eye drops and dispensing aids.qxp iga 18/08/2017 … · instilling eye drops eye drops and...

Eye Drops and Dispensing Aids

Eye Drops and Dispensing Aids.qxp_IGA 18/08/2017 13:49

This free booklet is brought to you by the charity, theInternational Glaucoma Association (IGA). Contact the IGA for further information or advice.

International Glaucoma AssociationWoodcote House, 15 Highpoint Business VillageHenwood, Ashford, Kent TN24 8DH

Sightline: 01233 64 81 70Monday-Friday 9.30am-5.00pm

Email: [email protected]

Your feedback is important to us. Please help us improve our informationby sending us your comments about the content and format of thispublication at [email protected] or by writing to us.

Charity registered in England and Wales No. 274681 and Scotland No. SC041550

© International Glaucoma Association 2017


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Eye Drops and Dispensing Aids: A Guide

Most people with glaucoma are treated with eye drops.There are several kinds but all of them reduce the pressure inyour eye. Used regularly as prescribed, they help keep thepressure at the right level for you, which reduces the risk ofyour eyesight becoming worse. Many people find it difficultto put eye drops in initially, and it is easy to forget to do itregularly. Glaucoma is usually a slow progressive conditionthat can ultimately result in impaired vision or evenblindness, so it’s important you take your drops asprescribed, unless your doctor tells you to stop using them.You should consider your drops are for life.

We have put this booklet together to help you. It tells youhow to put drops in, and about a variety of different aids, alldesigned to make putting your own drops in easier. We haveincluded other useful information, such as our top tips foreye drop users, and there’s a section on the different dropsyou might be prescribed and what they do, plus a simpledescription of your eye and how it works.

Karen OsbornChief Executive


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Contents Page

About your eye? 3

How should I use my eye drops? 5

Getting into the routine 8

What types of glaucoma drops are there? 10

Are you struggling with your eye drops? 14

Top tips 20

Frequently asked questions 23

Further help and information 25


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About your eye

The eye is shaped like a ball. The tough white outer coat iscalled the sclera and its front surface is covered by a thinlayer called the conjunctiva which also lines the eyelids. Theclear outer layer at the front of the eye is called the corneaand both the cornea and conjunctiva are covered by the tearfilm. Behind the cornea is the iris (the coloured part of theeye) with the pupil forming a hole in its centre.

Cross section through the eye showing the major structuresPatient Pictures. Health Press Limited (Oxford)

The space between the cornea and the lens is filled with aclear fluid, called aqueous humour. This fluid maintains thepressure in the eye (the intraocular pressure).

Retina

Vitreous Humour(clear jelly)

Lens

Optic Nerve(sends information

to the brain)

Iris

Pupil

Aqueous Humour(watery fluid)

Cornea

Ciliary Body(produces aqueous humour)

TrabecularMeshwork

Sclera

Choroid

Macula

SuspensoryLigaments

Conjunctiva


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The pressure is determined by the balance between the fluidproduction inside the eye and its drainage out of the eye.

On the inside at the back of the eye is the retina, which isthe light sensitive layer onto which an image of what isbeing seen is focussed by the cornea and the lens workingtogether. The central area of the retina, where the mostdetailed vision is to be found, is known as the macula andhas a very high density of light-sensitive cells. Further awayfrom this central detailed vision area is the area of the retinawhich also provides our peripheral vision.

Immediately under the retina is the choroid, which is thelayer of the eye that provides the blood supply to the cells ofthe retina and onto which the retina is attached. Light thathas passed through the front of the eye and is focussed ontothe retina, is finally converted into a series of complexelectrical impulses by retinal photoreceptor cells known asrods and cones. These signals pass along the optic nerve tothe back of the brain, where the final image is processed.

Figure 1. Instilling eye drops


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How should I use my eye drops?

