Module 5: Considerations Regarding Eye Medication

The Importance of Eye Drops

One of the most important practices in global health is the provision of follow-up care to patients in the developing world. International surgical missions with no commitment to supporting patients throughout their postoperative recovery provide low-quality health care and may cause significant harm to the patient and local community.(1) With any surgery, diligent adherence to postoperative protocol is essential to avoid complications. The eye is a particularly delicate and intricate surgical site, and postoperative complications can easily lead to vision loss. After eye surgeries, eye drops are prescribed to control postoperative inflammation and prevent infection, as well as to treat a host of other eye conditions. Professor of ophthalmology Dr. Bill Lloyd elaborates on the importance of using drops after eye surgery:

“Cataract surgery is a relatively brief procedure but, as I advise my patients, the real healing doesn't even begin until the operation is concluded… There is much that needs to be done before clear, long-term vision can develop. All of that rehabilitation occurs away from the hospital, away from the surgeon. … Patients manage their own healing. Besides avoiding strenuous activity and observing careful hand-washing, proper application of the prescribed eyedrops is the most important thing a patient can do to relieve post-op discomfort and to prevent complications after surgery. New research data supports this time-honored advice.(2) Patients who faithfully instilled their nonsteroidal anti-inflammatory eyedrops after surgery were more comfortable than those who did not use their drops. Feeling no pain is a good thing, but keeping your eyesight is even more valuable. Folks who used their NSAID eyedrops (products like Xibrom, Acular LS, Nevanac and others) were far less likely to develop Cystoid Macular Edema (CME). CME is a common cause of vision loss after cataract surgery.”(3)

What are barriers to effective eye drop use?

Despite overwhelming evidence supporting the importance of using prescribed eye drops, non-compliance is still a widespread problem:

“Kass and associates demonstrated with an electronic medication monitor built into an eye drop bottle that 62% of patients surveyed omitted 10% of prescribed doses and 15% of patients omitted 50% of prescribed doses.”(4)

“In the second study, all 20 cataract patients on a specific medication regimen revealed non-compliance. The total number of drops over the 14-day evaluation period should have been 70, but the average actual dosage by patients was just 33 drops.”(5)

So where is the breakdown between doctors’ knowledge of the importance of eye drops and patients’ non-compliance? The following are four common barriers to effective eye drop use among ophthalmic patients.

• Inability to self-administer

For most patients, administering eye drops does not come as naturally as applying a cream or swallowing a pill. Many report difficulty with correct eye drop administration, leading them to misuse drops, or to abandon using them altogether.

“We found that many patients lack the manual dexterity to administer their own eye drops. Many reported ‘difficulty getting one drop out’ as the reason they preferred having an assistant, a response supported by previously published observations that over 37% of patients instill 2 or more drops per eye treatment. The volume of the conjunctival sac is smaller than a drop from most commercial droppers. Therefore, the administration of multiple drops per treatment is, at best, an unnecessary waste and, at worst, a potentially harmful practice, because the risk of side effects increases when excess drug drains into the nasolacrimal system and is systemically absorbed.”(6)

• Educational barriers

For many patients, the importance of post-surgical eye drops is not obvious. This is particularly true now, in a time where modern surgical techniques allow patients to return home almost immediately. While short recovery periods are certainly desirable, “the problem with feeling so well is that it is difficult to persuade healthy, active persons that they should follow post-operative guidelines.”(7) When patients feel healthy, are uncertain about the purpose of using eye drops, or do not understand just how vital eye drops are to a successful surgery, they may see no reason to diligently use their drops. Even when patients are aware of the importance of following postoperative guidelines, many of them have not been educated about proper eye drop storage and administration:

“Eye care providers often neglect the importance of instruction on how to handle, store, and administer eye drops. They do not ask patients how the medications are stored, whether patients rely on others for administration, and how patients actually place the medication on the eye. These issues may be related to the relative success or failure of new eye drop bottle designs as well as the success of currently prescribed therapies.”(8)

• Forgetfulness

For most patients, using eye drops multiple times is not a habit engrained in their daily regimen. Many patients may forget to administer eye drops regularly. Moreover, some patients seem not to realize that they are forgetting to use their eye drops:

“We find that more than 90% of patients swear they never miss a single drop.  I am sure a lot of them believe that, but we know it is not true.  We interviewed hundreds of patients by telephone asking them, “Do you take our therapy with 100% adherence?”, and more than 90% swore they never missed a single drop, even though we know from their pharmacy refill data that they were missing 33% of their doses.”(9)

• Dislike

A final common barrier to post-surgical eye drop use is that some patients find it unpleasant to administer eye drops, and thus avoid doing so.

“In response to the open-ended question ‘What do you not like about administering your glaucoma medications?’ many patients described no problems, but common responses also included frustration with difficult-to-handle bottles (14.1%), problems getting the proper dosage into the eye (12.9%), and general dislike of putting eye drops in their eyes (11.2%).”(10)

It is important to note that the studies cited above were all conducted in Western populations, with patients who generally have health insurance and regular access to medical care. This population is vastly different from those patients living in extreme poverty in the developing world. Because they are less familiar with regular health care and medical treatments, it is likely that the patient population in developing countries is even more prone to non-compliance with postoperative protocol.

How do you ensure correct eye drop administration?

Successful treatment and effectiveness depends on the proper administration of the medication, which requires education.

