BNF for Children 2011-2012

BNFC 2011–2012 11.6 Treatment of glaucoma 525Indication and doseSee notes aboveFunduscopyNeonate and child apply 0.5% eye drops 20minutes before examinationMydriacyl c (Alcon) AEye drops, tropicamide 0.5%, net price 5 mL = £1.29;1%, 5 mL = £1.60Excipients include benzalkonium chloride, disodium edetateSingle useMinims c Tropicamide (Bausch & Lomb) AEye drops, tropicamide 0.5% and 1%. Net price 20 0.5 mL (both) = £9.01SympathomimeticsPHENYLEPHRINE HYDROCHLORIDECautions cardiovascular disease (avoid or use 2.5%strength only); tachycardia; hyperthyroidism; diabetes;susceptibility to angle-closure glaucoma; seealso notes aboveContra-indications 10% drops in neonates and childrenSide-effects eye pain and stinging; blurred vision,photophobia; systemic effects include palpitations,arrhythmias, hypertension, coronary artery spasm;very rarely angle-closure glaucomaIndication and doseMydriasisSee notes aboveSingle useMinims c Phenylephrine Hydrochloride (Bausch &Lomb)Eye drops, phenylephrine hydrochloride 2.5%, netprice 20 0.5 mL = £9.53Excipients include disodium edetate, sodium metabisulphite11.6 Treatment of glaucomaGlaucoma describes a group of disorders characterisedby a loss of visual field associated with cupping of theoptic disc and optic nerve damage and is generallyassociated with raised intra-ocular pressure.Glaucoma is rare in children and should always bemanaged by a specialist. Primary congenital glaucomais the most common form of glaucoma in children,followed by secondary glaucomas, such as followinghereditary anterior segment malformations; juvenileopen-angle glaucoma is less common and usuallyoccurs in older children. Primary angle closure glaucoma(acute closed-angle glaucoma, narrow angle glaucoma)is very rare in children; it results from blockage ofaqueous humour flow into the anterior chamber and is amedical emergency that requires urgent reduction ofintra-ocular pressure, see below.Treatment of glaucoma is determined by the pathophysiologyand usually involves controlling raised intraocularpressure with surgery and drug therapy. Drugsthat reduce intra-ocular pressure by different mechanismsare available for managing glaucoma. A topicalbeta-blocker or a prostaglandin analogue can be used. Itmay be necessary to combine these drugs or add others,such as miotics, sympathomimetics, or carbonicanhydrase inhibitors, to control intra-ocular pressure.For urgent reduction of intra-ocular pressure and beforesurgery, mannitol 20% (up to 500 mL) is given by slowintravenous infusion until the intra-ocular pressure hasbeen satisfactorily reduced (see section 2.2.5). Acetazolamideby intravenous injection can also be used forthe emergency management of raised intra-ocular pressure.Standard antiglaucoma therapy is used if supplementarytreatment is required after iridotomy, iridectomy, or adrainage operation in either primary open-angle oracute closed-angle glaucoma.Beta-blockersTopical application of a beta-blocker to the eye reducesintra-ocular pressure effectively in primary open-angleglaucoma, probably by reducing the rate of productionof aqueous humour. Administration by mouth alsoreduces intra-ocular pressure but this route is not usedsince side-effects may be troublesome.Cautions, contra-indications, and side-effectsSystemic absorption can follow topical application tothe eye; therefore, eye drops containing a beta-blockerare contra-indicated in bradycardia, heart block, oruncontrolled heart failure. Important: for a warning toavoid in asthma, see below. Consider also other cautions,contra-indications, and side-effects of beta-blockers(p. 87). Local side-effects of eye drops include ocularstinging, burning, pain, itching, erythema, dry eyes andallergic reactions including anaphylaxis and blepharoconjunctivitis;occasionally corneal disorders have beenreported.Important Beta-blockers, even those with apparent cardioselectivity,should not be used in patients with asthma or ahistory of bronchospasm, unless no alternative treatment isavailable. In such cases the risk of inducing bronchospasmshould be appreciated and appropriate precautions taken.Interactions Since systemic absorption may followtopical application the possibility of interactions, inparticular with drugs such as verapamil, should beborne in mind. See also Appendix 1 (beta-blockers).BETAXOLOLCautions see notes aboveContra-indications see notes aboveSide-effects see notes aboveLicensed use not licensed for use in childrenIndication and doseSee notes aboveApply twice dailyBetaxolol (Non-proprietary) AEye drops, solution, betaxolol (as hydrochloride)0.5%, net price 5 mL = £1.90Excipients may include benzalkonium chloride, disodium edetate11 Eye