Supporting Information

Supporting Information

Colour coding within the updated Community Eyecare Guidelines

All medications that are only available to IP optometrists/OMPs for direct prescription will be coloured blue within the guidelines. These medications may be issued through other means under certain circumstances (e.g. emergency supply, written order, PGD etc)

Dose and duration guidance/sources of evidence used to support the Community Eyecare Guidelines

Dosage and duration of treatment guidance is aligned with the College of Optometrists formulary and the British National Formulary wherever possible. Where information is lacking within the BNF or the BNF states ‘see product literature’ then the Summary Product Characteristics (SmPC) (taken from the Electronic Medicines Compendium) will be consulted for dose and duration information.
Where there is no consensus between these sources, guidance comes from Scottish formularies or from expert opinion. The source of the guidance is cited as;

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary of Product Characteristics (SmPC) taken from the Electronic Medicines Compendium Electronic medicines compendium (emc)
Advisory alignment with Scottish formularies (where a clear majority is present)*
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

For detailed information on the methodology used for CEG updates, please see the full methodology document which can be found here [link to Methodology page]

Generic advice from The College of Optometrists Clinical Management Guidelines ⁽¹⁾, Formulary ⁽²⁾and The BNF ⁽³⁾

Practitioners should work within their scope of practice and where necessary seek further advice or refer the patient elsewhere⁽¹⁾ Herpes simplex keratitis (HSK) - College of Optometrists
When undertaking invasive procedures (eg Alger Brush, lacrimal syringing), optometrists should ensure that appropriate medical malpractice (professional indemnity) insurance, clinical governance arrangements are in place and the College of Optometrists guidance on expanded scope of practice is followed ⁽¹⁾Corneal (or other superficial ocular) foreign body - College of Optometrists
The dose and duration of medical therapy will depend on the type and severity of the condition ⁽²⁾
Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems. They should be switched to unpreserved preparations ⁽¹⁾ (if available and according to local formulary restrictions ⁽⁷⁾) Ocular rosacea - College of Optometrists
Treatment with topical antibiotics may modestly improve short-term clinical remission and render patient less infectious to others; however the potential benefit of antibiotics needs to be balanced against the risk of adverse drug reactions and antibiotic resistance ⁽¹⁾ Conjunctivitis (bacterial) - College of Optometrists
The combined use of a topical antibiotic (e.g. chloramphenicol 0.5%) to reduce bacterial load, alongside a topical steroid (e.g. prednisolone sodium phosphate 0.5%) to control inflammation, is a widely adopted approach and theoretically sound. However, it is important to note that the immunosuppressive properties of corticosteroids may increase the risk of secondary infection ⁽¹⁾ Keratitis (marginal) - College of Optometrists
All patients on topical steroid drops or ointment should have their intraocular pressures checked initially, then measured again at appropriate intervals e.g. 2 weeks and every 4 weeks for 2-3 months⁽¹⁾ Ocular rosacea - College of Optometrists
Concomitant use of ocular formulations containing corticosteroids with ocular formulations containing NSAIDs may increase the risk of corneal healing problems, leading to corneal melt or scarring and loss of vision ⁽³⁾Ketorolac trometamol | Drugs | BNF | NICE

Generic prescribing advice ^(6,7)

