Most products can be purchased over the counter at a cost less than the prescription charge

Selection of product is based upon viscosity which increases in the order:

hypromellose - polyvinyl alcohol - carbomer

Patients with more severe disease such as Sjögren's syndrome usually require more viscous products.

Hypromellose should be prescribed generically. The 0.3% is standard; other strengths should be reserved for specialist recommendation.

Due to the need for frequent installation of these products, the development of allergy to preservative can occur. Preservative allergy is usually diagnosed by an ophthalmologist and may necessitate a change of lubricant as outlined above. Lacri-Lube ointment is preservative free but contains lanolin and wool fat.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include dry eyes and sore tired eyes.

Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Product selection is based upon the lowest acquisition cost within each class.

Drugs used for dry eye disease not listed here:

• Ciclosporin, see 11.4.2 Other anti-inflammatory preparations
  • NICE TA369: Ciclosporin (Ikervis) is recommended as an option for treating severe keratitis in adults with dry eyes that has not improved despite treatment with tear substitutes (December 2015)

Polyvinyl alcohol

• Eye drops 1.4% (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply as required, up to six times a day

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Hypromellose

• Eye drops 0.3% (£0.71 = 10ml)

Indications

• Dry eye conditions

Dose

• Apply one drop as required, up to 6 times daily

Notes

1. 0.3% is standard; other strengths should be reserved for specialist recommendation

Carbomers

• Carbomer '980' 0.2% ophthalmic liquid gel (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply one drop 3-4 times daily or as required (maximum 6 times daily)

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Liquid paraffin

• Eye ointment (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply a small strand of ointment to the eye, once daily, before going to bed

Notes

1. May cause temporary visual disturbance so best suited for application before sleep
2. May be used in combination with artificial tear drops during the day
3. Paraffin containing products should not be used in contact lens wearers
4. Some preparations contain lanolin and wool fat
5. Some products have extended expiry dates – refer to individual manufacturer details
6. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Preparations for patients with preservative allergy

Polyvinyl alcohol

• Single use eye drops 1.4% (click here for preferred brand)

Indications

• Dry eye conditions in patients with preservative allergy

Dose

• Apply as required

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Hypromellose

• Eye drops 0.3% - preservative free (click here for preferred brand)

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Carbomers

• Carbomer '980' 0.2% ophthalmic liquid gel single dose units preservative free (click here for preferred brand)

Indications

• Dry eye conditions in patients with preservative allergy

Dose

• Apply one drop as required

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Carmellose

• Single use eye drops 0.5% - preservative free (click here for preferred brand)
• Eye drops 0.5% - preservative free (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Sodium hyaluronate

• Eye drops 0.2% (preservative-free) (click here for preferred brand)
• Single unit dose eye drops 0.4% (preservative-free) (click here for preferred brand)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. Sodium hyaluronate is more expensive than other ocular lubricants but maybe more cost effective for patients who do not use an entire bottle every month as the drops remain sterile in the bottle for longer than 28 days after opening. Please refer to the individual product information and remind patients not to dispose of the bottle after 28 days
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Thealoz Duo

(Sodium hyaluronate 0.15% / trehalose 3%)

• Eye drops preservative free (£8.99 = 10ml)

Indications

• Dry eye conditions

Dose

• Apply as required

Notes

1. For patients who cannot tolerate sodium hyaluronate 0.2%, or who have been diagnosed with severe dry eye and sodium hyaluronate 0.2% is not sufficient.
2. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients)

Other preparations

Mucolytic eye preparations

Acetylcysteine eye drops are mucolytic and reduce the viscosity and tenacity of mucus in the eye, it is only recommended for use in dry eye syndromes with abnormal mucus production.

Ilube

(Acetylcysteine)

• Eye drops 5% (£80.95 = 10ml bottle)

Indications and dose

• Treatment of dry eye syndromes associated with deficient tear secretion, impaired or abnormal mucus production
  • 1 or 2 drops instilled into the affected eye(s) 3 or 4 times daily

Notes

1. Prescribe by brand to avoid confusion
2. Treatment must be initiated by a secondary care eye specialist, including first prescription
3. Response to treatment with Ilube should be reassessed at least every 6 months by specialist, and where appropriate repeat prescribing may be performed by primary care on specialist advice
4. Ilube contains benzalkonium chloride which may cause eye irritation

Acetylcysteine

• Eye drops 5% preservative-free (unlicensed preparation)