“Giving patients a thorough understanding of the condition for which the medication is prescribed can make clear the vital importance of taking that medication. When patients know what they’re working towards, it can sometimes provide enough motivation to make them remember to take their eye drops.”(11)

Healthcare providers must make it blatantly clear to patients that the success of their surgery depends on their compliance with postoperative protocol. In addition to educating patients about the importance of eye drops, a crucial role of the healthcare provider is to explain and instruct each patient on the proper use of the eye drops that are prescribed. The healthcare provider should emphasize to the patient that he or she must use the medication exactly as prescribed by the doctor. It is also important to thoroughly explain how to administer eye drops correctly. The proper technique for using eye drops is explained in detail below:

“First, grasp the lower eyelid near the margin with the thumb and index finger and pull outward to create a pouch in the lower cul-de-sac. Then, without touching the dropper tip to any ocular structures, position it above the eye by direct visualization. Just before releasing a drop, look upward. Allow the drop to settle by gravity into the lower cul-de-sac before releasing the eyelid. With the drop in place, close the eyelids and apply pressure to the nasolacrimal duct or forced eyelid closure for at least 2 minutes to minimize drainage and systemic absorption.”(12)

Finally, it is important to follow up with patients to ensure that they are indeed using their prescribed eye drops. When asking patients about their compliance, be careful to avoid an accusatory tone. Instead, present open-ended questions and statements about their recovery process.

“We say to the patient, ‘How are the medicines?’ (an open-ended statement).  Give the patient an opportunity to voice some concerns and tell you a problem.  You might then say, ‘Do you know that the medicine is important in protecting you from blindness?’ and get their feedback on that.  If the patient says, ‘Well, I really do not think I am likely to go blind,’ you have identified the patient who almost surely is not adhering.  You can tell the patient, ‘We know that you could go blind from glaucoma, but you can maximize your chances of keeping your vision if you follow the program.’ Thus, you are asking the patient something, you are telling the patient something, and then you ask, ‘Now, what do you think about taking the medicine?  Do you think it is important to you?’ You try to get feedback again.  This restructures the situation in most offices where the patient’s first encounter is a technician who says, ‘You took your medicine last night, did you?’  Once the patient encounters that, the patient is going to be in a mode of ‘this-is-my-story-and-I’m-sticking-to-it.’  Once patients are forced into lying, they are going to keep lying because they would be committing 2 social errors: (1) admitting they were not doing something good for themselves; and (2) admitting they were just lying to the person in the other room.  As we have learned from the literature on hypertension and HIV drugs, we really have to change the typical doctor-patient approach, which is the doctor sitting on a pedestal and the patient down in the chair.  We need to change that to more of a teamwork approach.  One way to do that is to empathize with the patient, for example, by saying, ‘I know keeping up adherence with this therapy is hard to do.’ You might even tell a story about yourself, such as, ‘Well, I am supposed to take a pill every day and not infrequently I find I forgot my pill from last night.  This is only human.’ This gives patients an opportunity and permission to admit how often they think they are taking their medicine.’(13)

How Patients Should Administer Their Eye Medication

Footnotes

(1) For more information, please see Unite For Sight Global Health Course Module 8: The Significant Harm of Worst Practices. https://www.uniteforsight.org/community-eye-health-course/module8.

(2) Henderson, B.A., Kim, J.Y., Ament, C.S., Ferrufino-Ponce, Z.K., Grabowska, A., & Cremers, S.L. “Clinical pseydophakic cystoids macular edema: Risk factors for development and duration after treatment.” Journal of Cataract & Refractive Surgery. 33.9 (2007): 1550-1558.

(3) Lloyd, B. “The Power of Postoperative Eyedrops.” September 2007. Eye On Vision. WebMD weblog. blogs.webmd.com. Accessed on 17 December 2008.

(4) Tsai, T., Robin, A.L., & Smith III, J.P. “An Evaluation of How Glaucoma Patients Use Topical Medications: A Pilot Study.” Transactions of the American Ophthalmological Society. 105 (2007): 29-35.

(5) Abelson, M.B., Tarkildsen, G., & Fink, K. “Taking Steps Toward Better Compliance.” Review of Ophthalmology. 13.2 (2006).

(6) Tsai, T., Robin, A.L., & Smith III, J.P. “An Evaluation of How Glaucoma Patients Use Topical Medications: A Pilot Study.” Transactions of the American Ophthalmological Society. 105 (2007): 29-35.

(7) “After Cataract Surgery: Convalescence & Post-Operative Care.” The Cascade Eye Center. www.cascadeeye.com.

(8) Tsai, T., Robin, A.L., & Smith III, J.P. “An Evaluation of How Glaucoma Patients Use Topical Medications: A Pilot Study.” Transactions of the American Ophthalmological Society. 105 (2007): 29-35.

(9) Quigley, H.A. “Addressing Patient Adherence to Glaucoma Therapy.” Interview with Henry D. Jampel, MD, MHS. Johns Hopkins Advanced Studies in Ophthalmology. 4.3 (2007): 81-84.

(10) Tsai, T., Robin, A.L., & Smith III, J.P. “An Evaluation of How Glaucoma Patients Use Topical Medications: A Pilot Study.” Transactions of the American Ophthalmological Society. 105 (2007): 29-35.

(11) Abelson, M.B., Tarkildsen, G., & Fink, K. “Taking Steps Toward Better Compliance.” Review of Ophthalmology. 13.2 (2006).

(12) Tsai, T., Robin, A.L., & Smith III, J.P. “An Evaluation of How Glaucoma Patients Use Topical Medications: A Pilot Study.” Transactions of the American Ophthalmological Society. 105 (2007): 29-35.

(13) Quigley, H.A. “Addressing Patient Adherence to Glaucoma Therapy.” Interview with Henry D. Jampel, MD, MHS. Johns Hopkins Advanced Studies in Ophthalmology. 4.3 (2007): 81-84.