# Situation: A 72-year-old man with type 2 diabetes mellitus and hypertension is scheduled for phacoemulsification with intraocular lens implantation in the right eye under topical anesthesia. Over the past 2 years he has noticed gradually blurred vision and glare when driving at night. After surgery, antibiotic eye drops, corticosteroid eye drops and an antibiotic eye ointment are all due at 22:00. Which plan is correct?

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> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 72-year-old man with type 2 diabetes mellitus and hypertension is scheduled for phacoemulsification with intraocular lens implantation in the right eye under topical anesthesia. Over the past 2 years he has noticed gradually blurred vision and glare when driving at night.

After surgery, antibiotic eye drops, corticosteroid eye drops and an antibiotic eye ointment are all due at 22:00. Which plan is correct?

## 보기

1. Both drops 5 minutes apart, with the ointment first
2. Both drops back-to-back, then the ointment 5 minutes later
3. Ointment first, then both drops one after the other
4. Both drops 5 minutes apart, then the ointment last **✔ 정답**

**정답: 4**

## 해설

When several eye medications are due together, the nurse waits at least 5 minutes between different drops so the second does not wash out the first, and gives drops before ointment, because ointment leaves a film that keeps drops from reaching the eye.

## 심화 해설

When several ophthalmic medications are ordered at the same time, the sequence and spacing determine how much of each drug actually reaches the ocular surface. The correct plan is to instill the two different eye drops 5 minutes apart, and to apply the ointment last.

The reason is straightforward. A drop that is instilled immediately after another drop will dilute and wash away the first medication before it can be absorbed. Waiting at least 5 minutes allows the first drop to remain in contact with the cornea and conjunctiva long enough for adequate absorption. Different eye drops should be separated by at least 5 minutes so the second drop does not rinse out the first.

Ointment must always be given after drops. Ointment forms a hydrophobic, occlusive film over the ocular surface. If ointment is applied first, that film creates a physical barrier that prevents subsequent drops from reaching the cornea and conjunctiva. Drops are given before ointment because an ointment film blocks or delays penetration of later drops. When the ointment is placed last, it also helps retain the previously instilled drops on the eye longer, which can enhance contact time.

The scenario involves a patient who has undergone phacoemulsification with intraocular lens implantation. Postoperative topical regimens after cataract surgery typically include an antibiotic to reduce the risk of postoperative endophthalmitis and a corticosteroid to control inflammation. The French Agency for the Safety of Health Products recommends topical antibiotic prophylaxis for any ocular surgery until the incisions are sealed, reflecting the importance of delivering the antibiotic reliably to the surgical site [2]. If the antibiotic drop is washed out by immediate instillation of the corticosteroid drop, or if it is blocked by an ointment applied first, the intended prophylactic coverage is compromised.

This patient also has type 2 diabetes mellitus. Diabetic patients undergoing cataract surgery are at increased risk for postoperative macular oedema, and topical anti-inflammatory agents are part of the preventive strategy in this population [3]. Reliable delivery of the corticosteroid drop is therefore clinically relevant. Giving the corticosteroid drop after a proper interval and before the ointment helps ensure that the anti-inflammatory drug reaches the ocular surface in an effective concentration.

| Order | Action | Rationale |
| --- | --- | --- |
| First | Instill antibiotic eye drop | Delivers prophylactic antimicrobial coverage to the surgical eye |
| Wait 5 minutes | Do not instill anything | Allows absorption and prevents washout by the next drop |
| Second | Instill corticosteroid eye drop | Controls postoperative inflammation; reduces risk of macular oedema in diabetic patients |
| Wait 5 minutes | Do not instill anything | Allows the corticosteroid to remain in contact with the eye |
| Last | Apply antibiotic eye ointment | Provides prolonged contact time and does not block absorption of the drops given before it |

Watch out! The ointment is never given first. An ointment base is greasy and forms a film that prevents water-based drops from reaching the ocular surface. If a patient needs both drops and ointment at the same scheduled time, the drops always precede the ointment.

Key point! The interval of 5 minutes applies between different drops. If only one drop and one ointment are ordered, the drop is given first and the ointment can follow after a brief pause, but the minimum interval between different drops remains the critical rule when multiple drops are due together.

In this scenario, giving both drops back-to-back and then applying the ointment 5 minutes later would cause the second drop to wash out the first. Giving the ointment first would block both drops. The only plan that preserves the therapeutic effect of each medication is to separate the two drops by 5 minutes and place the ointment last.References (research sources)

- [2][Antibioprophylaxis in ocular surgery: AFSSAPS recommendations].GuidelineCochereau I, Korobelnik JF, Robert PY, Hajjar J, French Agency for the Safety of Health Products (2011) · DOI: 10.1016/j.jfo.2011.05.002

- [3]Management of macular oedema in diabetic patients undergoing cataract surgery.Research articleBoscia F, Giancipoli E, D'Amico Ricci G, Pinna A (2017) · DOI: 10.1097/ICU.0000000000000328

## 임상 시나리오

Eye Medication SequencingPost-cataract surgery topical regimen
When multiple eye medications are due together, separate different drops by at least 5 minutes to prevent the second drop from washing out the first. Always give drops before ointment.

Ointment forms an occlusive hydrophobic film that blocks later drops from reaching the cornea. Applied last, it helps retain previously instilled drops and prolong contact time.

CautionDo not place ointment first or give drops back-to-back. Both errors reduce drug absorption and compromise postoperative infection and inflammation control.

## 핵심 개념

- **phacoemulsification** — Cataract surgery technique using ultrasound to emulsify and remove the lens before intraocular lens implantation
- **topical anesthesia** — Local anesthetic applied to the ocular surface for surgery without injection
- **endophthalmitis** — Severe intraocular infection, a serious postoperative complication after cataract surgery
- **occlusive film** — Hydrophobic barrier formed by ointment that blocks or delays penetration of subsequent eye drops
- **contact time** — Duration a medication remains on the ocular surface, affecting drug absorption

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