Guideline number &title

371FM.1 GUIDELINES ON OCULAR LUBRICANT CHOICE IN THE TREATMENT OF
DYSFUNCTIONAL TEAR SYNDROME (TEAR DEFICIENCY)

Overview

Dry eye syndrome is the term used for a group of conditions that vary in severity and
prognosis. Treatment varies in intensity and is largely symptomatic.
Generally:
1. Meibomian gland dysfunction/tear lipid abnormalities: • May occur in, e.g., rosacea or seborrheic blepharitis • Best managed with carbomer or hyaluronate preparations • Is a very common cause of dry eye syndrome • May occur in, e.g., Sjogren’s syndrome or rheumatic disease • Managed with thinner tears (e.g. hypromellose 0.5%) + nocturnal ointment + punctal • Is not as common a problem as 1 above • Often requires a combination of very frequent drops/ointment and punctual occlusion. Ocular lubricants may only form part of the treatment regimen, e.g. anterior blepharitis usually
requires lid hygiene + a short course of topical antibiotics, whereas posterior blepharitis needs
lid massage + warm compresses and, in more severe cases, a short course of mild topical
steroid and possibly an oral tetracycline. Specialist input would usually be expected before
this stage.
Preservatives

Concerns have been raised regarding some of the preservatives contained in ocular
lubricants and their potential for ocular toxicity, which appears to be exacerbated by reduced
tear production. Preservative-free (PF) lubricant drops may be considered in moderate to
severe dry eye conditions, indicated by:
• Frequency of treatment with drops exceeds 6 times daily, on a long-term basis. • Frequency of treatment with a gel exceeds 4 times daily, on a long-term basis (gel formula lubricants linger longer on the eye and, although they provide more prolonged relief, the preservatives remain in contact with the eye for longer). • Proven allergy to all preserved drops in Formulary. • Immediately following eye surgery, until healing is confirmed, if a lubricant is indicated
The Committee for Medicinal Products for Human use (CHMP) concluded that preservative-
free drops are a valuable alternative for some patients, but they do not recommend their use
.
Formulary choices

The Formulary choices represent the most cost-effective treatments, particularly in primary
care, and should be tried before prescribing other types/brands of ocular lubricants.
Individual patients may find products, other than the Formulary choices, more effective. Their need for a non-Formulary product may be taken into consideration via the non-Formulary request route, if it is appropriate. Uncontrolled if printed
If an ophthalmologist recommends primary care prescribing outside of the Formulary choices,
the reason must be noted on the discharge summary. The product requested must be
included in the BHT Formulary.
Prescribing Choices
PRESERVED OCULAR LUBRICANTS
1st choice, depending on the type of dry eye (see 1 - 3 above) is either:
Hypromellose 0.5%* 10 ml bottle (contains benzalkonium chloride (BAK) preservative)
Carbomer 980 0.2% - brand supplied should be the most cost effective available.
At present, in primary care, this is Clinitas Gel® 10 g (carbomer 980 0.2% with cetrimide
preservatives)

2nd choice
Hydroxypropyl
guar 10 ml bottle (Systane® 10 ml contains Polyquad® preservative)
• If incomplete relief is achieved using drops/gel, liquid paraffin eye ointment (as Lacri-Lube 3.5 g) may be prescribed for night time use, in addition to drops/gel. • If the patient has a proven allergy to the preservatives BAK and cetrimide, hydroxypropyl guar (Systane® 10 ml (NOT the preservative-free single dose unit (SDU))) should be tried
next. Systane® contains Polyquad®, a less irritant preservative.
• If the patient also cannot tolerate Systane® preserved drops, a preservative-free lubricant
NOTE: Systane® 10 ml bottle is licensed for 6 months use once opened, instead of the
normal 28 days. There is a risk of contamination during this period of use, but if being used 4
or more times a day, in each eye, a bottle would last a month. On this basis, hypromellose
0.5% remains the least costly option for the majority of patients. Seer proposed place of Systane® in treatment.
PRESERVATIVE-FREE OCULAR LUBRICANTS

1st choice
Sodium hyaluronate single dose units 0.4% 0.5 ml pack of 30 (Clinitas® SDU). Each
SDU contains 0.5 ml (8 - 10 drops) and may be resealed and reused for up to 12 hours.
Suitable for uncomplicated patients with simple dry eye only.
Please make sure that the patient understands this aspect of use.
Note: This product differs from Clinitas Gel® above.

2nd choice
Carmellose 1% single dose units 0.4 ml pack of 30 (e.g. Celluvisc® SDU).
This is the least expensive SDU preservative-free product and is the Formulary choice for
those patients in whom sodium hyaluronate (above) is unsuitable/not appropriate. Use
once only in both eyes if required and then discard. Not resealable.

3rd choice
Hydroxypropyl guar (Systane® SDU) 0.8 ml pack of 28. Single use.
Use only if patient fits all criteria and carmellose 1% unsuitable. Use once only in both
eyes if required and then discard. Not resealable.
Patients needing ocular lubricants following eye surgery should receive single-use drops;
carmellose 1% or hydroxypropyl guar, supplied by secondary care. Post-operative review
should include an assessment of continued need and transfer to alternative product (e.g.
preserved drops or preservative-free sodium hyaluronate (Clinitas® SDU) for repeated use as
above), before care is transferred to GP.
Uncontrolled if printed
Guidelines on Ocular Lubricant Choice in the Treatment of Dysfunctional Tear Syndrome (Tear Deficiency) Sally Spence, Formulary Support Pharmacist, BHNHST Lynn Wallis, Prescribing Support Pharmacist, Bucks PCT Buckinghamshire Healthcare NHS Trust/Aylesbury Vale and Chiltern Clinical Commissioning Groups Uncontrolled if printed

Appendix: Treatment Pathways
Pathway 1 - Initial Treatment of Patient with Dry Eye Syndrome in Primary Care

Patient complains of dry eye
symptoms
NOTE: If paying for script, hypromellose and Clinitas are cheaper to buy OTC. Purchase price of Systane may vary. Trial of hydroxypropyl guar (Systane) drops4 Uncontrolled if printed
Pathway 2 - Treatment of Patient with Dry Eye Syndrome in Primary Care

Pathway 1 has been followed but the patient has experienced symptoms of allergy to all drops prescribed*. A preservative-free product may be considered. The formulary choice for uncomplicated dry eye is sodium hyaluronate unit dose eye drops (Clinitas SDU). If this product is unsuitable, the 2nd choice unit dose formulary product is carmellose 1%. If this product is also unsuitable, the 3rd choice unit dose formulary product is hydroxypropyl guar (Systane SDU). If the problem is still not resolved, request advice
Pathway 3 - Treatment of Patient with Dry Eye Syndrome in Primary Care following consultation with Ophthalmologist

Request to prescribe eye lubricant received from ophthalmologist. Is the product requested included in the Uncontrolled if printed

Source: http://www.bucksformulary.nhs.uk/docs/Ocular%20Lubricants%20BHTCG%20371.pdf