An upright eyedrop bottle: accuracy, usage of excess drops, and contamination compared to a conventional bottle

Ocular Pharmacology

Treatment of ocular diseases presents unique challenges and opportunities for the clinician and for the clinical pharmacologist. Ophthalmic pharmaceuticals, typically given as liquids, require consideration of solubility, physiological pH, and osmolarity, as well as sterility and stability, which in turn requires optimal pharmaceutics. Ocular tissue levels are challenging to obtain in humans, and the clinical pharmacokinetics is typically blood levels, which are primarily related to safety, rather than efficacy. The eye is a closed compartment with multiple physiological barriers with esterases and transporters, but relatively little cytochrome oxidases. Delivery routes include topical, intravitreal, and systemic. Patient dosing involves not only adherence issues common to all chronic diseases, but also performance requirements on eye drop instillation. Therapeutically, ocular diseases and their pharmacological treatments include both those analogous to systemic diseases (e.g., inflammation, infection, and neuronal degeneration) and those unique to the eye (e.g., cataract and myopia).

Assistive technologies and strategies to support the medication management of individuals with hearing and/or visual impairment: A scoping review

BACKGROUND

Individuals with sensory impairment (visual and/or hearing) experience health inequalities and increased the risk of medication-related iatrogenic disease compared with the general population. Assistive technologies and tailored strategies could support medication management for individuals with sensory impairment to reduce harm and increase the likelihood of therapeutic benefit.

OBJECTIVE

This scoping review identified assistive technologies and strategies to support medication management of/for people with hearing and/or visual impairment.

METHODS

Standard scoping review methodology was used to identify studies that evaluated technologies or strategies designed to support people with sensory impairment with independent medicine management. Electronic databases were searched (MEDLINE, Embase, CINAHL, ACM, Cochrane) from inception to 18/07/22. Independent duplicate screening, selection, and data extraction were undertaken.

RESULTS

Of 1231 publications identified, 18 were included, reporting 17 studies, 16 of which evaluated technologies to assist people with visual impairment and one study to assist people with hearing impairment. The range of technologies and devices included: applications for android phones (n = 6); eyedrop-assistance devices (n = 5); audio-prescription labelling/reading systems (n = 2); touch-to-speech devices (n = 2); continuous glucose monitoring system (n = 1); magnifying technology (n = 1). Ten studies tested early-stage prototypes. Most participants could operate the technologies effectively and deemed them to be useful.

CONCLUSIONS

Despite the increasing number of medicine-related assistive technologies, there has been limited empirical evaluation of their effectiveness for supporting individuals with sensory impairment. Prototypes appear to be useful for people with visual or hearing impairment, however wider 'real-life' testing is needed to confirm the benefits of these technologies.

Identifying and addressing common contributors to nonadherence with ophthalmic medical therapy

PURPOSE OF REVIEW

To discuss common reasons for nonadherence and review existing and emerging options to reduce nonadherence with ocular medical therapy and optimize therapeutic outcomes.

RECENT FINDINGS

Nonadherence can arise from patient-related issues (e.g. physical, cognitive) and healthcare-related issues (e.g. cost, access to care). Multiple strategies have been developed and evaluated to overcome these barriers to adherence. Identifying nonadherence and its cause(s) facilitates the development of strategies to overcome it.

SUMMARY

Many common causes of nonadherence can be mitigated through a variety of strategies presented.

Comparison of the Usability of Eye Drop Aids and the Conventional Bottle

(1) Background: Eye drops are the most common route of administration for ophthalmic medications. Administering drops can be a major hurdle for patients, potentially resulting in noncompliance and treatment failure. The purpose of this study is to compare the efficacy and safety of two different aids and the conventional bottle for eye drop instillation; (2) Methods: An interventional crossover study involving standard eye drop bottle, Opticare aid and Autodrop aid. The study included healthy subjects without a history of regular eye drop use; (3) Results: Twenty-six subjects were enrolled. Of those subjects, 96% and 92% were able to assemble the eye drop bottle into the Autodrop and the Opticare aids, respectively. Subjective assessment indicated that Autodrop was significantly easier to assemble than Opticare (95% CI: -1.6802 to -0.1659, p = 0.02). When using either aid, there was no contamination of the bottle tip, which occurred in 46% of subjects when no aid was used (p = 0.0005). Fewer drops were expelled when using the conventional bottle as compared to the aids (p = 0.05 compared to Autodrop, p = 0.1 compared to Opticare); (4) Conclusions: Autodrop and Opticare can assist patients with eye drop placement. These aids completely prevented bottle tip contamination, which was frequently observed when the conventional bottle was used alone.

Novel Postoperative Dropless Protocol for Micro-Incision Vitrectomy Surgery

BACKGROUND AND OBJECTIVE

To evaluate the outcomes of a novel postoperative dropless protocol for 25-gauge and 27-gauge micro-incision vitrectomy surgery (MIVS).

