NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include dry eyes and sore tired eyes.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Ointments should not be used during contact lens wear.

These drugs are used here, but are listed elsewhere in the formulary:

Ciclosporin, see 11.4.2 Other anti-inflammatory preparations

• NICE TA369: Ciclosporin (Ikervis) 1mg/ml 0.3ml single use eye drops are recommended as an option for treating severe keratitis in adults with dry eye disease that has not improved despite treatment with tear substitutes (December 2015)

Mild dry eye

Patients requiring lubricant eye drops up to four times a day in both eyes

Polyvinyl Alcohol

• Eye drops 1.4% (click here for preferred brand)

Indications

• Tear deficiency

Dose

• Apply as required, up to four times a day

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Hypromellose

• Eye drops 0.3% (£0.64 = 10ml)

Indications

• Tear deficiency

Dose

• Instil frequently for adequate relief

Notes

1. Please ensure that the % of hypromellose is stated on all prescriptions, only the 0.3% is included in the formulary.

Moderate dry eye

Patient requiring lubricant eye drops four times a day in both eyes

Preservative-free preparations of lubricants should be prescribed if used regularly more than four times a day.

Patients using preservative-free eye drops in multiple-use containers could be at risk of serious eye infection due to microbial contamination of the product. Doctors should exercise caution when prescribing multiple-use eye drops without preservative in patients at high risk of infection.

Carbomers

• Carbomer '980' 0.2% ophthalmic liquid gel (click here for preferred brand)

Indications

• Dry eyes including keratoconjunctivitis sicca, unstable tear film

Dose

• Apply 3-4 times daily or as required

Notes

1. The ability of carbomers to cling to the eye surface may help to reduce frequency of application to four times daily.
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Severe dry eye

Patient requiring lubricant eye drops 2 hourly during waking hours to both eyes

Sodium hyaluronate

• Eye drops 0.2% (preservative free) (click here for preferred brand)
• Single unit dose eye drops 0.4% (preservative free) (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. Sodium hyaluronate is more expensive than other ocular lubricants but maybe more cost effective for patients who do not use an entire bottle every month as the drops remain sterile in the bottle for longer than 28 days after opening. Please refer to the individual product information and remind patients not to dispose of the bottle after 28 days.
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Thealoz Duo

(Sodium hyaluronate 0.15% and trehalose 3%)

• Eye drops preservative free (£8.99 = 10ml)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. For patients who cannot tolerate sodium hyaluronate 0.2%, or who have been diagnosed with severe dry eye and sodium hyaluronate 0.2% is not sufficient.
2. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients).

Polyvinyl Alcohol

• Single use eye drops 1.4% - preservative free (click here for preferred brand)

Indications

• Tear deficiency

Dose

• Apply as required

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Hypromellose

• Eye drops 0.3% - preservative free (click here for preferred brand)

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Carbomer

• Carbomer '980' 0.2% ophthalmic liquid gel single dose units - preservative free (click here for preferred brand)

Indications

• Dry eyes including keratoconjunctivitis sicca, unstable tear film

Dose

• Apply 3-4 times daily or as required

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Carmellose

• Single use eye drops 0.5% - preservative free (click here for preferred brand)
• Eye drops 0.5% - preservative free (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Patients with severe dry eye requiring lubricant at night to both eyes

Liquid Paraffin

• Eye ointment (click here for preferred brands)

Indications

• Dry eye conditions
• Recurrent corneal epithelial erosion

Dose

• May cause temporary visual disturbance and is best suited for application before sleep, may be used in combination with artificial tear drops.

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Other preparations

Macrogols (polyethylene glycols)

• Systane eye drops (£4.80 = 10ml)
• Systane single use eye drops preservative free (£4.80 = 28 x 0.8ml unit dose)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. Hydroxypropyl guar maybe more cost effective for patients who do not use an entire bottle every month as the drops remain sterile in the bottle for 6 months after opening. Remind patients not to dispose of the bottle after 28 days.

Sodium chloride

• Single use eye drops preservative free 0.9% (£7.43 = 20 x 0.5ml unit dose)
• Eye drops 5% (unlicensed preparation)
• Eye ointment 5% (unlicensed preparation)

Light liquid paraffin

• Eye drops 10ml (unlicensed)

Balanced Salt Solution (BSS)

• Eye irrigation solutions 19ml, 500ml

BSS plus

• Eye irrigation solutions 500ml

Mucolytic eye preparations

Acetylcysteine eye drops are mucolytic and reduce the viscosity and tenacity of mucus in the eye, it is only recommended for use in dry eye syndromes with abnormal mucus production.

Ilube

(Acetylcysteine)

• Eye drops 5% (£80.95 = 10ml bottle)

Indications and dose

• Treatment of dry eye syndromes associated with deficient tear secretion, impaired or abnormal mucus production
  • 1 or 2 drops instilled into the affected eye(s) 3 or 4 times daily

Notes

1. Prescribe by brand to avoid confusion.
2. Treatment must be initiated by a secondary care eye specialist, including first prescription.
3. Response to treatment with Ilube should be reassessed at least every 6 months by specialist, and where appropriate repeat prescribing may be performed by primary care on specialist advice.
4. Ilube contains benzalkonium chloride which may cause eye irritation.

Acetylcysteine

• Eye drops 5% preservative-free (unlicensed preparation)