BNF for Children 2011-2012

524 11.5 Mydriatics and cycloplegics BNFC 2011–201211 Eye11.5 Mydriatics andcycloplegicsAntimuscarinics dilate the pupil and paralyse the ciliarymuscle; they vary in potency and duration of action.Short-acting, relatively weak mydriatics, such as tropicamide0.5% (action lasts for 4–6 hours), facilitate theexamination of the fundus of the eye. Cyclopentolate1% (action up to 24 hours) or atropine (action up to 7days) are preferable for producing cycloplegia forrefraction in young children; tropicamide may be preferredin neonates. Phenylephrine 2.5% is used formydriasis in diagnostic or therapeutic procedures;mydriasis occurs within 60–90 minutes and lasts up to5–7 hours. Phenylephrine 10% drops are contra-indicatedin children owing to the risk of systemic effects.Mydriatics and cycloplegics are used in the treatment ofanterior uveitis, usually as an adjunct to corticosteriods(section 11.4.1). Atropine is used in anterior uveitismainly to prevent posterior synechiae and to relieveciliary spasm; cyclopentolate or homatropine (actionup to 3 days) can also be used and may be preferredbecause they have a shorter duration of action.Cautions and contra-indications Darkly pigmentedirides are more resistant to pupillary dilatation andcaution should be exercised to avoid overdosage.Mydriasis can precipitate acute angle-closure glaucomain the very few children who are predisposed to thecondition because of a shallow anterior chamber. Atropine,cyclopentolate, and homatropine should be usedwith caution in children under 3 months owing to thepossible association between cycloplegia and the developmentof amblyopia; also, neonates are at increasedrisk of systemic toxicity.Skilled tasks Children may not be able to undertake skilledtasks until vision clears after mydriasis.Side-effects Ocular side-effects of mydriatics andcycloplegics include transient stinging and raisedintra-ocular pressure; on prolonged administration,local irritation, hyperaemia, oedema, and conjunctivitiscan occur. Contact dermatitis can occur with the antimuscarinicmydriatic drugs, especially atropine.Toxic systemic reactions to atropine and cyclopentolatecan occur in neonates and children; see section 1.2 forsystemic side-effects of antimuscarinic drugs.AntimuscarinicsATROPINE SULPHATECautions risk of systemic effects with eye drops ininfants under 3 months, see notes aboveSide-effects see notes aboveLicensed use not licensed for use in children foruveitisIndication and doseCycloplegiaChild 3 months–18 years apply drops or ointmenttwice daily for 3 days before procedureAnterior uveitisChild 2–18 years 1 drop up to 4 times dailyAtropine (Non-proprietary) AEye drops, atropine sulphate 0.5%, net price 10 mL =£2.78; 1%, 10 mL = £9.50Single useMinims c Atropine Sulphate (Bausch & Lomb) AEye drops, atropine sulphate 1%. Net price 20 0.5 mL = £12.71CYCLOPENTOLATE HYDROCHLORIDECautions see notes aboveSide-effects see notes aboveIndication and doseSee notes aboveCycloplegiaChild 3 months–12 years 1 drop of 1% eye drops30–60 minutes before examinationChild 12–18 years 1 drop of 0.5% eye drops 30–60 minutes before examinationUveitisChild 3 months–18 years 1 drop of 0.5% eyedrops (1% for deeply pigmented eyes) 2–4 timesdailyMydrilate c (Intrapharm) AEye drops, cyclopentolate hydrochloride 0.5%, netprice 5 mL = £6.73; 1%, 5 mL = £6.73Excipients include benzalkonium chlorideSingle useMinims c Cyclopentolate Hydrochloride (Bausch &Lomb) AEye drops, cyclopentolate hydrochloride 0.5% and1%. Net price 20 0.5 mL (both) = £9.64HOMATROPINE HYDROBROMIDECautions see notes aboveSide-effects see notes aboveLicensed use not licensed for use in children under 3monthsIndication and doseSee notes aboveChild 3 months–2 years (0.5% only) 1 drop dailyor on alternate days adjusted according toresponseChild 2–18 years 1 drop twice daily adjustedaccording to responseHomatropine (Non-proprietary) AEye drops, homatropine hydrobromide 1%, net price10 mL = £2.57; 2%, 10 mL = £2.71Available without preservatives as manufacturedspecials from Moorfields Eye HospitalEye drops, homatropine 0.125% and 0.5%, 10 mL,available as a manufactured special from MoorfieldsEye Hospital, see also ‘special-order’ manufacturersor specialist importing companies, p. 809Excipients include chlorhexidineTROPICAMIDECautions see notes aboveSide-effects see notes above