Proper Dropper

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.