Sir,

The recently updated NICE glaucoma guidelines1 highlight the need for explaining to patients the technique of how to instil an eye drop. In an attempt to elevate the cornea away from the lower lid to reduce the chance of the dropper touching the cornea, we often ask our patients to look up. This movement may hyperextend their neck and atlanto-occipital joints.

We report a case of significant neck damage following the use of eye drops. A 67-year-old gentleman was diagnosed with glaucoma and commenced on Latanoprost (Xalatan, Pfizer) eye drops. Five days later he experienced numbness and paraesthesia in his hands, which continued for 6 months. A neurological examination showed brisk upper limb reflexes and an extensor plantar response consistent with an upper motor neurone lesion. Subsequent spinal MRI (Figure 1) showed severe degenerative change between C3/4 and C6/7 with compression of the cord (cervical spondylosis with myelopathy). The patient was advised to avoid neck hyperextension when instilling his drops. On subsequent neurosurgical review 2 months later, his symptoms had settled and no surgery was required.

Figure 1
figure 1

MRI spine showing severe degenerative change between C3/4 and C6/7 with compression of the cord (cervical spondylosis with myelopathy).

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Nucci et al2 have previously reported a case of atlanto-axial dislocation caused by administration of eye drops in a child with Down's syndrome. This case report suggests that we should also perhaps explain to patients that there is no need to forcefully hyperextend the neck, as drops can effectively be instilled without such neck movement. Gentle lower lid retraction can help avoid the bottle contacting the eye, as this can result in contamination of the bottle contents.

Rather than asking our patients to ‘look up’, we should consider asking, ‘keep your head still and with your eyes only look up’, perhaps with a helper's gentle hand support on the back of their head to avoid neck hyperextension. Patients can also try the semi-recumbent position to aid drop application, or, alternatively, their carers can instil the drop.

Patients with musculoskeletal problems do require eye healthcare professionals to assess their needs in a holistic manner in order to aid concordance with long-term topical therapy, and to reduce the risk of serious spinal sequelae.