Eyes

Question 1

Preservative-free formulations for eye treatments are usually more expensive than formulations that contain preservatives. Who should PF formulations be reserved for?

Answer 1

Patients with preservative hypersensitivity or signs of preservative toxicity, or when a patient wears soft contact lenses and wearing glasses is not an option.

Question 2

Anti-bacterials for eyes, e.g. chloramphenicol

• Bacterial eye infections are usually self-limiting and resolve without treatment within 1-2 weeks.

Self care advice:
- Remove contact lenses until all symptoms have resolved
-Lubricant eye drops can help reduce discomfort
-Clean infected secretions away from the eyelids using a cotton wool ball
-Wash hands regularly

Answer 2

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Question 3

Antiviral eye preparations

-Urgently refer all patients with suspected herpes simplex to the hospital eye department

Ganciclovir 0.15% eye gel

Answer 3

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Question 4

Corticosteroids

Topical steroids should normally only be used on recommendation by an ophthalmologist for a defined length of time and should not normally be on repeat prescription. Steroid eye drops should not be prescribed for undiagnosed red eye.
1. Hydrocortisone sodium phosphate 3.35mg/ml PF eye drops (Softacort) is Grey consultant/ specialist initiation For non-infectious allergic or inflammatory conjunctival disease, where a preservative-free eye drop is required beyond initial acute treatment. Specialist to communicate instructions for tapering and treatment length. Treatment over 14 days is off-licence.

Answer 4

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Question 5

Allergic Conjunctivitis and Other Anti-Inflammatory Preparations

For treatments of self-limiting conditions such as allergic conjunctivitis patients are encouraged to selfcare. Sodium cromoglycate and Otrivine-Antistin can be purchased over the counter.

• Sodium cromoglycate (Murine hayfever relief) is used prophaylactically before the onset of predictable seasonal allergies such as hayfever and vernal kerato-conjunctivitis and can be purchased over the counter.
• Otrivine-Antistin is used to relieve acute ocular symptoms of allergy and can be purchased over the counter. Where the condition is systemic (e.g. in hayfever), oral antihistamines are often preferred.
• Ciclosporin 0.1% eye drops (Ikervis) GREY after consultant/specialist initiation.

Answer 5

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Question 6

Mydriatics and Cycloplegics

-Cyclopentolate hydrochloride eye drops 0.5%, 1%
-Tropicamide eye drops 0.5%, 1%

1. Cyclopentolate reaches its maximal effect in 30-60 minutes. This lasts for about 40 minutes; complete recovery may take up to 24 hours.
2. Tropicamide produces rapid-onset mydriasis of short duration, reaching its maximal effect at 40-60 minutes. Recovery may take up to 6 hours.

Answer 6

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Question 7

What are the first line treatments of glaucoma?

Answer 7

Latanoprost 50mcg/ml, first line prostaglandin analogue
Betaxolol eye drops, first line beta blocker

Question 8

What are the second-line treatments for glaucoma, if intraocular pressure target is not achieved by first-line?

Answer 8

Dorzolamide eye drops (carbonic anhydrase inhibitor)

Brimonidine eye drops (alpha2 agonist)

Question 9

Combination Eye Preparations

Answer 9

Latanoprost/timolol
Dorzolamide/timolol
Brinzolamine/brimonidine
Brimonidine/timolol

• Combination preparations should only be considered if IOP not controlled on monotherapy.
• If the patient is intolerant to preservatives the 1st line option is PF latanoprost.
• Most glaucoma eye drops are now prescribed generically, with exception of some combination
  preparations. Where generic prescribing of eye drops is recommended due to cost-effectiveness, both primary and secondary care clinicians should follow this advice.

Question 10

Tear Deficiency, Ocular Lubricants and Astringents

-For treatments of minor conditions such as dry eyes/ sore tired eyes, patients are encouraged to self-care by measures such as good eyelid hygiene and avoidance of environmental factors. Lubricant eye treatments that consist of a range of drops, gels and ointments can be easily purchased over-the-counter.

Hypromellose (AaproMel) alternative cost-effective brands include Lumecare Tear Drops & Teardrew.
Polyvinyl alcohol (Sno-Tears)
Carbomer 0.2% (Clinitas Carbomer Gel)

Question 11

What is age-related macular degeneration?

Answer 11

A progressive eye condition that effects the retina and causes a progressive loss of vision (mainly in over 55s)

Question 12

What are the two types of macular degeneration?

