Putting in eye drops and ointments
Attention
- Make sure tip of bottle/tube kept clean and does not touch eyelid, eye or lashes
What you do
- Ask person to lift chin and look up
- Pull down lower lid so pouch forms and put drops — Figure 8.4 or ointment — Figure 8.5 in pouch
- Write date opened on bottle or tube. Throw away when treatment finished or after manufacturer
recommended time (usually on bottle or tube)
Irrigating (washing) eye — to remove burning chemical
Attention
- Do not try to neutralise alkali or acid burn with chemical antidote. Always use water or
normal saline
- Do not give person local anaesthetic eye drops to take away and use. Will not be able to
feel further injury or damage
- Watch for respiratory distress (breathing problems) from soft tissue swelling in upper airways after chemical burn
to eye
What you need
- Helper to hold the eyelid open or to irrigate
- Normal saline connected to IV giving set OR tap water in bottle, cup, syringe
- pH test strip or U/A test strip (showing pH)
- Anaesthetic eye drops (eg oxybuprocaine, tetracaine [amethocaine])
- Sterile cotton bud
- Fluorescein stain
What you do
- Start irrigating (washing) affected eye/s immediately
- Tell person to blink. Gets chemical out from under eyelid
If outside clinic — hold eyelids apart and use gentle flow of water over eye from inside to outside
— Figure 8.6
If in clinic
- Give person or helper water to start irrigating eye.
- Tell them to keep doing this until you are ready
- Put in anaesthetic drops
- Set up IV giving set with 1L warmed normal saline
- Hold eyelids apart, use gentle flow of normal saline over eye from inside to outside — Figure 8.6
- Do not poke or touch anaesthetised eye. There will be no blink reflex
- Do single eversion of eyelid, then double eversion if you can. Wash tarsal plate (under
eyelid) to reach fornix (upper eye) — Figure 8.7
- Gently pull down lower lid and wash white of eye
- Use moist cotton bud to take off any specks on eye surface, or matter in corners of
eye
For alkali burns (eg lime, bleach, cement) or acid burns (eg battery fluid, toilet cleaner, rust remover)
- Will keep burning until completely removed
- Irrigate (wash out) eye for at least 30 minutes
- 5 minutes after stopping wash out, test pH of conjuctiva (eyeball) with pH test strip
or pH pad on urine dipstick — Figure 8.8
- If pH is not 7 — keep washing out until pH is 7 or same as unaffected eye. Recheck
after each 1L fluid
- Stop irrigation when pH is 7 in all parts of eye, including under eyelid
- If pH testing not available — keep irrigating
- Alkalis may need to be washed out for 2–3 hours
- When finished irrigating, do full eye assessment
- Urgent specialist consult
Single eversion of eyelid
Attention
- Use with every chemical injury, possible foreign body, trachoma check
- Very important to tell person what you are going to do. Some people are very sensitive
to having eyelid everted. You will need their help
What you need
- Wooden applicator stick or cotton bud
What you do
- Person can sit or lie down. You sit or stand in front of them
- Ask person to tilt head back and keep looking down, try not to blink
- With one hand, take hold of eyelashes and gently pull eyelid forward. This breaks
the suction between upper lid and eyeball — Figure 8.9
- With other hand, hold applicator stick across upper lid above lid fold — Figure 8.10
- Push down slightly on applicator stick and at same time pull upper eyelid out and
up and back over stick
- When lid has been everted take applicator stick away and keep lid everted by holding
lashes against eyebrow — Figure 8.11
- When finished
- Ask person to blink eyelid back to normal
- OR tell person to keep looking down while you gently fold eyelid down
Double eversion of upper eyelid
Used when very top of eyeball needs to be seen or irrigated — chemical burns or objects
on eye surface that can’t be seen with single eversion
Attention
- If emergency (eg chemical burn) — keep irrigating until you put in drops then do
procedure as quickly as possible so you can start irrigating again
- Procedure very painful — always use anaesthetic drops. Take about 2 minutes to work
properly
What you need
- 2 sterile cotton buds
- Anaesthetic eye drops (eg oxybuprocaine, tetracaine [amethocaine])
What you do
- Put in anaesthetic eye drops and wait 2 minutes if not an emergency
- Do single eversion of eyelid — Figure 8.12
