NSAIDS, Corticosteroids & Their Ophthalmic Use

Inflammation of tissues if not too severe can be managed by anti-histamines and NSAIDs. If the inflammation is more severe then corticosteroids are useful.

Corticosteroids can act as anti-inflammatory agents as well as having a number of other effects on the body. Therapeutic corticosteroids work to directly block the production of inflammatory mediators (prostaglandins) while NSAIDs act as inhibitors of the enzymes that produce the prostaglandins.

OCULAR NSAIDs

Uses

• For seasonal allergic conjuntivitis eg diclofenac sodium 0.1% avail as PoM Voltarol Ophtha Multidose 5ml. For use QDS to reduce redness, discomfort and lacrimation assoc w/SAC. Supplemental anti-histamines will probs be needed to reduce residual itching etc. They shouldn't normally be used for more than a few weeks - then mast cell stabilisers can take over.
• As a topical analgesic. Again diclofenac sodium 0.1% can be used in the management of pain/discomfort after abrasions of the cornea and conj and also after refractive surgery. This is usually for a short period of time eg QDS for 2 days.
• Before & after general surgery to the eye eg cataract surgery or the extraocular muscles in strabismus surgery

The use of anti-inflammatory drugs on the eye has been promoted whenever there was evidence of the possible development of inflammatory signs/where clear inflammation was present or the eye had been subjected to trauma where inflammation was an expected sequel to the trauma. By reducing the tissue production of prostaglandins NSAIDs can be very effectively used prophylactically.

Different Preparations

• DICLOFENAC SODIUM is marketed as PoM Voltarol multidose w/a unit dose for those w/allergy to preservatives (thiomerosal). As a NSAID is can reduce the risk of CM oedema post-cataract ops. It also maintains mydriasis during surgery and has sufficient anti-inflammatory efficacy to be used to manage general ocular inflammation after surgery too for up to 4-6wks. It means narcotic analgesics (corticosteroids) can be used less. There is now a P oral diclofenac that an optom can sell or at least recommend.
• KETOROLAC TROMETAMOL ophthalmic solution 0.5 (PoM Acular 5ml bottle) is indicated as a prophylactic for inflammation and associated symptoms following cataract surgery. Its use is similar to diclofenac eg TDS for the day prior to surgery and then TDS for up to three wks (ie better than Voltarol)
• FLURBIPROFEN ophthalmic solution (PoM Ocufen 10x0.4ml SDUs) 0.03%soln in 1.4% PVA. Only indicated for intensive use as a general anti-inflamm drug for cataract ops, esp in case where corticosteroids are contraindicated.

Additional Supply optoms can use topical diclofenac sodium to control pain following eg recurrent corneal erosion w/chronic tear film instability - painful episodes of loss of poorly adherent epithelium.

CORTICOSTEROIDS FOR OPHTHALMIC USE

• Corticosteroids take a relatively long time to work ie days so way need to be given for several days before any effect is obvious whereas NSAIDs can produce effects in hours. Antihistamines can produce effects between minutes and hours
• No routine access to optoms but should be on future lists. Px currently has to go to GP or ophthalmologist since nurse prescribers can only access non-ocular steroids.

Indications for use

Primarily for non-infectious inflammatory disorders

• Assoc w/chronic chemical or drug irritation of the eyelids that leads to oedema of the eyelid margins and palp. conj. eg those w/severe allergic reactions of any type, seasonal allergies, acute or subacute allergic blepharitis from airborne sources or contact w/chemicals or drugs etc
• Chronic irritation of palp/bulbar conj assoc w/repeated exposure to allergens (eg Vernal Conjunctivitis) or assoc w/mechanical-chemical irritation (eg CLPC)
• For superficial punctate keratitis of almost any aetiology, generalized diffuse keratitis of a non infectious aetiology, toxic keratitis and when there's non-ulcerating active stromal involvement
• For acute/subacute/chronic inflammatory conditions of the sclera, anterior uveal, iris and cornea assoc w/mechanical, chemical or bacterial trauma
• Adjunct use in generalized iritis & anterior uveitis

CLINICAL USE OF CORTICOSTEROIDS

DOSING

• Should be started at 3-4x a day when the presenting signs are mild to moderate, in very severe cases every two hours for the first 24 only. In many cases you're only going to use them short term anyway and up to 3wks maximum. Should show improvement in 48h and definite improvement in 7 days. In some cases if there isn't a great improvement in primary care might need to be referred to ophthalmologist. In special cases the therapy can continue for many months and we have to start paying attention to the various side/adverse effects
• Therapy shouldn't be abruptly discontinued. Slowly reducing dose should allow us to see how inflamed the eye actually is and avoid there being an acute rebound response. Reduce to twice a day then once a day after a day or so and monitor. Should allow us to see true status of corneal/conj surfaces including any sign of infection

