Many practitioners overlook the power of coaching and educating their patients when it comes to the actual mechanics of drop instillation
Drop therapy is a mainstay of treatment for a number of ophthalmic conditions – from glaucoma to ocular surface disease to cataract/refractive surgery. Busy clinicians might spend time educating patients about their condition and why they are taking a certain topical medication, but are they talking to patients about how to correctly instill drops in the eye? If patients are unable to adequately use their medication, our treatment efforts have already failed.
When I see a patient who is taking drops for the first time or a patient who has been on a particular medication but without the expected efficacy, I make sure they are applying the drops correctly. I begin by saying, “This does not have to be challenging – instilling drops should be simple.”
First, I instruct patients to use a brace. This might be the opposite hand from the one holding the bottle or, if that is not possible, their cheek or forehead. Next, I tell patients to put a drop in the lower cul-de-sac. This is important to ensure they avoid hitting the bottle tip or the applicator on their cornea and causing an abrasion. Lastly, I tell them they do not need to flood the eye. One drop is all they need. Often people mistakenly think more is better, and we know that is certainly not the case with ocular medications.
Nasolacrimal occlusion and passive eyelid closure
If I am using nasolacrimal occlusion to reduce systemic absorption of the drop medication – for example, in the case of a beta-blocker – I instruct patients to use passive eyelid closure after the drop is dosed for one minute while using their index finger to occlude the puncta at the same time. I use a handout to illustrate the technique. Otherwise, I have them do passive eyelid closure for 60 seconds to ensure there is effective absorption to the target tissue. I tell patients to gently close their eyes, sit back, and let it absorb, reminding them not to rub their eye or move it all around. That is all there is to it; sometimes, we just need to demystify the process for them.
For patients who I believe might have a challenge – such as patients with Alzheimer’s disease, Parkinson’s disease, or arthritis – I ask them to instill a drop of artificial tears in their eye while they are in my office so I can see if they are successful. Watching the patient, helping with the correct hand motion, and giving them tips for proper administration can be very beneficial. My technicians do much of the coaching and education, and they will spend extra time with a patient who is new to drops, particularly if the patient has questions.
Drops are too big
A very common question from patients: “If some of the drop drips on my cheek, do I need to instill a second drop?” Well, the cul-de-sac, reservoir, and absorptive capacities of the eye is six to eight microliters, much smaller than the 35 to 50 microliter size of an average drop (1–3). It is well established that excess medication is linked to ocular and systemic toxicity (4,5). With prostaglandin analogues, for example, these effects include hyperemia, contact dermatitis, pigmentary changes, and periorbitopathy (6). As mentioned above, beta-blockers have cardiovascular activity; therefore, overflow leakage through the nasolacrimal duct with subsequent systemic absorption has the potential to cause bradycardia, respiratory depression, fatigue, and even impotence (4,5). Although patients will experience some overflow onto their cheek, it does not mean they need to instill another drop. I explain to patients that they do not want to flood their eyes with more medicine than they need.
Secondary adapters are available that fit onto bottles to help regulate the dose, make it smaller, and the drops easier to instill. Adapters can also make it easier for patients to hold a bottle over the bridge of their nose. Some examples of these include GentleDrop (BeDo Solutions), Nanodropper, and Eyenovia's OpteJet dispenser.
If the physician does not recognize that patients are struggling to properly instill their drops, it might be easy to assume the medication is not efficacious and therefore abandon the drop prematurely. There is a possibility that, due to poor technique, the doctor may under-appreciate the opportunity of a class of medicine. When I prescribe preservative-free products, I emphasize this feature to the patient and they often appreciate the option of drops coming in individual droppers, if available (see sidebar, Preservative-Free and Alternative Preservative Drops). Remember, however, that individual ampules cannot be used with an adapter.
Patients have many concerns around drops; questions range from their shelf life to proper storage, to what to do if the tip touches the eye. Safety of course is top of mind with recent cases of blindness and even death linked to illegal drops. I remind patients that branded products from trusted manufacturers undergo a rigorous development process and regulatory process for approval that includes studying safety and proper storage. In other words, it is exceedingly rare for issues to arise with FDA-approved products.
