unit dose eye drops 0.1% 0.3mL

For children and adolescents

11.11

Treatment of burns

11.11

Visco-elastics

11.11

Other

Holoclar

Formulary

79,000 - 316,000 cells/cm2 living tissue equivalent

NICE TA467: Holoclar for treating limbal stem cell deficiency after eye burns

Voretigene neparvovex

(Luxturna^®)

Formulary

Tertiary Centre only

NICE: Voretigene neparvovec for treating inherited retinal dystrophies caused by RPE65 gene mutations

....

Non Formulary Items

Key

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

	High Cost Medicine
	Cancer Drugs Fund
	NHS England
	Homecare
	ICB
	Low carbon footprint
	Medium carbon footprint
	High carbon footprint

Status	Description
	Green: Appropriate for initiation and ongoing prescribing in both primary and secondary care. Generally, little or no routine drug monitoring is required.
	Green (Restricted): Appropriate for initiation and ongoing prescribing in both primary and secondary care provided: Additional criteria specific to the medicine or device are met, or The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway. Generally, little or no routine drug monitoring is required.
	Red medicines: Medicine is supplied by the hospital for the duration of the treatment course. Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP. Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this. Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care.
	Amber level 0: Suitable for prescribing in primary care following recommendation or initiation by a specialist. Little or no specific monitoring required. Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care. Brief prescribing document or information sheet may be required. Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information. When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe.
	Amber level 1 (with shared care): Suitable for prescribing in primary care following recommendation or initiation by a specialist. Minimal monitoring required. Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care. Full prior agreement about patient’s on-going care must be reached under the shared care agreement. Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care.
	Amber level 2 (with shared care and enhanced service): Initiated by specialist and transferred to primary care following a successful initiation period. Significant monitoring required on an on-going basis. Full prior agreement about patient’s on-going care must be reached under the shared care agreement. Suitable for enhanced service. These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements).
	Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria. Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need.
	Grey medicines: Medicines which have not yet been reviewed or are under the review process. GPs and specialists are recommended not to prescribe these drugs. This category includes drugs where funding has not yet been agreed.
	Refer to local guidance and local commissioning arrangements