Answer 12

Dry
Wet

Question 13

Dry Macular Degeneration
-Progresses slowly

Wet Macular Degeneration
-New blood vessels develop beneath and within the retina, leads to a rapid deterioration of vision
-Split into ‘wet-active (neovascular lesions that may benefit from treatment) and wet-inactive (neovascular disease with irreversible structural changes)

The aim of treatment for both is to slow progression

Answer 13

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Question 14

Treatment

Drug treatment only recommended for patients with wet-active age-related macular degeneration
-First-line treatment is an intravitreal anti-vascular endothelial growth factor (anti-VEGF)
-Should be stopped if patient develops severe and progressive visual loss despite treatment

Question 15

What is the most frequently used treatment for dry eye?

Answer 15

Hypromellose eye drops

Question 16

Dry Eye Drug Treatment

-Hypromellose tends to be first-choice
-Carbomers and polyvinyl alcohol are suitable alternatives.
-Ocular lubricants containing sodium hyaluronate or carmellose sodium can be used in moderate or severe dry eye.

Question 17

What are the two main parts of the eye?

Answer 17

-Anterior segment
-Posterior segment

Question 18

To which part of the eye are most drugs commonly administered?

Answer 18

To the anterior segment

Question 19

Corticosteroids and the Eye

Answer 19

-Local administration for treating anterior segment inflammation
-Frequent application for the first 24-48 hours, thenr educe as inflammation is controlled.

Three main dangers associated with their use:
-‘Red eye’ if the steroids are used when the diagnosis is uncomfirmed. If herpes simplex virus is present then it can be aggravated.
-‘Steroid glaucoma’
-‘Steroid cataract’ can follow prolonged us

Question 20

Eye Anti-Inflammatory Preparations

Eye drops containing antihistamines:
- Antazoline with xylometazoline
-Lodoxamide
-Sodium cromoglicate

Answer 20

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Question 21

What is glaucoma?

Answer 21

A group of eye disorders characterised by a loss of visual field associated with pathological cupping of the optic disc and optic nerve damage.

Question 22

What are some risk factors for developing glaucoma?

Answer 22

Raised intraocular pressure
Age
Family history
Ethnicity
Corticosteroid use
Myopia
T2 diabetes
CVD
Hypertension

Question 23

Chronic Open-Angle Glaucoma

-Most common
-Where the drainage of the aqueous humour through the trabecular meshwork is restricted, and the angle between the iris and the cornea is normal.
-Asymptomatic at first, progresses to vision loss

Acute Angle-Closure Glaucoma

-Less common
_Occurs when outflow of aqueous humour from the eye is totally blocked by bowing of the iris against the trabecular meshwork.

Answer 23

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Question 24

Ocular Hypertension/Chronic open-angle glaucoma Treatment

-Offer 360 degree selective laser trabeculoplasty (SLT) to patients at risk of visual impairment within their lifetime.
-Patients who choose not to have SLT should be offered latanoprost, tafluprost, travoprost or bimatoprost eye drops.

Question 25

What drug types can be used to treat glaucoma?

Answer 25

Beta blockers
Carbonic anhydrase inhibitors
Sympathomimetics
Prostaglandin analogues
Miotics

Question 26

What sympathomimetics can be used to treat glaucoma, and what side-effects can they cause?

Answer 26

Brimonidine
Dipivefrine

Blurring, foreign body sensatin, dryness, headache, fatigue, hypotension, eyelid edema

Question 27

Which beta blockers can be used to treat glaucoma, and what are the potential side-effects?

Answer 27

Timolol: bronchospasms, bradycardia, depression, impotence
Betaxolol: fewer pulmonary side-effects due to selective blockage.

Question 28

Which prostaglandin analogues can be used to treat glaucoma, and what are the potential side-effects?

Answer 28

Latanoprost: pigmentation of eyelashes and eyelids
Bimatoprost: blurred vision, eyelid redness, darkened iris, darkened eyelashes
Travoprost: same as bimatoprost

Question 29

Which carbonic anhydrase inhibitors can be used to treat glaucoma, and what are the side-effects?

Answer 29

Dorzolamide: eye irritation, bitter taste
Brinzolamide: same as dorzolamide
Acetazolamide: alaise, depression, weight loss, kidney stones

Question 30

Pilocarpine is a miotic used to treat glaucoma. What are some potential side-effects?

Answer 30

Posterior synechia
Keratitis
Miosis
Brow ache
Increased salivation