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An Improved Technique for Glaucoma Eye Drop Administration

Submitted by dave on Fri, 05/15/2009 - 2:40pm
 
 
An Improved Technique for Drop Administration
for Patients with Limited Vision
Robert Ritch, MD1,2
Karim N. Jamal, BA1
Rabia Gurses-Özden, MD1
Jeffrey M. Liebmann, MD1,2 
 
From the Departments of Ophthalmology, 1The New York Eye and Ear Infirmary, New York, NY, and 2The New York Medical College, Valhalla, NY. 
Mr. Jamal’s present address is The University of Texas Southwestern Medical Center at Dallas, Dallas, TX 
Running title: Ritch / Drop administration 
Supported in part by the Albert and Audrey Pekelny Research Fund of the New York Glaucoma Research Institute, New York, NY, and the ARVO/Weisenfeld Albert G. Mosler Student Fellowship Grant Program (Karim N. Jamal). 
Correspondence: Robert Ritch, M.D., Professor and Chief, Glaucoma Services, and Surgeon Director, The New York Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003
Tel: (212) 673-5140  FAX (212) 420-8743
No financial interest 
 
Abstract

 

Purpose: To describe a new, highly accurate, tactile technique to increase accuracy in the self-administration of eye drops.
Methods: Ten patients with loss of fixation (£20/400) in one eye and ten patients with loss of fixation in both eyes instilled one drop of artificial tears in each eye using the method normally employed at home. The time required to instill each drop, the number of drops squeezed from the bottle, and location of the drops’ landing points were recorded. The patients were then instructed in a new technique for instillation, guided through the procedure once, and allowed to practice until comfortable with it. All measurements were then repeated.
Results: In patients with loss of fixation in one eye, an additional 3.2 ± 4.1 sec were required to instill a drop using the new method (p<0.0001, paired t-test; range, -7 to 18 sec). The mean number of drops dispensed decreased by 0.1 ± 0.6 drops (p = 0.60, paired t-test; range, -2 to 1 drop). The accuracy of drop placement increased from 80.0% to 82.5%. In subjects with loss of fixation in both eyes, using the new method increased the time needed to instill a drop by 3.8 ± 3.8 sec (p<0.0001, paired t-test; range, -3 to 13 sec). The average number of drops dispensed decreased by 0.1 ± 0.6 seconds (p= 0.25, paired t-test; range, -2 to 1 drop). The accuracy of placement increased from 63.0% to 85.0%.
Conclusion: This method of drop instillation should be beneficial for patients in terms of efficacy, cost, and safety.
 
Introduction

 

      Correct instillation of eye drops is crucial for successful treatment of eye disease. Many patients have difficulties instilling eye drops, especially patients with loss of fixation, who cannot see the tip of the bottle. These patients may turn to harmful techniques, such as touching the dropper tip to the eye, or wasteful ones, such as feeling the sensation of drops hitting the eye or lower lid.1 Non-compliance may become an issue as well, resulting from a combination of poor drop administration and frustration. The frustration stems from an inability to see the bottle tip.
      We describe a new method of drop instillation which increases the accuracy with which eye drops are dispensed, thereby decreasing the incidence of harmful techniques, and possibly increasing compliance. 
Methods 
      Two groups of patients were used in this study, those with loss of fixation (£20/400) in one eye and those with loss of fixation in both eyes. Using the method employed at home, the patients were asked to instill one drop of artificial tears in each eye. To remove the bias created by chance, the patient was requested to repeat the procedure. The time required to instill each drop, the number of drops squeezed from the bottle, and location of the drops’ landing points were recorded. Time was measured from the point the subject had the uncapped bottle in hand until the patient believed one drop had successfully been instilled into the eye. 
The patients were then instructed in a new instillation method:
  1. The patient can be seated or lying down.
  2. Hold the bottle between the thumb and index finger of one hand.
  3. Using the other hand, grasp the center of the lower lid with the ipsilateral index finger and pull the lid down. It is important that the index finger be bent at a right angle at the middle knuckle (proximal interphalangeal) (figure 1).
  4. While holding the bottle, place the second knuckle of the thumb (interphalangeal joint) against the first knuckle of the index finger (metacarpophalangeal joint) holding the lid down. The hand holding the bottle should be perpendicular to the hand holding the lower lid (figure 2).
  5. Slide the second knuckle of the thumb slowly towards the eye along the index finger of the other hand, using the finger as a guide. Stop once the thumb rests upon the second knuckle of the index finger (figure 3).
  6. Tilt the head back and look up at the ceiling. The dropper tip should be aimed downward (figure 4).
  7. At this point, the bottle tip should be directly above the eye. Without moving the position of the hands, squeeze until a drop falls into the eye.