There are various ways to put drops in your eye and you willneed to decide which is best for you.

l Before you begin, make sure your hands are washed andclean. Some drops need to be shaken. If that applies toyours, it should say on the bottle or in the leaflet thatcomes with it. Remember to shake the bottle each time you use it.

l One of the simplest ways of putting drops in is to sitcomfortably in front of a mirror, or if you prefer you caninstil your drops whilst lying down, pull down the lowereyelid with a finger of one hand, with the other handsqueeze or tap the bottle according to the instructions,and let the drop fall into the pocket between your eyeand the lower lid (see figure 1). Please see the IGAwebsite for a short video on how to instil your eye drops.www.glaucoma-association.com

l After putting the drop in your eye, close your eye gentlyand press softly on the inside corner of the eye, by thenose, with a finger for one to two minutes (see figure 2).This will help to slow the rate at which the drop drainsout through the tear duct into your throat, rather thanstaying in the eye where it is needed. A small amountmay still drain through the tear duct and be swallowed.This is not usually harmful but, if the amount of eye dropsentering your body through the tear duct is minimised, so too is the potential for side effect problems. Repeatwith the other eye if necessary.


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Figure 2. Closing the tear duct

Putting in more than one dropIf you need to administer/instil a different drop into thesame eye, wait at least five minutes, or however long youhave been advised; this prevents the first drop being washedaway by the second.

Contact lensesIf you use contact lenses, never put a drop in your eye whilst wearing a lens unless advised by your clinician andallow 15 minutes after using your drops before inserting alens. Contact lens wearers should avoid using eye dropswhich contain preservatives. Please speak to your doctor orpharmacist about alternative preservative free eye drops.

Another way to instil drops is to lie on the bed with onepillow (see figure 3). It is sometimes easier to hold the eyedrop bottle horizontally in your hand and place the screw


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part of the bottle on the bridge of your nose. Look upwardsand squeeze the bottle gently. The drop should fall into theeye. If it doesn’t it will be in the corner next to your nose andit will run into the eye if you turn your head slightly.

Figure 3.


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Getting into the routine

Damage to vision caused by glaucoma is permanent and can’t be reversed. However, treatment can prevent or reduceany future damage by ensuring that the pressure in your eyedoesn’t get too high. So if you have been diagnosed withglaucoma, it is essential to use your eye drops regularly asprescribed if you want to preserve your eyesight.

So you don’t forget to put your drops in, it’s worth gettinginto a routine and sticking to it. For instance, unless thebottle needs to be stored in the door of the fridge, you could keep it by your toothbrush so you are reminded whenyou brush your teeth. Some people find it helpful to make a chart with the days of the week on it where they can tickoff every time they use their drops. There is a drop calendaravailable to download at www.glaucoma-association.com oralternatively you can call our Helpline on 01233 64 81 70.

If you use a drop more than once a day, try to ensure thetimes when you put them in are evenly spaced. For example,if they go in twice a day, aim for 12 hours apart. The mostimportant thing, though, is to settle on a routine you canmanage and remember every day. This helps to ensure thatthe drop does not wear off before the next dose is due, and sowill help stabilise your eye pressures and treatment plan.

StorageMost drops are stored at ordinary room temperature (not next to a radiator or in direct sunlight) but some


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need to be kept in a fridge before the bottles are opened.Look at the leaflet that comes with your drops or check with your pharmacist to be sure you know the correct wayto store your drops.

Single dose unit drops Some of the single dose unit drops may be packaged withina sachet or pouch inside the box, and when the seal is open,all the drops within the sachet/pouch have a limited expirydate, for example seven days. Look at the leaflet that comeswith your drops or check with your pharmacist to be sureyou know the correct expiry once opened.

Expiry date Don’t continue to use a bottle for more than a month after it has been opened or the date marked on the bottle if this issooner. Start a new one. It is a good idea to make a note ofwhen you open the bottle to help you remember when youopened it, so that you don’t forget to order a replacementbottle from the GP/pharmacy before it has run out and youdon’t use it after it has expired. The safest way to dispose ofold bottles is to return them to your pharmacy.

Keeping drops in the fridge If you have difficulty knowing whether a drop has gone into your eye, you can try keeping the bottle in the door of the fridge (not the freezer). You will then feel the coldnessof the drop going into your eye. However, always be sure to check in the patient information leaflet or with yourpharmacist that your drops can safely be stored this way,before doing this.


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Travelling Sometimes you might need to keep your drops cool when theweather is hot, for instance if you are travelling or out for theday. The IGA has cool wallets available to purchase, thatprevent your drops from becoming warm for up to 45 hours.They contain gel crystals which only require soaking in coldwater to activate. Refrigeration is not required.

