Advances in glaucoma treatments have resulted in more IOP-lowering drop options than ever before. Yet, one of the biggest obstacles that optometrists continue to face is patient non-compliance with drop regimens. These compliance issues often reduce the effectiveness of the therapy.

This article, which includes interviews with three optometrists, discusses how to identify and address the issues surrounding patient non-compliance with glaucoma treatment regimens.

SET THE RIGHT TONE WITH EDUCATION

The first step to limiting non-compliance is setting the tone during the office visit — specifically, emphasizing the importance of the glaucoma therapy at the time the drops are prescribed, says Austin Lifferth, OD, FAAO, Optometric Management’s “Glaucoma” columnist, who practices at Center for Sight in Carmel, Ind. The reason: If patients don’t understand why they are on a drop, they are less likely to remain compliant, he notes.

“If patients come back and question why they’re using this drop, then I instantly feel as though it was a missed opportunity,” Dr. Lifferth stresses. “Doctors should be directly involved in the education, but the more people from the office that are involved, the better. The technician can ask how things are going with the drop during the work-up. Sometimes, patients are more willing to admit to a technician if they are struggling with compliance, as they may not want to feel as though they’re letting the provider down.”

It’s also important to recognize that patients are usually overwhelmed when they are first learning about glaucoma management. So, Dr. Lifferth says that doctors need to be prepared to repeat information over time.

“It’s natural that on that first visit, the patient is completely overwhelmed with a lot of information,” he says. “Just hearing the word ‘glaucoma’ can be overwhelming. So, we need to be mindful that there is likely information the patient did not retain.”

INSPIRE SELF-EFFICACY IN PATIENTS

In helping patients with compliance, Dr. Lifferth adds that doctors should keep in mind that much of it is about “self-efficacy.” Indeed, a July 2015 study in Ophthalmology found that, compared to patients who were compliant, non-compliant patients were more likely to report both poor self-efficacy and difficulty with drop administration.¹

“The patient has to believe they can do it to be successful,” he explains. “It is our job to help them realize they can do it. The way that we talk about compliance and empower our patients to take this on can make a difference in their success.”

For example, Dr. Lifferth suggests paying attention to word choice and messaging, which should instill confidence to adhere to and successfully administer the medication. Sayings tend to stick with patients and help them take it all more seriously — one of Dr. Lifferth’s favorites is “routines preserve vision.”

UNDERSTAND AND ADDRESS REASONS FOR NON-COMPLIANCE

A key toward alleviating compliance issues is to first understand the cause, says Brett G. Bence, OD, FAAO, director of optometry and partner at Northwest Eye Surgeons in Seattle. For some patients, it might be a matter of poor dexterity in which they physically struggle with the bottle. For others, compliance issues might have to do with memory and forgetfulness.

Understanding why patients might struggle can allow doctors to customize a solution. For example, Dr. Bence asks patients to administer a lubricant eye drop while in the exam chair.

“If they can’t instill the drop themselves, we need to talk about whether a caregiver or someone else could help,” he says.

(In addition to caregiver assistance, drop administration tools may help patients who struggle to instill drops. For examples, see bit.ly/OM2203Adherence .)

If it’s more of a matter of forgetting, Dr. Bence says that he tries to find ways that patients can make drops part of their everyday routine.

“I suggest that if they tie their drop regimen with something else they do regularly, like walking the dog, brushing their teeth, or taking pills, it will become part of a schedule for them,” he says. “It’s a little trick that seems to work for a lot of patients. If they take drops around breakfast or dinner, I ask them to put a bottle on their table as a reminder.”

Dr. Lifferth agrees that routine is key. “It’s human nature that we forget things that aren’t part of our routine,” he says. “I tell patients that ‘routines preserve vision.’ Finding a way to make glaucoma drops routine is a critical factor in a patient’s success. Whether they need to use Post-it notes or a reminder on a calendar they check every day, patients have to come up with a way that they can remember their drops on a regular basis.”

In addition, a January 2019 study in Eye & Contact Lens reported that glaucoma medications can be associated with ocular surface disease (OSD), most often due to preservatives in the drops.² By addressing OSD, through such means as preservative-free drops, decreased use of drops with preservatives, and treatment of OSD, compliance with glaucoma medications may be improved, the study showed.

Drug costs also have been cited as a barrier to compliance.¹ In this instance, combination drops, drug manufacturer patient assistance programs, compounded drugs, or savings via third-party discount cards have been reported as possible solutions to help lower costs where appropriate.³

Michael Cymbor, OD, FAAO, managing partner of Nittany Eye Associates with locations in Pennsylvania, says, unfortunately, there is no great way to determine whether a patient is truly being compliant. He also noted that most studies conclude that patients take their drops approximately 50% of the time, regardless of what they report.⁴ “Sometimes, the best we can do is determine whether there is a problem with [instillation] technique.”