 

After the method was verbally explained, patients were guided through the procedure once, and allowed to practice it until comfortable. All measurements were then repeated. The three variables were compared using Microsoft Excel software. 
Results 
      Twenty patients (10 with loss of fixation (£20/400) in one eye and 10 with loss of fixation in both eyes) were enrolled. The mean age was 70.0 ± 17.0 years (range 28 to 91 years).
      In patients with unilateral loss of fixation, an additional 3.2 ± 4.1 seconds were necessary to instill a drop using our method (p< .0001, paired t-test; range, -7 to 18 seconds). The mean number of drops dispensed decreased by 0.1 ± 0.6 drops (p = 0.60, paired t-test; range, -2 to 1 drop). The accuracy of these patients increased from 80.0 % to 82.5% (table 1).
      In subjects with bilateral loss of fixation, using the new method increased the time needed to instill a drop by 3.8 ± 3.8 sec (p<.0001, paired t-test; range, -3 to 13). The average number of drops dispensed decreased by 0.1 ± 0.6 (p= 0.25, paired t-test; range, -2 to 1 drop). The accuracy of drop placement increased from 63.0% to 85.0% (p=0.001, paired t-Test) (table 2). 
Discussion 
      The accurate use of eye drops is crucial to the clinical management of eye disease, particularly chronic disease such as glaucoma. Difficulty instilling drops properly can often lead to poor compliance.1-3 Patel and Spaeth4, 5 stated that two significant factors influencing compliance were inconvenience and unaffordability. In a study of 200 patients, 57% had problems with instillation, the most common difficulties being keeping the hand steady, directing the bottle correctly, and poor visibility of the bottle tip.1 In another study, 49% of patients said they had “difficulty aiming” the bottle, while 36% of patients said they had problem associated with poor vision.6
      Poor technique may also be potentially harmful. In an observational study of eye drop administration, Kass et al7 reported that 26.3% of patients touched the dropper tip to the globe, and that 23.3% touched the tip to the eyelids and/or eyelashes. Hosoda et al8 found that 54.9% of patients touched either the eyeball or periocular tissue with the container tip. Another study reported 63% of patients touching the eye with the dropper tip.5
      Inaccuracy, leading to drop wastage and increased expense, is another problem. When observed, over 48% of patients dispensed two or more drops, while 24% dispensed three or more drops per eye per treatment.7 The mean number of drops reaching the conjunctival sac per treatment was 1.98 ± 1.87.7
      In a series of 141 patient interviews, over 20% of patients indicated that they were partly or totally dependent on others for drop administration.9 In another study, up to 70% of patients could not hit the eye with an eye drop from a conventional bottle.2 Burns and Mulley10 reported that less than 33% of patients over age 75 applied drops themselves, and that one-third of patients who relied on others to instill drops lived alone. They also estimated that nearly 50% of patients who self-administered drops were unlikely to succeed in instilling the drop into the conjunctival sac. Few of these patients had been prescribed aids or appliances to improve their eye-drop application technique.
      A number of positioning aids have been developed to assist in eye drop instillation. Devices such as plastic molds for empty eyeglass frames11 sprays,12 holes drilled into eyeglass lenses to fit bottle tips,13, 14 an angulated dispensing tube,15 a modified cone with a hole on the top to accommodate the bottle tip,16 and a mirrored positioning aid,17 as well as mass-produced compliance aids such as Ophthalmic Rods,18 Easidrop,19 Autodrop,5 Autosqueeze, and Opticare20, 21 have been unsuccessful for a variety of reasons, such as improper device alignment over the eye, physical inability to properly operate the device, and continued difficulty visualizing the dropper tip. Techniques for steadying the hand22 and application of drops to the medial canthus23 have also been described. In some cases, if multiple medications are prescribed, separate devices may be needed for each bottle.24
      Our method of drop instillation addresses several of the problems that arise from improper technique. The use of proprioception instead of vision allows patients with decreased visual acuity to take their medication accurately. When executed correctly, it ensures that the dropper tip does not touch the globe or periocular tissue, reducing the chances of contamination or corneal abrasion. Finally, since this is a self-administrative technique, there is a decreased dependence on the presence of others to instill eye drops.The use of this technique should lead to decreased frustration and increased compliance. The increase in accuracy should also directly decrease the amount of wasted drops, thereby having a significant economic impact.  
References 
1. Winfield AJ, Jessiman D, Williams A, Esakowitz L. A study of the causes of non-compliance by patients prescribed eyedrops. Br J Ophthalmol 1990;74:477-480. 
2. Brown MM, Brown GC, Spaeth GL. Improper topical self-administration of ocular medication among patients with glaucoma. Can J Ophthalmol 1984;19:2-5. 
3. Donnelly D. Instilling drops: difficulties experienced by patients following cataract surgery. J Adv Nurs 1987;12:234-235. 
4. Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthalmic Surg 1995;26:233-236. 
5. Busche S, Gramer E. Improved eyedrop administration and compliance in glaucoma patients. A clinical study. Klin Monatsbl Augenheilkd 1997;211:257-262. 
6. Williams A, Winfield A. Topical medication for eye patients. Nursing Times 1990;86:42-43. 
7. Kass MA, Hodapp E, Gordon M, et al. Patient administration of eyedrops. II.  Observation. Ann Ophthalmol 1982;14:889-893. 
8. Hosoda M, Yamabayashi S, Furuta M, Tsukahara S. Do glaucoma patients use eye drops correctly? J Glaucoma 1995;4:202-206. 
9. Kass MA, Hodapp E, Gordon M, et al. Patient administration of eyedrops: I.  Interview. Ann Ophthalmol 1982;14:775-779. 
10. Burns E, Mulley GP. Practical problems with eye-drops among elderly ophthalmology outpatients. Age Ageing 1992;21:168-170. 
11. Wisher S. An assistive eye-drop mold. Am J Occupational Ther 1991;45:751-752. 
12. Mansour A, Aswad MI, Traboulsi EI. Spraying topical ophthalmic preparations. Am J Ophthalmol 1984;97:245. 
13. Freeman MI. A method for delivery of ocular medications. Ophthalmology 1979;86:1202. 
14. Tennant J. Instillation of eyedrops (corresp). Am J Ophthalmol 1979;87:104-105. 
15. Overaker RF, Dodge BC, Epstein D. A new eyedrop dispensing bottle. Am J Ophthalmol 1999;128:368-370. 
16. Sheldon GM. Self-administration of eyedrops. Ophthalmic Surg 1987;18:393-394. 
17. Ritch R, Astrove E. A positioning aid for eyedrop administration. Ophthalmology 1982;89:284-285. 
18. Gwon A, Borrmann LR, Duzman E, et al. Ophthalmic rods. New ocular drug delivery devices. Ophthalmology 1986;93:82-85. 
19. Rivers PH. Compliance Aids—do they work? Drugs and Aging 1992;2:103-111. 
20. Corlett A. Aids to compliance with medication. Br Med J 1996;313:926-929. 
21. Averns H, Hall J, Webley M. Role of opticare eye drop delivery system in patients with rheumatoid arthritis. J Rheumatol 1999;26:2615-2618. 
22. Morlet N, Kelly M, Morlet GC. A method of drop administration. Ophthalmic Surg Lasers 1997;28:687-689. 
23. Loewenstein A, Bolocinic S, Goldstein M, Lazar M. Application of eye drops to the medial canthus. Graefes Arch Clin Exp Ophthalmol 1994;232:680-682. 
24. Law S. Development and Utilization of the Eyedropper Adaptation Device: An example of interdisciplinary cooperation. Home Healthcare Nurse 1987;5:50-51. 
 
