Studies demonstrate poor compliance (from between 20% to 60%) with prescribed glaucoma medication regimens.^1,2 Additionally, estimates show 10% of glaucoma-related blindness results from patient non-compliance to their anti-glaucoma drugs. The barriers to non or poor drug adherence are:¹

1. Mistrust in the physician
2. Skepticism that glaucoma will cause vision loss
3. Skepticism that glaucoma medications are effective
4. Poor knowledge about glaucoma
5. Perceived addition to life stresses
6. Side effects
7. Poor self-efficacy
8. Forgetfulness
9. Difficulties with the medication schedule
10. Cost
11. Difficulty with eye drop administration

Here, I provide three steps to overcome these barriers:

1 CREATE A COMFORTABLE ATMOSPHERE

To overcome the first bullet point, it is our obligation to create an environment where patients feel comfortable. The average doctor interrupts the patient after 12 seconds of speaking.² Even if this interruption is not verbal, body language and attitude convey volumes to our patients. So that patients can maintain their vision and quality of life, it is paramount they feel comfortable with us.

To create a comfortable atmosphere, which creates trust, I use an in-room scribe to take care of the clinical notetaking. This way, I can give my undivided attention to the patient, allowing them to be and feel fully heard. I have two screens in each exam room: one for my scribe to annotate my findings, and another facing the patient that allows me to show and explain tests and testing results.

2 PROVIDE DISEASE/TREATMENT EDUCATION

To conquer bullet points two through six, we must provide patient education. One of my passions in practice is educating patients. Ensuring patients understand my findings, the tests performed, as well as how and why we are (or are not) beginning treatment are huge priorities for me. After providing a definition of glaucoma, an explanation of how the diagnosis has been made, how the proposed treatment is going to help, what the patient should expect (e.g. side effects, such as ocular dryness), and how the determination will be made whether the treatment is working, I ask every patient, “Did that make sense? Are there any questions you have about anything we did, or did not discuss?”

Next, I encourage the patient to write any questions they may forget to ask prior to our next appointment, so we can go over each one at the next patient visit. (We should keep in mind that patients typically remember less than 50% of what is discussed during a visit).² I tell them, “I never want any patient leaving an appointment with more questions than they came in with.” Patients must be “on board” with not only the diagnosis and the proposed treatment, but also be fully aware of the repercussions of leaving the disease untreated. I try to make every effort to ensure the patient understands that we will and need to work as a team to manage their glaucoma. (See “Follow the Three R’s,” p.48.)

3 REASSURE/PROVIDE RESOURCES

To conquer bullet points seven through 11, we should take the time to reassure patients from the day of diagnosis to every follow-up appointment that glaucoma is a manageable condition. This can be illustrated by the many resources available that make it so.

Setting alarms on one’s phone is an effective resource for remembering to instill drops. Also available: the EyeDropAlarm app and the e-pill Eye Drop Medication Reminder.

For patients who use four medications daily — common in the average American older than age 65 — we can offer them the resource of surgical options. (See “Primary Open-Angle Glaucoma: Surgical Options,” below.)

Medication cost can often be circumvented via the use of a combination drop, generic drugs, compounded drugs, drug manufacturer patient assistance programs, or through third-party discount cards, such as GoodRx. (See “IOP-Lowering Drugs,” below.) At my practice, we have made these discount cards available in each of the practice’s exam rooms.

Finally, accessories that aid in drop instillation, or can even reduce the size of the drop to extend the life of the bottle, are resources for patients who have difficulty with drop administration. (See “Examples of Drop Administration Tools,” p.25.)

Examples of Drop Administration Tools

AutoDrop (Owen Mumford). AutoDrop employs clamps to facilitate the squeezing of the bottle.

 

Cress Dropper (Wilson Ophthalmic). This utilizes a flexible arched applicator that fits on the ridge of the nose, enabling the tip to apply the drop in the corner of the eye.

 

 

Ezy Drop Guide & Eye Wash Cup (AvaCare Medical). This employs a cup that fits directly over the eye to facilitate drop instillation.

 

 

E-Z Drops Eye Drop Application Strips (E-Z Drops). This utilizes a reflective strip that holds the bottle, enabling the patient to see the reflection of their eye to properly instill the drops.

 

 

Eye Drop Helper (Magic Touch). The Eye Drop Helper employs a rubber thimble that holds one drop at its tip for instillation.

 

 

Nanodropper (Nanodropper, Inc.). This FDA-listed bottle adapter reduces the volume of the drop, which helps reduce waste due to overflow, and cost by helping the user get more use out of each bottle.

