Eye Ointments

24/10/2011

Equipment
Eye ointment Tissues

Recommended Practice
Explain procedure to the patient. Wash hands and perform eye toilet if necessary. At the bedside, check the eye ointment with another nurse (or in the case of mydriatics, with a Registered Nurse) against the written order on the drug chart to ensure: correct medication correct patient (identify patient verbally and with wrist band) correct eye check expiry date correct order (if more than one medication) Before applying ointment to patients eye, squeeze small amount of ointment onto a clean tissue, ensuring tip does not contact tissue. Ask the patient to look upwards. Gently draw down the lower lid, place 1cm of ointment along the margin of the lower lid. Do not touch the eye or eyelid with the tip of the ointment tube. Ask the patient to close eyes for one minute, and remove any excess ointment from eyelid with a tissue. Use a clean tissue for each eye. Cleanse excess ointment from the tube with a tissue and then replace cap. Discard any used articles.

References

Evidence Summary: Medication (Ocular): Administration

2009

Author
Copyright (c) 2012 The Joanna Briggs Institute licenced for use by the corporate member during the term of membership

1 of 4

Jane Carstens B.App.Sc. (Nursing), B.Bus.Com. (Journalism)

Summary

Question
What is the evidence on administration of ocular medication?

Clinical Bottom Line

Ocular medications are most commonly delivered in the form of topical ointment or drops. Topical ophthalmic treatment is commonly prescribed to treat existing conditions, prevent or treat infection or inflammation, and to promote comfort and prevent damage to ocular structures.1 Treatment may be short or long term. It is suggested that one drop instilled into the lower fornix is adequate since the eye cannot cope with anymore fluid and will overflow and exit via the nasolacrimal drainage channels.1 (Level IV) Eye ointment should be applied to the upper rim of the inferior fornix in a 2cm line starting from the nasal canthus. 1 (Level IV) Drops should be instilled before ointment is applied, as ointment 'waterproofs' the eye. Ideally five minutes should be left between drops to the same eye otherwise the previous drops will be washed away and not absorbed.1 (Level IV) Adverse systemic effects can be minimised by asking patients to close their eyes gently and count to 60 after the instillation of drops. This prevents the drop being moved onto the nasolacrimal system where it would be unavailable for absorption.1 (Level IV) Descriptive studies suggest that in the clinical environment eye medications are frequently kept on bedside lockers, rather than in the medication trolley or drug cupboard, and are often not given at the prescribed time or are not prescribed when the patient is admitted to hospital.1 (Level IV) Topical ophthalmic therapy is prescribed at a frequency designed to allow optimum concentration of drugs into the ocular tissues to produce an optimum therapeutic effect. Changes in the interval between drops or ointment and missed doses can reduce the effectiveness of therapy.1 (Level IV) Eye drops facilitate absorption of medication but are suggested to have a shorter duration of action than ointments.2 (Level IV) The efficacy of eye drops relates primarily to the volume of solution delivered and the capacity of the conjunctival sac. Viscous solutions have delayed absorption rates, extending the therapeutic effects for longer periods than water-soluble drops. 2 (Level IV) Informed consent should be obtained prior to administering ocular medications. 2 (Level IV) All ocular medications should be checked against the prescription order to ensure the correct drug and strength is administered to the correct eye. 2 (Level IV) The literature recommended checking the expiry date and examining the solution/ointment for any abnormalities. Thorough hand washing was recommended prior to removing the cap

Copyright (c) 2012 The Joanna Briggs Institute licenced for use by the corporate member during the term of membership

2 of 4

from ocular solutions or ointments to avoid cap and container contamination.3 (Level IV) Position the patient to lay supine or in a chair with the head slightly tilted back and the chin upwards.4 (Level IV) Hyperextension of the neck should not occur in patients with cervical spine injuries. 4 (Level IV) Gently displacing the lower eyelid (inferior fornix) downward opens the conjunctival sac and the medication drop may be directed into this space. Medication used for corneal lubrication and anaesthetic drops are the exception for this technique. Application of drops onto the cornea is associated with increased patient discomfort and reduced efficacy.2 (Level IV) The delivery of ocular medications may result in systemic absorption and this poses inherent risks. 4 (Level IV) Topical ophthalmic medication administration is best suited for treatment of the cornea, conjunctiva, anterior segment structures and the ciliary body.5 (Level IV) It is also recommended that ointments or gels be inserted last, as they have extended absorption times. Post-administration assessment for systemic and local adverse effects was suggested on commencement of new or multiple ocular medications, or where the nurse is unfamiliar with the patient or the medication.6 (Level IV) Nursing staff should understand the likely duration of treatment to help ensure that patients do not discontinue important therapy or are not given repeat prescriptions for unnecessary medications.1 (Level IV) Many patients do not use eye drops as prescribed for Glaucoma for reasons including forgetfulness, being prescribed a large number of medications, difficulty instilling the drops, busy lifestyle, and not understanding the benefits.7 (Level I) People who wear contact lenses should avoid drops with preservatives as they increase corneal contact time and may lead to corneal toxicity.8 (Level IV) Ocular medication is governed by the same controls as medications delivered via other routes.8 (Level IV) When two or more ocular medications are prescribed, there should be a 3-5 minute interval between instillations in the same eye.8 (Level IV) Side effects of ocular medications include headaches, lack of focus, dryness, irritation, allergy, disorientation, mental confusion, shortness of breath and hallucinations.8 (Level IV) Patients receiving corticosteroid eye drops should be reviewed as there is a risk of developing steroid-induced glaucoma. There are also risks of secondary infection, corneal thinning, and possible corneal perforation.8 (Level IV)

Characteristics Of The Evidence

This evidence summary is based on a structured search of the literature and selected evidence-based health care databases. Evidence included in the summary is from: Non-analytic studies and expert opinion. 1-6,8 A systematic review including 7 random controlled trials and 1 quasi controlled trial involving 690 participants.7

Copyright (c) 2012 The Joanna Briggs Institute licenced for use by the corporate member during the term of membership

3 of 4

Best Practice Recommendations

Caution should be taken regarding eye drops since they may have adverse systemic effects, and patients can experience allergic reactions to some ophthalmic treatments. (Grade B) Nurses must take responsibility for knowing the effects and side effects of treatment, including interactions with systemic medication. (Grade B)

References
Marsden J, Shaw M. Correct administration of topical eye treatment. Nurs Stand. 2003; 17(30): 42-44. (Level IV) Kelly J. Topical ophthalmic drug administration: a practical guide. BJN.1994;3(10): 518-520.(Level IV) McConnell E. Instilling eye ointment Nurs.1999;29(8): 14.(Level IV) McConnell E. Clinical do's & don't's. Instilling eye drops, Nurs .2003; 31(9): 17. (Level IV) Duvall B. Kershner R. Ophthalmic medications and pharmacology. J Ophthalmic Nurs Technol.1998; 17(4):151-158.(Level IV) Miller C. Keeping an eye on the hidden effects of eye drops, Geriatr Nurs.1998;19(5): 293-294. (Level IV) Gray TA, Orton LC, Henson D, Harper R, Waterman H. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database Syst Rev. 2009:2. (Level I) Watkinson S, Seewoodhary R. Administering eye medications. Nurse Stand.2008:22 (18): 42-48. (Level IV)

Copyright (c) 2012 The Joanna Briggs Institute licenced for use by the corporate member during the term of membership

4 of 4