4.1. Therapeutic indications

i. Inhibition of peroperative miosis during cataract surgery (Voltarol Ophtha Multidose has no intrinsic mydriatic properties and does not replace standard mydriatic agents).

ii. Treatment of post-operative inflammation in cataract surgery.

iii. Control of ocular pain and discomfort associated with corneal epithelial defects after excimer PRK surgery or accidental non-penetrating trauma.

iv. Control of inflammation after Argon Laser Trabeculoplasty (ALT).

v. The relief of the ocular signs and symptoms of Seasonal Allergic Conjunctivitis (SAC).

vi. Treatment of inflammation and discomfort after strabismus surgery

vii. Treatment of ocular pain and discomfort after radial keratotomy

4.2. Posology and method of administration

Voltarol Ophtha eye drop solution is for instillation into the conjunctival sac only. It should never be injected subconjunctivally, nor should it be directly introduced into the anterior chamber of the eye.

Adults:

Prophylaxis of preoperative miosis

Apply 1 drop four times during the 2 hours before surgery.

Control of post-operative inflammation

Apply 1 drop 4 times daily for up to 28 days.

Control of Post-PRK pain and discomfort

Apply 1 drop 2 times in the hour prior to surgery, 1 drop 2 times five minutes apart immediately after PRK surgery and then post-operatively 1 drop every 2-5 hours while awake for up to 24 hours.

Control of ocular pain associated with corneal epithelial defects after accidental non-penetrating trauma.

Apply 1 drop 4 times daily for up to 2 days.

Control of post-ALT inflammation.

Apply one drop 4 times during the 2 hours before ALT, and then one drop 4 times daily for up to 7 days.

The relief of the ocular signs and symptoms of Seasonal Allergic Conjuctivitis.

Apply one drop 4 times daily for as long as required.

Treatment of inflammation and discomfort after strabismus surgery

One drop 4 times daily in the 1st week, thrice daily in the 2nd week, twice daily in the 3rd week and as required in the 4th week

Treatment of ocular pain and discomfort after radial keratotomy.

Pre-operatively one drop before surgery, post-operatively one drop immediately after surgery, and then one drop 4 times daily for up to 2 days.

Paediatric use: Voltarol Ophtha and Voltarol Ophtha SDU are not indicated for use in children. Paediatric experience is limited to a few published clinical studies in strabismus surgery.

Following instillation of the eye drops, nasolacrimal occlusion or closing the eyes for 5 minutes may reduce the systemic absorption. This may result in a decrease in systemic side effects and an increase in local activity.

4.3. Contraindications

Patients with known hypersensitivity to any of the ingredients.

Like other non-steroidal anti-inflammatory agents, Voltarol is also contraindicated in patients in whom attacks of asthma, urticaria or acute rhinitis are precipitated by acetylsalicylic acid or by other drugs with prostaglandin synthetase inhibiting activity. Intraocular use during surgical procedure is also contraindicated.

4.4. Special warnings and precautions for use

The anti-inflammatory activity of ophthalmic non-steroidal anti-inflammatory agents (NSAIDs) may mask the onset and/or progression of ocular infections. In the presence of infection, or if there is a risk of infection, appropriate therapy (e.g. antibiotics) should be given concurrently with Voltarol Ophtha Multidose.

Although there have been no reported adverse events, there is a theoretical possibility that patients receiving other medications which may prolong bleeding time, or with known haemostatic defects may experience exacerbation with Voltarol Ophtha Multidose.

Caution should be exercised when topical NSAIDs such as diclofenac are used concomitantly with topical steroids (see section 4.5 Interaction with other medicinal products and other forms of interaction).

Following instillation of the eye drops, nasolacrimal occlusion or closing the eyes for 3 minutes may reduce the systemic absorption. This may result in a decrease in systemic side effects and an increase in local activity.

This medicine contains 0.0014 mg benzalkonium chloride in each drop, which is equivalent to 0.05 mg/ml.

Benzalkonium chloride has been reported to cause eye irritation, symptoms of dry eyes and may affect the tear film and corneal surface. Should be used with caution in dry eye patients and in patients where the cornea may be compromised.

Patients should be monitored in case of prolonged use.

Benzalkonium chloride may be absorbed by soft contact lenses and may change the colour of the contact lenses. Patients should be advised to remove contact lenses before using this medicinal product and to wait at least 15 minutes before reinsertion.

4.5. Interaction with other medicinal products and other forms of interaction

Concomitant use of topical NSAIDs such as diclofenac and topical steroids in patients with significant pre-existing corneal inflammation may increase the risk of developing corneal complications, therefore caution should be used.

An interval of at least five minutes between the application of the different medicinal products must be allowed.

4.6. Pregnancy and lactation

Pregnancy

There are no clinical data from the use of Voltarol Ophtha or Voltarol Ophtha Multidose during pregnancy. Even if systemic exposure is lower compared with oral administration, it is not known if the systemic Voltarol Ophtha or Voltarol Ophtha Multidose exposure reached after topical administration can be harmful to an embryo/foetus.

During the first and second trimester of pregnancy, Voltarol Ophtha or Voltarol Ophtha Multidose should not be used unless clearly necessary. If used, the dose should be kept as low and duration of treatment as short as possible.

During the third trimester of pregnancy, systemic use of prostaglandin synthetase inhibitors including diclofenac may induce cardiopulmonary and renal toxicity in the foetus. At the end of the pregnancy prolonged bleeding time in both mother and child may occur, and labour can be delayed. Therefore, Voltarol Ophtha or Voltarol Ophtha Multidose is not recommended during the last trimester of pregnancy.

Lactation

Diclofenac is excreted in breast milk. However, at therapeutic doses of Voltarol Ophtha no effects on the suckling child are anticipated. Use of ocular diclofenac is not recommended during breast feeding unless the expected benefits outweigh the possible risks.

4.7. Effects on ability to drive and use machines

Patients with blurred vision should refrain from driving a vehicle or operating machines.

4.8. Undesirable effects

Very frequent: Eye pain.

The other frequently observed adverse reaction is a transient, mild to moderate eye irritation.

Other less frequently observed reactions are eye pruritus, ocular hyperaemia and blurred vision immediately after instillation of the eye drops.

Punctate keratitis or corneal disorders have been observed, usually after frequent application.

In patients with risk factors of corneal disorders such as during the use of corticosteroids or with concomitant diseases such as infections or rheumatoid arthritis, diclofenac has been associated, in rare cases, with ulcerative keratitis, corneal thinning, punctuate keratitis, corneal epithelium defect and corneal oedema, which might become sight-threatening. Most patients were treated for a prolonged period of time.

Allergic conditions have been reported for ocular reactions such as conjunctival hyperaemia, allergic conjunctivitis, eyelid erythema, oedema, and pruritus, and systemic hypersensitivity reactions such as urticaria, rash, eczema, erythema, pruritus, cough and rhinitis.

In rare cases dyspnoea and exacerbation of asthma have been reported.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme. Website: www.mhra.gov.uk/yellowcard

4.9. Overdose

There is practically no risk of adverse effects due to accidental oral ingestion, since a 5ml bottle of the eye drops contains only 5mg of diclofenac sodium, corresponding to about 3% of the recommended maximum daily adult dose of Voltarol after oral administration. By way of comparison, the maximum oral daily dose for diclofenac sodium recommended in children is 2mg/kg body weight.