While recovering from his vitrectomy, Professor Nathan Efron found his eye drop and ointment regimen to be a tedious episode during his personal journey of retinopexy, cryopexy, vitrectomy and IOL surgery.
Although eye care practitioners undoubtedly take great care in considering the right combination, dosage and application frequency of topical eye medications they prescribe, I suspect only scant attention is paid to the practicalities of how patients ought to go about instilling eye drops and ointments. We just take this for granted: of course, everyone knows how to do this… don’t they?
Well, in my case, and I suspect in the case of many patients, the answer is ‘no’. Having never had to self-administer eye drops or ointments before, I was at a total loss as to how to do this. Not only did I have to develop techniques for getting these medications into my eye, but I also had to deal with sometimes complex logistical arrangements for instilling different drops at different frequencies.
Recipe for Confusion
Following both my initial vitrectomy and revision procedure, I was sent home with the following panoply of concoctions:
I had so set up nine iPhone alarms throughout the day…
To avoid confusion, I drew up a schedule listing what drops I had to take at what time. What a palaver!
- Paracetamol/Codeine (500/9.6mg) – two tablets every four hours while
- Isopto Homatropine 2 per cent eye drops (Alcon) – four times per day for one week.
- Prednefrin Forte eye drops (prednisolone acetate 10mg; phenylephrine hydrochloride 1.2mg per 1 ml) (Allergan) – four times per day for eight weeks.
- Azopt 1 per cent eye drops (Brinzolamide 10mg/ml) (Alcon) – twice per day for four weeks.
- Tobrex ointment 0.3 per cent (Tobramycin 3mg/ml) (Alcon) – four times per day until tube is empty.
- Lacri-Lube eye ointment – four times per day after ceasing Tobrex, as required.
Various guidelines need to be borne in mind when using eye drops and ointments, including ‘use by’ dates and ‘expiration after opening’ time frames. The order that these medications are applied may be pertinent; I was advised to apply ointments last. Some eye drops need to be shaken vigorously immediately before use; Prednefrin Forte, which has elements of the formulation incorporated as a suspension, is a case in point.
Most of these medications were to be taken four times a day. So I set four alarms on my iPhone, for 8am, noon, 4pm and 8pm. That part was easy. However, one of the few instructions I did receive about instilling drops and ointments was to wait at least three minutes between applications to avoid flooding my eye. That means at least nine minutes to instil all medications. I found this to be a tedious intrusion into my day.
My eye medication regimen became more complex during the recovery period following my first vitrectomy.
My intraocular pressure had dropped to two mmHg and I had a hyphaema and flare in my anterior chamber. Appropriately, I was advised to cease taking Azopt but increase the frequency of Prednefrin Forte to six drops per day. This meant I had so set up nine iPhone alarms throughout the day. In the following sequence, the asterisk symbol* indicates the time to instil Prednefrin Forte, and the sword symbol† indicates the time to instil the other medications: 7am*, 8am†, 10am*, noon†, 1pm*, 4pm*†, 7pm*, 8pm† and 10pm*. To avoid confusion, I drew up a schedule listing what drops I had to take at what time. What a palaver!
The Efron Technique
Suzanne was kind enough to instil my eye drops and apply my ointments first thing in the morning. It can be very useful having a wife who is a therapeutically-endorsed optometrist! But after Suzanne headed off, I was left ‘home alone’, having to devise my own technique for getting these medications into my eye.
I found the most difficult aspect was avoiding the natural aversion blink reflex when a huge liquid eye drop is heading straight for your eyeball. Yes, I know the advised technique is to pull down your lower eyelid and insert the drop there, but I found this really hard. You can’t work out exactly where the dropper is relative to your everted lower lid when looking directly upwards. I found numerous instructional video clips on eye drop instillation on YouTube, but none were very helpful. So I had to develop my own technique, and you might find this useful when instructing others how to self-administer eye drops…
Basically, I developed a two-handed technique, as shown in Figure 2. This sequence depicts instilling drops into my right eye from a dropper held in my right hand (after washing both hands first, of course). Rest the left hand on the cheek below the right eye and gently pull down the lower lid with the left index finger, while looking directly ahead into a mirror (2A). Hold the dropper between the thumb and index finger of the right hand and bring that hand to rest on the back of the left hand (2B), pointing the dropper horizontally and directly towards the lower canthus (2C) (you may need to turn your head slightly to the side to confirm alignment of the dropper with the lower lid). Fix both hands and head as a single unit, and tilt your combined head-hands unit back (2D&E) until you are looking directly upwards (2F). At this point, the dropper will be directly and vertically aligned with your lower canthus. Simply squeeze the dropper to instil the drop.
I found that with a little practice, this technique worked almost every time!
I quickly discovered that an entirely different but much simpler approach was required for applying ointments. My first few attempts at applying ointment were thwarted by the peculiar way in which ointment oozes from the tip of the tube. I found that when I squeezed the tube slowly, the ointment tended to curl back on itself, leaving a big blob of curled up ointment on the tip of the tube. When I tried to touch this blob of ointment onto my lower lid, the ointment didn’t seem to want to release. That is an unacceptable approach anyway, as it is important to avoid contact of the tip of the dropper or ointment tube with the eye or lids to prevent contamination. Nevertheless, I tried to coax the ointment into my lower cul-de-sac, but ended up with ointment everywhere except in my eye. Again, I needed to develop a viable technique…
The solution was surprisingly simple. I would adopt the same posture as per Figure 2A-C, but instead of tilting my ‘head-hands’ unit backwards, I quickly and forcibly squeezed the ointment tube, resulting in a linear stream of ointment shooting into my lower canthus. Although this technique can result in more ointment entering the eye than intended, at least the ointment ended up in the designated location! Anyway, there seemed to be enough ointment in the tube to last for a week using my ‘explosive burst’ technique.
While some of my topical eye medications only needed to be applied for the first week after surgery, Azopt and Prednefrin Forte eye drops had to be used post-surgically for four and eight weeks, respectively. Of course I understand the reason for this, but nevertheless, instilling eye drops four times a day for eight weeks is a long time, and quite an intrusion into one’s lifestyle. I stayed at home for two weeks following my revision vitrectomy surgery, and taking these medications while domiciled was not really a problem. Having to remember to apply the drops at work and when going about leisurely activities on the weekend for the next six weeks was the problem!
I guess the whole point of this particular blog is that, as eye care practitioners, we shouldn’t take for granted the potential difficulties regarding the use of eye drops and ointments that confront our patients. Instilling eye drops and ointments into another person’s eye is easy. We do it all the time in routine clinical practice. We could do it in our sleep. But self-administration of eye drops and ointments – in terms of application technique, logistical organisation and lifestyle intrusion – can be a real challenge, as this professor of optometry found out.
Professor Nathan Efron is a researcher at the Institute of Health and Biomedical Innovation and School of Optometry and Vision Science, Queensland University of Technology. He is currently president of the Australian College of Optometry and vice-president of the International Society for Contact Lens Research.