glaucoma compliance
Improving Your Glaucoma Patients' Compliance
Learn why patients don't comply -- and how to change this common problem.
BY JAY D. PETERSMA, O.D., Johnston, Ia.

"Compliance is the act of following the recommendations of your doctor."

It sounds easy enough. All of our patients surely follow our instructions and are completely on top of their medical therapy for their glaucoma, right? Just like all of our patients using disposable contact lenses change their lenses on time . . . wrong!

Among all treatable diseases, the glaucoma patient is one of the most likely to comply poorly with their doctor's recommendations. If fact, as many as one half of all glaucoma patients fail to take their eye drops correctly.

Zeroing in on compliance

Let's operate on the premise that glaucoma treatment aims at lowering IOP to prevent loss of ganglion cells, and therefore the loss of vision. It's simply not enough for us to simply prescribe these drops and say, "See you in three months . . . next patient, please!"

Progression of glaucomatous damage will often lead to the need to use more potent drugs or the need to use more drugs, which may be inappropriate if the glaucoma has progressed because of noncompliance rather than treatment failure. Interestingly, in the trenches of clinical practice, I've determined that a large amount of treatment failure is in fact compliance failure.

"I don't have a problem"

Many individuals are unaware that they have glaucoma until late in the course of the disease. In the most common types of chronic glaucoma, it's rare to have any symptoms. In fact, it's rare for a glaucoma patient to have any pain, redness or change in vision until the optic nerve and ganglion cells are significantly damaged or IOP reaches high levels. Thus it's hard to convince many patients of the need to undergo treatment, and some may even deny the need for treatment entirely.

"I don't see any difference"

One of the biggest causes of noncompliance rests in the fact that the benefit of glaucoma treatment isn't readily apparent. Contrast that with a patient who has a bacterial infection. When this patient uses an antibiotic he'll often see results (e.g., improvement in condition and feeling better) within a day or two. As a result, this patient is highly motivated to finish therapy.

But what do we have to show for glaucoma treatment? No change. In fact, the ultimate goal of glaucoma treatment is to prevent further vision loss. Most of the time, a treated glaucoma patient has no idea whether his treatment is working or not. Even if treatment is effective, his vision is usually not improved, and many times degrades for some other unrelated reason. How motivating is that?

A tough commitment

The most common types of glaucoma require lifelong treatment. And once you start therapy, it rarely ends. Add to that the fact that these drugs have side effects. Some eye drops absorb into the blood and can affect heart rate, blood pressure, breathing and even mental function. Fortunately, newer medications have fewer undesirable side effects, but it nonetheless remains an issue.

"I can't follow the schedule"

In the Ocular Hypertension Treatment Study, 40% of patients in the treatment group required more than one medication to achieve the therapeutic goal of a 20% IOP reduction. Furthermore, 50% of patients who had newly diagnosed glaucoma and who began therapy with a single agent were no longer being treated with that regimen at the end of two years. Use of glaucoma medications is often inconvenient and when you consider how much patients spend on these drugs that produce no apparent change in their quality of life, it's not hard to see why they comply so poorly.

Improving compliance

You can take several approaches to improving patient compliance with glaucoma medication: use the right drug, teach patients, help them keep things straight, use combination drugs and consider prostaglandins.

Using the "right" drug. It's important to use a medication based on each patient's lifestyle. This means knowing something about your patient's work, sleep and leisure habits, and selecting a medication that will work well with these regular habits, while at the same time, produce the least amount of side effects. Also consider the cost of each drug and whether it's a part of a formulary to which the patient's insurance company may bind him.

Teach your patients. Education is the single most important way to improve compliance. Be sure the pharmacy clearly and correctly labels medication with intended dosing. Spread the dosage out as evenly over a 24-hour day as is practical. (Think about the patients who show up at your office on q.i.d. eye drops who've had minimal instruction and take them at waking, 11 a.m., 2 p.m. and dinner. Then they're done until the next day. Don't let that happen.)

Demonstrate proper eye drop instillation and review it often at clinic visits. Have patients show you how they instill their eye drops and coach them in any needed areas.

We often hear about recommending punctual occlusion after drop instillation. I find it much easier to ask a patient to sit with his eyelids gently closed for five minutes after instilling the drops. It's the pumping action with each blink that sucks the eye drop into their punctum, so not blinking stops it completely. This will greatly increase the amount of drug that the eye absorbs and will reduce the amount that's systemically absorbed. It also lets the drug work in the eye instead of in other systems. (I've seen this gain additional 6 mmHg to 10 mmHg lower pressure in some cases.)

Help them keep things straight. Some O.D.s recommend that patients keep their medicine in the refrigerator so they know when the cool drop hits the eye. Wouldn't it be better to keep the bedtime or early morning drop on the night stand, so the patient could instill it before going to sleep or right after waking? Some argue that refrigeration prolongs the life of the drop, but the bottle shouldn't last long enough for this to be an issue.

Referring to medications by the color of the cap or the shape/size of the bottle can help patients (and those who may help them administer their medications) avoid confusion about which drugs to use when.

A written schedule can help patients who are on multiple medications. Simply relate the time of use to daily events such as waking and evening mealtime, for b.i.d. use. Fortunately, we've moved away from miotic therapy that required dosing every six hours, and even better now are two drugs in the same bottle.

Use combination drugs. Studies comparing combination drugs (such as timolol and dorzolamide) with timolol plus pilocarpine given separately showed a 4-to-1 preference for the combination drug. One of the main reasons given was that the combination drug was much easier to schedule (therefore, compliance was far superior). The combination drug also allows patients to obtain and use two medications while paying for only one bottle, which might improve compliance among patients concerned about the cost of prescription drugs.

Consider prostaglandins. It's been shown that the effect of once-daily beta blocker eye drops will cause fewer side effects than b.i.d. use and will produce nearly the same effect.

Now we're learning that the effect of prostaglandin drugs may be two days or more. In the case of a patient who really needs the drug but who has a financial hardship, is it unreasonable after a couple weeks to drop back to every other day dosing? It's certainly not advocated, but remember, the goal is to keep patients in therapy.

And lastly, don't forget: Most pharmaceutical companies have need-based programs where your patients who are financially strapped can get their drugs for free by going through the proper channels. (Editor's note: Visit optometricmanagement.com for a list of the drug makers' patient assistance programs, which includes contact information.)

Keep up the fight

Incorporate some of these ideas into your glaucoma visits and you'll improvements in compliance. With the advances in modern glaucoma medical therapy and some time selecting the right drugs and educating your patients, sight loss because of glaucoma will quickly die out in your practice.

References available on request.

Dr. Petersma has been in private practice since 1988. He's on the Board of Trustees at the Iowa Optometric Association and is co-owner of Fresh Starts, Optometric Practice Start-up Consultants.