Dr. Bence agrees that identifying non-compliance isn’t so simple, but it’s fair to assume all patients are going to experience times of non-compliance, for various reasons. The goal is to minimize those times of non-compliance with patient buy-in, he adds.

“I think a key issue is that patients don’t see the deficit,” he says. For example, continues Dr. Bence, if a patient takes pain-relieving medicine for a painful joint, that’s a very tangible effect. “But if you aren’t actually experiencing vision loss, it’s a little different. That’s why it comes down to building trust in what you’re telling them about compliance.”

REDUCE THE NUMBER OF DROPS

Oftentimes, the number of drops a patient takes affects compliance. For example, the drop may increase cost, the chances of side effects, and medication allergies, all of which may affect compliance.

“If we have to do a drop instruction sheet to help patients understand what drops to take and when to take them, then they’re already on too many drops,” Dr. Lifferth says. “I think that understanding one drop is reasonable and patients can comply. But as we get into two or three drops and different cap colors, then we need to ask whether there is a better way to have better control with less dependence on a drop.”

Dr. Cymbor agrees: “As we add a second drop, all of those side effects are just being compounded. Plus, we’re making it even harder for the patient to remember.”

An Expert Review of Ophthalmology article, published in July 2019, advises that simplifying drug regimens, such as lowering drop frequency and number of bottles used, could be useful for improving patient adherence.³ Solutions to simplify regimens include combination drops, compounded drugs, and surgical procedures (e.g., selective laser trabeculoplasty [SLT] and microinvasive glaucoma surgery [MIGS]), which can reduce the number of drops needed by patients.

Physical limitations can also be a reason to reduce drop use. Dr. Cymbor says that if he asks a patient to demonstrate drop insertion and “they are losing dexterity and having difficulty, it may be worth considering a laser or surgical approach.”

He customizes glaucoma treatment by using SLT as a first-line therapy for about 85% of his patients, he says.

“Side effects aside, the poor compliance rates are the elephant in the room,” Dr. Cymbor says. “When I can tell that a patient on drops has a progressing condition and I ask them whether they are using the drops regularly, they often tell me they are. But the state of their eye says otherwise, and it’s quite hard to know what is really happening at home. The SLT laser simply removes all of that uncertainty.”

UNDERSTAND DIFFERENCES IN PATIENTS

Oftentimes, these doctors say that customizing the glaucoma solution to each patient might look a little different for each patient. It may also require deploying more than one approach to treatment.

“Even though we advocate for SLT and several MIGS procedures, it’s uncommon for patients with mild-to-moderate stage glaucoma to go off of their medication altogether long term,” Dr. Bence says. “It’s generally beneficial if we can get the patient down to just one drop per day. The goal is always to do what we can to reduce the IOP to a well-considered target, the one variable we work to control, and that plan needs to be individualized.”

“We see patients who are on multiple drops and have already had a MIGS procedure,” he continues. “Most also had SLT at an earlier time. Now, it’s about how we move forward and control intraocular pressure when there are less options. In these cases, it’s often a balance of surgical and laser procedures, as well as medications, so compliance again is an important consideration.”

KEEP EACH PATIENT’S POTENTIAL IN MIND

Ultimately, a doctor should remain open-minded to a patient’s needs, says Dr. Bence. “Not every patient responds to every treatment in the same way.”

Dr. Lifferth agrees.

“There is no one-size-fits-all approach to glaucoma care,” he says. “At the end of the day, we have to find what is going to work best for each of our patients, whether it’s tailoring our educational messaging or tweaking the treatment plan, we have to keep each patients’ potential for compliance and overall success in mind.” OM

REFERENCES

1. Newman-Casey PA, Robin AL, Blachley T, et al. The Most Common Barriers to Glaucoma Medication Adherence: A Cross-Sectional Survey. Ophthalmology. 2015 Jul;122(7):1308-16. doi: 10.1016/j.ophtha.2015.03.026.
2. Zhang X, Vadoothker S, Munir WM, Saeedi O. Ocular Surface Disease and Glaucoma Medications: A Clinical Approach. Eye Contact Lens. 2019;45(1):11-18. doi:10.1097/ICL.0000000000000544
3. Holt JC. Acquire Medication Adherence. Optometric Management. March 2022. https://www.optometricmanagement.com/issues/2022/march-2022/acquire-medication-adherence . Accessed February 15, 2023.
4. Robin AL, Muir KW. Medication adherence in patients with ocular hypertension or glaucoma. Expert Review of Ophthalmology, 1029:14:4-5, 199-210, DOI: 10.1080/17469899.2019.1635456