- Take second cotton bud and lift lower edge of inverted inner eyelid — Figure 8.13 so you can see very top of eyeball — Figure 8.14
- Lid will not stay in place on its own. Hold it up with cotton bud as you irrigate
or take out foreign body
Making emergency eyelid retractor
Attention
- Safely made from standard sized paper clip
- Gives good view of cornea and eye ball unless serious swelling
- Surface of eye not sterile so retractor unlikely to introduce contaminants
What you need
What you do
- Wipe clip with sterile wipe and let dry
- Use clip to hook up eyelid — Figure 8.18
Fluorescein staining — to check for surface eye damage
Attention
- Store fluorescein drops in refrigerator. Warm to room temperature before use
What you need
- 10–20mL normal saline in 20mL syringe
- Ophthalmoscope. Blue filter is best then green
- OR other bright light source (eg pencil torch)
- Fluorescein sodium 2% drops
- OR fluorescein sodium ophthalmic strips (eg Fluorets)
- Sterile gauze swabs
What you do
- If pus or watery discharge — wash eye with normal saline
- Warn person that fluorescein may sting eye
- Put 1–2 fluorescein drops in small ‘pouch’ made in lower lid. Do not put straight onto cornea
- OR use fluorescein strip
- Add drop of normal saline or anaesthetic to tip then touch to inner side of lower
lid
- Ask person to blink
- Look at cornea with blue or green light from ophthalmoscope or slit lamp or bright
light
- If penetrating eye injury (perforation of eyeball) — will show fluid leak washing
away fluorescein stain (waterfall effect) — Urgent medical consult
- If new corneal injury or defect — will see pooling of bright, lime green colour (staining)
in that area
- Old corneal injury scars look opaque (whitish-grey) usually do not stain
- Record in file notes. Draw size, shape, position of injury/staining
- Gently wash out fluorescein with normal saline, clean around eye with tissues
Taking object off eye surface with irrigation or cotton bud
Attention
- Do not give person local anaesthetic eye drops to take away and use. Will not be able to
feel further injury or damage
- If foreign body on cornea is central and over pupil — needs to be removed in hospital
What you need
- 2.5 magnification head loupe (fits around head and used to see small objects in eye)
- Bright light
- Normal saline in 20ml syringe or IV giving set. Use tap water in an emergency
- Sterile cotton bud, wet with normal saline or anaesthetic eye drops
- Anaesthetic eye drops (eg oxybuprocaine, tetracaine [amethocaine])
- Antibiotic eye ointment, if needed
- Eye pad, tape
What you do
- Eye assessment
- Check vision
- Look for other signs of injury, make sure object isn’t sticking into eye
- Lie person down comfortably. Stabilise head. Use foam head ring, if available
- Use magnification loupe to magnify area
- Angle bright light at 45° to surface of eye
- Evert upper eyelid, look for foreign body/s
- Pull down lower eyelid, hold upper and lower eyelids apart
- Irrigate (wash out) eye to remove small objects not stuck to eye (non-adherent)
- Lift off objects sticking to eye surface with moist cotton bud
- If this doesn't work — put in 2 drops of anaesthetic eye drops and wait a few minutes for them to work
- Do single or double eversion of eyelid
- Sweep around under lid with wet cotton bud
- If you remove object
- Check vision again
- Check fluorescein staining, check for surface (corneal) damage. Will usually be small
area
- Put in antibiotic eye ointment, if needed
- Put on eye pad
- Ask person to come back next day for check
- If you can’t remove object
- Talk with eye specialist
- OR If you are skilled — see Taking object off eye surface with needle
Taking object off eye surface with needle
Attention
- Do not attempt until other methods have not worked
- Do not attempt if object within 4mm of pupil — needs to be removed in hospital
- Cornea is tough. You will need firm steady approach to remove foreign body
- Make sure you lift out all of foreign body not just a small piece
What you need
- 2.5 magnification head loupe (fits around head, used to see small objects)
- Anaesthetic eye drops (eg oxybuprocaine, tetracaine [amethocaine])
- 25G needle on 2mL syringe (to use as handle)
- Antibiotic eye ointment or drops (eg chloramphenicol)
What you do
- Check vision
- Put in anaesthetic eye drops, wait 2 minutes
- Put on magnification loupe