FOLLOWUP

• Mild-Moderate -review after a week, more severe every three days til substantial resolution of condition has occurred. Periodic examinations (every 2 weeks) are necessary for longer term treatments to monitor the efficacy of the steroid regimen, to allow appropriate changes in regimen and monitor the adverse effects
• Assessment should include general inspection inc eyelid eversion, slit lamp w/anterior chamber assessment for cells/flare and evaluation of pupil/iris esp for signs of acute inflammatory reaction. Patient records should include notes as to inflamm magnitude. Allow safety of use of drugs should be reconsidered every time - is an infection (bacterial, viral, fungal, protozoan) present? Are adverse reactions developing?

WARNINGS

• Generally contraindicated in purulent infections. Can mask and interfere with concurrent bacterial infections in which lots of gunk may obscure other conditions/underlying infections. Any infection should be managed properly using an antibiotic. Get infection under control before starting w/steroids generally. The eye quietening effects of the roids may not show all of the expected early signs and symptoms of an infection
• Excessive topical ocular roid therapy may retard the natural re-surfacing/healing processes of the surface membranes. Do not overuse - nothing more that q4 or q6 except in initial treatment of v.severe conditions (see above) Can lead to stromal thinning and loss of cornea!
• IOP may be raised and 'steroid glaucoma' induced. IOP should be periodically assessed. Only really 'common' in a specific bunch of people who are predisposed ('steroid responders'). Time period where IOP rise can be detected = 2 to 3 weeks - this is why steroid use is normally limited to around this time cos any chance of a rise happening within the first two to three weeks is minimal. Check the IOPs beforehand!

CONTRAINDICATIONS

• Concurrent active HSV infection. Can exacerbate it. Initial slit lamp w/flu should rule HSV out
• Concurrent fungal/protozoan infections. Again may exacerbate
• Active tuberculosis infections. Same again
  

PRODUCTS (more potent as you go down)

• Hydrocortizone as eyedrops/ointment can be used for relatively superficial non-infectious inflammatory conditions of the eyelids or conjunctiva where there is no major defect or sign of ulceration 1% PoM eyedrops 10ml bottle, 0.5% PoM generic ointment 3g tubes. Used by hospitals and GPs
• Betamethasone is indicated for use in moderate inflammatory conditions of eyelids, conj, cornea and ant seg assoc w/allergic, chemical or mechanical trauma. 0.1% eyedrops (PoM Betnesol) or 3g tube ointment PoM Betnesol white soft paraffin/liquid paraffin
• Dexamethasone is generally for moderate inflammations but can be used intensively for severe inflammations including as a post-op steroid. Avail as eye drops 0.1% w/hypromellose 0.5 in 5ml or 10ml bottles and also minims for post-op use. Some combos w/antibac drugs are also available
• Prenisolone is indicated for moderate or severe inflammations. Prednisolone sodium phosphate ophthalmic solution is available at 0.5% in a 10ml bottle and minims are available for A&E or post-op one off uses. PoM Pred Forte 1.0% is also avail in 5ml and 10ml bottles. No generic products but some in combo w/antibacs
• Fluorometholone - potent but used in UK at 0.1% for mild-moderate inflammations when a rapid response is deemed appropriate. Avail as eye drops at 0.1% concentration w/PVA in PoM FML Liquifilm 5ml or 10ml bottles
• Rimexolone and loteprednol are indicated for intensive use either to manage uveitis or for post-op use. They are 'soft' corticosteroids that have substantial anti-inflam effects but are biotransformed so rapidly to what appear to be inactive metabolites that the side effects profile is lessened
  

Mast Cell Stabilisers

Seasonal allergic conjunctivitis peaks in the spring and in the autumn. Perennial allergic conjunctivitis is ongoing and can have a peak depending on where you live. 'Sealed up homes' in the winter are bad for it. Allergic conjunctivitis involves sustained release of histamines and prostaglandins by conjunctival mast cells. Mast cell stabilisers attenuate this release.

