The air needs emptying out initially when the tube is first opened to avoid the old toothpaste problem of fingers warming the air behind the product leading to uncontrollable wasted drug. There is usually a small amount in the nozzle. The first time the tube is squeezed the product in the nozzle is usually ejected suddenly with a 'pfff' sound and a small amount will be lost. This is inevitable but if you are aware that this will happen and warn users to be careful then the loss can be minimised. Continue to squeeze out the air very gently until the product shows at the nozzle and the tube appears two-thirds empty.

3. We ask owners to aim to use only the equivalent of the top pointed section of a biro i.e. 2mm. We have heard some use the image of a grain of rice.. make it a short grain then. Inevitably they will use more than this, but they will probably end up using 3 mm which is the actual target.

4. We show them our preferred site which is to wipe the small amount onto the underside of the upper eyelid. We tell them that the ointment base is excellent and it will spread over the eye with normal blinking. 

 Apply sparingly to the underside of the upper eyelid. The ointment base is excellent and it will spread with normal blinking. Don't forget to tell the patient not to blink when you apply the ointment!

5. The tube should be kept at room temperature. If it is particularly warm then the base becomes oily and it is difficult to get that small dose. We have had owners tell me they put it in the fridge for 10 - 15 minutes to firm it up that sounds like a good idea and seems to work well. If it is in the fridge too long it becomes semi-solid and we had a few clients burst the crimped end of the tube when they kept it in the fridge overnight.

6. Don't roll up the tube during use to get that last drop out. There have been some clients end up with cracked tubes and waste. To be fair Schering Plough have allowed us to replace at no cost to owners in those situations without question, but we would suggest not to roll up the tube.

7. The package insert says to throw any unused product away four weeks after opening. All eye products have to say that, although on one of our own dogs we would use a tube for six weeks, but no longer. We cannot tell owners to do differently from Schering Plough's recommendation as that would be unethical. Schering Plough do not disagree with this approach. We also advise owners that one client managed eight weeks of use but then came in with an obvious bacterial secondary conjunctivitis. The tube does not contain any preservatives or antimicrobials.

8. We aim for 12 hourly dosing. It seems to be worth the effort to keep treatments evenly spaced and it definitely works better twice daily than extra product given just once. Most clients manage to make a tube last for six when dosing both eyes twice a day, which we think is satisfactory. This means it is never worth reducing to once daily applications as they will only waste product left over at the end of the six weeks.

Optimmune is not a panacea but works very well in the majority of cases. We feel that we should tell owners plainly at the start of use that they are beginning a lifetime treatment. It has an excellent ointment base which we wish they could market without the expense of adding cyclosporin! Some cases do appear to respond well for a few months and then the effect can fall off. We still do a few PDTs each year - maybe 10 or 12, but we used to do the same number of PDTs before optimmune, during which time our case load has increased ten fold.

If you have any queries regarding the use of Optimmune please don't hesitate to contact us.

Optimmune - Schering Plough's flagship product. We have found it has given excellent results in most cases.

There are only 3.5g in the 10g tube, so don't think that you have been short changed!

Try to aim to use only 2mm of ointment - about the size of the nib of a biro or very small grain of rice - this will probably result in about 3mm being used which is what you want.

Squeeze the tube very gently to expell the air inside. There will be a small amount of ointment in the nozzle which will be ejected suddenly as you squeeze, so be careful.