Tutorial: How to do punctal occlusion after instillation of eyedrops
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8 months ago
Wren 350
@wren

Do you do punctal occlusion after instillation of eyedrops? It’s recommended.

Punctal occlusion is simply, with your eyes closed, pressing (reasonably gently) with your index fingers on the inside corners of your eyes (for up to five minutes). You’re aiming to block the tear ducts.

You are not squeezing your nose bridge. You are not touching your eyes.

Its purpose is to prevent eyedrop residue circulating through the rest of the body via the tear drainage system (aka nasolacrimal duct). This helps prevent or minimize systemic side effects from eyedrops. Also, the punctal occlusion helps the absorption of the eyedrop and can result in lower intraocular pressure (IOP) than you would otherwise get if not practising punctal occlusion. The best practice recommended time to do punctal occlusion for is five minutes.

The article linked to below includes the statement:

“Following the ocular instillation of drugs prepared in solutions, suspensions, and ointments, the pharmacologically active chemicals within these vehicles are pumped from the periocular area by the eyelids down the nasolacrimal outflow paths to the nasal mucosa. The vascular nasal mucosa can readily absorb the drugs delivered in these vehicles, resulting in measurable systemic blood levels, which can be associated with significant systemic toxicity. In other words, blinking following eye drop or ointment instillation within the eye discourages the intraocular penetration of a drug by minimizing ocular contact time and maximizes the systemic absorption of a drug as it is quickly and efficiently pumped into the nasolacrimal system and ultimately exposed to the vascular nasal mucosa. This effectively minimizes therapeutic effect and maximizes systemic toxicity of topically applied medications.”

Transactions of the American Ophthalmological Society 2008 Dec; 106: 138–148. The Importance of Eyelid Closure and Nasolacrimal Occlusion Following the Ocular Instillation of Topical Glaucoma Medications, and the Need for the Universal Inclusion of One of these Techniques in All Patient Treatments and Clinical Studies

There are no truly good videos of punctal occlusion technique, but these two might be of some help:

These images arae helpful too. Please see a more detailed description at: https://teachmeanatomy.info/head/organs/eye/lacrimal-gland/

Anatomical Location of lacrimal gland

Anatomical Structure

rx:medications side-effects nasolacrimal-drainage-system eye-drops punctal-occlusion • 1.2k views
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Entering edit mode

What a great reply! That 2008 article makes me shake my head in disbelief and makes me so grateful for this community!

In the following rant, am I missing something? Or is this nuts?

The disbelief is that with all the ophthalmologists I've seen, NOBODY has done any training on occlusion, much less to make sure I understand that IT AFFECTS WHETHER THE MEDICINE GETS INTO THE EYE. Yet here we have it, 2008:

"the literature suggests that [doing this] improves ... penetration of [drops] and discourage systemic absorption."

And then, exploding-head BOOM: "The FDA and NIH discourage these techniques in studies of ... medications." WHAT??

(Is this still true in 2021??)

And this paper has only been cited 36 times, according to Google Scholar. Good heavens!

(Mind you, I hate the news that if I want my drops to work, it's going to take me five minutes PER DROP. I say this because I'm advocating for something I DON'T LIKE, because the SCIENCE SAYS SO and I'm science driven.) (And I really can't believe that the profession isn't all over this with teaching aids and reminders.)

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Entering edit mode
15 months ago
EyeTidbits • 70
@eyetidbits

Great info! However, I tried punctal occlusion before, but it caused some medication loss because part of the drop got dabbed onto my fingers (& seemed to have a capillary effect, drawing medication toward my finger). So, instead, I learned to just aim the drop further away from tear duct & just keep eyes closed (no blinking, which washes medication down tear duct & sinuses, causing systemic absorption).Squeezing a smaller-size drop or using a microdropper also reduces systemic absorption from excess. Below is an article-link that mentions the simpler alternative practice of keeping eyes closed, except for more potent meds like B-blockers: https://www.glaucoma.org/treatment/putting-in-eye-drops.php

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Yes, it’s normal for eyedrop excess to spill out of the eye. The eyedrop medication amount is designed to allow for this.

People have devised various routines around punctal occlusion, some of which may help alleviate what you experienced - excess eyedrop on your fingers. In a timely manner, I put my eyedrops in, wipe the excess away with a tissue, do punctal occlusion for 5 minutes, blow my nose (to help clear anything that may have got that far) and then wash my index fingers and, with a washcloth, the skin around my eyes.

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I tried punctal occlusion before, but it caused some medication loss because part of the drop got dabbed onto my fingers (& seemed to have a capillary effect, drawing medication toward my finger).

Most eye drops are 30 to 50 microliters in volume. The eye can only hold around 7 to 10 microliters (maybe less). Therefore, even if a full 50% of the medication was drawn onto your finger, you would still have more than enough of the eye drop remaining to saturate your eye's capacity.

So, instead, I learned to just aim the drop further away from tear duct & just keep eyes closed

Why not do both? If you aim the drop further away from tear duct, you will further reduce any concerns about the potential capillary effect drawing medication onto your finger.

However, the capillary effect requires a small tube, which your finger is not. Therefore, I don't think it is very likely that your finger is attracting the medication. Maybe it was squeezing some medication out. As I said, that should be be a concern. However, if you instill your eye drops away from the nasal side of your eye, as you said, it should let you perform punctal occlusion without any of the medication ending up on your finger.

In my case, I use a microdrop of 7.5 micoliters. If I were using a larger drop, I would be happy for the excess to end up on my finger. The eye can't hold the full size of a drop, therefore, the rest ends up in your body.

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15 months ago
hashfiteyes • 40
@hashfiteyes

Most definitely a must,I put my eye drops lying down,use a tissue to gently press on the rear ducts with the eyes closed for a few minutes,whilst some deep breathing, afterwards I normally spray fresh water on and around the closed eyes so as to wipe away the residue around the eyes, sometimes I also splash water on closed eyes, depending on my mood and how lazy or active I feel!😁.... Good evening to all from Thailand ❣️

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