Principles and protocol for ophthalmic medication instillation/application

General principles – instilling drops

The aim of all eye medications is to achieve the maximum therapeutic effect from the ophthalmic medications and to minimise the risks, side-effects and complications associated with their use. When teaching patients and carers the correct technique for cleaning and instilling drops/ointment to the eye, there are some general principles to follow.

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The medication is delivered in a manner that avoids risk of trauma and/or cross-infection. The latter includes care of drop dispenser and any drop aid used, and instillation technique.

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The drops and ointment should be administered in the correct strength, to the correct patient, into the correct eye, at the correct time and at the appropriate interval.

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All patients must have their drop technique assessed even if they are curre- ntly instilling drops for other ophthalmic conditions, e.g. chronic glaucoma.

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The opportunity for self-medication by the patient should be maximised, taking into account his state of wellbeing. Style and technique will vary between individuals; if the patient is observed to have a drop technique that is adequate, it should not be changed. Where necessary, arrangements for district nurse support should be made.

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In a hospital setting, a record must be kept of all drops instilled and ointment applied.

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Medication that has passed its expiry date must not be used. Any opened drops and ointment must not be used after 28 days (British National For- mulary 2009).

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Patients need to know the action and the possible side-effects of their medication.

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Unless directed otherwise by medical staff, ask the patient to remove his contact lenses prior to instilling drops and ointment. Depending on the patient’s ocular problem, it may be necessary to advise the patient to stop wearing contact lenses until the condition has resolved and treatment is completed.

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Patients need to know that drops may sting and some may leave an un- pleasant taste in the mouth.

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If patients are on more than one type of drop and/or ointment to the same eye, the order of delivery should be as per pharmacy criteria.

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Normally, one drop is sufficient. Additional drops may reduce the effective- ness as they increase tear-duct stimulation and outflow. It may also increase the amount of systematic absorption. In addition, any excess drops may overflow onto the cheek and, over a period of time, may cause skin irritation.

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The capacity of the fornix is approximately 30µl and the average drop size is between 25–50µl.

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With certain medications, there will be a specific request from the oph- thalmologist to occlude the punctum to reduce still further any risk of

systemic absorption via mucous membranes of the canaliculi, nose and mouth. However, some medications may be prescribed specifically for their action on the lacrimal apparatus and so punctal occlusion is not desirable.

In addition, it is not desirable to occlude the punctum digitally following some types of surgery.

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As the period for effective therapeutic absorption of medication is from 1 to 1.5 minutes, patients should be taught to close their eyes slowly and to keep them closed for a slow count to 60. Keeping the lids gently closed without squeezing reduces lacrimal duct outflow and maximises medication contact with ocular structures.

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An appropriate time interval of approximately 3 minutes is necessary be- tween each drop in order to prevent dilution and overflow.

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All medication should be delivered to the correct location. This is generally the lower fornix but can include the cornea, lids, periocular wounds and the socket.

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Drops must be stored according to the manufacturer’s instructions. This includes some drops to be stored in a refrigerator at all times, even before opening, and others that must be stored in the refrigerator only after opening.

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Before using eye drops, patients – or whoever is instilling the drops – should be instructed to shake the bottle to ensure even distribution.

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Pharmacy will label all drop boxes with patient, dose, order and storage instructions. They will also have available upon request, large-print labels.

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Certain medications may have an effect on vision. This effect may be tran- sient or may last for the duration of the treatment.

General principles – application of eye ointment

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Ointment may be prescribed in addition to drops.

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Ointment should be applied after any prescribed drops have been instilled, leaving approximately a 3-minute interval between medications.

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Ointment may be prescribed for structures other than the eye.

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Ointment may be prescribed for use after first dressing, and this may not happen for up to 1 week in the case of some oculoplastic surgery.

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If requested, visual acuity should be recorded before ointment is applied as ointment clouds vision. Any existing ointment excess is normally removed prior to taking visual acuity measurement.

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A 5-mm strip of ointment should be applied to the inner edge of the lower fornix of the appropriate eye.

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The patient should close his eye and remove excess ointment with a swab.

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The patient should be advised that the ointment is likely to cause blurring of vision because of its viscous nature.

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In the case of wounds on the lids, face or eye socket, ointment should be squeezed directly onto the wound. It may be dispersed using a moistened swab. If requested to do so by the ophthalmic surgeon, the wound or scar should be massaged using the ointment.

General staff principles on eye medication

Compliance with medication or other therapeutic regimen may be defined as a ‘responsible process of self care, in which the patient works to maintain his or her health in close collaboration with healthcare staff; instead of following rules that are prescribed, the patient shows an active commitment to self care’

(Kyngas et al., 2000).

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Drops and ointment are drugs, and some eye medications will have a sys- temic affect other than on the eye.

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All trust/employer policies for drug administration should be followed in conjunction with these principles. This includes hand hygiene.

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The nurse should explain to the patient what she is going to do and should obtain his consent and co-operation.

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Where appropriate, the patient/partner/carer should be involved. The dis- trict nurse should be involved where it is felt necessary to ensure that the eye treatment is delivered.

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Staff should be honest about the effects and side-effects of drops, including stinging and discomfort.

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For inpatients – including any day cases – a patient already on glaucoma medication prior to surgery should have it confirmed whether any new medi- cation prescribed is in addition to, or instead of, the glaucoma medication.

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Before the patient is discharged, it should always be ensured thatall relevant eye medications, including any that the patient may have been on prior to any ocular surgery, have been prescribed.

General patient principles on eye medication

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The medical and nursing staff will tell the patient about the drops or oint- ment used.

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The nursing staff will instruct the patient on when and how to instil his drops and/or apply ointment safely.

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Staff should instruct the patient about the importance of hand washing be- fore and after instilling drops or applying ointment to help prevent infection.

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Staff must ask the patient about any current medication as this could affect the choice of treatment.

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Pharmacy and nursing staff should determine the best way to help the patient distinguish between the different types of drop bottles that have been prescribed.

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Nursing and medical staff should talk with the patient at each visit about how they are managing the drops or ointment regimen.

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Staff should advise the patient that devices are available for purchase to help with eye-drop administration. These include bottle attachments to help squeeze the bottle; those to help open the cap; and those to help the patient remember to take the next drop. Information on these devices is available in the hospital pharmacy or community pharmacy. The district nurse or practice nurse may also have the relevant information.

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The patient should be reminded that drops and ointments are pre- scribed for his use only. Drops and ointments should be stored according

to the manufacturer’s instructions, which in some cases will be in the refrigerator.

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As with all drugs, advise the patient that medications should be stored in a place out of reach of children and animals.

Special considerations for instilling eye medication in children Instilling any drops in children can be traumatic for the healthcare profes- sional, the child and parents. Be truthful if a child asks if the drops will sting.

Show the drops to the child and, if appropriate, allow the child to handle the drops. If instilling fluorescein drops, it is helpful to place a drop on the child’s hand to demonstrate the colour. Involve the child in the instillation of the drops by giving them some tissues to hold and instruct them to dab the eye after the instillation. If a child refuses to open her/his eyes, instil the drops in the inner canthus of the closed lid and when the child opens his/her eyes, hopefully some of the drops will slide in.

Post-operative eye care

The majority of post-operative ophthalmic patients attend for surgery as a day case and, as a result, may be taught to perform their own first dressing at home since some of these patients may not necessarily be reviewed the next day.

General principles

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The eye should be cleaned only if necessary, e.g. when discharge is present.

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Staff should instruct the patient about the importance of hand washing before and after carrying out any procedure to the eye.

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Cartella shields should be washed with soap and water if necessary. The shield should be stored dry.