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Keywords: Medicines administration/ Nursing Practice drops/Ointment Practice educator ●This article has been double-blind Medicines management peer reviewed The administration of topical eye medications must be given the same priority and attention to safety as drugs administered by the systemic route How to administer eye drops and ointments

Learning points... 5 practice Why eye drops and ointments are prescribed points Eye drops Complications with the administration of these topical drugs 1and ointments Procedure for administration of eye drops and ointments are prescribed to treat acute or long-term Author Mary Shaw is senior lecturer at For patients to gain maximum thera- eye conditions University of Manchester. peutic effect, it is imperative that topical Topical eye Abstract Shaw M (2014) How to eye medication is given the same priority 2medications administer eye drops and ointments. as medications that are administered sys- are subject to the Nursing Times; 110: 40, 16-18. temically. The standards governing the same standards Eye drops and eye ointments are the main administration of topical eye treatments as drugs given treatment for most eye conditions and after are exactly the same as those covering by other routes eye surgery or surgery to the periocular other routes of administration; profes- Interactions structures. This article outlines the role sional guidance on the administration of 3can occur nurses play in ensuring the safe adminis- medicines is available from both the between different tration of topical eye medication and that Nursing and Midwifery Council (2010) and types of eye drops patients adhere to their treatment regimens. the Royal College of Nursing (2013). and also with Nurses, patients and carers need a good drugs delivered he are a vital part of the cen- knowledge and understanding of the ther- by other routes tral nervous system. They convert apeutic effects and potential side-effects Systemic light into electrical impulses that of the topical drugs they administer. They 4absorption Tare transmitted to the occipital must also be familiar with potential drug of eye drops and region of the brain, where they are inter- interactions that can occur between dif- ointments occurs preted into meaningful images. The eyes ferent types of eye drops and ointment, via the conjunctival enable us to navigate our environment, see and also between these and drugs delivered blood vessels or fine detail, interpret colour, and maintain by any other route (Andrews, 2006) – as an the nasal mucosa our health and safety while performing example, eye drops may interact everyday activities. However, little atten- with insulin. 5dispensing tion tends to be paid to the eyes or their sur- aids can help rounding structures until something goes Administering drops and ointment patients to wrong with them; Marsden and Shaw (2003) Eye drops and ointment should be admin- self-medicate highlighted health professionals’ lack of istered: understanding of eye conditions. » At the correct time; » In the correct strength; Administration principles » Via the correct route; Eye drops and ointment are prescribed to » To the right person; treat acute or long-term eye conditions » Into the correct eye. and/or the structures surrounding eyes. Some eye drops have a long-acting effect They are the mainstay of treatment for eye on the so it is vital they are instilled disease as they are administered directly to into the correct eye. For example, atropine their site of action and are, therefore, more 1% makes the eye light sensitive as the pupil effective than medications administered will not contract in bright light. Adminis- orally. They are also used to prevent or treat tration procedures are stated in Boxes 1 and 2. or inflammatory conditions and, It is vital to establish the patient is not in some instances, are used to relieve dis- allergic to any of the eye drops or ointment comfort or to prevent damage, such as ingredients. Before instilling these, the eye with dry-eye treatment (Marsden, 2007). and should be examined for signs

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FIg 1. instillation of FIg 2. close tear duct FIg 3. eye drop eye drops dispenser