Severity of symptoms needs to be ascertained first. Intermittent mild-moderate itching can be solved w/eye baths, decongestants or anti-h eye drops. Moderate-severe = hyperaemia/injection, lacrimation, mucus discharge, nasal stuffiness will respond to mast cell stabs in conjunction w/oral antihistamines. Severe = chronic oedema of lid margins and conj, w/infiltrates and badass discomfort/foreign body sensation. This may also need NSAIDS or topical corticosteroids.

Guidelines for use

NB These drugs aren't 'cure-all'

• C/I - Known allergy to drugs or ingredients (BkCl??) Can do patch test to work out what Px is allergic to
  
• IND - for prophylactic use to offset the severity of ocular reactions to allergens
• NOT for occasional use or provision of short term or acute relief of the symptoms of allergic conj. That's topical ocular decongestants or antihistamines
• Dosing needs to be regular and continuous - every four or six hours depending on severity. Should start using them before peak of season to facilitate development of tolerance and to prevent palp conj changes/damage. Remember you're attenuating symptoms not actually getting rid of them
• Px education is really important - regular doses are the only way it's gonna work. Maintenance of a 'quiet' eye throughout the day may take 2 to 4 weeks of QDS although some improvement can be shown in 7 to 10 days. For VKC it could take 4 to 8 weeks to reach the maintenance state. May still need topical decongestant after extreme exposure.

Available Preps

All P Meds in 5-10ml bottles

• Sodium Cromoglicate 2% widely avail as P eg Opticrom Allergy Eye Drops, Clarityn Allergy Eye Drops (not w/anti-h like the tablets!) likely w/BkCl & EDTA. Can use w/CLs before and after but not during. Wait 5 minutes at least before putting lens in.
• Lodoxamide (2nd gen MCS) PoM Alomide (additional supply only) and P Alomide Eye Drops 0.1% concentration. P Med is indicated for Seasonal Allergic Conj & CLPC although shouldn't be used w/lenses in.
• Nedocromil Sodium avail as PoM. Canary yellow colour so can't be used w/CL wear at all

NOTE!11 Cobblestone Papillae = VKC, Lumpy = CLPC, Meaty Papillae on lower lid = chalmydial infection - refer to GP for oral MCS.

SUPPLEMENTALLLLLL: ORAL ANTI-HISTAMINES FOR ALLERGIC CONJ

Additional supply only. Very good if you have a runny nose an all. Note some older drugs induce drowsiness. Any pharm dispensing will advise Px of this. Newer antihistamines are non-sedating so there won't be any drug induced drowsiness.

Some antihistamines do have sympathomimetic potential so again their use in Px w/cardiac probs, HBP, Epilepsy, Asthma, Liver & Kidney disease is not recommended. There was a general warning in 1994 for use of some of these products esp terfenadine cos it could create cardiac arrthymias that were maybe fatal. Terfenadine is PoM. This doesn't apply to all the other antihistamines but again their use ain't recommended.

Current available SL and P Meds

• Chloramphenamine eg P Piriton, Calimal, Pollenase in 30 to 60 tab packs w/syrup for kids. Useage up to QDS.
• Acrivastine eg P Benadryl Allergy Relief 7, 12, 24 tablets. Dosage up to QDS
• Clemastine SL/P Allereze and P Tavegil. Dose = bd or up to every four hours
• Loratidine eg P Clarityn 7-14 tab packs. Once a day
• Cetirizine P Benadryl one-a-day P Cetirizine P Piriteze. Also oral syrups for paediatric use

All these prods don't have substantial risk of ADRs.

Ophthalmic Topical Astringent Eyedrops, Decongestants + Antihistamines

AGAIN CAN SELL + SUPPLY GSL, SL, UNLICENSED PRODS IN COURSE OF PRACTICE

Topical decongestants and antihistamines are needed when the px's ocular irritation/discomfort is a chemical irritant, an allergen or both. Oral antihistamines are used too.

1. TOPICAL ASTRINGENT EYEDROPS

Astringents are meant to have some sort of cleansing action beyond that of saline. Borate eye washes were astringent and used to be the main treatment for anything. They are revived in the form of these eyedrops and known as 'natural' cleansers/moisturisers. They are normally indicated for prn use for any form of MILD eye irritation/discomfort which proves to be responsive.

• P Optrex Eye Drops 10ml bottle w/witch hazel
  
• SL Optrex refreshing eye drops 10ml bottle w/witch hazel and glycerin
• P Zinc Sulphate 0.25% Eye Drops 15ml bottle

2. EYE BRIGHTENER PRODUCTS

These have no medical definition and are generally used by people who have slightly irritated/tired eyes w/hyperaemia that is unacceptable cosmetically. They contain small amounts of both astringents and decongestants and the products have similar warnings to those prods w/higher concentrations. They also contain natural/plant type stuff.

