Eyes

Question 1

Framycetin (Soframycin 0.5%, 8 mL)

Answer 1

1. Aminoglycoside (eye)
2. Bacterial eye infections
   not active against Pseudomonas
3. Bacterial conjunctivitis
   Adult/child = 1 drop Q2-4h for 2 days; then if improvement, 1 drop QID for 5 days.

Other infections
Adult/child= initially 1 eye drop Q2h; then if improvement, 1 drop TDS.

4. Pregnancy/Breastf= safe to use.
   Allergic reaction to an ocular aminoglycoside—cross-allergenicity may occur; increased risk of allergic reaction.
   Clinical effect
5. If irritation occurs stop using and see a doctor.
   Ocular irritation and superficial punctate keratitis are common; other adverse effects include delayed corneal epithelial wound healing, retinal toxicity (if there is leakage through corneoscleral wound) and, rarely, hypersensitivity reactions.
   More likely to cause contact allergy than gentamicin or tobramycin.

Question 2

Gentamicin (Genoptic 0.3%, 5 mL)

Answer 2

1. Aminoglycoside (eye)
2. Bacterial eye infections
   Accepted: Prophylaxis after surgery (if chloramphenicol unsuitable)
   Gentamicin has anti-pseudomonal activity.
3. Bacterial conjunctivitis
   Adult/child = 1 drop Q2-4h for 2 days; then if improvement, 1 drop QID for 5 days.

Prevention of infection after surgery
Adult/child, 1 drop QID until epithelium healed (rarely >4 days).

4. Pregnancy/Breastf= safe to use.
   - gentamicin should be reserved for use by ophthalmologists and for serious infections not responding to treatment with other topical antibacterials (after taking sample for microbiological culture)
5. Generally well tolerated.
   If irritation occurs stop using and see a doctor.
   Ocular irritation and superficial punctate keratitis are common; other adverse effects include delayed corneal epithelial wound healing, retinal toxicity (if there is leakage through corneoscleral wound) and, rarely, hypersensitivity reactions.

Question 3

Tobramycin (Tobrex 0.3%, 5mL, OR Tobrex oint 0.3%, 3.5g)

Answer 3

1. Aminoglycoside (eye)
2. Bacterial eye infections
   Accepted: Prophylaxis after surgery (if chloramphenicol unsuitable)
   Gentamicin has anti-pseudomonal activity.
3. Bacterial conjunctivitis
   Adult/child = 1 drop Q2-4h for 2 days; then if improvement, 1 drop QID for 5 days.
   Eye ointment may be used as an adjunct to drops at night, or as a single agent 3 times daily, eg in children.

Prevention of infection after surgery
Adult/child, 1 drop QID until epithelium healed (rarely >4 days).

4. Pregnancy/Breastf= safe to use.
   - tobramycin should be reserved for use by ophthalmologists and for serious infections not responding to treatment with other topical antibacterials (after taking sample for microbiological culture)
5. Generally well tolerated.
   If irritation occurs stop using and see a doctor.
   Ocular irritation and superficial punctate keratitis are common; other adverse effects include delayed corneal epithelial wound healing, retinal toxicity (if there is leakage through corneoscleral wound) and, rarely, hypersensitivity reactions.

Question 4

Quinolones (eye)
Ciprofloxacin (Ciloquin, Ciloxan 0.3%, 5 mL)
Ofloxacin (Ocuflox 0.3%, 5 mL)

Answer 4

1. Ciprofloxacin, Ofloxacin
2. Keratitis and severe conjunctivitis
3. Adult/child
   Severe bacterial conjunctivitis
   CIPRO= 1 drop Q2h while awake for 2 days; then if improvement, 1 drop Q4H while awake for 5 days.
   OFLOX= 1 drop Q4H for 2 days; then if improvement, 1 drop QID for up to 8 days.
   Keratitis
   CIPRO= First day, 1 drop every 15mins for the first 6 hours, then once every 30mins.
   Second day, 1 drop every HOUR.
   From third day until healed, 1 drop Q4H.