PATIENTS AND METHODS

The institutional review board approved a single-center, retrospective study. A total of 493 surgeries were identified, and 451 cases from 369 patients met eligibility criteria. Instead of pre- or postoperative drops, patients were given a novel postoperative dropless protocol consisting of subconjunctival injections of a 1:1 cefazolin:dexamethasone mix at each sclerotomy and intravitreally, and injection of posterior sub-Tenon's Kenalog. Primary outcome measure was cases of postoperative endophthalmitis.

RESULTS

There was one presumed case of endophthalmitis. Anterior chamber paracentesis sample was negative for culture and Gram stain. For all patients, mean logMAR best-corrected visual acuity improved from 0.65 (±0.69) to 0.57 (±0.61) postoperatively (P = 0.004). Mean intraocular pressure increased from 14.5 (±4.3) to 15.5 (±4.8) postoperatively (P < 0.001). Mean follow-up was 96 days.

CONCLUSION

This novel postoperative dropless protocol could potentially be a convenient alternative to topical eye drops for patients undergoing MIVS, but further study is required to establish its safety. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:587-592.].

A Randomized Controlled Clinical Trial to Compare Conventional Drug Instillation to A Device Dropper Method in Medical Treatment of Glaucoma

PURPOSE

To compare and analyze the performance of a device dropper (DD) over conventional drop instillation (CDI) method on ease of administration, compliance, patient satisfaction, and intraocular pressure (IOP) control in persons with glaucoma on ocular hypotensive medications.

METHODS

We enrolled 72 individuals with primary open-angle glaucoma or ocular hypertension, on treatment with fixed combination (α agonist+β blocker) drugs for at least 6 months. These were randomized into two groups (36 in each arm). Group 1 administered the drug with a DD and Group 2 used CDI method. Recruited individuals were interviewed for subjective difficulties using a formatted questionnaire at first month follow-up and IOP change from baseline was evaluated.

RESULTS

Baseline demographic and ocular characteristics were similar in both groups. 57.1% in the conventional instillation and none in the DD had reported difficulty in using the eye drops on follow-up visit. DD group had significantly less spillage and contamination of eye surface or dropper tips, required minimal assistance, accurately targeted on first drop placement directly into the eye compared to CDI group (p-value<0.001). Mean IOP was comparable between the two groups.

CONCLUSION

DD instillation method was observed to be easier to administer, more accurate in targeting the conjunctival cul-de-sac, reduced wastage with lesser contamination compared to the CDI technique. DDs may be expected to have better compliance and effectiveness in medical management of glaucoma.

The Design and Development of an Eye Drop Aid for Glaucoma Patients

Visual impairment is an important public health problem. A cataract is the most common eye disease, and surgical methods are mostly used. Unlike a cataract, glaucoma may lead to permanent loss of vision and can be treated appropriately using eye drops. In this study, the researchers aimed to create, design, and develop a device called “Eye Drop Aid of Naresuan University (EDANU).” This research employed mixed methods using an in-depth interview and questionnaire, which were conducted with a group of 10 experts to provide preliminary data for the design and a group of 20 volunteers to test the efficacy and safety of the EDANU compared with the instructions of the Xal-Ease™ eye drop administration and instructions as recommended by the Pharmacy Council of Thailand in the laboratory. It was found that the EDANU, which was designed and developed as a prototype using thermoplastic polyurethane, which is a highly flexible material, was more accurate, reliable, and safer than the Xal-Ease eye drop administration. The EDANU displayed efficient statistical significance and proved to be safe for using in the laboratory.This was a device that could help glaucoma patients and their caregivers have a better quality of life because this device was more accurate, reliable, and safer than the other two methods. However, the EDANU is still in the process of prototype development, and, in the future, it would still be necessary to study with a human clinical trial.

Improving Adherence to Topical Medication in Patients with Glaucoma

The glaucomas form a heterogenous group of conditions, which collectively account for one of the most common irreversible causes of blindness worldwide. The only treatment, for which there is evidence, to stop or slow glaucomatous disease progression is to lower intraocular pressure (IOP); this is most often initially achieved with topical medication. Adherence to anti-glaucoma therapy is known to be low even when compared with adherence to therapy for other chronic conditions. We performed a PubMed search to review evidence as to how adherence to and persistence with anti-glaucoma medications might be improved. Approaches to improving adherence include technological (such as using smart drop bottles or automated reminders) use of instillation aids, improving communication with patient education and improving tolerability of eye drop formulations. There is limited short-term evidence that automated reminders can be effective and, unfortunately, instillation aids have not proved to be efficacious with respect to improving adherence. A range of factors have been identified which affect adherence and persistence, although only a multi-faceted approach has proven evidence of efficacy, compared to improved patient education alone. There is now a wider range of available preservative-free eye drops, which have been shown to be non-inferior in achieving IOP control, with fewer side effects and improved short-term adherence. Further studies relating to adherence are warranted, particularly given the projected increase in glaucoma prevalence worldwide.

