How We Mix Our Own Dilating 'Cocktail'

Ophthalmology

By: Sandy Shaut Vega

Published: 10/10/2007

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By streamlining our eye-dilating process, we save time and money on every cataract case.


We used to spend way too much time and money dilating our cataract patients. Not only were we using a different set of eye-drop orders for each of our five ophthalmologists, but our staff was spending about an hour giving each patient nearly 20 drops. You can imagine how the pre-op nurses dreaded busy cataract surgery days at our hospital-based, freestanding ASC. I'd like to share with you our new, simpler and streamlined method of dilating.

Cocktail-soaked pledget
It all starts with our specially formulated dilating cocktail. Our hospital pharmacy mixes and delivers the "cocktail" to the surgery center on Monday, the day before our cataract days. The cocktail consists of Ciloxin 5cc, Voltaren 2.5cc, Cyclogyl 1% 2.5cc and Viscous Neo Synephrine 10% 2.5cc. The pharmacist mixes the drops in that order in a sterile container. We use the solution for the 72 hours it lasts when refrigerated, usually about 20 patients.

We instruct our cataract patients to arrive 60 to 90 minutes pre-op. After reception checks them in, the pre-op nurse admits them, confirming the operative eye by placing a "right" or "left" sticker on the patient's forehead. We then instill two drops of Alcaine, a numbing drop, into the patient's eye.

Two minutes after we place the Alcaine drops, the pre-op nurse uses a non-toothed metal sterile forceps (we use a new forceps for each patient) to remove a pledget that has been soaking in the eye cocktail. We make our own pledgets. We cut Ocucel, an instrument wipe made by Alcon, into 2mm-by-20 mm tufts and soak them in the solution.

The nurse places the pledget in the patient's lower eyelid; this is carried out as a clean procedure. We instruct the patient to keep the eye closed until the pledget is removed in surgery. We place a piece of paper tape over the eye as a reminder. Within 10 minutes, the eye is dilated to our physicians' satisfaction, and the dilation is maintained for the duration of the surgery.

Save Time with a Compounding Pharmacy

Julie Macuch, RN, Plymouth, Mass.

In our single-specialty eye center, we dilate our patients with drops that are compounded for us by a compounding pharmacy. The drops cost $1 per patient, only 15 cents more than when we were administering individual drops to patients. The process is much less staff-intensive. Patients need only one drop instead of three or four and they dilate in 20 minutes instead of an hour-plus. Only occasionally does a patient require two drops, and never more than that.

The compound our physicians prefer consists of pheneylephrine 10%, tropicamide 1% and cyclopentolate 1%, but, says Barry Cadden, RPh, the director of pharmacy at the New England Compounding Center, "there are 40 to 50 possible combinations."

Each compound consists of at least one dilating drug, such as phenylephrine, cyclopentolate or topicamide, and each often contains an anesthetic, such as proparacaine, and an anti-inflammatory, such as flurbiprofen or ketoralac, he says. Mr. Cadden's compounding pharmacy doesn't generally add antibiotics to the mixtures because they shorten shelf life.

"[With compounding], you get all the original concentrations of the drugs, because we build the compounds individually from the actual chemicals," says Mr. Cadden. "We work with the facility and physicians to customize their own compound based on what they like. If it can be made safely, we will make it into a combination for them."

Ms. Macuch ("crumblis@aol.com")) is the co-director of Plymouth Laser and Surgical Center in Plymouth, Mass.

Note the average price (per-bottle price in parenthesis) of the cocktail's ingredients.

  • 5cc Ciloxin ($24.89),
  • 2.5cc Voltaren ($34.07),
  • 2.5cc Cyclogyl 1% ($13.11), and
  • 2.5cc Viscous Neo Synephrine 10% ($27.35).

At one time, we used one bottle of each eye drop per patient That means we were spending, on average, almost $100 per patient - on eye drops alone. Our cocktail method costs about $5 per patient.

In addition to the significant supply savings, our patients are more relaxed because we don't have to disturb them every five minutes to instill more eye drops. This approach also frees up nurses to start the process on the next patient and to provide patient care. In the more than two years that we've been using this eye-dilating process, no infections or corneal abrasions have occurred. And our ophthalmologists feel that the dilation achieved is far superior to that with any previous regimen they have used.

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