ASORN Quick Question #13
January 2005

Dilating and other drops given one at a time five minutes apart are labor intensive for the nursing staff. Combination drops have been used (Apt and Hendrick. 1980. American Journal of Ophthalmology 89:553-59). Wick delivery has been promoted (Ong-Tone. 2003. Journal of Cataract and Refractive Surgery. 29:2060-62).

Respondents were asked answer the questions considering only surgery for which the eye must be dilated. About 140 members representing 36 states and one foreign country completed the survey. Results are given in number of responses.

1. What medications are ordered preoperatively at your workplace?
1. phenylephrine 2.5% (Neosynephrine) = 121
2. cyclopentolate 1% (Cyclogyl)  = 100
3. tropicamide 1% (Mydriacyl) =  66
4. atropine 1% = 25
5. tropicamide 0.5% (Mydriacyl) = 15
6. scopalomine 0.25%  = 9
7. flubiprofen sodium 0.03% (Ocufen) = 50
8. ofloxacin 0.3% (Ocuflox) =  30
9. diclofenac sodium 0.1% (Voltaren)= 21

Other drops mentioned included;

10. gatifloxacin 0.3% (Zymar) = 26
11. moxifloxacin 0.5% (Vigamox) = 17
12. ketorlac (Acular) = 15
13. phenylephrine 10% (Neosynephrine) = 11
14. Several other drops were mentioned once or twice as well as a variety of anesthetic drops or gel.

2. Are these drops given one at a time or in premixed combinations?
1. One at a time = 86
2. Premixed = 21
3. Administered in combination on a wick or pledget = 23
4. Only one source was listed for purchasing combination drops: New England Compounding Center.

3. How many total drops are given in the intervals below? (For the purpose of this question, consider drops only as given initially, not additional drops administered for difficult-to-dilate eyes.)
   1. 9-12, 5 minutes apart or greater = 23
   2. 9-12, usually less than 5 minutes apart = 9
   3. 6-8, 5 minutes apart or greater = 26
   4. 6-8, usually less than 5 minutes apart = 17
   5. Less than 6 = 29
   6. Administered in combination on a wick or pledget = 25
   7. Other:  = 14
      • Mix drops in xylocaine gel
      • Mix drops and give one drop times two, five minutes apart
      • 4 drops 5 minutes apart
      • 4 drops 10 minutes apart
4. If administered via a wick or pledget, who prepares the mixture?
1. RN = 33
2. Surgeon = 5
3. Technician = 0
4. Pharmacist = 12

5. How long does it usually take for adequate dilation?
1. 60 minutes = 5
2. 45 minutes = 17
3. less than 45 minutes = 112

Comments:

1. Pledgets

1. “Occasionally causes discomfort and additional tetracaine must be administered…saves us an hour of admission time.”
2. “We administer one set of drops pre-op in a dilating room. If this is not adequate, or if time is short (due to transport, etc) we will place a pledget for 10-15 minutes and receive full dilation.”
3. “We tried a pledget and got more complaints of discomfort from the patient and pupillary dilation was not as good or as quick. We also tried a mixture of drops in a gel base. The nurses prepared this mixture in the morning each surgery day. The preparation was more labor intensive for our nurses than just giving the drops…Our dilating procedure of giving 4 drops and then 5 minutes later, 4 more drops takes 10 minutes…”
4. “We have begun using the pledget method since 1/1/05 and found that MOST of our patients dilate well. There is always the occasional patient who does not dilate. We start with a drop of proparacaine prior to the pledget.”
5. “We made the switch from individual drops to pledgets 4 years ago. Doctors, staff, and patients much happier now! (Plus it saves money!!)”
6. Two comments mentioned corneal abrasions and/or pledgets being forgotten.

2. Mixed drops

1. “Drops are premixed by an RN and instilled one drop 5 minutes apart for 2 doses.”
2. “We mix our own drops and have found it much less labor intensive and less costly than administering one drop at a time.”
3. “Our mixture of tropicamide 1%, Acular 0.5%, and phenylephrine HCL 10% works great given every 5 minutes times 3, but we can get adequate dilation from just one drop if given at least 30 minutes to dilate. Also having the patients close their eyes really speeds up dilation.”
4. “We use a total of 5 drops preoperatively, over 20 minutes total time: one drop antibiotic, 4 drops compounded dilation drops.”
5. “We mix 5 ml. of 2% preservative free lidocaine jelly with 16 drops each of Cyclogyl, Mydriacyl, Quixin, Volataren, and 10% Neosynephrine. Instill 1/2ml in operative eye and patch approximately one hour preop. Dilation is rapid and sustained throughout procedure.”
6. “We have many surgeons, each with their own preferences….Not all are mixed. When the order is for premixed drops, the RN mixe them. We also have some surgeons who order the dilating drops mixed with lidocaine jelly.”
7. “We use a xylocaine jelly with drops added to the jelly. Works very well. Dilation usually takes 30 minutes.”

3. Methods

1. “Same day units give the eye drops to the surgical patient.”
2. “Every surgeon is different as to drops and medication type. Patient might start the drops at home.”