BNF for Children 2011-2012

518 11.2 Control of microbial contamination BNFC 2011–201211 Eyecorticosteroids for conditions not responding to topicaltherapy. The drug diffuses through the cornea and sclerato the anterior and posterior chambers and vitreoushumour. However, because the dose-volume is limited,this route is suitable only for drugs which are readilysoluble.Drugs such as antimicrobials and corticosteroids maybe administered systemically to treat an eye condition.Preservatives and sensitisers Information on preservativesand on substances identified as skin sensitisers(section 13.1.3) is provided under preparationentries.11.2 Control of microbialcontaminationPreparations for the eye should be sterile when issued.Eye drops in multiple-application containers include apreservative but care should nevertheless be taken toavoid contamination of the contents during use.Eye drops in multiple-application containers for homeuse should not be used for more than 4 weeks after firstopening (unless otherwise stated).Eye drops for use in hospital wards are normally discarded1 week after first opening (24 hours if preservative-free).Individual containers should be provided foreach child, and for each eye if there are special concernsabout contamination. Containers used before an operationshould be discarded at the time of the operation andfresh containers supplied. A fresh supply should also beprovided upon discharge from hospital; in specialistophthalmology units it may be acceptable to issueeye-drop bottles that have been dispensed to the patienton the day of discharge.In out-patient departments single-application packsshould preferably be used; if multiple-applicationpacks are used, they should be discarded at the end ofeach day. In clinics for eye diseases and in accident andemergency departments, where the dangers of infectionare high, single-application packs should be used; if amultiple-application pack is used, it should be discardedafter single use.Diagnostic dyes (section 11.8.2) should be used onlyfrom single-application packs.In eye surgery single-application containers should beused if possible; if a multiple-application pack is used, itshould be discarded after single use. Preparations usedduring intra-ocular procedures and others that maypenetrate into the anterior chamber must be isotonicand without preservatives and buffered if necessary to aneutral pH. Specially formulated fluids should be usedfor intra-ocular surgery; large volume intravenous infusionpreparations are not suitable for this purpose. Forall surgical procedures, a previously unopened containeris used for each patient.11.3 Anti-infective eyepreparations11.3.1 Antibacterials11.3.2 Antifungals11.3.3 AntiviralsEye infections Most acute superficial eye infectionscan be treated topically. Blepharitis and conjunctivitisare often caused by staphylococci; keratitis andendophthalmitis may be bacterial, viral, or fungal.Bacterial blepharitis is treated by lid hygiene and applicationof antibacterial eye drops to the conjunctival sacor to the lid margins. Systemic treatment may berequired and may be necessary for 3 months or longer.Most cases of acute bacterial conjunctivitis are selflimiting;where treatment is appropriate, antibacterialeye drops or an eye ointment are used. A poor responsemight indicate viral or allergic conjunctivitis or antibioticresistance.Corneal ulcer and keratitis require specialist treatment,usually under inpatient care, and may call for intensivetopical, subconjunctival, or systemic administration ofantimicrobials.Endophthalmitis is a medical emergency which alsocalls for specialist management and often requires parenteral,subconjunctival, or intra-ocular administrationof antimicrobials.For reference to the treatment of crab lice of the eyelashes,see section 13.10.411.3.1 AntibacterialsBacterial eye infections are generally treated topicallywith eye drops and eye ointments; systemic treatment issometimes appropriate in blepharitis.Chloramphenicol has a broad spectrum of activity andis the drug of choice for superficial eye infections.Chloramphenicol eye drops are well tolerated and therecommendation that chloramphenicol eye dropsshould be avoided because of an increased risk ofaplastic anaemia is not well founded.Other antibacterials with a broad spectrum of activityinclude the quinolones, ciprofloxacin, levofloxacin,moxifloxacin, and ofloxacin; the aminoglycosides,gentamicin, neomycin, and tobramycin are also activeagainst a wide variety of bacteria. Gentamicin, tobramycin,quinolones (except moxifloxacin), and polymyxinB are effective for infections caused by Pseudomonasaeruginosa.Ciprofloxacin eye drops are licensed for corneal ulcers;intensive application (especially in the first 2 days) isrequired throughout the day and night.Trachoma, which results from chronic infection withChlamydia trachomatis, can be treated with azithromycinby mouth [unlicensed indication].Fusidic acid is useful for staphylococcal infections.Propamidine isetionate is of little value in bacterialinfections but is used by specialists to treat the rare butpotentially sight-threatening condition of acanthamoebakeratitis (see also section 11.9).