How advances in glaucoma treatment help address the ‘non-compliant’ patient

The past three decades have shown incredible advances in our treatment options for glaucoma. In 2021, we celebrated the 25th anniversary of the launch of the first prostaglandin analog. With this advance, an entire generation of our colleagues have known a first-line glaucoma therapy that offers once daily dosing.

Today, alpha agonists, beta blockers carbonic anhydrase inhibitors (CAI), combination drugs, and rho kinase inhibitors, along with prostaglandins, have expanded our arsenal in the battle to lower (IOP). Yet, I continue to see patients who admit to poor or inconsistent anti-glaucoma drop usage. As a clinician treating a potentially blinding condition, this revelation does not sit well.

In this column, I discuss how to assess patient compliance with their anti-glaucoma drop, and the steps I take in cases of non-compliance.

AN HONEST DISCUSSION

To gain an accurate clinical picture of the patient, I suggest discussing openly and honestly with them their drop-taking regimen. After all, IOP readings are meaningless if the patient forgot to take their anti-glaucoma drop last night. I typically ask, “When was the last time you missed a drop of your medication?” Asking in a non-judgmental way assumes drops are missed from time-to-time and, thus, will typically elicit an honest answer. Plus, open-ended questions that do not require only a “yes” or “no” response get patients talking. For example, if you ask patients whether they forgot to take their drop, they will often answer “no,” telling me exactly what they think I want to hear.

ASSESSING ALTERNATIVES

In cases in which non-compliance with the anti-glaucoma drop proves to be too great a barrier (based on honest discussion, the patient’s mental state, ocular irritation, mobility, etc.), we have other options. For example, for patients who have mild-to-moderate glaucoma in need of cataract surgery, I recommend minimally invasive glaucoma surgery (MIGS) performed at the time of cataract surgery. I have found that many glaucoma patients who struggle to comply with their anti-glaucoma drop are open to the idea of utilizing a MIGS procedure to reduce or, in some cases, eliminate their reliance on their drop. I have also discovered that patients are thrilled about decreasing/eliminating the on-going cost of the anti-glaucoma drop. Some insurance carriers allow other treatments, such as goniotomy or endocyclophotocoagulation, in lieu of a stent. For patients non-compliant with their anti-glaucoma drop who have severe glaucoma, we discuss other surgical options, such as selective laser trabeculoplasty.

For non-compliant patients who give stinging, irritation, or redness as reasons for failing to take their anti-glaucoma drop, I have found that a preservative-free drop is a game-changer. After all, chronic use of topical medications can lead to ocular surface disease (OSD). Generally speaking, the more drops our patients take, the more likely they are to experience OSD. Preservative-free drops are available in prostaglandin analogs, CAI/beta blockers, and a beta-blocker. I have discovered they are a well-tolerated option for patients taking two or more drops per day.

REDUCING THE BURDEN

In looking back at my 25-year prescribing habits, I am surely “dropping the number of drops” my glaucoma patients use. Decreased dosing, surgical options, and preservative-free drugs can reduce patient burden, leading to better clinical outcomes. OM

DR. EARLEY serves as a therapeutic optometrist at Northeast Ohio Eye Surgeons in Medina, Ohio, where he spent 23 years as vice president/secretary, and was the director of human resources. He is the clinic director of Bright EyeDeas Vision Clinic, a free clinic serving the uninsured, and a member of the AOA and the Ohio Optometric Association. Dr. Earley speaks nationally on specialty contact lenses, macular degeneration, dry eye disease, and practice management. He is a consultant for Alcon, and serves as a KOL for Notal Vision, and MacuHealth.. Email him at tearley@neohioeye.com.