Picture sequence of Irrigation Procedure
I. Drug Installation
A. Purpose: To deliver saline or drug solutions to the eye
B. Categories:
i. Saline / Ocular lubricants (White or clear caps)
a. Saline
b. Artificial Tears
c. CL wetting solutions
ii. Anesthetics (White or clear caps)
a. Proparacaine HCL (Ophthaine)
b. Benoxinate (Fluress)
c. Tetracaine
iii. Mydriatics (Red caps)
a. Mydriacyl (Tropicamide)
b. Phenylephrine HCL (Neosynephrine)
iv. Cycloplegics (Red caps)
a. Cyclogel
b. Atropine
v. Miotics (Green caps)
a. Pilocarpine
b. Isoflurophate
c. Echothiophate ("irreversible" miosis)
vi. Others: Antibiotics, Anti-glaucoma
(Yellow and other colors)
C. Delivery systems:
i. Solutions
ii. Suspensions: Shake well before using
iii. Ointments: 1/2 to 1 inch strip in lower cul-de-sac
a. Twist tube at end of procedure to interrupt ointment flow
b. Pull upper lid over lower lid to avoid expulsion of ointment
iv. BE SURE TO CHECK EXPIRATION DATE PRIOR TO USING ON THE EYE
v. BE SURE TO ASK ABOUT PATIENT ADVERSE REACTIONS TO OTHER OR
SIMILAR DRUGS
D. Instructions:
i. Warn patient that drop may "sting" or "smart" briefly
a. Anesthetic use will reduce effect of drugs that follow
b. NOTE: In office, refrigeration of bottle prior to use will
reduce patient "sting" response (sting due to acidic pH)
as well as help preserve the solution from decomposing
faster.
ii. Tell patient length of action of the drug
a. Anesthetic: Effect immediate -- lasts about 10 minutes
b. Mydriatics & Cycloplegics: Effects in 15-30 minutes
-- lasts 2-4 hours
c. Ointments: Blurry or Filmy vision
(usually used at bedtime)
iii. Tell patient how often solutions should be used and how much
E. Techniques:
i. Wash your hands prior to touching patient
ii. Instruct patient to look up as well a tilt head back
a. Do not let patient watch the tip come close to eye
b. DO NOT let patient watch drop as it falls toward the eye
iii. Tug on lower lid to expose cul-de-sac
a. Two hand technique
b. One hand technique
c. Alternative technique
1. Have patient look down toward floor -- May be preferred
technique for the patient as they cannot see drop comming.
2. Drop placed on upper bulbar conjunctiva to flow over
cornea
iv. Maintain tip of bottle 1/2 to 1 inch above lash path
a. DO NOT PLACE TIP OF BOTTLE BELOW LASH PATH AT ANY TIME
b. Hold upper lid if necessary
c. DO NOT CONTAMINATE BOTTLE
1. Do not touch lashes, brow, skin or hair with tip of
bottle
2. Do not touch patient with cap of bottle held in hand
v. Squeeze bottle to deliver one drop to area (not on cheek)
vi. Occlude puncta if necessary for absorption for 30 to 60 seconds
vii. Alternative to punctal occlusion:
Close eyes for 30 to 60 seconds - may be desired technique to
keep patient from contaminating area with fingers.
viii. Dropping Children (technique when not cooperative)
a. Have parent hold hands
b. Use TWO HANDED technique
c. Trap head if necessary with arms extended (raised)
d. REASSURE child AT ALL TIMES
(Crying tends to dilute actions)
e. Alternative technique: Spray Bottle deliver systems
ix. DO NOT ALLOW
a. Patient to blot most of solution out of eye with tissue
Note: Drop size = 20 ul ----- Cul-de-sac = 7 ul
Most of solution will run out of the eye onto cheek.
b. Patient to rub eye after anesthetic instillation
(Topical anesthetic tends to soften the corneal ephthelium)
II. Pledget drug delivery
A. Purpose: To place drug in specific region of the eye
B. Example: Punctal anesthesia
i. Break cotton stick to about 1 inch length
ii. Soak cotton with anesthetic
iii. Patient to look up and away from nasal punctum
iv. Place cotton along lid margin of slightly exposed puncta
v. Have patient close lids along length of cotton
vi. DO NOT LET CORNEA RUB AGAINST Q-TIP
III. Patient Drop Self-installation
A. Patient is to wash hands prior to starting procedure
B. Align using mirror
C. Place drops into lower cul-de-sac
D. Alternative technique
i. Look to side into mirror and drop solution onto nasal or
temporal conjunctiva
E. Advise patient to cool solution prior to use as the eye is
sensitive to temperature
IV. Eye Irrigation
A. Purpose:
i. To remove unwanted particles (foreign bodies) from the eye
ii. To dilute effect of alien solution or material in the
anterior orbit
iii. To flush area of excessive dye
B. Preparation
i. Patient tilts head back
ii. Fold tissue and have patient form trough below orbit on
cheek
C. Procedure
i. Patient looks up while stream of fluid is directed to lower
conjunctiva
a. Move lower lash back and forth to flush entire area
ii. Patient looks down while stream of fluid is directed to
upper conjunctiva
a. Move upper lash back and forth to flush entire area
b. Move upper lash up and down to flush underneath upper lid
iii. Perform irrigation for minimum of 5 changes of direction
or 5 seconds
iv. Perform multiple irrigations if needed
v. DO NOT
a. Use excessive force in delivering stream of fluid to eye
b. Direct stream of fluid directly onto cornea
(exception: FB removal)
vi. Allow patient to dry surrounding adnexa when finished
D. If insufficient flush or patient relief, repeat procedure