Correctly and repeatedly instilling postoperative eye drops is a known difficulty for patients. A study published in the Journal of Cataract and Refractive Surgery showed only two-thirds of patients feel confident in instilling eye drops, and 42% believed they never missed their eye on instillation.¹

The potential lack of adherence to the postoperative drop regimen can lead to complications, the most devastating being endophthalmitis. Though a rare occurrence, it’s dire enough to warrant consideration of every possible protection against it. By educating patients on the why, what, when, and how regarding their responsibility after surgery, they will make more informed decisions that lead to better compliance.

Education best practices

Explain the basics. Because most patients undergoing cataract surgery have not regularly used eye drops, they require preoperative training to ensure proper and safe instillation. To begin, provide the patient with answers, for example:

• Why? The eye is susceptible to infection and inflammation after surgery because during the procedure, an opening is made into the eye.
• What? Medications that come in topical drop form help heal the wound faster than the body can on its own. Using them helps to ensure the best vision possible after surgery. Antibiotics help fight harmful bacteria. Corticosteroids reduce and control inflammation. This helps relieve swelling, pain, and irritation following surgery. Non-steroidal anti-inflammatories (NSAIDs) help reduce discomfort and discourage macular edema.
• When? Each medication has its own dosing instruction.

Provide consistent information throughout the patient experience. As with any patient instructions, be sure to have a discussion with all surgeons in which verbiage is consistent with their practice preferences. All staff should use the same vocabulary agreed upon to maintain consistency throughout the patient encounter.

Identify difficulties. Patients may experience difficulty in aiming the drops, extending the neck, preventing excess drop leakage, avoiding contamination of the bottle tip, and generating enough force to expel a drop from the bottle.¹ Identify difficulties and recommend solutions, such as: Have the patient recline at an angle to facilitate installation. Place the bottle between the thumb and index finger and brace the thumb on the nose. Practice with artificial tears prior to surgery. Store the bottles in the refrigerator (unless contraindicated), as feeling the cold drop can ensure success.

Recognize that each patient comes from both a different health and cultural background. They may speak a different language. They may have unique physical or cognitive abilities. Some patients benefit greatly from pre-filled charts and graphs while others find an explanation of the mechanics of applying the medication more beneficial.

Become the student. Not all students learn effectively the same way. Some patients learn well from written instructions while others learn from a humorous conversation. Handouts, videos, and in-person demonstrations are easily adaptable methods of instructions. Discuss within your practice which methods you want to explore and ask each patient how they learn best. Have multiple options available.

Remain open-minded. While those in eye care explain these topics all-day every-day, patients are likely hearing them for the first time, so we may need to change up how we describe these details. Recognize that some patients may appreciate technical terms while others benefit more from simpler terms explaining anatomy or physical functions.

Show them. Demonstrate the various methods of proper technique for administration for the patient however your practice feels is appropriate.

Ask them to show you. Take empty medication bottles (leftover from clinic use, rinsed thoroughly, and labeled "DEMO") filled with sterile saline to show patients how easily drops can come out of the bottle and how easy it is for multiple drops to come out without realizing it. Use bottles of medications that are prescribed so patients can feel the thickness of the plastic generally consistent with the manufacturer. Have each patient show you how they would administer their medication. Give them pointers on how to improve their technique, if needed.

First impressions matter. Let the patient feel the bottle and squeeze it over a waste basket or paper towel. Familiarity with the bottle will help those patients become more comfortable doing it themselves.

See a need, fill a need. Physical limitations may inhibit proper administration (frozen shoulder, tremor, etc.), so having multiple approaches for physical administration is helpful. If you notice that a patient physically struggles in the office, have an assistive device (more information below) to demo for them. Provide information to help find these devices if your practice does not offer them via retail or as part of a surgical package.

Provide written instructions. Many patients find a check-off chart with pre-filled dates extremely helpful. (See Table 1.) This can easily be incorporated into a flyer that stays in the patient’s operative folder or turned into an After Visit Summary phrase in most EMRs.

Help identify drops. Offer common identifying information, such as cap color and phonetic spelling, for each medication so patients can easily distinguish between different medications. (See Table 2.) This helps decrease miscommunication.

Minimizing the burden

A number of options can reduce or eliminate post-operative drop burden. These include:

Compounded drops. Instead of multiple bottles that have the potential to confuse patients, some practices may opt to offer custom preparations as part of their surgical package. With these drops, compounding pharmacies can synthesize a higher concentration than what may be commercially available.

Drop-free options. Advances in intraoperative drugs can help avoid complications and allow patients to eliminate or reduce the number of topical drops required postop.² Intraoperative intracameral (injectable) drugs include Dexycu (dexamethasone intraocular suspension 9%, EyePoint Pharmaceuticals), and injectable compounded multidrug formulations, such as Dropless Tri-Moxi (triamcinolone 15mg/mL + 1mg/mL moxifloxacin, Imprimis) and Dex-Moxi (dexamethasone 0.1% + moxifloxacin hydrochloride 0.5%, Ocular Science).

Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix), is an insert placed in the punctum to help improve pain and dry eye symptoms fequently associated with cataract surgery. Another drug, Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros), which is added to ocular irrigating solution used during cataract surgery, helps prevent intraoperative miosis and reduce postoperative pain.

According to the 2014 ASCRS Endophthalmitis Survey, 47% of American surgeons are using some type of intracameral injection after cataract surgery, and this number is up 20% from the data reported in 2007.³

Resources for affordable medications. For patients who express concerns about drug costs, assistance is available through manufacturer savings programs, foundation programs, such as EyeCare America (aao.org/eyecare-america ) and price comparison websites, such as GoodRx.com .

Cataract kits. These bundled kits can be customized to each practice’s needs. Tape, solar shields, night shields, artificial tears, assistive devices, calendar stickers, business cards, and after-hours phone numbers are popular contents of these bundles.

Assistive devices. Products, such as Autosqueeze by Owen Mumford and Autodrop by Ableware, are available for patients with dexterity challenges. These devices, which give the patient more surface area to hold when administering drops, can often be found at larger pharmacies and online medical supply retailers.

If patients have difficulty seeing the dropper bottle, E-Z Drops (ezdrops.com ), designed by a COA, attaches to the side of drop bottles. It features a reflective adhesive strip that gives the patient something to focus on during administration.

Now what?

Educating patients on how to use their eye drops involves more than just how to instill them. Explain the side effects from the drops so that patients are educated on what to expect when they use them. The eyes may feel dry and scratchy, so recommending an appropriate artificial tear during the day in between their post-operative drops will help them keep more comfortable. Explain that medications that require shaking may leave a white stringy discharge intermittently. This is normal. Explain the crucial symptoms never to ignore, and instruct them where to go for timely care should they need it. OP

REFERENCES:

1. An J, Kasner O, Samek DA, Lévesque V. Evaluation of eyedrop administration by inexperienced patients after cataract surgery. J Cataract Refract Surg. 2014 Nov.
2. Assil, KA, Greenwood MD, Gibson A, Vantipalli S, Metzinger, JL, Goldstein MH. Dropless cataract surgery: modernizing perioperative medical therapy to improve outcomes and patient satisfaction, Current Opinion in Ophthalmology: January 2021 - Volume 32 - Issue - p S1-S1.
3. Chang D, Braga-Mele R, Henderson B, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS Member Survey. J Cat Refract Surg. 2015 June.