A 50-year-old man who has open-angle glaucoma presented with initial IOPs of 30 mm Hg in the right eye and 42 mm Hg in the left eye; central corneal thickness also was reduced in both eyes (< 500 μm). Dilated exam revealed glaucomatous cupping, with cup/disc ratios of 0.75 in the right and 0.7 in the left eyes with inferior notching. He was placed on a topical prostaglandin analogue, but failed to return for his three month follow-up. Instead, he returned a year later, reporting non-compliance to his medication use.

Poor compliance in glaucoma is a significant problem, despite the availability of effective topical therapy. The cost of poor compliance is high, with progressive vision loss and eventual blindness the result. Up to 80% of people with glaucoma do not take their medications as prescribed, according to a recent study in Ophthalmology. Several causes have been identified, including lack of knowledge about the disease, forgetfulness, multiple drops and difficulties accessing medication. (See more on this in “Look Beyond IOP in Glaucoma,” p.26.)

Here, we discuss two barriers and at-home strategies to improve compliance in glaucoma.

Identifying poor-compliant patients and providing tools they can use to address their barriers to taking medication consistently is essential at an early stage to prevent disease progression.

BARRIER: LACK OF RECOGNITION

Poor knowledge about glaucoma is a major contributing factor to patient non-compliance. Patients without symptoms in the early stages of the disease may not realize the importance of daily adherence to medication use. Optometrists can overcome this via two ways:

1. Providing, and continuing to provide, education. Patients are often uncomfortable with asking questions. Therefore, we should encourage them to do so. Specifically, we should talk to patients about why and how to use their medications. Additionally, we should educate staff about glaucoma, as patients often ask them questions. Also, we should provide written instructions that reiterate the process for medication instillation that the patient can refer back to at home. Further, we should provide educational information and brochures, in a preferred language and large print, that stress that glaucoma is progressive and irreversible.

Optic nerve photography, VFs and nerve fiber layer analyses are also quite helpful in educating the patient about glaucoma. These are particularly useful when discussing disease progression and recommendations for more aggressive therapy, such as surgery.

Smartphone technology is an excellent tool as well. Glaucoma apps can provide education, track and record history, IOPs and drops. These apps allow patients to set alarms on their phones to remind them to take their drops and notes from their visits. Additionally, there are HIPAA-compliant platforms that may allow information to be part of a medical record, such as text messaging or other secure messaging platforms that enable communication with patients or colleagues. For example, a recently published study on patients who used an EHR to get reminders for glaucoma medications, reveals 74% of them found the reminders useful, according to JAMA Ophthalmology.

Training staff to stress the importance of follow-up care is crucial because almost 20% of patients do not visit their eye care doctor in the 18 months after the glaucoma diagnosis, reports a study in Ophthalmology. This is an area where enlisting the help of family members and friends can be helpful. Making sure that a patient’s family is aware of the helpful role they can play will be instrumental when trying to ensure compliance with medication and appointment scheduling. When a patient misses an appointment, we should set in place a procedure that this patient is called to remind them they missed the appointment and to make a new one, adding another preventative measure to ensuring patients receive their eye care. (See also “Legal: Handle Loss to Follow-Up,” p.48.)

2. Providing monitoring tools. Poor compliance leads to higher IOP, which is a major risk factor for glaucoma progression. Advances in at-home IOP monitoring technologies, such as the Icare HOME tonometer and Sensimed SA’s Triggerfish one-time use contact lens, may help to improve compliance. The devices provide clinicians with a better understanding of the role of IOP and IOP fluctuation in the progression of glaucoma. When the clinician shares these data with the patient, the additional education may help improve patient compliance to the prescribed medication(s).

The Icare HOME tonometer is a handheld device that employs a disposable probe to measure IOP, and it does not require a topical anesthetic prior to use. It takes six rapid IOP measurements, then calculates IOP and stores it in the device’s memory, along with the date, time and quality score. This data can then be accessed by the practitioner, using the device’s specialized software.

The Triggerfish, FDA approved in 2016, does not measure IOP, but rather records fluctuations in the ocular dimensions, such as volume changes and biomechanical properties of the eye. The American Academy of Ophthalmology recently reported that more research is needed before the data from the Triggerfish device can be widely translated into clinical practice.

BARRIER: COGNITIVE ISSUES

Patients may have cognitive issues, such as forgetfulness and confusion, which can cause them to miss regular dosing periods and could result in them not waiting a sufficient amount of time between applications of different medications. Optometrists can overcome this barrier by:

• Prescribing a once-daily preparation. Patients may experience fewer missed doses while using once-daily vs. twice-daily preparations, and patients appreciate having their therapy simplified.
• Teaching drop use. We should have staff teach patients and their families to instill the drops and provide drop dispensing aids and a personalized card and/or magnet with the cap colors.
• Providing a schedule. We should illustrate a drop schedule around routine events, such as waking, lunch or bedtime.
• Glaucoma app/smart speakers. The glaucoma apps previously mentioned are valuable here. Additionally, smart speakers, such as Amazon’s Alexa or Google Home, may help provide an alarm and/or spoken instruction and facts about the disease. A family member may be needed to help with set up.

ADDRESS POOR COMPLIANCE

Despite significant progress in early detection and treatment, glaucoma remains a formidable challenge, with millions of Americans losing their sight. Therefore, patient compliance is extremely important for effective and successful treatment of their disease. OM

DR. REYNOLDS is a consultative optometrist at Your Eye Specialist and adjunct faculty at Nova Southeastern University College of Optometry. She currently serves as the president of the National Optometric Association.

DR. KUBAL is dual-fellowship trained in glaucoma and corneal disease and a graduate of Harvard University and Johns Hopkins Medical School. He specializes in glaucoma and other diseases at Your Eye Specialist.