There is a large wallet that holds up to four eye drop bottlesor 30 single dose unit eye drops, and a small wallet that takesa single bottle or 10 single dose unit eye drops.

What types of glaucoma drops are there?

The name on the bottleThere are various kinds of pressure lowering eye drops used in the treatment of glaucoma. All the drugs used in themhave standard pharmaceutical names, which are not tradenames. If your drops are only labelled with the names of the drug or drugs they contain, they are said to be ‘generic’.However, many drops are better known by their trade name,chosen by the company that developed the drug and have the patent. There are certain glaucoma drops where use inchildren are restricted (please see our booklet Glaucoma inBabies and Children).


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Here is a list of trade names and their generic equivalents.

Trade name Generic name Trade name Generic nameAlphagan brimonidine Saflutan UD tafluprostAzopt brinzolamide Teoptic carteololBetagan+UD levobunolol Timoptol+UD timololBetoptic+UD betaxolol Tiopex UD timolol (gel)Iopidine+UD apraclonidine Travatan travoprostLumigan+UD bimatoprost Trusopt dorzolamideMonopost UD latanoprost Xalatan latanoprostPilocarpine+UD pilocarpine

UD=Unit Dose

Combination drops, usually containing timolol and anotherdrug are also available under different trade names. However,a new combination drop Simbrinza, does not contain timolol.

Trade name Generic nameAzarga timolol and brinzolamideCombigan timolol and brimonidineCosopt+UD timolol and dorzolamideDuoTrav timolol and travoprostGanfort+UD timolol and bimatoprostSimbrinza brinzolamide and brimonidineTaptiqom UD timolol and tafluprostXalacom timolol and latanoprost


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Generic substitutes for branded dropsAs patents on glaucoma drops expire, more patients arereceiving a generic version of their prescription in place of a branded one. The active ingredient(s) are the same and at the same concentration. Other constituents may varyslightly but the eye drops are essentially similar. The bottleand packaging are likely to be different, and may vary fromone prescription to another.

Most people have no trouble with generic drops, but there canbe some issues. For example, the design of the bottle mightnot fit your compliance aid or you may not be able tosqueeze the new bottle if the plastic is too hard. Very rarelythe slightly different formulation may not suit you. If youexperience any difficulty you should discuss it with your eyespecialist, GP or pharmacist. Alternatively Sightline - the IGAtelephone helpline, will be able to help and advise.

Combination dropsIf you need two different types of medication, using acombination drop can have advantages over using twoseparate drops. It saves both time and having to keep twodifferent bottles. It also means that you deliver lesspreservative into your eye, which may reduce the possibilityof developing an allergic reaction to the preservatives. Forpatients who pay for their prescriptions, only one prescriptioncharge is levied for a combination drop.


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Different categories of dropsThe drugs used in eye drops to treat glaucoma fall intoseveral categories, according to the way in which they work.Alpha agonists (apraclondine and brimonidine)These act to reduce the production of fluid in the eye andpossibly to improve the flow of fluid out of the eye. They are usually used two or three times a day. Brimonidine islicenced for the long term treatment of glaucoma butapraclonidine is for short term use following, or to delay, laser treatment. Possible side effects include a dry mouth,tiredness and general weakness. Very occasionally peoplemay develop a severe allergic reaction to these drops. If thishappens, the eye becomes increasingly red, sore and sticky. It can take several months for this to happen, but if it does,you should consult your ophthalmologist or generalpractitioner without delay.

Beta blockers (betaxolol, carteolol, levobunolol and timolol)The action of these drops is to reduce the production of fluidin the eye. They are used once in the morning or twice a day,as advised by your ophthalmologist. They are not usuallyprescribed for anyone susceptible to chest or breathingproblems. Possible side effects include a slow pulse, dizziness and tiredness. In some people these drops maycause depression, loss of libido or impotence. However, most people have no problems with them.


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Carbonic anhydrase inhibitors(brinzolamide and dorzolamide)The action of these drugs is to reduce production of fluid inthe eye. These drops are used two or three times a day ontheir own, or twice a day if with another drop. Possible sideeffects include redness of the eye, crusty eyelashes, fatigueand a bitter taste in the mouth.

