Drug reference
Treatment of vitreomacular traction, including when associated with a macular hole of diameter less than or equal to 400 microns (specialist use only) ▶BY INTRAVITREAL INJECTION ▶Adult: 125 micrograms for 1 dose, to be administered into the affected eye, concurrent administration to both eyes is not recommended
PDF page 1279
Active or suspected ocular or periocular infection. aphakia. exudative age-related macular degeneration. high myopia. history of rhegmatogenous retinal detachment. ischaemic retinopathies. large diameter macular hole (> 400 microns). lens zonule instability. proliferative diabetic retinopathy. recent intra-ocular injection (including laser therapy). recent ocular surgery. retinal vein occlusions. vitreous haemorrhage
PDF page 1279
History of uveitis (including severe active inflammation). non-proliferative diabetic retinopathy. significant eye trauma
PDF page 1279
NICE decisions ▶Ocriplasmin for treating vitreomacular traction (October 2013) NICE TA297 Ocriplasmin is recommended as an option for treating vitreomacular traction in adults, only if: . an epiretinal membrane is not present and . they have a stage II full-thickness macular hole with a diameter of 400 microns or less and/or . they have severe symptoms. www.nice.org.uk/guidance/ta297 Scottish Medicines Consortium (SMC) decisions The Scottish Medicines Consortium has advised (August 2014) that ocriplasmin (Jetrea ®) is accepted for restricted use within NHS Scotland for the treatment of patients with vitreomacular traction plus macular hole, regardless of whether they have epiretinal membrane formation, and in patients with vitreomacular traction alone (no epiretinal membrane and no macular hole).
PDF pages 1279, 1280
▶Common or very common Dry eye. eye discomfort. eye disorders. eye inflammation. haemorrhage. retinal pigment epitheliopathy. vision disorders
PDF page 1279
Manufacturer advises use only if potential benefit outweighs risk—no information available.
PDF page 1279
Manufacturer advises use only if potential benefit outweighs risk—no information available.
PDF page 1279
Monitor intra-ocular pressure, visual acuity, and for signs of intra-ocular inflammation or infection following injection.
PDF page 1279
For further information on administration, consult product literature.
PDF page 1279
There can be variation in the licensing of different medicines containing the same drug. Solution for injection ▶Jetrea (Oxurion N.V.) Eye Ocriplasmin 1.25 mg per 1 ml Jetrea 0.375mg/0.3ml solution for injection vials | 1 vial P £2,500.00 (Hospital only) Chapter 12 Ear, nose and oropharynx CONTENTS Ear page 1259 Otitis externa Removal of earwax Nose Nasal congestion Nasal infection Nasal inflammation, nasal polyps and rhinitis Oropharynx Dry mouth Ear Ear Otitis externa Otitis externa is an inflammatory reaction of the meatal skin. It is important to exclude an underlying chronic otitis media before treatment is commenced. Many cases recover after thorough cleansing of the external ear canal by suction or dry mopping. A frequent problem in resistant cases is the difficulty in applying lotions and ointments satisfactorily to the relatively inaccessible affected skin. The most effective method is to introduce a ribbon gauze dressing or sponge wick soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution p. 1264. When this is not practical, the ear should be gently cleansed with a probe covered in cotton wool and the patient encouraged to lie with the affected ear uppermost for ten minutes after the canal has been filled with a liberal quantity of the appropriate solution. If infection is present, a topical anti-infective which is not used systemically (such as neomycin sulfate p. 1261 or clioquinol) may be used, but for only about a week as excessive use may result in fungal infections; these may be difficult to treat and require expert advice. Sensitivity to the anti-infective or solvent may occur and resistance to antibacterials is a possibility with prolonged use. Aluminium acetate ear drops are also effective against bacterial infection and inflammation of the ear. Chloramphenicol p. 1261 may be used but the ear drops contain propylene glycol and cause hypersensitivity reactions in about 10% of patients. Solutions containing an anti-infective and a corticosteroid are used for treating cases where infection is present with inflammation and eczema. In view of reports of ototoxicity, manufacturers contra- indicate treatment with topical aminoglycosides or polymyxins in patients with a perforated tympanic membrane (eardrum) or patent grommet. However, some specialists do use these drops cautiously in the presence of a perforation or patent grommet in patients with chronic suppurative otitis media and when other measures have failed for otitis externa; treatment should be considered only by specialists in the following circumstances: . drops should only be used in the presence of obvious infection; . treatment should be for no longer than 2 weeks; Oral hygiene page 1275 Dental caries 2.1 Oral ulceration and inflammation Oropharyngeal bacterial infections Oropharyngeal fungal infections Oropharyngeal viral infections Ear, nose and oropharynx . patients should be counselled on the risk of ototoxicity and given justification for the use of these topical antibiotics; . baseline audiometry should be performed, if possible, before treatment is commenced. Clinical expertise and judgement should be used to assess the risk of treatment versus the benefit to the patient in such circumstances. A solution of acetic acid 2% acts as an antifungal and antibacterial in the external ear canal. It may be used to treat mild otitis externa but in severe cases an antiinflammatory preparation with or without an anti-infective drug is required. A proprietary preparation containing acetic acid 2% (EarCalm ® spray) is on sale to the public. For severe pain associated with otitis externa, a simple analgesic, such as paracetamol p. 465 or ibuprofen p. 1203, can be used. A systemic antibacterial can be used if there is spreading cellulitis or if the patient is systemically unwell. When a resistant staphylococcal infection (a boil) is present in the external auditory meatus, flucloxacillin p. 586 is the drug of choice; ciprofloxacin p. 590 (or an aminoglycoside) may be needed in pseudomonal infections which may occur if the patient has diabetes or is immunocompromised. The skin of the pinna adjacent to the ear canal is often affected by eczema. A topical corticosteroid cream or ointment is then required, but prolonged