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CLINICAL: CHRONIC ILLNESS Patients are often concerned that they will overdose, but they


can be reassured that the eye will only hold one drop at a time. This is also why there should be a gap of at least 10-15 minutes between each drop used. Systemic side effects can often be reduced by punctal occlusion – the patient pressing down firmly at the inner nasal corner of their closed eyes. This stops the drop from draining into the back of the throat by obstructing the nasolacrimal duct. Changes to treatment regimes can also be problematic. The


new drop may give more ocular side effects, therefore the patient stops using the drops or attends the GP surgery to complain of sore eyes, dry throat or other symptoms, asking for their ‘old’ drops again. Unfortunately, most of the time drops are changed because of increasing IOP (one of the reasons for continued monitoring) therefore changing back to any previous regime can cause more harm than good. If you are asked about this, you can always seek advice from your local eye unit.


OTHER TREATMENTS A number of laser treatments can be employed to increase aqueous drainage if drops fail to reduce the IOP appropriately. However these may not reduce the need for eye drops. Surgical interventions such as trabeculectomy can be offered, however again this operation often requires significant follow-up and does not guarantee that drops will not be required following surgery, so adherence to eyedrops remains a priority.


ADHERENCE CASE STUDY A 68-year-old lady had been prescribed eyedrops for many years. Her visual fields were progressively getting worse. Her drops had been changed and there were limited treatment options left. She arrived at the clinic for the first time – this should read my clinic (she has been seen by other clinicians for many years but not by a nurse so the my is quite important. We discussed her drop regime and she eventually admitted that she was taking her drops intermittently, usually before clinic but otherwise didn’t like them so didn’t bother – she could see, continued to drive, and maintained her social life. We discussed the options and her choices. She was free to choose not to take the drops but needed to accept the consequences. I presented her the deteriorating visual fields which starkly showed large black patches, not present when she first came to the clinic. This helped her to put the problem into context. We further discussed her symptoms when using drops, as she was thought she was allergic to all drops. PGAs make the eye red, this is a known side effect and not an allergy; CAIs make the eye


dry, also a known side effect and not a symptom of allergy. She arrived at her own conclusion that the eyedrops were needed to prevent further field loss and agreed to try again with the drops. We used a single drop regime, to keep it simple for the patient. I am pleased to report that her adherence has improved and her visual field loss has been stable for the last two years. Perhaps you could ask patients during routine visits about their


eye drops, and explain why they are so important, as you may be able to prevent sight loss. Eyedrop adherence is vital to maintain- ing visual fields allowing patients to continue to drive, work and be an active member of society.


BOX 4. TAKE-HOME MESSAGES


A visit to the optician can save sight; it’s not just about glasses. Those with first-de.gree relatives with glaucoma should attend yearly and the test is free. Eye drops that lower IOP do not mean a patient has glaucoma


as they may not have optic disc damage. These patients risk progressing to glaucoma without treatment. Encourage patients to use their eye drops daily as prescribed.


Complex regimes can be linked to everyday activities such as meal times, bedtime. Try to encourage patients to instil their own drops so that if


things change, they are fully equipped to manage by themselves. Ring the local eye unit medical secretaries to ask for advice


before changing any long-term medication, as eye drop regimes are usually changed for a reason.


REFERENCES 1. Kanski JJ. Clinical Ophthalmology - A systematic approach. Edinburgh: Butterworth-Heinemann; 2007.


2. Ring L. The glaucomas: primary open-angle glaucoma and congenital glaucoma in Field D, Tillotson J and MacFarlane M (eds). The Ophthalmic Study Guide for Nurses and Health Professionals. Keswick: M&K Publishing; 2009.


3. National Institute for Clinical Excellence (NICE) Glaucoma Diagnosis and Management of Chronic Open Angle Glaucoma and Ocular Hyperten- sion. London: NICE; 2009. Available at: www.nice.org.uk/nicemedia/ live/12145/43791/43791.pdf


4. Rudnicka AR, Mt-Isa S, Owne CG et al. Variations in Primary Open- Angle Glaucoma Prevalence by Age, Gender & Race: A Bayesian Meta-Analysis. Invest Ophthalmol Vis Sci 2006;47(10):4254–61.


5. Brandt JD, Beiser JA, Kass MA et al. Central Corneal Thickness in the Ocular Hypertensive Treatment Study (OHTS). Ophthalmology 2001;108(10):1779-98.


BOX 3. INSTILLING EYE DROPS


1. Rest the palm of the hand on the cheek, using one finger to pull the lower lid down.


2. Using the finger and thumb of the other hand to hold the open eye drop bottle, rest this hand on top of the hand on the face with the tip of the bottle within view.


3. Tilt the head backwards to look at the ceiling, not the eye drop bottle, keeping both hands in the same place.


4. Squeeze the bottle according to the individual bottle design, and allow one drop to fall into the eye.


6. Ellis J, Evans J, Ruta D, et al. Glaucoma incidence in an unselected cohort of diabetic patients: is diabetes mellitus a risk factor for glaucoma? Br J Ophthalmol 2000;84(11):1218-24.


7. Hoyng P, Kitazana Y. Medical treatment of normal tension glaucoma. Surv Ophthalmol 2002;47(Suppl 1):S116-24.


8. Djafari F, Lesk M, Harasymowycz PJ, et al. Determinants of adherence to glaucoma medical therapy in long term patient population. J Glaucoma 2009;18(3):238-42.


9. Konstas AGP, Maskaleris G, Gratsonidis S et al. Compliance and viewpoint of glaucoma patients in Greece. Eye 2000;14(5):752-6.


10. Lacey J, Cate H, Broadway DC. Barriers to adherence with glaucoma medications: a qualitative research study. Eye 2009;23(4):974-93.


34 Nursing in Practice March/April 2012


www.nursinginpractice.com


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