Glaucoma Therapy & Compliance

Glaucoma, a chronic, progressive, and most often asymptomatic disease, is the second leading cause of blindness worldwide. It is a preventable cause of blindness if timely effective and successful glaucoma therapy is provided.

Patient adherence to the medication is a constant challenge that is now recognized as an essential component to treatment.

Several studies have demonstrated that patients are more likely to be adherent to their medication if they understand the disease and the rationale for treatment and if their treatment regimen is simplified.

Patient compliance with glaucoma medication remains a major problem. According to a study nearly 45% of patients using an electronic monitoring device who knew they were being monitored, used their drops less than 75% of the time.

In addition, patients reported far higher medication use than their actual behavior. This raises concerns as to whether patients are truly compliant, how to identify compliance concerns, and how to boost adherence to prescribed regimes.

However, there are several steps to address the challenge of patient non-compliance with glaucoma therapy.

Identifying “Red Flags.”

The staff can identify compliance “red flags” using “open-ended questions,” such as, “What medications are you taking?” followed by, “What is the color of the bottle cap on the glaucoma medications you are taking?”

If it’s a chronic medication that they’re supposed to be taking every day and they don’t know the color of the bottle cap, they probably aren’t taking it. The staff might also ask, ‘What time do you take the medication?’

Identifying non-compliant patients can take a little bit of sleuthing via intentional questions that could identify the need for concern. Also staff look at e-prescribing notes to see how many times the medication was filled.

Uncovering the “Why,” and Remaining Calm

It’s important to get to the bottom of why patients are non-compliant to help correct issues. For example, sometimes it’s a struggle with memory or a cost issue, whereas other times patients dislike the drops and skip them intentionally.

Understanding Options to Help Compliance

• Accommodate the patient’s routine. The key is to make it easy for the patient. Most of the time, doctors are prescribing first-line agents, which are always taken at night, before bed.

If a patient has a routine nighttime ritual, then perhaps the drops should be kept near where that ritual occurs. If they read a book every night, perhaps they should be kept on the nightstand. When you can fit it into their routine, patients are more likely to comply.

• Simplify dosing regimens. While an additional drop may help lower IOP, complex dosing regimens have been shown to contribute to noncompliance. Options to simplify dosing include prescribing a drop that requires less frequent dosing or prescribing a combination drop.
• Address side effects, particularly ocular surface disease. Long-term installation of glaucoma drops can compromise the ocular surface, especially among the elderly, for which dry eye disease is more prevalent.

Doctors must address dryness in the glaucoma population — it isn’t always an option to just stop their medications.

There are prescribed glaucoma therapies out there for dry eye, but often times doctors don’t want to add more drops to their regimen due to making compliance even more difficult.

Options to consider are neurostimulation, thermal pulsation, devices that aid in Meibomian gland clearance, and nutraceuticals.

• Considering surgical options. Surgery to lower IOP may reduce or even eliminate the patient’s burden of taking drops. Recently, the LiGHT study demonstrated the benefits of selective laser trabeculoplasty, or SLT, as a first-line treatment for patients who have glaucoma.
• Share what works.  Listening to patients’ experiences and sharing their “best tips for compliance,” such as using a reminder, is also effective. Patients have relayed tips like using phone alarms, taping the top of the box to their coffee machine, or associating it with a task they do every day.

Barriers to glaucoma therapy compliance

• Skepticism about glaucoma-related vision loss
• Skepticism about medication effectiveness
• Poor glaucoma knowledge
• Poor self-efficacy
• Mistrust of physician
• Difficulty administering drops
• Cost
• Side effects
• Forgetfulness
• Difficulties with the schedule
• Life stress

Education is key.

A  study in the Expert Review of Ophthalmology reported the interventions that improve adherence to glaucoma therapy include “face-to-face” counseling along with education. The education should come from both the doctor and the staff, with the staff reiterating the compliance message.

That messaging should emphasize that glaucoma is progressive and irreversible. It should stress the importance of attending each office visit, regardless of whether the patient experiences any glaucoma symptoms.

Education must also deliver the message of how important it is to take medications as prescribed. The compliance education should be part of every visit. All doctors have seen some patients mistakenly assume after finishing a single bottle that they are “cured” or others who make mistakes with dosing.

Doctors can never assume that the patient fully understands what they’re supposed to be doing even if they’ve already been taking the medication. Patients should be reminded about medication details along with glaucoma therapy, such as properly spacing drops or what to do if they miss a dose.

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