Cholinergic agonist (pilocarpine)These act to improve the flow of fluid out of the eye through its usual route and the drops are used three or fourtimes a day.

Prostaglandin/prostamide analogues(bimatoprost, latanoprost, tafluprost and travoprost)Their action is to improve the flow of fluid out of the eyethrough a different route from the usual one: the uveoscleralroute. The drops are used once a day, usually at night.Possible side effects include a pink eye that usually improvesover a period of time. The iris may darken in colour (morecommonly in those with green or hazel eyes and lesscommonly in blue eyes). Eyelashes may grow longer anddarker and in a small percentage of patients, the skin aroundthe orbit of the eye may darken.

Are you struggling with your eye drops?

The IGA Sightline often receives calls from people who havedifficulty instilling (putting in) their drops. This sectiondescribes the range of different eye drop dispensing aids,


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some of which may be prescribed and a large number areavailable from the IGA. We know that the easier people findit to put their drops in the more likely they are to stick withtheir daily routine. At the time of going to press, thedescriptions are accurate to the best of our knowledge andbelief. Our Sightline staff are happy to advise on whichdispenser would best suit your needs. All dispensers comewith full instructions for use and you can contact Sightline ifyou would like these in large print.

The Opticare is a hand-sized dispenser with an eye piece foraiming the drop accurately. It has a large squeezable area tomake it easy to administer a measured dose and can beprescribed free of charge to those who are eligible. It is bestsuited for round bottles, and there are black and grey rubbercollars which come with the Opticare for bottles which mayneed adjustment to fit. There are some generic drops thatmay require the use of the two collars.

Most bottles can be openedand closed without removingthem from the Opticare. Thefollowing bottles are very easyto use in this aid:

• Allergan drops: Alphagan 5ml,Betagan 5ml, Combigan 5ml,Ganfort 3ml and Lumigan 3ml.

• Alcon drops: Azopt 5ml,Betoptic 5ml and Iopidine 5ml. Opticare


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The Opticare Arthro has an adjustable eyepiece and longhandles for maximum effect with little pressure. It isespecially designed for those with hand and arm mobilityproblems such as arthritis or sports injury. It is alsoparticularly good for use by a carer/relative who administerdrops for the patient since the device offers flexiblepositioning. It’s available free of charge on prescription tothose who are eligible. The blue coloured Arthro 5 can beused with 2.5ml and 5ml round bottles.

The cream coloured Arthro 10 can be used with 10ml and15ml round bottles. Unfortunately Cosopt, Duotrav,Timoptol, Timoptol LA , Travatan, Trusopt, Xalacom andXalatan bottles do not fit in this dispenser.

Opticare Arthro


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The Alcon Eyot is for use with the Alcon branded bottlesAzarga, Azopt, Duotrav and Travatan eye drops. It is designedto specifically fit the shaped bottles, and make it easier toposition the bottle over the eye and squeeze the bottle.

The Eye Care bottle opener, which comes with the AlconEyot, makes it easy to remove and replace the tops of bottleswhen they are in the dispenser. It has different sized endsand is made of an easy grip rubber material.

The Autodrop is another small device suitable for a widevariety of eye drop bottles. It’s an eyepiece that holds thebottle and helps aim the drop into your eye, while yousqueeze the bottle with your fingers. The Autodrop is notsuitable for Cosopt and Trusopt (unless round).

Alcon Eyot

Autodrop


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The Autosqueeze which is like a pair of butterfly wings, fitsaround the bottle neck. It is designed with raised grooveswhich makes squeezing easier and so this aid is particularlyuseful for people with arthritis or limited hand mobility.

It only works well with round bottles and can be used onits own or with the Autodrop.

Single Dose Unit Eye Drops

The Celluvisc Compliance Aid, originally designed for artificial tearsis aimed at helping people using single dose unit eye drops. It is made for accurate positioning and easier grip control.

Autosqueeze Autodrop andAutosqueezecombined

Celluvisc


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The Eyot (Thea) is similar to theCelluvisc Compliance Aid and hasan additional button to help yousqueeze out the eye drop, whichis helpful if you find the plasticdifficult to squeeze.