Figure legends 
Figure 1. The patient grasps the center of the lower lid using the index finger of the nondominant hand and pulls the lid down. The index finger is bent at a right angle at the middle knuckle (proximal interphalangeal).
Figure 2. While holding the bottle, the second knuckle of the thumb (interphalangeal joint) of the dominant hand is placed against the first knuckle of the index finger (metacarpophalangeal joint).
Figure 3. After sliding the second knuckle of the thumb slowly towards the eye along the index finger, the thumb rests upon the second knuckle of the index finger.
Figure 4. The patient’s head is tilted back, the dropper tip is aimed downward, and the bottle tip is directly above the eye. At this point, the patient is ready to squeeze the bottle.  
 
 
Table 1. Assessment of the technique in patients with loss of fixation in one eye (n=10) 
  Before Technique After Technique
Mean Time ± SD to instill drop (seconds) 8.47 ± 3.80
(3, 17)
 11.69 ± 4.69
(5, 30)
Mean Number of Drops dispensed ± SD 1.18 ± 0.65
(0, 3)
 1.11 ± 0.40
(0, 2)
% of Drops Hitting the Eye 80.0 82.5

 

 
Table 2. Assessment of the technique in patients with loss of fixation in both eyes (n=10) 
  Before Technique After Technique
Mean Time ± SD to instill drop (seconds) 9.36 ± 3.39
(5, 19)
 13.15 ± 3.42
(6, 20)
Mean Number of Drops dispensed ± SD 1.28 ± 0.51
(1, 3)
 1.18 ± 0.52
(1, 3)
% of Drops Hitting the Eye 63.0 85.0

 

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