of improvement or deterioration. In case of tion (www.-association.com) has the same quantities. This may cause sensi- the latter, medical help should be sought developed a compliance briefcase that tivity, resulting in sore eyes. If this occurs, without delay. contains samples of most types of eye drop the proprietary item may be dispensed. aids and provides these free of charge to It should be noted that generic bottles Systemic absorption eye units in the UK. are not a uniform size and, as a result, the Systemic absorption (SA) of eye drops and drop size itself may be larger. This can ointments occurs via the conjunctival Generic eye drops result in the drug not lasting as long as the blood vessels or the nasal mucosa. This is a Many eye drops are now off licence and a proprietary brand. particular issue when drugs such as beta- generic product may be prescribed. Generic blockers are prescribed (Marsden, 2007). preparations are generally cheaper than Safety considerations For example, the beta-blocker timolol can proprietary products; they usually contain After administration of eye drops or oint- cause bronchoconstriction, , the same ingredients but not necessarily in ments, patients must be advised against bradycardia, nausea, diarrhoea, anxiety, depression, hallucinations and . Box 1. Procedure for instilling eye drops These effects can be reduced through the use of punctual occlusion (keeping the eye ● Position the patient comfortably, either sitting or lying down (semi-prone or closed for a slow count of 60) after adminis- recumbent) with the head supported tration. Alternatively, the patient can apply ● Wash hands before and after instilling eye drops to prevent cross infection and to digital pressure to the tear drainage system remove drug residue from the hands at the nasal corner of the closed eyelids (Fig ● Some local policies require that non-sterile gloves are used when instilling eye 2). These techniques minimise the amount drops or ointment and that an aseptic non-touch technique is used for first post- of drug being taken into the nasolacrimal operative dressing and application of eye drops (Shaw et al, 2010) system and into the systemic circulation. ● Cleaning the eye may be required, for example when there are crusty or purulent In a theatre setting or when the eye is deposits on the eyelids. Clean the lids with non-woven or cotton wool swabs dipped thought to have been lacerated or pene- in cooled boiled water or sterile (cotton wool is contraindicated when trated, preservative-free eye drops must be there are sutures on the skin) used to stop potentially sight-threatening ● Establish that you have the correct eye drops and that they have not expired complications. The preservative will cause ● Gently agitate the bottle before use to make sure the drug is properly mixed intraocular irritation and inflammation. ● Warn the patient the drops will sting transiently when administered (Andrews, 2006) Eye ointment, if prescribed for the eye ● Instil the eye drop into the space (fornix) created by gently pulling down the lower itself, should be applied into the lower lid (Fig 1) fornix in a strip of approximately 5mm. If ● Ask the patient to look up – this helps to ensure the eye drop does not land directly prescribed for treating the eyelids, care onto the sensitive cornea should be taken to ensure the ointment is ● Once the eye drop is instilled, release the , using a tissue or swab to dab any not be placed in the eye itself. excess from the cheek ● Avoid holding the tissue too close to the eye, to prevent the drug wicking away Eye drop dispensing aids from the eye Eye drop dispensing aids (Fig 3) can help ● Where multiple drops and/or ointment are prescribed for one or both eyes, the patients to self-medicate and become inde- order of administration is important to ensure maximum therapeutic effect of each pendent in managing their own condition, (Andrews, 2004) (see Table 1) particularly when it is long term, such as ● Only one drop of each drug is required; more than this will create overflow onto the open-angle glaucoma. The dispensing aid cheek. Ideally, five minutes should elapse between administration of a different eye must match the patient’s needs and must drop to achieve maximum therapeutic effect (Andrews, 2006) also fit the eye drop bottle. When patients Closed eye technique are prescribed several different eye drops, Alster et al (2000) recommended a technique for patients who find it difficult to have they will need an aid for each bottle. drops instilled directly into the eye, for example, children or older people: Eye drop aids are available on prescrip- ● Ask the patient to lie flat or with their head tilted back tion but some pharmaceutical companies ● Administer a drop of the medication onto the closed eyelid in the nasal corner provide them free of charge for their prod- ● Ask the patient to open the eye and close it gently once the drug has entered it ucts. The International Glaucoma Associa-

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Box 2. Procedure for Table 1. Order of eye drop/ointment applying eye ointment administration