Patients' Experience of Using Eye Drop Guide Device to Aid Self-Administration of Glaucoma Medications

Purpose

To determine the characteristics of the patients who preferred using the eye drop guide (EDG) regularly and their opinions toward the guide in order to select the patients for prescribing the EDG appropriately.

Patients and Methods

Fifty-seven glaucoma patients who completed the primary study, “The effect of ‘eye drop guide’ on the success rate of eye drop self-instillation in glaucoma patients”, were included. Patients’ instillation techniques, routine instillation or using the EDG, were chosen independently. After 4–6 months, they were interviewed about the frequency of EDG use and their rating scores toward the guide in 4 aspects including aiming aids, contamination prevention, reduction of drop waste, and ease of use. The differences in opinion scores between each frequency group and the factors associated with the regularity of EDG use were statistically analyzed.

Results

Of fifty-seven patients completing the interview, 19.3% used the EDG everyday, while 45.6% had never used the EDG. The nonusers rated significantly lower scores in all aspects (p-value < 0.005). From multivariate analysis, the factors associated with the preference not to use the EDG were administering in supine position (p-value < 0.001, adjusted OR 34.866, 95% CI 4.974–244.412) and more than one eye drop use (p-value = 0.048, adjusted OR 5.280, 95% CI 1.018–27.396).

Conclusion

The EDG should be selectively prescribed for the particular patients who had one medication and performed instillation in sitting or standing position. Although the regular EDG users tended to have positive opinions on the EDG, their long-term compliance with the guide was underinvestigated.

Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Program Pilot Study on Eye Drop Instillation Technique and Self-Efficacy

PURPOSE

To assess the Support, Educate, Empower (SEE) personalized glaucoma coaching program impact on (1) eye drop instillation technique and (2) eye drop instillation self-efficacy.

DESIGN

Prospective pre-post pilot study.

PARTICIPANTS

Patients with a diagnosis of glaucoma or ocular hypertension taking ≥1 glaucoma medication, ≥40 years old, spoke English, self-administered their eye drops, and ≤80% adherent to their glaucoma medication by electronic monitoring.

METHODS

Eye drop administration was video recorded before the first SEE in-person coaching session, which included teaching eye drop instillation techniques using a motivational interviewing-based approach. At the third and final in-person counseling session 6 months later, eye drop administration was video recorded. Participants' self-efficacy was assessed using the validated Eye Drop Technique Self-Efficacy Scale (EDTSES) survey at baseline and 1 month after completion of the program. Before and after intervention videos were assessed by an observer masked to time point. Before versus after intervention comparisons were made using McNemar's and paired t tests.

MAIN OUTCOME MEASURES

The main outcome was change in participants' eye drop instillation technique as measured by (1) accuracy of an eye drop landing on the eye, (2) ability to instill an eye drop on the first attempt, and (3) contaminating the bottle by contact with ocular surface, eyelashes, and skin. The secondary outcome measure was before versus after change in the EDTSES score (6 items, each assessed on a 3-point Likert scale, with higher scores indicating better self-efficacy).

RESULTS

Thirty-nine participants completed the SEE intervention, 38 with before and after EDTSES scores and 31 with video recordings. Six of 31 participants instilling drops outside the eye before intervention improved their technique after intervention, whereas 2 participants worsened (P = 0.157). From before to after intervention, participants demonstrated significant improvement in not touching the ocular surface (P = 0.046), the eyelashes (P = 0.020), or the skin (P = 0.025) with the bottle tip. A significant increase was found in eye drop instillation self-efficacy from an average score of 2.6 (standard deviation [SD], 0.3) to 2.8 (SD, 0.2) on the EDTSES score (P = 0.007).

CONCLUSIONS

The SEE program significantly decreased eye drop bottle contamination, increased eye drop instillation self-efficacy, and demonstrated an insignificant increase in ability to instill drops successfully and accurately.

Aids for eye drop administration

One aspect to eye drop adherence is successful instillation of the drops; however, it is well known that many patients struggle with this task. Difficulties may include aiming their drops, extending their neck, preventing excess drop leakage, avoiding contamination of the bottle tip, and generating enough force to expel a drop from the bottle. Instillation aids are devices that aim to ameliorate one or more of these barriers. We review the literature on instillation aids to describe the options available to patients and to report evaluations of their efficacy. Most instillation aids studied improved objective or subjective outcomes of eye drop instillation, including improved rates of successful administration and increased patient satisfaction compared with standard eye-drop bottles. Although further research is warranted, instillation aids may be an underutilized resource for the many patients who struggle to administer their own eye drops.