OFLOX=Days 1–2: 1 drop every 30mins while awake, then at 4 and 6 hours after going to bed.
Days 3–7: 1 drop every hour while awake.
From day 8 until healed: 1 drop QID.

4. Hx tendon damage OR hypersensitivity w/quinolone use= reaction may recur; avoid use if possible.
   Pregnancy= Unlikely to be a concern due to low systemic maternal dose.
   Breastfeeding= May be used.
5. If irritation occurs stop using and see a doctor.
   CIPRO - unpleasant taste
   - mild transient ocular irritation
   Infrequent or rare
   - keratitis (photophobia, corneal infiltrates and staining), allergic reactions (very rare reports of severe hypersensitivity including angioedema, anaphylaxis, Stevens-Johnson syndrome)

Question 5

Chloramphenicol
eye drop= Chlorsig 0.5%, 10 mL
single use= Minims Chloramphenicol 0.5%, 0.5 mL
eye oint= Chlorsig 1%, 4 g

Answer 5

1. broad-spectrum bacteriostatic activity against Gram-positive, Gram-negative (except Pseudomonas spp.) and anaerobic bacteria; good ocular penetration
2. Bacterial eye infections
   Accepted=
   Prevention of infection after corneal abrasion OR ocular surgery.
3. Bacterial conjunctivitis
   Adult/child= 1 drop Q2H while awake for 1–2 days then, if improvement, 1 drop QID for up to 5 days.

Eye ointment may be used at night if drops are used during the day, or as a single agent 3-4 times daily.

Bacterial blepharitis
Massage eye ointment into lid margin once or twice daily for 1 week (in some cases, up to 3 weeks’ treatment may be needed).

Prevention of infection after corneal abrasion
Adult, child, 1 eye drop (or eye ointment) 4 times daily until healed (usual duration 3–5 days).

4. Pregnancy/Breastf= safe to use.
Clinical effectiveness
Irritation
Allergy
Recurrent infection

5. If irritation occurs stop using and see a doctor.
EXPIRY= 28 DAYS
HOW TO USE
WASH HAND BEFORE AND AFTER
DON'T SHARE DROPS/OINT OR TOWELS

Common (>1%)
stinging or burning after instillation
Infrequent (0.1–1%)
unpleasant taste
Rare (<0.1%)
hypersensitivity reactions, eg angioedema, anaphylaxis, dermatitis

Question 6

Aciclovir (Zovirax® eye ointment OR AciVision)

Answer 6

1. Antiviral
2. Herpes simplex epithelial keratitis
3. Adult/child= apply about 1 cm of 3% eye ointment into the lower conjunctival sac 5 times daily for 14 days, or for 3 days after corneal epithelium healed, whichever is shorter.
4. Pregnancy/Breastf= safe to use.
5. If irritation occurs stop using and see a doctor.
   Common (>1%)
   transient mild stinging after instillation
   Infrequent (0.1–1%)
   superficial punctate keratitis, allergic reactions

Question 7

Latanoprost eye drop, 0.005%, 2.5 mL, Lanpro, Xalaprost, Xalatan, PBS

Bimatoprost eye drop, 0.03%, 3 mL, Bimtop, Lumigana, PBS
eye drop, 0.03%, 0.4 mL (single use), 30, Lumigan PF, PBS

Travoprost eye drop, 0.004%, 2.5 mL, Travatan, PBS

Tafluprost eye drop, 0.0015%, 0.3 mL (single use), 30, Saflutan, PBS PRESERVATIVE FREE!

https://www.youtube.com/watch?v=SkH73XQPxKM&feature=youtu.be&fbclid=IwAR0WS4EPPXFBmThidM_K5QbAg5IlZrc6XNojHboV7riEa4rT84ewTlRVouU

Answer 7

1. Prostaglandin analogues
2. Glaucoma, Ocular hypertension - FIRST LINE
3. Evening dosing is preferred for optimal effect.
   Adult, 1 eye drop once daily, preferably at night.
4. • Intraocular pressure
     - eye changes (colour, vision, etc.)

inflammation (iritis, uveitis)= use w/caution as may worsen inflammation.