● Establish what the eye ointment has Order Drug been prescribed to treat – it may be for A Local anaesthetics Mydriatics and cycloplegics structures other than the eye, such as ● Oxybuprocaine hydrochloride ● Atropine an eyelid wound ● Proxymetacaine ● Cyclopentolate ● Wash hands before and after ● applying ointment, to prevent cross Miotics ● Tropicamide infection and to remove drug residue ● (eye drops) ● Some local policies require that B Sympathomimetics Tear deficiency products non-sterile gloves are used when ● Phenylepherine ● Acetylcysteine instilling routine eye ointments and that ● ● Carbomers an aseptic non-touch technique is used ● ● Hydroxyethylcellulose for the first post-operative dressing ● ● Hypromellose and application of eye ointment (Shaw ● Polyvinyl alcohol et al, 2010). ● Sodium chloride ● If prescribed for the eye itself, instil a C Non-steroidal preparations Steroids thin ribbon of the ointment into the ● Diclofenac ● Betamethasone lower fornix then ask the patient to ● ● close the eye ● Fluorometholone ● The ointment may take a few moments ● to melt and spread over the eye. Initially, it may cause some blurring of the vision D Carbonic anhydrase inhibitors ● Wipe the excess from the eyelids ● Cefuroxime ● ● Normally, when a patient is ● (eye drops) analogues prescribed eye ointment, it is necessary ● ● Bimatoprost to clean the eyelids before the next ● ● Latanoprost treatment is applied ● Gentamicin ● ● If patients are applying their own ● Neomycin ● Travoprost ● Penicillin ointment but find the ribbon technique Ointments awkward, suggest they squeeze a blob ● Acyclovir of the ointment into the lower fornix ● Miconazole ● Atropine Anti-inflammatory ● Betamethasone ● ● Chloramphenicol driving or operating machinery until their ● Lodoxamide ● Chlortetracycline vision has cleared and/or their eyes have ● Sodium cromoglicate ● Gentamicin stopped stinging. Beta-blockers ● Hydrocortisone Correct medication storage is essential. ● Betaxolol ● paraffin Some eye drops, such as chloramphenicol, ● Carteolol ● Pilocarpine must be stored in a refrigerator before and ● after opening while others are stored in the ● refrigerator after opening only – it is impor- ● Timolol tant to read the instructions carefully. In hospital settings, eye drops should Source: Andrews (2004) be discarded after seven days and replaced if the treatment continues. In non-hospital ensure the drugs are used at the correct Administration. Manchester: Central Manchester FT. Marsden J (2007) An Evidence Base for settings, drop bottles should be replaced time and in the correct order (Table 1), with Ophthalmic Nursing Practice. Chichester: Wiley. every 28 days (Andrews, 2006). an appropriate time lapse (ideally five min- Marsden J, Shaw M (2003) Correct administration utes) between drugs when more than one is of topical eye treatment. Nursing Standard; 9: 17, Documentation prescribed. One drop of each drug is suffi- 42-44. Nursing and Midwifery Council (2010) Standards The drugs administered should be docu- cient and action should be taken to ensure for Medicines Management. tinyurl.com/ mented accurately in patients’ notes in the risk of adverse systemic absorption is NMCMedsManagement accordance with local and national guid- minimised. Drop-dispensing aids can be Royal College of Nursing ( 2013) Better Medicines Management: Advice for Nursing Staff and Patients. ance, and nurses should also evaluate the used to enable patients to become self-suffi- London: RCN. tinyurl.com/RCNBetterMedsManage effect of treatment (RCN, 2013; NMC, 2010). cient with eye drop administration. NT Shaw ME et al (2010) Ophthalmic Nursing. Chichester: Wiley-Blackwell. Conclusion References Alster Y et al (2000) Intraocular penetration of Nurses, patients and carers must have an vancomycin eye drops after application to the For more on this topic go online... up-to-date knowledge and understanding medial canthus with closed lids. British Journal of Patient support to reduce risk of of the therapeutic effects and potential Ophthalmology; 84: 3, 300-302. diabetic retinopathy side-effects of the topical drugs they are Andrews S (2006) Pharmacology. In: Marsden J. Ophthalmic Care. Chichester: Whurr Publishers. Bit.ly/NTRetinopathyRisks using for eye conditions. They should also Andrews S (2004) Order of Eye Drop/Ointment

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