Typical dosages for adult patients are given within the Community Eyecare guidelines. These dosages will not be suitable for all and need to be considered alongside patient factors and the clinical presentation. If practitioners are treating patients under the age of 18 years of age they need to apply caution and should check appropriate dosage on BNF for Children (BNFC) or within local formulary guidance if available.
Within the dose & duration advice section of the Community Eyecare Guidelines, drug options are typically listed in the order they are mentioned within the College of Optometrists Clinical Management Guidelines and are not in order of treatment hierarchy / preference for the condition
Be mindful of local guidance (including Health Board treatment ladders, flowcharts and formularies) when prescribing any medications. For local prescribing advice please see the prescribing section within your Health Board area on the eyes.nhs.scot website and if unavailable contact your local Health Board for further information
As far as is practicable, adhere to the local formulary in terms of first choice, second choice drugs etc and be cautious when prescribing medications off-license/off-label, particularly if alternatives are available
As with any medications, exercise caution when making a prescribing decision for patients with a known sensitivity or previous adverse reaction, for young children and the elderly, for patients who are pregnant/breast-feeding or those are known to have impaired renal function
When prescribing it is generally sensible to keep the regimen as simple and straightforward as possible, especially for patients with reduced capacity. Consider given written guidance for the patient and/or carer(s) to improve compliance
Always be aware of potential contraindications and if unsure, consult relevant sources before prescribing (e.g. BNF Interactions Interactions A to Z | BNF | NICE)
Before prescribing any antimicrobial medications be mindful of the risk of developing resistance and of inherent stewardship responsibility SAPG | Scottish Antimicrobial Prescribing Group
If you become aware of any adverse events/reactions to any medications these can be reported to the Medicines & Healthcare Regulatory Agency (MHRA) via the Yellow Card scheme Yellow Card | Making medicines and medical devices safer
Where no dosing advice is available or is conflicting, practitioners should consult local or National guidance (such as BNF/BNFC or The College of Optometrists Formulary)
In some instances non-IP practitioners may issue a written order for medications; this should always be in the best interests of the patient and bearing in mind alternative options for referral and prescribing including intra-referral to an IP colleague
When prescribing ocular lubricants there are a variety of products available based on the severity of the condition being managed. Always refer to local formularies for suitable options within your Health Board.

Useful advice and information ^(6,7)

If managing a condition which falls under GOS-SS (Specialist Supplementary) be aware of the relevant Scottish Government guidance https://www.eyes.nhs.scot/for-professionals/legislation/and manage the patient accordingly
If managing a condition where there are potential systemic implications/which may affect an area beyond the globe and adnexa or which requires prescribing of an oral medication consider co-managing with the GP or other specialities such as dermatology/rheumatology. It is good practice to notify the GP of any medications prescribed
Patients will all respond differently to treatment based on multiple factors. Some medications may cause unwanted effects (such as steroid response) and may have to be tapered to control the condition and avoid rebound
In all cases use clinical judgement to determine the most appropriate recall period depending on severity of the condition and the response to treatment. It is sensible to offer worsening advice and to consider use of ‘safety netting’ appointments so that patients are encouraged to return within a reasonable timescale
In an effort to reduce unnecessary referrals for conditions which are not sight threatening/urgent and to refer patients within an appropriate timeframe, make yourself familiar with local communication channels between Primary and Secondary care such as triage telephone contacts, secondary care support email addresses or local peer groups where advice can be sought prior to referring a patient (where time allows)
When undertaking any procedure where there is a risk of sharps injury be aware of relevant National and local policies relating to procedure in the event of injury (see web links below)
All Health Boards have their own policies relating to safe sharps disposal. It is important to be aware of these policies and contact your local Health Board for advice in advance of sharps use so that safe disposal is in place

Common weblinks to useful resources

“Annex C of the Statement”

https://www.eyes.nhs.scot/for-professionals/legislation/

The College of Optometrists Clinical Management Guidelines

Clinical Management Guidelines - College of Optometrists

Healthcare Improvement Scotland safe disposal of waste (including sharps)

Safe disposal of waste (including sharps) | Right Decisions

NSS National Infection Prevention and Control Manual Standard Infection Control Precautions (SICPs) 1.10 Occupational Safety: Prevention and Exposure Management (including sharps)

National Infection Prevention and Control Manual: Chapter 1 - Standard Infection Control Precautions (SICPs)

Central directory of links to prescribing resources

Prescribing and local formulary guidance can change regularly. Practitioners should always endeavour to prescribe based on the most current available guidance both local and National. If unsure seek appropriate advice, at all times acting in the best interests of your patient(s).

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National Resources

The College of Optometrists Formulary (Members only)

Optometrists' Formulary - College of Optometrists

British National Formulary (BNF)

BNF (British National Formulary) | NICE

British National Formulary for Children (BNFC)

BNFC (British National Formulary for Children) | NICE

BNF Interactions

Interactions A to Z | BNF | NICE

Clinical Knowledge Summaries (NICE)

CKS | NICE

Specialist Pharmacy Service Medicines Supply Tool (drug shortages)

Tools – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice

Electronic Medicines Compendium (Summary of Product Characteristics)

Electronic medicines compendium (emc)

NHS Pharmacy First Scotland

Formulary links by Health Board are usually located in the Prescribing section of individual Health Board pages on eyes.nhs.scot

Health Boards

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot