Why are eye drops so bewildering??

Preface: if any of this is wrong, great – please tell me!

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“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.