While glaucoma follow-up appointments are necessary, we know all too well that they can be challenging for patients to keep. Interestingly, many of the barriers that affect patient medication adherence¹ (see Figure 1) also affect patient appointment adherence.

Here, I provide a list of modifiable barriers specific to patient follow-up appointment adherence, and the patient education needed to overcome said barriers. (See “More on Glaucoma” below.)

MODIFIABLE BARRIERS

• Limited or lack of formal education.²
• The belief that follow-up is less important if one uses glaucoma medications).²
• Low disease knowledge scores³ (i.e., unfamiliarity with necessary treatment duration⁴, lack of knowledge regarding the permanency of glaucoma-induced vision loss⁴).
• Advanced glaucoma.⁵
• Lack of visual symptoms.⁴
• Long wait times.⁶
• Perception that their condition is not serious.⁶
• Lack of transportation.⁷

OVERCOMING THE BARRIERS

With the exception of “long wait times,” and “lack of transportation,” I have found that the aforementioned modifiable barriers can be overcome via “[…highlighting] the importance of understanding clinical characteristics associated with poor follow-up adherence, such as disease severity and the use of medications. [As such], providers are encouraged to educate patients regarding the importance of follow-up adherence to prevent the risk of future undetected and irreversible vision loss.”⁵

Also, a triad approach of trying to improve patient education, transportation services, and clinic efficiency may increase adherence to recommended appointment intervals.^3,8 Further, perhaps social workers, primary care providers, patient navigators — a sort of allied health professional approach — may help improve appointment adherence.⁹ OM

References
1. Newman-Casey PA, Robin AL, Lee P, Blachley T, et al. Original article: The Most Common Barriers to Glaucoma Medication Adherence. A Cross-Sectional Survey. Ophthalmology. 2015;122(7):1308-1316. doi: 10.1016/j.ophtha.2015.03.026. (As a side note, it has been observed that those patients who are nonadherent to their appointments are also more likely nonadherent to be less to their medications as shown in this reference:  

2. Lee BW, Sathyan P, John RK, Singh K, Robin AL. Predictors of and barriers associated with poor follow-up in patients with glaucoma in South India. Arch Ophthalmol. 2008;126(10):1448–1454. doi: 10.1001/archopht.126.10.1448.

3. Lee BW, Murakami Y, Duncan MT, et al. Patient-related and system-related barriers to glaucoma follow-up in a county hospital population. Invest Ophthalmol Vis Sci. 2013;54(10):6542-8. doi: 10.1167/iovs.13-12108.

4. Murakami Y, Lee BW, Duncan M, et al. Racial and ethnic disparities in adherence to glaucoma follow-up visits in a county hospital population. Arch Ophthalmol. 2011;129(7):872–87. doi: 10.1001/archophthalmol.2011.163.

5. Ung C, Murakami Y, Zhang E, et al. The association between compliance with recommended follow-up and glaucomatous disease severity in a county hospital population. Am J Ophthalmol. 2013;156(2):362-9. doi: 10.1016/j.ajo.2013.03.005.

6. Kosoko O, Quigley HA, Vitale S, Enger C, Kerrigan L, Tielsch JM. Risk factors for noncompliance with glaucoma follow-up visits in a residents' eye clinic. Ophthalmology. 1998;105(11):2105–2111. doi: 10.1016/S0161-6420(98)91134-4.

7. Nwabuo CC, Dy SM, Weeks K, Young JH. Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension. PLoS One. 2014;9(8). :e103090. doi: 10.1371/journal.pone.0103090. Note: Although this study focused on systemic hypertension, the parallels between glaucoma and hypertension have similar barriers and these inter-disease barriers are relevant in our care for patients with glaucoma. 

8. Thompson AC, Thompson MO, Young DL, et al. Barriers to Follow-Up and Strategies to Improve Adherence to Appointments for Care of Chronic Eye Diseases. Invest Ophthalmol Vis Sci. 2015;56(8):4324-31. doi: 10.1167/iovs.15-16444.

9. Leiby BE, Hegarty SE, Zhan T, et al. A Randomized Trial to Improve Adherence to Follow-up Eye Examinations Among People With Glaucoma. Prev Chronic Dis. 2021;18:E52. doi: 10.5888/pcd18.200567.

DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry.” For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at glaucomaqd@yahoo.com.