- Put needle firmly onto 2mL syringe
- Ask person to keep both eyes open and fixate on distant target (eg door handle). This
lessens eye movement
- Hold eyelids apart to stop blinking
- Brace hand holding syringe against side of head
- Put needle flat on cornea with bevel facing away from cornea (eye surface) to stop it scratching or sticking in
- Scrape an area slightly larger than object
- Gently lift under edge of object with bevel, then lift up and off eye surface — Figure 8.19
- Check vision again
- Check fluorescein staining, look for eye surface (cornea) damage. Some is expected
- Give antibiotic eye ointment or drops to prevent secondary ulceration. Must give even if you were able to remove foreign
body
- Put on eye pad until local anaesthetic drops have worn off — try to leave on for 1–2
hours, but at least 20 minutes
- Ask person to come back next day for check
- If you can’t remove object — specialist consult
Putting on eye pads or shields
- Use eye pad to
- Keep eyelids from moving over injured area and causing pain and friction
- Protect eye after using anaesthetic drops
- Keep light out of pupil dilated with drops
- Use eye shield to protect eye from compression
Attention
- Do not use pad on eye with bacterial or viral infection (eg ulcer, iritis, conjunctivitis)
- Always use pad on anaesthetised eye
- Eye pad needs to be comfortable but firm enough to stop eyelid movement
- Tape pad on securely
- Make sure skin around eye clean and dry before using tape
- Use eye shield without eye pad if
- Penetrating eye injury
- You suspect perforation — see Fluorescein staining
What you need
- 2 clean/sterile gauze eye pads or 2 ordinary gauze swabs folded in half
- OR 1 gauze eye pad/gauze swab and 1 plastic eye shield (pressure patch) with elastic
strap
- OR 1 plastic eye shield with no eye pad
- 25mm paper tape
What you do
- If using ordinary gauze swabs — fold 1 in half
- Ask person to keep both eyes closed
- Put eye pad or folded swab over injured eye — Figure 8.20
- Hold pad/swab in place (person can do this)
- Put second pad over top of first — Figure 8.21
- Tape pad from forehead to top of cheek as tightly as possible with enough tape to
cover whole pad. Check it is comfortable
- OR Cover first pad with plastic shield and tape in place — Figure 8.22
- Shield needs to sit on brow and cheek, avoid pressure on the eye itself
- Make sure it isn’t too tight
- Change pad/s every 24 hours
- If penetrating eye injury or suspected perforation — apply eye shield without eye pad/gauze
If you don’t have eye shield — make one by cutting bottom off polystyrene cup — Figure 8.23, Figure 8.24
Retinal photography
Retinal cameras capture digital images of the central retina which includes the optic
nerve head and macular. Much easier than using direct ophthalmoscope. Images can be
shared to monitor retinopathy or assist with decisions in emergencies
Diabetic photoscreening and monitoring
- If diabetes — should have a retinal check once every 12 months or sooner if known
to have retinopathy
- If overdue — take photos opportunistically
Retinal photos do not replace the need for regular eye checks with eye specialists/optometrists
Acute care
- Unexplained vision loss (especially if sudden) AND/OR severe headaches – take photos
Central retinal photographs do not show all the retina. There may be problems in the peripheral retina (eg retinal detachments)
that can only be seen with an ophthalmoscope
Attention
- If the pupils are too small or if there are media opacities (eg corneal scarring,
cataracts) it will not be possible to get clear photos
What you need
What you do
- Turn off all lights and make room as dark as possible, makes pupils get large
- Tell patient there will be a bright flash of light but nothing will touch or hurt
the eye
- Photograph the eye you are most worried about first. Follow manufacturers instructions
- Photograph other eye
- If the photograph of second eye is darker and blurry, wait 5 minutes for pupil to
get large again then retake photo
- If photographs are dark and blurry — medical consult about using tropicamide dilating drops to try and get better quality photos
- Using dilating drops can, very rarely, cause acute glaucoma. Tell patient to return if symptoms develop in next 24 hours
- If not trained to interpret photos — share with person who is (eg medical officer,
optometrist, eye specialist)