Preface: if any of this is wrong, great – please tell me!
“Bewilder” is such a great word. It means to lead astray, to disorient … and, fittingly, the origin of the word is unknown!
And bewildered is how I feel after 17 months of using prescription eye drops (following cataract surgery and then glaucoma). My condition is stable – no increase in vision problems, everything’s under control – but it’s likely that I’ll be using eye drops forever, and there’s no good science about how to use them right. I’m settling in to this new reality, doing the best I can, but I think we can do better – so I have complaints. :-)
My normal blog style is to present positive advice on what I’ve learned, and on this topic I’ll get there someday. But for this post I’ll just rant about the ridiculous range of issues I’ve encountered personally, or have heard about from others:
No evidence-based best practices
It turns out there is no research at all, no evidence-based advice on how to “instill” eye drops correctly. There are many YouTubes with different advice, but not a single research paper in all of ophthalmology on which method succeeds in getting the right amount of medicine into the eyeball.
This is ridiculous! Eye drops are the primary way of managing eye conditions, and there’s no science about what method works??
Correct me if I’m wrong, all you out there. But I’ve asked on my FitEyes community and it seems this is true.
Pathetic patient education (in reality)
Most patients I know say they were never really taught carefully how to do eye drops right, and nobody I know has ever had their skill checked, the way you’d be checked at work for an important new job task.
Most of us patients often miss, spilling a drop or two of medicine onto ourr eyelid or cheek. Imagine if it were this hard to get the right number of pills into your mouth!
Naturally, nobody I know has been asked by their eye doctor whether they need help learning to do it. If we don’t speak up and say we need help, we can fall short unnecessarily on this vital home care task.
A relatively minor related point: nobody I know was ever told by their eye doctor or pharmacist that the bottle cap color tells you what kind of medicine it is.
BAK preservative problems
To prevent bacteria growing in a bottle after it’s been opened, a preservative called BAK (benzalkonium chloride) is commonly used in some drops. But for some people (including me) it can cause horrible irritation, so a PF version (preservative-free) may be needed, if one is available.
- See this New York Times Magazine article: Eye Drops Were Supposed to Help Her Vision. Why Did It Feel Worse?
- The helpful-though-opinionated Dry Eye Shop is anti-BAK and has an informative article about the preservative’s problems.
- PF drops come in single-use (or single-day) vials. They are always more expensive and often not covered by prescription insurance.
- No you can’t get your money back for the drops they prescribed that you can’t use.
The mystery of punctal occlusion
After you put in a drop, you’re supposed to press against the inside corner of your eye, where it drains (“punctal occlusion”), so the drop of medicine stays on the eyeball and gets to where it’s needed:
- Many people say that although occlusion may have been mentioned at some point by their doctor, it was never expressed as a really important skill. (My original eye doctor said it’s not really necessary – “it’s okay to just close your eye”!)
- Again there is no evidence-based advice on how long to hold it closed! Some say “for a minute,” some say “couple of minutes,” some firmly say five minutes, and one doctor video I saw said ten minutes.
- Right after my cataract surgery I had to use 6 drops at different times of day, so that would have been an hour of my day spent holding the eye closed after drops.
- This is the best concise description & video I’ve found on it. Ironically, the page doesn’t use the term “punctal” so it took some deft googling to find it.
- Notice that although the video says to only put in one drop, it gives no advice on how to achieve that … many people have trouble, especially with shaky or arthritic hands.
Managing your inventory
In the photo, notice the duplicate bottles. I suppose I should have known that a doc might prescribe more of something without checking whether I already have it … and now I know I should check my inventory before filling a new prescription.
But even that’s hard, because I’ve learned some drops expire N days after you open them, which means I should really write the opening date on the tiny label.
This is unusually important in ophthalmology, I suspect, because the common approach to a problem is to prescribe some drops and say “Let’s see if this works – I’ll see you in a month or two.” For me it was not uncommon to have a drop prescribed again later, after it was discontinued six months earlier.
OK, enough for now.
I hope this “rant dump” will clear the air so I can get to work on publishing what to do about all this.
It’s a challenge. But vision … well, it’s worth protecting.
Similar problems with medicine for toddlers, especially antibiotics. We are given a special syringe to make sure the dosage is perfect, but no way to force a toddler to take it… they try with flavoring, we try mixing it up with food. I remember being bewildered indeed.
e-Patient Dave says
A senior member of the FitEyes community replied about his (obviously expert and savvy) experience:
I have found that some components of the eye drop emulsion evaporate from the plastic bottle over time. If I keep my eye drops inside a sealed glass jar with a metal lid (e.g., a Mason-type jar) in the refrig, it dramatically extends the life of the eye drops. The drops I am using today “expired” over 6 months ago, and my data shows that there has been no loss of efficacy. (Note: I have had glaucoma for more than a decade and am very familiar with the mechanism of action of every drop I take, and I have my own tonometer and use it several times a day to monitor status. My point is not that others should do what I do – it’s that eye drops can have far greater impact if well managed.)
Also, I would prefer to keep a collection of different eye drops, not unlike yours. Unfortunately, I do not have such a collection now, but having a large collection of different drops allows for very good experimentation with a tonometer. You need that in order to optimize your own medication program.
Mary Arneson says
I’m just using them for dry eyes, but I used to occasionally prescribe antibiotic drops for short term use. My instructions for patients and the instructions I’ve gotten from my own doctors are about what you describe — not really adequate. It’s too late for me to change; I’ve been retired for years but maybe your complaint will result in some YouTube videos providing better guidance.
e-Patient Dave says
Hi Mary – rather than (more) YouTubes, what I’d really like is some studies on what works and doesn’t! :-/ There’s no shortage of such videos https://www.youtube.com/results?search_query=how+to+instill+eye+drops and as the post said, they vary widely!
When all this started for me, the Mayo video at top of that search was what I trusted. Note that punctal occlusion is only mentioned at the end, as something “your doctor may recommend”! This video recommends holding it for five minutes.
I know you’re an MD, as is your husband – what do you make of this?? Am I making a big deal about something that doesn’t really matter?
Again, I first saw this video at the very beginning of my journey when I had 6 drops a day, with 3 in the morning. Waiting ten minutes between drops (as she recommends here) really put a dent in my day.
Bart Windrum says
Not to mention that the force with which drops emerge from bottles changes. I use lubricating drops since I live in a semiarid clime for 40 years. I’ve acquired a deft touch with full bottles where drops emerge unaided. And, I’ve learned to store the bottle upside down when it’s nearly empty so the liquid is at the dispense tip when I open and use it…and I get a lot more product life using this method. I do pull out the lower lid some but quite unscientifically.