use should be avoided. Otitis media Acute otitis media Acute otitis media is a self-limiting condition that mainly affects children. It is characterised by inflammation in the middle ear associated with effusion and accompanied by the rapid onset of signs and symptoms of an ear infection. The infection can be caused by viruses or bacteria; often both are present simultaneously. Children with acute otitis media usually present with symptoms such as ear pain, rubbing of the ear, fever, irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea. Symptoms usually resolve within 3 to 7 days without antibacterial drugs. The use of antibacterials generally does not prevent common complications of acute otitis media such as short-term hearing loss, perforated eardrum, or recurrent infection. Acute complications such as mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis, are rare. g Children and their carers should be given advice about the usual duration of acute otitis media, self-care of symptoms such as pain and fever with paracetamol or ibuprofen p. 1203, and when to seek medical help. In children aged 3 years and over who do not have a perforated eardrum, pain can be relieved with anaesthetic ear drops in addition to oral analgesics [unlicensed use]. Children and their carers should be reassured that antibacterial drugs are usually not required. An immediate antibacterial drug should be given if the child is systemically very unwell, has signs or symptoms of a more serious illness, or is at high risk of complications such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, or young children who were born prematurely. An immediate antibacterial drug can also be considered if otorrhoea is present, or in children under 2 years of age with bilateral otitis media. See Antibacterial therapy for otitis media in Ear infections, antibacterial therapy p. 534. Children with acute otitis media associated with a severe Ear, nose and oropharynx systemic infection or acute complications should be referred to hospital. h Otitis media with effusion Otitis media with effusion (glue ear) occurs in about 10% of children and in 90% of children with cleft palates. Systemic antibacterials are not usually required. If glue ear persists for more than a month or two, the child should be referred for assessment and follow up because of the risk of long-term hearing impairment which can delay language development. Untreated or resistant glue ear may be responsible for some types of chronic otitis media. Chronic otitis media Opportunistic organisms are often present in the debris, keratin, and necrotic bone of the middle ear and mastoid in patients with chronic otitis media. The mainstay of treatment is thorough cleansing with aural microsuction which may completely resolve long-standing infection. Local cleansing of the meatal and middle ear may be followed by treatment with a sponge wick or ribbon gauze dressing soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution p. 1264; this is particularly beneficial for discharging ears or infections of the mastoid cavity. An antibacterial ear ointment may also be used. Acute exacerbations of chronic infection may also require systemic treatment with amoxicillin p. 579 (or erythromycin p. 569 if penicillin-allergic); treatment is adjusted according to the results of sensitivity testing. In view of reports of ototoxicity, manufacturers contraindicate topical treatment with ototoxic antibacterials in the presence of a tympanic perforation or patent grommet. Ciprofloxacin p. 1261 or ofloxacin eye drops p. 1236 used in the ear [unlicensed use] or ear drops [both unlicensed; available from ‘special-order’ manufacturers or specialist importing companies] are an effective alternative to such ototoxic ear drops for chronic otitis media in patients with perforation of the tympanic membrane. However, some specialists do use ear drops containing aminoglycosides or polymyxins [unlicensed indications] cautiously in patients with chronic suppurative otitis media and a perforation of the tympanic membrane, if the otitis media has failed to settle with systemic antibacterials; treatment should be considered only by specialists in the following circumstances: . drops should only be used in the presence of obvious infection; . treatment should be for no longer than 2 weeks; . patients should be counselled on the risk of ototoxicity and given justification for the use of these topical antibiotics; . baseline audiometry should be performed, if possible, before treatment is commenced. Clinical expertise and judgement should be used to assess the risk of treatment versus the benefit to the patient in such circumstances. It is considered that the pus in the middle ear associated with otitis media also carries a risk of ototoxicity. Removal of ear wax Ear wax (cerumen) is a normal bodily secretion which provides a protective film on the meatal skin and need only be removed if it causes hearing loss or interferes with a proper view of the ear drum. Ear wax can be softened using simple remedies such as olive oil ear drops or almond oil ear drops; sodium bicarbonate ear drops p. 1264 are also effective, but may cause dryness of the ear canal. If the wax is hard and impacted, the drops can be used twice daily for several days and this may reduce the need for mechanical removal of the wax. The patient should lie with the affected ear uppermost for 5 to 10 minutes after a generous amount of the softening remedy has been introduced into the ear. Some proprietary preparations containing organic solvents can irritate the meatal skin, and in most cases the simple remedies indicated above are just as effective and less likely to cause irritation. Docusate sodium p. 1265 or urea hydrogen peroxide p. 1265 are ingredients in a number of proprietary preparations for softening ear wax. If necessary, wax may be removed by irrigation with water (warmed to body temperature). Ear irrigation is generally best avoided in young children, in patients unable to co- operate with the procedure, in those with otitis media in the last six weeks, in otitis externa, in patients with cleft palate, a history of ear drum perforation, or previous ear surgery. A person who has hearing in one ear only should not have that ear irrigated because even a very slight risk of damage is unacceptable in this situation. Otitis externa ANTIBACTERIALS › AMINOGLYCOSIDES
PDF pages 1280, 1281, 1282
125 micrograms for 1 dose, to be administered
First-line fragment. Read the complete Indications and Dose section above.
PDF page 1279
