Instilling Eye Drops

Article written by Dr Richard L Cooper, Ophthalmologist, Launceston, Tasmania

In order to lower pressure in an eye, as with a tyre or balloon, you can cut down the flow of fluid into the eye or of air into the tyre or balloon. Alternatively the eye’s fluid drain can be opened up or in the case of a tyre the valve can be pressed to release the air. Some of the latest eye drops lower eye pressure very efficiently indeed by both reducing the amount of fluid getting into the eye and by helping the fluid to leave the eye. The glaucoma pressure lowering drugs are used mainly as eye drops, occasionally as tablets and capsules or sometimes as injections in an emergency situation.

Eye drops are usually quite difficult to put into the eye. Even the most agile person takes time to become used to the technique. There are some special applicators available for those with weak or stiff wrists and hands or for those with bad tremor or trembling hands. These are often available from chemists.

There are several methods for getting drops into the eye. Some people lie down, while others sit or stand. Some find leaning against a wall or a door helpful and others use a mirror. The lower eyelid can be gripped and pulled out like a small pouch. While the eyes look up a one drop dose is dropped into the eyelid "pouch". The eyes should then be closed gently. You should have a clean tissue or handkerchief handy to carefully mop up any excess drops or tears that will spill onto the cheek.

Figure 1. Try to hold your forefinger on the corner of the eye, gently pressing against the nose so as to stop the drops going down the tear ducts into the nose. It is important to keep the eye gently closed for at least two minutes.

While the eye is closed after each drop, gentle pressure with one finger against the nose in the inner corner of the lids, for at least two minutes will help prevent the drops from going down the tear ducts into the nose, from where the drugs get into the blood stream and cause side effects. Keeping the eye closed also increases the amount of drug getting into the eye, simply by reducing the amount being lost down the tear duct.

Another way of getting the drops in, described by ophthalmologist, Dr Nigel Morlet from Perth, Western Australia, is by holding the bottle upside down between the thumb and middle fingers with the index finger touching the bottom of the bottle.

Figure 2. The bottle is held upside down, and the forefinger can be used on the bottom of the bottle to press it if squeezing is difficult.

The bottle is then placed on the forehead with the thumb between the bottle and the forehead as shown below. You should be able to see the end of the dropper bottle straight ahead.

Figure 3. With the thumb nail on the forehead, you should be able to see the tip of the bottle straight ahead.

You should then gently pull the lower lid down.

Figure 4. Tilt the head back and gently pull the lower lid down as you watch the tip of the bottle. You may have to move the bottle up the forehead.

As you look up with your head tilted back or while you look at the ceiling if you prefer to lie down, you will still see the end of the bottle’s dropper straight ahead, as an outline. Sometimes you will have to adjust the position of the thumb nail on the forehead so that the drop falls into the eye. You may press the end of the bottle with the index finger or you can squeeze the bottle between the thumb and third finger. With a bit of practice the drop should land in the eye. Often your ophthalmologist will have some sample bottles of artificial tears for practice, or they can be bought over the counter. Because they are harmless you can use these frequently in order to get the method right.

The eye is able to hold only a small amount of eye drop solution, so usually some will be lost from the eye on closing the lids. If you are not sure if the dropping has been successful, put another drop in immediately. Some drops do not sting, in which case storing them in the ordinary part of the refrigerator will let you feel the cold drop as it touches the eye. Always wait at least five minutes between each type of drop. We often find that patients (or the doctors and nurses!) do not remember this. Drops will be diluted or washed out if the drops are put in immediately after each other.

If you forget a drop during the day it is safe with most drop types to put an extra one in as soon as you remember and to continue at the normal evening times. With timolol (Timoptol, Tenopt), laevobunolol (Betagan), betaxolol (Betoptic) and any other "beta-blocker" drops, it is probably better to put one in immediately you remember and then again the next morning rather than an extra drop in the evening because they are very powerful and can cause side effects.

Drops must be spread as evenly around the waking hours as possible. Some patients have been known to take all their drops for the day within a half an hour to get it over with, so as not to interrupt their routine! This is not a good thing and results in the eye pressure usually being out of control for most of the day. You must try to keep to a routine. The time between each drop has been worked out for each drug, based on how long each controls the pressure. You do not have to get up in the middle of the night to put the drops in unless your eye specialist tells you to do so.

The best time to start the drops is when you wake up, because in most people, this is when the eye pressure starts to rise. If you are having twice a day drops, the next one would go in twelve hours later, or as near to twelve hours as possible. Occasionally a drop such as latanoprost (Xalatan) has to be used only at night, so put this one in at bedtime.

It is useful to have a chart written out with the days of the week so that the drops can be ticked off. It is generally getting easier nowadays because the newer types of drop are longer-acting than previously, and do not have to be used more often than twice or even once a day.

If you experience itching of the eyelids, soreness, burning or a feeling as though something is in the eyes all the time, you may be developing an allergy to the drops. Allergies can occur at any time, not necessarily as soon as you start the drops. Secondly you can become allergic to the preservative or antiseptic used in the drops, not to just one type of drug. The treatment for this problem is usually to stop the drop and see your family doctor or eye specialist immediately so that an alternative drop can be prescribed.

Reference

Morlet N and Kelly M. Improving drop administration by patients. Journal of Ophthalmic Nursing and Technology. 1996; 15: 60-64.

Morlet N, Kelly M, Morlet GC. A method of drop administration. Ophthalmic Surgery and Lasers. 1997; 28:

These articles cannot be reproduced without the prior consent of Glaucoma Australia Inc.