The Dropaid is also designed for accurate positioning overthe eye with easy grip control. It is particularly good if youhave limited thumb dexterity, as you can use your otherfingers/palm to grasp the levers which squeeze out the eyedrop. Take care though if you have had surgery and speakwith your clinician/pharmacist to check the aid is not tooclose to your eye.

The Eyot (Thea)

Dropaid


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Top tips

l Follow your clinician’s instructions and only administerthe number of drops advised, which is usually only onedrop. Take your medication on time every time, as evenlyspaced out through the day as possible.

l Always wash your hands before and after using your eyedrop bottles.

l Eye drop dispensers are for individual use. They arepersonal items which shouldn’t be shared betweenpatients to avoid any contamination.

l Wash your dispenser regularly in warm soapy water.

l To avoid contamination, never touch the nozzle of thedropper bottle and avoid contact with the eye.

l After putting in a drop, close your eye gently and presssoftly on the inside corner with a finger for one to twominutes. Then wait five minutes, or according to medicaladvice, before instilling a different drop into the same eye,to prevent the first being washed away.

l Never use drops after the expiry date printed on thepackaging. Discard a bottle of eye drops four weeks afteropening and start a new one. It is a good idea to writethe date that you open the bottle onto the label, so youknow when it will expire. For single dose unit eye drops,


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always check the expiry date once you open the outerpouch/sachet and this varies between drops and is notalways 28 days. Single dose unit eye drops should beused once only and discarded.

l Order further supplies from your GP, if necessary, beforeyour eye drops finish to ensure that you do not run out.

l Hand in any unused or expired medicines to your local pharmacist.

l If you use contact lenses, remove them before instillingeye drops and wait at least 15 minutes before re-insertingthem, unless advised otherwise by your clinician.

l Store eye drops and all medicines out of the reach andsight of children and out of direct sunlight. Store yourdrops as instructed, whether that be at room temperature(never near a radiator) or in the door of the fridge. If yourdrops are to be stored at room temperature and you findit difficult to feel your drops going into your eye, speak toyour pharmacist to find out whether it is safe for you tostore them in the fridge instead. This may make it easierto feel the drop going into the eye.

Some eye drops may sting or irritate for a short whileafter putting them in, but let a clinician, nurse orpharmacist know if symptoms become worse or youexperience any other side effects.


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If you sometimes forget your medication:

l Establish a routine and stick to it. For example, if yourdrops are stored at room temperature it might help to putyour drops by your toothbrush so that you remember toput them in when you brush your teeth. You can also seta reminder/alarm on your mobile phone.

l Create a chart with the days of the week so that eachdrop can be ticked off. A calendar is available from theIGA helpline or website.

If you use different types of drops:

l Use drops in the same order each time, for example bycolour or by bottle size, to reduce the possibility ofmaking a mistake.

l If you have difficulty telling the different bottles apart, it may be useful to use coloured stickers, larger labels orelastic bands around the bottles to distinguish them.

l If you use eye ointments for another condition, use theseafter putting in your drops waiting at least five minutesbefore doing so.


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Frequently asked questions

If I go on holiday, particularly to a warm climate, and thereis no 'fridge, where should I keep the drops?

Keep your drops in a cool place out of the light. A cool wallet,available from the IGA, helps to keep the drops cool, for upto 45 hours.

Should I let the eye doctor know if I develop other medicalconditions e.g. raised blood pressure or diabetes?

Yes. It may influence the treatment they prescribe you.

Can I do yoga exercises?

Yes, except for exercises involving the head being lower thanthe heart for an appreciable time e.g. headstands. This tendsto increase eye pressure.

Can I play wind instruments?

Playing a wind instrument such as a trumpet increases theeye pressure, but the effect will depend on how much, andhow often, you play. It is best to ask your eye specialist if itwould be suitable in your particular case.


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Patient support group

We have many patient support groups around thecountry run by hospital staff for the benefit of people with glaucoma. A list of these, along with contact details,can be found in our newsletter or on our website atwww.glaucoma-association.com

Buddies

If you are due to have surgery or laser treatment for your glaucoma, you may feel that you would benefit from speaking to someone else who has already had that experience.

We have a list of people who are willing to do this. You may find that after your own experience that youdecide that you too would like to become a buddy.