 

 

Opticare Eye Drop Dispenser (Gulden Ophthalmics). The Opticare Eye Drop Dispenser is a bottle case used to facilitate grip, squeezing, and drop accuracy. The case’s eyepiece also holds the upper lid to prevent blink reflex.

 

 

SimplyTouch (SimplyTouch LLC). This employs a tab that holds one drop and enables the user to touch their eye with the tab for instillation.

 

IOP-Lowering Drugs

ALPHA-ADRENERGIC AGONISTS

Apraclonidine (iopidine 0.5% and 1%, Novartis and generic)

 

Brimonidine: 0.2% preserved with BAK and 0.15% non-BAK preservative and 0.1% (Alphagan P, Allergan, preserved with Purite)

 

BETA-BLOCKERS

 

Beta-1 selective betaxolol hydrochloride 0.5% (generic) and 0.25% (Betoptic-S, Novartis)

 

 

Levobunolol hydrochloride 0.5% (Betagan, Allergan) and 0.25% and 0.5% (generic)

 

 

Timolol hemihydrate 0.25% and 0.5% (Betimol, Akorn)

 

 

Timolol maleate 0.25% and 0.5% (Timoptic, Timoptic Ocudose and Timoptic XE, Bausch + Lomb) and 0.5% (Istalol, Bausch + Lomb, and generic)

 

CARBONIC ANHYDRASE INHIBITORS

 

Acetazolamide 125 mg and 250 mg tablets (generic) and 500 mg sustained-release capsules

 

 

Brinzolamide 1% (Azopt, Novartis)

 

 

Preservative-free dorzolamide 2% (generic and Trusopt, Merck)

 

 

Preservative-free Dorzolamide 2% (Dor, ImprimisRx)

 

FIXED COMBINATION

 

Brimonidine 0.2%/timolol 0.5% (Combigan, Allergan)

 

 

Brinzolamide/brimonidine 1%/0.2% (Simbrinza, Novartis)

 

 

Dorzolamide 2%/timolol 0.5% (generic and Cosopt, Akorn)

 

 

Netarsudil 0.02% and latanoprost ophthalmic solution 0.005% (Rocklatan, Aerie Pharmaceuticals)

 

PROSTAGLANDIN ANALOGUES

 

Bimatoprost 0.03% (generic)

 

 

Bimatoprost 0.01% (Lumigan, Allergan)

 

 

Latanoprost 0.005% (generic and Xalatan, Pfizer)

 

 

Latanoprost ophthalmic emulsion 0.005% (Xelpros, Sun Pharma)

 

 

Latanoprostene bunod 0.024%, (Vyzulta, Bausch + Lomb)

 

 

Tafluprost ophthalmic solution 0.0015% (Zioptan, Akorn)

 

 

Travoprost 0.004% (generic and Travatan Z, Novartis)

 

RHO-KINASE (ROCK) INHIBITOR

 

Netarsudil and latanoprost ophthalmic solution 0.02%/0.005% (Rocklatan, Aerie Pharmaceuticals)

 

COMPOUNDING PHARMACIES

Compounding pharmacies, such as ImprimisRx and OSRX (Ocular Science), produce formulations that may contain one or multiple IOP-lowering medications in a single bottle.

For example:

 

ImprimisRx offers preservative-free drops (brand name Simple Drops), including latanoprost 0.005%, and various options consisting of timolol 0.5%, brimonidine 0.15%, dorzolamide 2%, and latanoprost 0.005%.

 

 

OSRX formulations (brand name OMNI) combine as many as four drugs — timolol 0.5%, brimonidine tartrate 0.2%, dorzolamide 2%, and latanoprost 0.005% — into a single drop.

 

A WINNING PLAN

If I have carried out my job, my patients feel comfortable enough with me to express their concerns, such as that they may not feel confident in their ability to remember to use their anti-glaucoma drops, or that lasers scare them. Armed with this information, I can customize a treatment plan that they are most likely to adhere to. I have found that tailoring disease treatment and follow-through to the patient’s individual needs are what create a winning plan of action, with the highest chance of consistency and success. OM

REFERENCES

1. Newman-Casey PA, Robin AL, Blachley T, et al. Most Common Barriers to Glaucoma Medication Adherence: A Cross-Sectional Survey. Ophthalmology. 2015;122(7):1308-1316.
2. OphthalmologyWeb. How Do You Ensure Patient Compliance with Glaucoma Medication? https://www.ophthalmologyweb.com/Tech-Spotlights/26552-How-Do-You-Ensure-Patient-Compliance-with-Glaucoma-Medication/ . (Accessed Jan 31, 2022.)

DR. HOLT practices full scope optometry in Northern California. He is in group practice at Anderson Eye Care. Email him at drjustinholt@gmail.com.