Benefits of eye drops and eye ointments

1. The practitioner should wash their hands and ensure to keep them dry before the procedure to prevent irritation of the eye.
2. When taking eye swabs, the patient is asked to look downwards and the upper eyelid is swabbed from the nasal corner outwards. The same process is repeated with the lower eyelid by asking the patient to look up. This helps to avoid touching the cornea with the swab inadvertently.
3. To instil eye drops, the patient is asked to look up and carefully pull the skin below the lower lid of the affected eye to make a fornix; the prescribed number of eye drops are then administered directly into the conjunctival sac.
4. The eyelid is then released and the patient is asked to close this eye for about one minute. It is important to inform the patient that this procedure could cause a blurred vision for a short time.

Evidence base

Benefits of eye drops and eye ointments

Eye drops and eye ointments are used to treat acute and chronic conditions of the eye and surrounding structures, including the lacrimal apparatus, eyelids and eyelash follicles. However, many healthcare professionals lack knowledge of eye diseases or eye trauma and the treatment required, including knowledge of topical eye medicines (Shaw 2014).

Nurses should prioritise treatment of ocular conditions with eye drops or eye ointment to ensure the maximum therapeutic effect and to minimise possible loss of vision. Failure to adhere to treatment regimens could, in some cases, lead to ocular discomfort, some loss of vision or even blindness.

Nurses require knowledge of the anatomy and physiology of the eye, as well as an understanding of the effects and side effects of medicines, including knowledge of any interaction that may occur with systemically or topically applied medicines. Eye drops and eye ointments are usually instilled or applied into the lower fornix, the pocket formed by gently pulling the lower eyelid down. Eye ointments may be prescribed for structures other than the eye, such as the eyelids, for example, following trauma or surgery to these structures (Shaw et al 2010).

Precautions to be considered

Patient education: some patients may resist attempts to instil eye drops. This may be because of a previous negative experience or a feeling of natural revulsion to the eyes being touched. Nurses should ensure that they explain to the patient why treatment is required, what could happen if treatment is delayed or not administered, and that treatment may result in minor discomfort, which will usually resolve quickly.

Closed eye technique: if there is difficulty instilling eye drops, nurses may need to consider alternative methods. The closed eye technique involves instilling one eye drop onto the nasal corner of the closed eyelid. The patient should then be encouraged to open the eye. The eye drop should flow into the eye (Alster et al 2000). It is imperative that nurses advise the patient that the eye drops will sting momentarily.

Avoid systemic absorption: the patient should be asked to close their eye following administration of eye drops or eye ointment for approximately one minute. This helps prevent systemic absorption and also maintains the drug in contact with the eye to aid therapeutic action. Systemic absorption should be avoided especially in respect of drugs that affect other body systems such as beta blockers (Marsden 2007).

Prevent cross-infection or contamination: effective hand hygiene and cleaning of equipment are necessary to reduce the risk of cross-infection or contamination. Hands should be washed before and after the procedure and at any point during the procedure if they become contaminated. Equipment, depending on the procedure, should be sterile (Shaw et al 2010). In some care settings, and depending on whether it is an uncomplicated eye drop instillation for a chronic condition or a post-operative dressing, the nurse may be required to wear sterile or nonsterile gloves and an apron. Generally, if instilling eye drops for diagnostic purposes, gloves do not need to be worn. Nurses should adhere to local policy regarding the use of personal protective equipment.

Eye assessment: before instilling eye drops or applying eye ointment, nurses need to establish the condition of the patient’s eye and surrounding structures. Assessment of the eye should continue throughout the course of treatment to determine if there is any improvement or deterioration, and should include observing the state of the skin surrounding the eye and assessing if the skin looks pink and sore, potentially indicating an allergic reaction to the medicine being administered. If an allergic reaction is suspected, the medicine should not be administered and medical staff should be informed immediately (Marsden 2007).

Usage of cotton wool swabs: it is not always necessary to clean the eye before instilling eye drops, but if there is evidence of crusting or discharge on the eyelids or surrounding structures, the eyelids should be cleaned using cotton wool swabs or non-linting swabs dipped in sterile saline or sterile water. The swab should be used to gently wipe the eyelid margins from the inner (nasal) canthus to the outer corner of the eyelid. In the domestic setting, cooled boiled water in a clean container may be used. Cotton wool swabs should not be used to clean the eyelids if there are sutures or lesions present because the cotton fibres may delay wound healing (Carr 2006).

Visual disturbance: some eye drops and all eye ointments cause some degree of visual disturbance, which is usually transient. Where necessary, nurses should advise the patient not to drive or operate machinery if their vision is compromised. Eye drops and eye ointment must be stored as per the manufacturer’s instructions and in accordance with local policy. In the home, they should be out of the reach of children.

Documentation: administration of eye drops or eye ointment must be documented, including any observations involving the eye and surrounding structures. If for any reason the eye drops or eye ointment was not administered, this must be documented and medical staff informed (Nursing and Midwifery Council 2010, Royal College of Nursing 2013).

Self-medication: every opportunity should be taken to educate the patient and/or their carers about treatment, including how to manage self-medication. If appropriate, nurses should show the patient or carer how to instil drops or apply ointment to ensure continuity of, and adherence to, the treatment regimen. In some cases, it may be necessary to recommend an eye drop dispensing aid for the patient to use. There are several types available and one should be selected based on the patient’s needs and preferences.

Learning points

1. It is important to understand the effects and side effects of medicines, including knowledge of any interaction that may occur with systemically or topically applied medicines.
2. Some patients may resist attempts to instil eye drops and alternative methods such as closed eye technique should be considered if difficulties are encountered.
3. After the administration of eye drops or eye ointment, the patient should be asked to close the eye to prevent systemic absorption especially in respect of drugs that affect other body systems, such as beta blockers.
4. Assessment of the patient's eye and surrounding structures is necessary to determine the progress of the treatment. If an allergic reaction is suspected, the medicine should not be administered and medical staff should be alerted.
5. Nurses should advise patients against driving or operating machinery if their vision is compromised.
6. Patients and/or carers should be educated about managing self-medication and if necessary an eye drop dispensing aid should be recommended.

Disclaimer: please note that information provided by RCNi Learning is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed at the bedside by a nurse educator or mentor. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence.

Useful resources

• Harper RA (2010) Basic Ophthalmology. 9th edition. American Academy of Ophthalmology, San Francisco.
• Marsden J (2006) Ophthalmic Care. Wiley-Blackwell, Chichester.

References

Alster Y, Herlin L, Lazar M, Loewenstein A (2000) Intraocular penetration of vancomycin eye drops after application to the medial canthus with closed lids. British Journal of Ophthalmology. 84, 3, 300-302.

Carr M (2006) Wound cleansing: sorely neglected? Primary Intention. 14, 4, 150-161.

Marsden J (Ed) (2007) An Evidence Base for Ophthalmic Nursing Practice. John Wiley and Sons, Chichester.

Nursing and Midwifery Council (2010) Standards for Medicines Management. NMC, London.

Royal College of Nursing (2013) Better Medicines Management: Advice for Nursing Staff and Patients. RCN, London.

Shaw M, Lee A, Stollery R (Eds) (2010) Ophthalmic Nursing. Fourth edition. Wiley-Blackwell, Chichester.

Shaw ME (2014) How to administer eye drops and ointment. Nursing Times. 110, 40, 16-18.