• Herpetic keratitis= avoid use if active, use with caution if hx of infection as reactivation may occur.
• Pseudophakia with torn posterior lens capsule, aphakia, risk factors for macular oedema—use with caution as prostaglandin analogues may further increase the risk of macular oedema.
• Pregnancy= Limited human data. Avoid use if possible (due to theoretical risk of uterine contractions) or seek specialist advice.
• Breastfeeding= Safe to use.
• if response to one is poor, consider trying another

5. If irritation occurs stop using and see a doctor.
   These eye drops may slowly and permanently change the colour of your eye making the iris appear darker.

Iris hyperpigmentation
Gradual (over months to years), usually irreversible, increase in iris pigmentation in treated eyes, especially those of mixed colour, eg blue/brown.

Eyelash changes
Gradual darkening, lengthening and thickening of the eyelashes; reversible when treatment stopped.

Periorbital changes
May include darkening of eyelid skin, deepening of upper eyelid sulcus, loss of periorbital fat and upper lid ptosis. Some of the effects appear to be reversible after stopping treatment.

• blurred vision, eye irritation

Refrigerate--> opened bottle below 25°C. 
EXPIRY= 28 DAYS
HOW TO USE
WASH HAND BEFORE AND AFTER
DON'T SHARE DROPS/OINT OR TOWELS

Question 8

General Eye Counselling

Answer 8

Counselling
If irritation occurs stop using and see a doctor.
Refrigerate–> opened bottle below 25°C.
EXPIRY= 28 DAYS
HOW TO USE
WASH HAND BEFORE AND AFTER
DON’T SHARE DROPS/OINT OR TOWELS

It is important to write the date on the bottle or tube when you first open it and to discard it 28 days later (unless told otherwise).

Before using eye medications, wash your hands then sit or lie down. Tilt your head back, look up and gently pull down your lower eyelid to form a pouch. Avoid letting the tip of the dropper or tube touch your eyes, skin or any other surface.

Use a clean tissue to mop up any excess.

Some people find it easier to use eye medications properly if they have someone help them or if they use a mirror.

Drops
Shake suspensions (cloudy liquids) gently before use.

Put 1 drop into the pouch (see above). If you think that the first drop missed your eye, put in another.

Try not to blink after putting in a drop. Close your eyes and gently press against the inner corner of your eye with your finger (over the tear duct) for 1–2 minutes. This increases the effectiveness of the eye drop and helps reduce the amount of medicine that gets into the rest of your body where it may cause side effects.

The eye pouch will be full after a single drop. If you need to use another eye drop at the same time of day, wait at least 3 minutes before using it.

If you find it difficult to tell whether a drop has gone into your eye and you don’t have someone to help, try storing your eye drops in a refrigerator, so you can feel when the cold drop goes in your eye.

Ointments
Squeeze a small amount (about 1 cm length) along the pouch (see above) then blink several times to spread the ointment. If you need to use drops at a similar time of day, use the ointment last.

Question 9

Timolol (Timoptol)

Alpha Agonist
Combigan (timolol 0.5%, brimonidine 0.2%, 5 mL)

Carbonic anhydrase inhibitors
Azarga (timolol 0.5%, brinzolamide 1% (suspension))
Cosopt (timolol 0.5%, dorzolamide 2%, 5 mL)

Prostaglandin analogues
Xalacom (timolol 0.5%, latanoprost 0.005%, 2.5 mL)
DuoTrav (timolol 0.5%, travoprost 0.004%)
Ganfort (timolol 0.5%, bimatoprost 0.03%, 3 mL)

Answer 9

1. beta blocker
2. Glaucoma, Ocular hypertension

3.Adult
Conventional drops, 1 eye drop OD or BD.
Gel-forming drops (Timoptol-XE®), 1 drop OD.

Fixed-dose combo w/bimatoprost, latanoprost or travoprost
1 drop OD.

Fixed-dose combo w/brimonidine, brinzolamide or dorzolamide
1 drop BD.

Betaxolol= 1 drop BD

4. Tx w/systemic betablocker= ↓ intraocular pressure (but less than with a topical beta-blocker). Adding a topical beta-blocker further ↓ intraocular pressure (but this may be less effective than using an alternative class of topical agent). Risk of systemic adverse effects is increased.