• SL Vital Eyes Brightener 10ml bottle w/flower petal extracts, small amount of witch hazel, trace amounts of zinc sulphate 0.02% and naphazoline 0.005%
• SL Optrex Fresh Eyes Brightener 8ml w/witch hazel, borate buffer, naphazoline 0.01% and BkCl. Similar drops can contain plant extracts, glycerine and EDTA

3. TOPICAL DIRECT ACTING DECONGESTANTS/DECON+ANTI-HIS COMBOS

Usually P Medicines. The decongestant activity is a result of direct alpha adrenergic action or direct histamine H1 blocking action - either attenuating vasodilation or even causing vasoconstriction. It's suggested that some alpha 2 receptors are also affected by the drug and that would relieve signs/symptoms such as discomfort, puffiness, chemosis and reflex lacrimation. If Anti-H is also included then expect efficacy against itchiness symptoms too. All the products contain BkCl and EDTA usually as preservative

• All products are meant to provide occasional relief of symptoms associated w/mildly irritated eyes and also improve the cosmetic appearance of the external eye, used eg 2-3 times daily. They aren't for use to whiten eyes that just need a wash. q2hr = excessive use
• Cause of irritation should be identified. If there's a genuine allergic component then use something w/anti-h. For dirt and dust an eyewash might have better results.
• They don't work as prophylactic agents. They have a slight affect but that's probs due to reflex tearing providing a mini 'eye wash'.
• Excessive use can cause rebound effects and an induced red eye. This is due to a mild toxic reaction or type IV allergic reaction due to prior sensitization to any of the ingredients of the eyedrops.

Guidelines for use

• Contrainds: Narrow angle glaucoma - adverse effect is angle closure
• Warnings for systemic diseases - shouldn't be recommended to anyone with HBP, Heart Probs, Stroke, Hyperthyroidism. Any sympathomimetic drug could increase BP. These prods don't contain high concs of the drugs but they are frequently overused and could produce systemic effects.
• Interactions - carefully supervise use if px taking MAO inhibitors/anti-depressants
• Not for use w/eye infections, will just relieve symptoms and do nowt else. Even mask them

Current drops available

• Naphazoline 0.01% alph-adrenergic eg P Murine. Also w/witch hazel 12% eg P Eye Dew Clear. All preserved w/BkCl. Also w/blue dye for cosmesis in Dazzling Eye Drops
• Xylometazoline 0.05% as a-1 and a-2 adrenergic in combo w/antazoline 0.5% as histamine H-1 blocker. Preserved w/BkCl and EDTA eg P Otrivine-Antistin

Topical Anti-H drops on their own are additional supply only.

Artificial Tears/Oc. Lubricants

UK OPTOMS MAY SELL & SUPPLY. USE OF ART. TEARS SHOULD BE SUPERVISED

• Art. tears is name for various avail preparations for tear film deficiencies thru stuff like ocular surface disease or use of systemic medications. These are medicinal products
• SIMPLE art. tears re-wet the eye but don't really act as a quality lubricant. They usually contain some salts and one or two polymers and have a viscosity that is similar to/slightly increased from human tears that's acheived w/low concs of various polymers.
  
• Artificial tears are generally iso or slightly hypotonic to the tear film and have a pH that is slightly acid to normal tears ie 6.5-7.5. pH is geared towards stability, comfort not so much.
  
• COMPLEX art. tears have a slightly different set of polymers (2 or more)
• Cellulose polymers such as hypromellose, carmellose and hydroxyethylcellulose are often used
• P-Polymers like PVA, PEG, Povidone and 'Tween' (which also has surfactant properties) are used also
• New prods could include sodium hyaluronate which is in 'rewetting drops' and not officially desig. art. tears. Also guar gum is found in ce marked rewetting drops and does provide a bit more lubrication than the trad polymers.

