How to instill eye drops and avoid contamination

February 15, 2017
Karen Bachman, COE, COMT, CCRC

Karen Bachman is practice administrator at The Eye Institute of Utah in Salt Lake City.
kbachman@theeyeinstitute.com

Eye drops and ointments are prescribed by doctors to treat acute or long-term ocular conditions. Drops and ointments are administered directly in the site of action and are therefore very effective in treating the diagnosed condition.

Eye drops and ointments are prescribed by doctors to treat acute or long-term ocular conditions. Drops and ointments are administered directly in the site of action and are therefore very effective in treating the diagnosed condition.

Proper instillation of drops or ointments is as critical as instructions for taking systemic medications. Ophthalmic staff and patients alike need to understand the proper technique for best delivery of the prescribed medication.

Previously in iTech: Minimally invasive surgical solutions for presbyopia

Explain, then instill

First, be courteous and explain to the patient what you are doing and what she will experience.

Are you instilling the drop to anesthetize the eye or to dilate? Will she feel a burning or stinging sensation? Will her vision be blurry after the drop is instilled?

Hand patient a tissue to blot away any excess drops

Next, follow these steps to instill the drops.

• Position the patient in a sitting position with head tilted back.

• Remove the cap from the bottle, and hold the dropper over the eye.

• Ask the patient to look up while gently pulling down the lower lid.

• Squeeze the dropper to release one drop into the lower cul-de-sac. Avoid applying pressure to the globe.

• Release the eyelid, and ask the patient to close the eye gently for 30 seconds to contain the drop. This allows even distribution of the eye drop, and prevents rapid clearance of medication caused by blinking.

• Placing more than one drop is a waste of the solution; the total capacity of the cul-de-sac is one-sixth of a drop.

Avoid touching the dropper to touch the conjunctiva, eyeball, eyelid, or eyelashes. If contact is made, the bottle is considered contaminated and should be thrown away. Be sure to firmly screw the top of the bottle back in place immediately after use.

Anesthetic drops are an exception to the method in which the patient looks up.

When instilling anesthetic drops, ask the patient to look down and direct the drop to the 12 o’clock position of the sclera.

This method is used because drops placed into the conjunctival sac are used to dilate the eyes or instill a medication to be in contact with the eye for a period of time. When instilling drops on the 12 o’clock scleral position, the patient will blink, closing the eyelids so the cornea goes underneath the upper lid (called Bell’s phenomenon or palpebral oculogyric reflex). This provides maximum coverage of the cornea with anesthetic.

Instilling ocular ointments is similar to instilling drops. Instill them in the lower conjunctiva sac by gently pulling the patient’s lower lid away, then placing the ointment directly from the tube into conjunctival sac. Place about a quarter-inch ribbon of ointment into the sac.

 

Patient drop instillation

We now know how to handle instillation of eye drops in our offices, but what about the patient?

Provide written detailed instructions with simplified language to patients.

Give an in-office drop instillation demo, then ask the patient to give it a try and offer feedback. If a family member accompanied the patient to the visit, suggest the family member try instilling the drops. An actual demonstration to instruct the patient on drop usage is especially critical if there is a language barrier between technician and patient.

One report shows that over 30 percent of patients miss the mark by placing drops on their eyelids or cheeks, over 70 percent touch the tip of the bottle to eyelashes, and only 25 percent comply with closing their eyes for a few moments after instillation. In addition, many patients squeeze out up to eight drops instead of one with each instillation.1

Be cognizant of any physical impairments that could impact patient compliance such as tremors or arthritis.  

Related: 4 steps to care for ophthalmic instruments

Contamination and hygiene

Drops contain preservatives to prevent bacterial growth during use. But preservatives cover only certain microorganisms. Good hygiene is required to prevent contaminated drops.

One study showed contamination in 44 percent of residues of eyedrops.2 Single-use containers have the advantage of continuous sterility, but they cost more than stocking larger sizes.

If contamination is suspected, err on the side of caution and discard the bottle.

Don’t forget to routinely check all drops for expiration date. Follow the expiration date on the label if the bottle is unopened. Manufacturers usually advise discarding open bottles 30 days after opening. Train your team to write on the bottle label the date it was opened.

Poor hygiene practices can lead to contaminated medication in the office as well as many illness, such as such as Salmonella, Campylobacter, methicillin-resistant Staphylococcus aureus (MRSA), flu, diarrhea, common cold, and impetigo.

Hand hygiene is a generic term that applies to handwashing, antiseptic hand wash, alcohol-based hand rub or surgical hand hygiene. Specific indications for hand hygiene are simple: Follow hygiene recommendations before and after patient contact to protect the patient and yourself.

Plain soap is good at reducing bacterial counts, but antimicrobial soap is better, and alcohol-based hand rubs are the best.3

Alcohol-based hand rubs may be a better option than handwashing with soap-less time because rubs act faster, less hand irritation, and less flow time. You don’t need to walk to a sink before taking care of the next patient. The time required can end up being a deterrent to frequent or proper handwashing.

The best hand rub technique is to apply the rub to the palm of one hand, and rub hands together covering all surface until dry. Make sure you allow the rub to dry.

Think about all you touch every day: doorknobs, toilet seats, animals, other people’s hands via handshake, and more. Germs live on almost everything. Handwashing is the most important act to help stop the spread of disease.

Evaluate your clinic to improve hygiene best practices by placing hand rubs at entrance to patient lanes and in clinic hallways for easy access. Provide staff with individual pocket sized containers as well.

References

1. Gupta R, Patil B, Shah BM, Bali SJ, Mishra SK, Dada T. Evaluating eye drop instillation technique in glaucoma patients. J Glaucoma. 2012 Mar;21(3):189-92.

2. Harte VJ, O’Hanrahan MT, Timoney RF. Microbial contamination in residues of ophthalmic preparations. Intern J Pharmaceutics. 1978(1):165-171.

3. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR. 2002 Oct 25;51.

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