W1: Instillation techniques and Irrigation

Lecture Overview

• Topics Covered:

  • Instillation Methods:

    • Drops

    • Ointments

    • Modifications for Children

  • Self-administration

• Learning Outcomes:

  • Understand instillation methods and issues.

  • Apply eye drops and ointments effectively after practical sessions.

Instillation of Eye Drops - Solutions & Suspensions

• Steps for Eye Drop Instillation:

  1. Wash hands thoroughly.

  2. Instruct the patient to tilt their head backward.

  3. Pull down the lower lid to form a pouch.

  4. Position the dropper over the eye without touching any surfaces.

  5. Ask the patient to look upward (and in) just before applying a drop.

  6. Apply the drop carefully.

  7. Release the lid and instruct the patient to close their eyes gently.

  8. Do not rinse the dropper; replace the lid immediately.

  9. Discard if the solution is altered in colour.

  10. If using multiple drops, wait approximately 5 minutes between applications.

General Points on Eye Drop Instillation

• Important Considerations:

  • Warn the patient about potential transient effects post-application. E.g., will it still, how their vision may be affected etc.

  • Obtain informed consent before proceeding with medication.

  • One drop is usually sufficient.

  • Apply to the inferior cul-de-sac (temporal aspect).

  • Instruct patient to close their eyes gently following instillation.

  • Consider punctal occlusion for 1 minute to enhance drug absorption.

Eyelid Closure & Punctal Occlusion

• Practice Overview:

  • Puncta occlusion by applying with thumb and forefinger is commonly practiced to minimize drainage of drops.

  • Questionable efficacy: potential to express medication via pressure instead of occlusion.

  • Evidence supporting the advantage of punctal plugs for glaucoma medications.

  • Closing eyes may also facilitate the absorption of medication and produce a similar effect.

Instillation of Ointments

• Steps for Ointment Application:

  1. Wash hands thoroughly.

  2. Have the patient tilt their head backward and gaze upward.

  3. Pull down the lower lid to form a pouch.

  4. Apply a ¼-½ inch (1 cm) of ointment in a sweeping motion inside the lower lid.

  5. Instruct to close eyes for 1-2 minutes; temporary blurring of vision may occur.

  6. Remove excess ointment from the eyelids using tissue.

  7. If using multiple ointments, wait about 10 minutes before applying the next.

     1. if using both ointments and drops, apply drops first then wait 5 minutes before applying ointments.

Drug Instillation in Children

• Challenges and Techniques:

  • Administering medication to children can be difficult.

  • Recommended positioning: Sit with head back, hand on forehead, mouth open.

  • At home, children may lie on their back during instillation.

  • If resistant, consider the following techniques:

    • Close eyes, gently pull down the lower lid and place drops through the lashes into the conjunctival sac.

    • Apply drop on eyelashes with eyes closed and encourage blinking.

  • Note on sprays: Must be prepared by a compounding pharmacy.

Patient Self-Administration of Eye Drops

• Instructions for Patients:

  1. Grasp the lower eyelid near the margin with the tumb and index finger.

  2. Pull outward to create a pouch in the lower cul-de-sac.

  3. Position the dropper above the eye without touching any surfaces.

  4. Look upward just before releasing a drop.

  5. Allow the drop to settle in the lower cul-de-sac.

  6. Close eyelids and apply pressure on the nasolacrimal duct for ~2 minutes to minimize drainage.

  

Self-Administration Aids

• Available Aids:

  • Eye drop funnel (available at Independent Living Centers).

  • DROPin Eye Drop Assist: A device that helps position the dropper.

  • Make-Up Glasses: Look similar to normal spectacles with one lens.

Addressing Self-Administration Issues

• Teaching Patients:

  • Educate patients on instillation techniques.

  • Ask patients if they need assistance with self-administration.

Key Questions for Patients on Self-Administration

• Important Questions to Assess Understanding:

  • Do they know the purpose of their drops?

  • Are they aware not to use expired medications?

  • Do they understand the importance of shaking suspensions?

  • Are they informed that ointments may blur their vision?

  • Can they successfully instill the drops (using guides)?

  • Do they know the proper number of drops to use and when?

  • Are they aware of punctal occlusion and eye closure benefits?

  • Do they know to avoid contaminating the cap and not touching the tip to any surfaces?

  • Do they understand proper storage for eye drops?

1d Ocular Irrigation

Lecture Overview

• Topic: Irrigating Options in First Aid

• Learning Outcomes:

  • Understand irrigation methods and associated issues

  • After practical work, ability to irrigate the eye proficiently

Irrigating Solutions in First Aid

• Immediate Action Required:

  • Chemical exposure demands copious flushing of the eye (20-30 minutes)

• Recommended Solutions:

  • Water is generally most available and more effective than saline

• Types of Burns:

  • Alkali Burns:

    • Cause severe damage to the cornea, penetrate rapidly to Aqueous chamber

    • Examples: Lime in cement, bleach, cleaners, ammonia in fertilizers

    • Treatment: Removal of particulates, copious irrigation, intraocular buffer

  • Acid Burns:

    • Causes less penetration, scarring

    • Examples: Car battery fluid, hydrochloric, sulfuric, acetic acids

    • Less critical composition of irrigating agent

Extraocular Irrigating Solutions

• Characteristics:

  • Physiologically pH & osmolarity balanced solutions

• Functionality:

  • Clear unwanted materials from ocular surface

• Example of Solution: Eyestream

  • Contains NaCl, KCl, MgCl, CaCl, sodium acetate, sodium citrate, BAK

  • Not suitable for intraocular use due to toxicity to corneal epithelium

  • Sterile but must be discarded after specific timeframes:

    • Not preserved: 24 hrs post-opening

    • Preserved: 1 week

Techniques for Irrigating the Eye

• Contraindications: Do not irrigate if the eye is perforated

• Preparation:

  • Use a towel or catch basin

  • Remove contact lenses

• Irrigation Procedure:

  • Tilt the patient’s head back for better access

  • Apply control to flow rate while flushing with a bottle

  • Flush cul-de-sac from inner to outer canthi (both top and bottom)

  • Instruct the patient to look in different directions during irrigation

• Duration of Irrigation:

  • 20 minutes to 2 hours; consider hospitalization if severe

Key Points for Irrigation

• Prioritize Actions:

  • Immediate irrigation over questioning the incident

  • Consider using anesthetic eye drops to ease the procedure

• Irrigation Volume:

  • Copious amounts (30 mins or longer) are often necessary

• Care during Procedure:

  • Perform gently to avoid further trauma

• Thoroughness:

  • Ensure no chemical remains to prevent additional damage

• Double Irrigation:

  • Irrigate both eyes unless injury is confirmed limited to one

• Patient Management:

  • Support the patient emotionally as they may be distressed

Indications and Contraindications for Eyestream

• Use Eyestream to Flush Out:

  • Chemical splashes from acid and alkaline burns

  • Foreign objects such as sawdust, grit, metal chips

  • Smoke and fumes exposure

• Do Not Use Eyestream:

  • when eye has collapsed through total penetration by a sharp instrument

  • For injection or intraocular surgery

  • For rinsing and soaking soft contact lenses

The Morgan Lens

• Usage:

  • Utilized in emergency departments for continuous irrigation

  • Hands-free system

• Application Procedure:

  • Insert lens under upper eyelid, have patient look up

  • Retract lower lid and drop lens in place

  • Secure a fluid collection device (irrigating solution)

• Goals of Use:

  • Provides soothing sensation; eye may remain closed during procedure

  • Continue irrigation until normal pH is achieved (usually 2 litres required)