ASSESSMENT PRE RECOMMENDING ART. TEARS

1. Objectively evaluate the tear film/oc surface using flu/rose b and measuring the tear prism/tear break up time. Important to get some sort of quantitative assessment that you can compare w/after using the art tears for some time.
2. Establish a true baseline condition - good to get px to stop using the ophthalmic prods they're using for a day before a detailed ee. Knowing the true nature of the px's condition can be helpful when selecting a prod to use.
3. Consider px preferences - important for compliancy. Some artificial tears sting and some don't, some smell/'taste' funny, some people won't like initial blurring of vision, be good w/multidose bottles etc etc etc
4. Preserved or non-preserved? The vast maj of px will be fine with multidose art. tear w/preservative but some will develop allergy. Unit dose & preserv. free are available if the patient might experience adverse reactions or feels that 6x a day use is needed
5. General allergy to eyedrops. need to work out if px is sensitive to a specific ingredient w/questioning before beginning NB no art tear/oc lub can be expected to compete w/an ongoing disease process or display satisfactory efficacy if there's poor ocular/peri-ocular hygiene.
6. Cost. Simpler products = cheaper. Unit dose forms = expensive. Larger bottles = cheaper.
7. Choose regimen. For the most part simple art tears are designed for use prn for the relief of mild & uncomplicated symptoms arising from stuff like
   

• working for extended periods in environment which may irritate eyes
• from inadequate blinking due to over-tiredness
• A dry atmosphere
• -----One or two drops can be expected to simply wash out tear film debris and irritants

8. Px Education & Communication: Give correct instructions, don't assume intelligence, get them to come back

FOR UNCOMPLICATED DRY EYE SYMPTOMS

All multi use bottles contain preservatives (usually BkCl) and include (ALL P MEDICINES)

• Saline eyedrops w/out polymers P NaCl Eyedrops. Minim version is 0.9%
• Hypromellose/hydroxypropylmethylcellulose 0.3% P Brolene Cool Eyes
• Hypromellose 0.32% P Artelac 10ml bottle
• Hypromellose 0.5% P Isopto Plain 10ml bottle
• w/PVA 1.4% P Liquifilm Tears 15ml bottle
• w/PVA 1.8%, Povidone 2%, NaCl, KCl & Amisol, Preserved w/EDTA & Polyquarternium-42: Clinitas Ultra 3 3ml bottle

Single dose options

• NaCl P Minims 0.9%
• Hypromellose 0.32% P Artelac SDU 0.5mlx30 or 60
• Hypromellose 0.3% w/dextran 0.01% SL Tears Naturale 0.5mlx28
• Hydroxyethylcellulose 0.44% as P Minims Artificial Tears
• Carboxymethylcellulose 0.25% in hypotonic mixed salts vehicle buffered w/borate & phosphate. foil sachets as 'Theratears'
• PVA 1.4% w/povidine 0.6% P Liquifilm Tears Preservative free

OCULAR LUBRICANTS & OTHER PREPS aka A STRONGER ARTIFICIAL TEAR W/MORE LUBRICATION

This sort of stuff is for a patient who actually has a dry eye ie Keratoconjunctivitis Sicca and needs something stronger than an artificial tear. They are indicated for use when there is a non-infective or non-toxic chronic irritation and inflammation of the conj w/poor traction of the lids across the ocular surface eg a px w/Sjorgens.

A lubricant does not replace the tear film with a simple aqueous fluid but w/a lubricating film with long residence time at the ocular surface. As such it doesn't improve the hydration of the ocular surface, merely reduces friction and the patient's symptoms which can usually be summed up w/BURNING! PAIN! SOMETHING IN IT! Actually supplementing the lubrication with artificial tears can be useful.

Selection of a lubricant depends on how much friction needs to be reduced and for how long. For example if you step up w/ nightly use of a lubricating gel or ointment then the px might change regimen from simple artificial tears every hour to lubricating tears every 3 or a liquid gel every 4 or 6 hours. NB Ointment during the day = matted lashes and smeary vision so not v popular for that.

As well as allergy to ingredients

• not to be used as primary therapy in follicular conjuntivitis
• use w/caution in toxic keratitis from excessive use of ophthalmic pharmaceuticals or systemic medications
  
• use w/caution in cases of vernal keratoconjunctivitis or atopic conjunctivitis. Other anti-inflamm drug therapy needed in that case

Examples of oc lubs

• Cellulose Polymer prods at 1% level eg Hypromellose P Isopto-alkaline (more comfort for px) Eye-Drops
• Sodium Hyaluronate is widely used in CL rewetting soln and 0.2% in Ocusan 20, 20x0.5ml or at 0.4% in SL Clinitas Soothe
• Carbomer Gels SL Optrex Dry Eye Liquid Gel for use 3 or 4 times a day and before bed. Also P Geltears and P Liquivisc. These contain a special polyacrylic acid gel that forms a coat on the eye's surface that thins rapidly with each eyeblink.
• Lubricating ointments (use 0.5-1cm long ribbon) w/low quantities of liquid paraffin or mineral oil, white paraffin & lanolin eg P Lacrilube 3.5g tube, P Lubritears 5g tube
  