In short, I believe that it is incumbent upon physicians to answer all of patients’ questions – including those around instilling drops – and fully address their concerns. Any unresolved concerns could lead to compliance issues, so we should not shrug off these legitimate questions. Instead, it is our responsibility to ensure that patients feel comfortable with their drops from an overall perspective and trust they are safe for the long haul. Taking the time to instruct patients fully on proper drop use will likely improve their adherence and, in turn, result in better efficacy and outcomes.
Preservative-Free and Alternative Preservative Drops
The National Glaucoma Foundation estimates that half of patients on long-term glaucoma therapy suffer from ocular surface disease. It’s widely known that the common preservative benzalkonium chloride (BAK) is a major culprit. Prolonged use and multiple medications compound the issue.
Free of all preservatives:
- Zioptan (tafluprost ophthalmic solution 0.0015%; Merck/Thea)
- Cosopt PF (dorzolamide - timolol ophthalmic solution 2%/0.5%; Merck/Thea)
- Timoptic in Ocudose (timolol maleate ophthalmic solution 0.25% and 0.5%; Merck)
- IYUZEH (latanoprost ophthalmic solution 0.005%; Thea)
BAK-free products that use other preservatives aiming to reduce toxicity:
- Travatan Z (travoprost ophthalmic solution 0.004%, preserved with SofZia; Novartis)
- Alphagan P (brimonidine tartrate ophthalmic solution, 0.1% or 0.15%, preserved with Purite; Allergan, an Abbvie Company)
Generic versions of preservative-free Zioptan, Cosopt, Timoptic, and Alphagan P are also available.
Ocular surface disease
Artificial tears are the backbone of ocular surface disease treatment due to their wide availability, but it is critical that providers make a recommendation that is appropriate for each patient. For those who need to use drops more than four times a day, many recommend preservative-free artificial tears. For contact lens wearers, lubricating products specifically labeled for contact lens wear are the best option. Below are some popular brands:
- Systane (Alcon)
- Biotrue (Bausch + Lomb)
- Refresh (Allergan, an Abbvie Company)
- Blink (Baush + Lomb)
- iVIZIA (Similasan Corp)
Acquired blepharoptosis or ptosis (droopy eyelid) is a common finding among our patients. Traditionally, this was often overlooked and underdiagnosed due to a lack of noninvasive treatment options. That changed with the 2020 approval of the first topical agent to address the condition. The agent is preservative free, adding to its utility in our patients – particularly those with other ocular conditions.
Upneeq (oxymetazoline hydrochloride ophthalmic solution 0.1%, RVL Pharmaceuticals)
- N Washington et al., “Ocular drug delivery,” Physiological Pharmaceutics: Barriers to Drug Absorption, 2nd edition, 249, CRC Press: 2001.
- S Mishima et al., “Determination of tear volume and tear flow,” Invest Ophthalmol., 5, 264 (1966). PMID: 5947945.
- W Scherz et al., “Tear volume in normal eyes and keratoconjunctivitis sicca,” Albrecht Von Graefes Arch Klin Exp Ophthalmol., 192, 141 (1974). PMID: 4548323.
- C Izazola-Conde et al., “Ocular and systemic adverse effects of ophthalmic and non-ophthalmic medications,” Proc West Pharmacol Soc.,54, 69 (2011). PMID: 22423585.
- L Quaranta, “Effects of topical hypotensive drugs on circadian IOP, blood pressure, and calculated diastolic ocular perfusion pressure in patients with glaucoma,” Invest Ophthalmol Vis Sci., 47, 2917 (2006). PMID: 16799034.
Medical Director and Founding Partner at North Bay Eye Associates in Sonoma, California, and Director of the Glaucoma Division at the California Pacific Medical Center in San Francisco, California, USA. He reports that he is a consultant for Iridex.