For further information on either of the above, please contact Sightline on 01233 64 81 70or [email protected]


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Further help and information

Telephone usThe IGA operates a telephone advice line,called Sightline.

If you would like to find out more about any of theinformation contained in this booklet, or you would liketo discuss any concerns you may have about glaucoma,you can call the IGA’s Sightline. Out of office hours there isan answer phone service where you can leave a messageand you will be called back.

Sightline: 01233 64 81 70Monday - Friday 9.30am - 5.00pm

Visit our website: www.glaucoma-association.comfor a wide range of information, to order other booklets orleaflets, or to participate in our on-line discussion forum.

Email us at: [email protected]

A full list of references and information sources used in thecompilation of this leaflet is available on request by phone:01233 64 81 70 (Sightline) or byemail: [email protected]


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Other IGA booklets and leaflets

The IGA produces a range of informational booklets andleaflets. These are constantly being reprinted, reviewed and updated, so call Sightline, or visit the website, to find out what is currently available.

Eye Drops & Dispensing Aids: A Guide

Author: Sarah Thomas, Lead Ophthalmic Pharmacist, Moorfields Eye Hospital NHS Foundation Trust

Edited by: Fiona Chiu, Lead Ophthalmic Pharmacist, Moorfields Eye Hospital NHS Foundation Trust

We value your feedback. Please help us improve ourinformation by sending us your comments about the contentand format of this publication to [email protected] orby writing to us.

International Glaucoma AssociationWoodcote House, 15 Highpoint Business VillageHenwood, Ashford, Kent TN24 8DH

The information contained in this booklet was correct at the time of printing.

Charity registered in England and Wales No. 274681and in Scotland No. SC041550

© International Glaucoma Association 2017


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Support us

l become a member

l fundraise for us

l make a donation

l Gift Aid it!boost your contribution to the IGA without giving more.If you are a UK taxpayer, we can claim gift aid on yourmembership or donation, and increase the value ofevery £1 you give to £1.25, at no extra cost.

IGA membershipJoin us to hear about the latest research,treatment and management of glaucomaAs a member you’ll receive our quarterly magazine IGANews, hear all about our latest advice and information,help shape policy, participate in surveys and patientresearch and receive invitations to events like our AnnualLecture, delivered by top glaucoma specialists.

Just £17.50 a year

To join simplyl call our membership line on 01233 64 81 71l visit the membership pages on our website

www.glaucoma-association.com


Fundraising

Glaucoma is the leading cause of irreversible blindness.Every year in the UK 11,000 people are diagnosed with the condition. There is no cure. But blindness fromglaucoma can be prevented. With early diagnosis,professional monitoring and life-long treatment, the vastmajority of people with glaucoma will retain useful sightfor life.

The IGA is here for everyone affected by glaucoma. Our services include a helpline, information leaflets likethis one, an online forum and local support groups, andevents for professionals and patients. We run awarenesscampaigns and we fund research that leads to advances in treatment. Our long term aim is to seek a cure but untilthen, our services are free to all who need them.

As a charity, we rely on donations. We receive noGovernment funding, so your support would make a realdifference. With your help, we can fund research intoearlier detection and better treatments that will protectfuture generations from glaucoma sight loss. Support ourwork and become a sight saver.

To donate call 01233 64 81 71, visit www.glaucoma–association.comor text SEEK17 £5 to 70070.

Thank you. Together, we can seek to find a cure.


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Don’t Forget!

• Use your eye drops as prescribed by your consultant to avoid further sight loss in most cases.

• Tell your close relatives that you have glaucoma. They are at higher risk than average so should be tested regularly, and first degree relatives over the age of 40 are entitled to free eye tests.

• Contact the IGA Sightline if you have anyquestions. We’re here to help - 01233 64 81 70

• Join us! You may save someone’s sight.


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The IGA is the only UK charity solely dedicatedto people with glaucoma. We are passionateabout helping and representing people with thecondition. We want a future where people livingwith glaucoma, and those at risk of developingit, have the knowledge and access to the carethey need to avoid preventable sight loss.

Printed: August 2017 Review: August 2020


eye drops and dispensing aids.qxp iga 18/08/2017 … · instilling eye drops eye drops and...

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