• Bland ointments w/higher concs of yellow soft paraffin and lanolin eg P Simple Eye Ointment generic 3.5g or 4g tubes. Yellow Paraffin is older & a bit more lubricating than white
• ADDNL SUPPLY ONLY Acetylcysteine eye-drops
• Glycerol/Castor oil: glycerin can be formulated from hosp. pharmacy by diluting w/water. Castor oil was once widely used and avail in minims.
  

Contact Lens Rewetting Solns etc

OPTOMS CAN SELL & SUPPLY GSL, SL & UNLICENSED PRODS IN COURSE OF PRACTICE AS LONG AS THEY HAVE A SECURE RETAIL PREMISES. THIS INCLUDES ALL OF THIS STUFF.

CL Rewetting solns

• For re-wetting a CL whilst in place on the eye.
• available to the general public SL/GSL for use as needed
• Question whether px should stay on em if they need them more than once an hour
• also 'CLs w/moisturisers' (in polymer matrix) now avail but no proof that they work yet
• Generally contain saline, a polymer, probs a wetting agent like poloxamer. Multi use bottles will have a preservative that isn't BkCl. More likely to be allergic to preservative or wetting agent.
  
• Wide range of multi-dose and unit dose products
• EG1 B&L Rewetting eye drops 10ml bottle w/NaCl, Hypromellose & a wetting agent. Preserved w/sorbic acid 0.25% & EDTA
• EG2 Blink revitalising eye drops 10ml bottle w/PVA 1.4%, phosphate buffer & chlorite/peroxyde preservative. Also avail as unit dose w/EDTA

• Regular use MAY offset adverse reactions to CL solns and MAY help keep CLs/oc surfaces clean. BUT these things are NOT LICENSED FOR THE TREATMENT OF THE CONSEQUENCES OF OCULAR SURFACE DRYING eg pitting staining or seal staining

What they should do

• Should promptly relieve symptoms - pretty much just provide comfort
  
• Help reduce chance of oc surface drying
• Older CL wearers may be more in need of them
• No standards yet on what makes a good rewetting drop

Moisturisers (SL/GSL)

• Supposed to provide soothing & refreshing effects for tired eyes
• NOT considered as true replacements w/tear deficiency
• Shouldn't be used with or just before CL wear and long term use should really be monitored esp w/multidose bottles
• All contain a polymer and various 'special ingredients'. No medicinal claims allowed to be made although 'dry eye'/'lubrication' could be written on bottle. Dry eye being the symptom! If you see signs of dry eye you're going to need at least an artificial tear.
  
• Used as needed for temporary relief of ocular discomfort
• EG1 SL Vital Eyes moisturiser 10ml bottle w/hydroxymethylpropyl cellulose 0.4%, Vit A and Vit E. Preserved w/chlorbutanol and polyhexanide
• EG2 SL Extreme Cooling Rohto Zi for Eyes 8ml bottle w/polysorbate 80 preserved w/chlorhexidine, Vit B6, Vit E, Potassium L-Aspartate and plant extracts like menthol for which no medicinal claims are made.

Astringent Eyewashes (GSL/SL)

• Usually saline w/small amount of phosphate buffer or are a mix of boric acid and sodium borate. Borate has more cleansing power than simple saline 110-300ml bottles are usually available. They often contain a preservative like BkCl or Thiomerosal and other astringents to promote cleansing like witch hazel/hamamelis water and glycerin (eg Optrex Eye Lotion) or maybe petal extracts (eg SL Vital Eyes Eye Wash)
• Often used @ end of working day for general cleansing/washing away of gunk. Often comes with goggle-style 'cap'. Bottle should be for one individual and thrown away after rel. short amount of time.
• Once actually formed mainstay of treatment. Non-medicinal for use p.r.n.

Emergency Eyewashes

• Eg when splashing chemical in eye very large volumes of eyewash (eg Optrex Emergency Eyewash 500ml or even tap water) are available to be continuously applied for at least 15 mins.
• More elaborate solns are formulated for use in operations like Balanced Salt Soln w/NaCl, KCl, MgCl2 etc

Lid Scrub/Hygiene Products

• Cleanse eyelid margins and lashes: meibomian glands, glands of moll, glands of zeis. NB If the lid margin is also inflamed it's probably blepharoconjunctivitis. Eyelid margin discomfort and decreased tear film stability can develop in cases of mild->moderate blepharitis or blepharoconjunctivitis which may be assoc w/meibomian gland dysfunction.
  