Tx w/bradycardic drugs= may further ↓ HR= monitor cardiac fn. Avoid combo w/verapamil (unless under specialist).

Cardiovascular
As topical beta-blockers are absorbed systemically, consider potential for cardiovascular effects.
C/I in bradyarrhythmia, 2nd‑/3rd-degree atrioventricular block or uncontrolled HF.

Respiratory
As topical beta-blockers may precipitate bronchospasm, they are generally C/I in asthma. However, betaxolol (which is beta1 selective) may be used with caution if required.

They may be used with caution in COPD; betaxolol may be preferred.

Surgery= Theoretical increased risk of bradycardia and hypotension during surgery.

Elderly
Systemic S/Es more common (hypotension= may cause falls).

Pregnancy= May be used. Monitor fetus for possible adverse effects, eg bradycardia.

Breastfeeding= Considered safe to use. Although adverse effects are unlikely, consider monitoring the infant.

5. If irritation occurs stop using and see a doctor.
   The most important adverse effects are systemic.
   Common (>1%)
   stinging on instillation (especially betaxolol solution), bradycardia, blurred vision
   Infrequent (0.1–1%)
   decreased corneal sensation, hypotension, fainting, fatigue, confusion, hallucinations, bronchospasm

Question 10

Brinzolamide
Azopt eye drop, 1% (suspension), 5 mL
Simbrinza eye drop, brinzolamide 1%, brimonidine 0.2% (suspension), 5 mL

Dorzolamide
Trusamide, Trusopta eye drop, 2%, 5 mL

Answer 10

1. Carbonic anhydrase inhibitors
2. Glaucoma, Ocular hypertension
3. Brinzolamide= 1 drop BD.

Dorzolamide= 1 drop TDS.
Adjunct to beta-blocker= 1 drop BD.

4. Compromised corneal endothelium—may increase risk of corneal oedema.
   Allergy to sulfonamides—may increase risk of allergy to carbonic anhydrase inhibitors.

Pregnancy= Avoid.
Breastfeeding= Limited data but considered safe to use.

5. If irritation occurs stop using and see a doctor.

Common (>1%)
ocular irritation (more common with dorzolamide), transient blurred vision (more common with brinzolamide), foreign body sensation, bitter taste
Infrequent (0.1–1%)
GI disturbance, headache, paraesthesia, dizziness, dermatitis
Rare (<0.1%)
allergic reactions, eg urticaria, angioedema
Brinzolamide=conjunctivitis, blepharitis, keratitis

Counselling
Your eye may feel uncomfortable for a little while after you have put in the drop. If you have blurred vision, avoid driving or operating machinery until your sight improves.

Question 11

Brimonidine

eye drop, 0.15%, 5 mL, Alphagan P 1.5, PBS
eye drop, 0.2%, 5 mL, Alphagan, Enidin, PBS

Answer 11

1. Alpha2 agonists
2. Glaucoma
   may be used by ophthalmologists in acute angle-closure crisis or to prevent ocular hypertension following laser surgery
3. 1 drop BD of either strength.
4. Severe cardiovascular disease—may worsen; use with caution.
   Children= C/I in children <2 years. Serious A/Es (eg CNS depression) are more likely esp if <6 years or <20 kg.

Pregnancy= safe to use. Avoid close to delivery (CNS depression and apnoea in neonate).
Breastfeeding= avoid, same as above

5. If irritation occurs stop using and see a doctor.

This eye drop may cause drowsiness or dizziness; avoid driving or operating machinery if you are affected.

fatigue, drowsiness, dizziness
Infrequent (0.1–1%)
bradycardia, hypotension

Rare (<0.1%)
uveitisCommon (>1%)
ocular allergy (below), hyperaemia, ocular irritation, dry mouth and nose, taste disturbance, conjunctival blanching, lid retraction, headache

Ocular allergy
Usually presents as a follicular conjunctivitis with symptoms such as hyperaemia, tearing and foreign body sensation. There may also be periocular dermatitis. In patients with a previous allergy to apraclonidine, the risk of allergy to brimonidine does not appear to be further increased.