• General cleansing w/this stuff should reduce the chance of other intra-epithelial/glandular/hair follicle infections of the eyelid margin
• You can use baby shampoo but it must be diluted and prepared immediately before each use. Much more likely to be successful w/proper product and treatment regimen
• SUPRANETTES (SL) - individually packaged wipes. Coarse gauze
• BLEPHARCLEAN (SL) wipes w/medium gauze, BLEPHASOL (SL, 100ml bottle)
• Wipes moistened w/soln containing mix of surfactants w/soothing agents & plant extracts (Hamamelis again)
• SL STERILID = foam gel w/natural oils, SL BLEPHAGEL = gel

Special Irrigation Solutions

• When toxic chemical or something is splashed into the eye the irrigation needs to be very aggressive to get rid and relieve discomfort. Oedema of the cornea/conj might be involved too
• Used as diagnostic aid to clear corneal oed so you can see in, an astringent for mucus threads, treatment for Fuch's dystrophy.
• Available to some hospital optoms if the ophthalmologist lets em have it
• EG1 Hypertonic NaCl 2% or 5% several drops over 15-20mins may be required. Hospitals can use other 'hypertonics' like glycerin 10-50% diluted w/sterile water
• EG2 Trisodium edetate (0.37-4%) - higher concs of EDTA than are found in eyedrops (<0.1%) used as therapy for band keratopathies that develop after systemic calcium imbalance
  

Access To/Use Of Medicines & Other Products by UK Based Optoms

NOTE: It's up to the GOC to make rules prohibiting/regulating sale and supply. They haven't done this yet but they have decided to provide guidelines to the college for generation of 'rules' pertaining to the scope of practice.

There are a couple of categories we need to know about; use and supply & use.

USE AND SUPPLY

• The optom may administer w/in course of practice and supply to px if 'in course of practice' (+if in an emergency if PoM - in 2005 all GSL & P medicines no longer bound by that so optom can obtain from company/pharmacy and sell @ retail price)

STAINING AGENTS

• Fluorescein sodium (P)
• Rose Bengal (P)
• These are logically reserved for use only cos px has no use for em

MYDRIATICS & DECONGESTANTS (sympathomimetics)

• phenylephrine hydrochloride up to 10% (P)
• xylometazoline hydrochloride (P)
• naphazoline salts (P)
• adrenaline and ephedrine salts (P) NOT AVAIL NOW

ANTIALLERGICS

• Antazoline up to 1% (P)
• Sodium Cromoglicate up to 2% eyedrops (P)

ART TEARS/LUBRICANTS/EYEWASHES/MOISTURISERS & IRRIGATION SOLNS

• anything suitable for eye irrig w/NaCl, witch hazel or other natural extracts, zinc sulphate and/or viscosity enhancing polymers (like PVA, hypromellose, hydroxyethylcellulose, dextran, povidone, carbomer, hyaluronate) designated as art. tears, ocular lubricants, moisturisers or rewetting solns. Also contains P products w/white or yellow liquid paraffin, lanolin

CYCLOPLEGICS & MYDRIATICS (anti-muscarinics)

• Cyclopentolate (PoM)
• Tropicamide (PoM)
• usually for diagnostic use only but could be supplied to px 'in an emergency'

ANTIMICROBIAL AGENTS

• Chloramphenicol drops up to 0.5% (P)
  
• Chloramphenicol ointment up to 1.0% (P)
• Propamidine (P)
• Dibromopropamidine (P)
• Fusidic Acid Viscous Eyedrops (PoM)

MIOTICS (parasympathomimetics)

• Pilocarpine salts and carbachol. Recently removed but avail to additional supply optoms

USE ONLY CATEGORY

• Optom may administer pharms containing these drugs but not supply to px under any circumstances or indeed use themselves.

TOPICAL ANAESTHETICS

• Tetracaine hydrochloride (PoM)
• Oxybuprocaine hydrochloride (PoM)
• Proxymetacaine hydrochloride (PoM)
• Lidocaine hydrochloride (PoM)
• this includes combos w/flu.

FURTHER BUMF

The optom used to have other antimicrobial agents, an anti-inflammatory agent and an alpha adrenoceptor blocker available for use only but they done got removed from the list.

Detailed records of P and GSL don't need to be kept by law but records of all PoMs used do, both wrt stock and on the px records.

The optom may also add a label to pre packaged pharmaceuticals without holding a manufacturer's licence for assembly of pharmaceuticals; there isn't a requirement to though. P and GSL pharms shouldn't be relabelled though unless specific permission to a specific optom is given. The label must include the px's name, directions for use, "keep out of reach of children", "for external use only" and the name and address of the supplying optom.

Use of Medicines by Optometrists Part One Sort Of Intro

Only those medicines designated for use by optometrists, orthoptists and opticians should be used on the public at large.

The MEDICINES ACT determines the use of drugs by optometrists

• Originally prepared in 1968, passed into law 1972, further defined for optometrists in 1978
• Act & its consequences periodically reviewed by drug advisory panel w/optom reps
• Original sections of act relevant to optoms are part III sections 51, 52, 57 & 58.
• Recent revisions of the law (notably SI's 764, 765, 766) mean that a large number of prods for ophthalmic use are now unlicensed and available for unrestricted sale ie not really pharmaceuticals anymore, but CE marked. SO optoms can advise on their use and supply them to the public providing it's in the course of their professional practice ie not food supplements or something we know nowt about. This includes CL related stuff as well as stuff designed for temporary relief for uncomf/irritated eyes + include herbal remedies & natural crap.
• A registered pharmacist can supply an optom w/certain pharms on receipt of an official signed order ie request on optom's letterhead. These are the specified PoMs (Mydriatics, Cyclopentolate, Chloramphenicol, Fusidic Acid) or P Medicines for diagnostic or therapeutic use. Optom must specify the exact quantities & keep accurate records
• Optom is allowed to use these drugs on their patients as part of eye evaluation or to administer them in an 'emergency'. In a similar 'emergency' the optom can supply certain PoMs to their patients if it has a 'use and supply' designation as opposed to 'use only'.
• In 2005 changes involving SIs 764, 765, 766 meant that the 'emergency' bit is only extended to the exempted PoMs. Px can administer any of this stuff themselves and optom can arrange for a personal supply w/a written order similar to a prescription. This includes 'entry level' optoms btw.
• Law changes in 2005 and 2007 meant that access to chloramphenicol was extended to the public at large with its reclassification as a P medicine. So optometrists could actually sell and supply that without it needing to be an emergency.
• One interpretation of 2007 change - optom should be on premises when P meds sold? Only actually _implies_ that. Optom maybe has to know Px as Px. Probably best!
• Sale and supply of prods that aren't the PoMs could be considered as a retail sale and no more but it would be best to keep a record.

The OPTICIANS ACT as relating to optometry and as revised in 2005 also provides indirect guidelines on the use of drugs by optoms

• 'ophthalmic optician' is now 'optometrist' and optom is as of SI.3299 (1999) allowed to diagnose eye diseases rather than simply arranging for referral and to use various drugs to treat the conditions. This implies making note of condition in px's records and noting reasons why not referred.

Three Main Classifications of Drogs:

1. GSL: Avail for public at large, unsupervised use, considered generally safe. Any retailer may sell as long as they have a secure premises (eg locked optom's office). Recently some prods aren't even GSL anymore so are 'non medicinal'. This includes eye vitamin products.

2. P MEDICINES: Generally sold/supp by registered pharmacist under supervision. Some avail from Hosp P for use by professionals. Also known as OTC. Considered generally safe for the public w/out supervision BUT the ingredients/concs/uses indicate that a control step is necessary - practitioner can make assessment of px's suitability - will be expected to ask a few questions relating to the C/I, specific precautions, possible drug interactions and warnings on potential adverse drug reactions. Pharm/optom assumes responsibility for giving appropriate instructions, then it's up to the px. Sold from behind counter w/px's verbal request. Some P classifed prods aren't available to the public but available to optoms for professional use upon production of a signed order. Can be supplied in bulk.

3. PoMs: The restricted access is more to ensure the safety of the general public since PoM listings designate those pharmaceuticals that contain drugs (or higher concs of drugs) which require some supervision. PoMs can be changed to P Meds whenever it can be established that use by the public@large doesn't produce any ADRs. It can go the other way also. Optom can obtain exempted PoMs by way of written order requesting supply & quantity, eg

• 10x 4g tubes of Chloramphenicol Eye Ointment 1%

Some of these are of the type that could be used in an emergency in which case optom can supply px directly or provide pharm w/a written order for a specific patient.