Improving Patient Compliance With Doctor Recommendations and Treatments

Patient compliance, or adherence to medical advice and treatment plans, is a critical component of effective health care, and thus, eye care. Despite its importance, non-compliance remains a significant challenge, leading to poorer outcomes, increased return visits, and higher costs. Understanding the reasons behind non-compliance and implementing strategies to improve it can make a substantial difference in patient eye and vision health and the overall efficiency of the eye care office.

Reasons for Non-compliance

Several factors contribute to patient non-compliance. These include complex medication regimens, side effects, lack of understanding of the treatment's importance, and financial constraints. We see this often with dry eye management. Additionally, psychological factors such as denial or overlooking the importance of the condition can also play a role. This is especially difficult if a patient has sought care with many doctors to solve their problem. Addressing these issues requires a multifaceted approach that considers the patient's perspective and circumstances.

Three Tips to Improve Compliance

1. Simplify treatment plans. Arguably, dry eye management has become complicated. One of the most effective ways to improve compliance is to simplify treatment plans. Complex regimens with multiple steps or drops can be overwhelming for patients. Eye care providers should aim to prescribe the simplest possible regimen that is still effective and encourage the patient to stick with it long enough to see an effect. Simplifying the treatment plan can make it easier for patients to follow.
   
   
2. Enhance patient education. Education is a powerful tool in improving patient compliance. Patients are more likely to adhere to treatment plans if they understand the importance of the medication and how it works. Eye care providers and staff should take the time to explain these aspects in a clear and accessible manner. Using visual aids, written instructions, and digital resources can help reinforce the information. Additionally, involving family members in the education process can provide additional support and encouragement for the patient.
   
   
3. Build a strong patient-provider relationship. Trust and communication between patients and providers (including staff) are crucial for compliance. Patients who feel heard, respected, and involved in their care decisions are more likely to follow advice. Building strong relationships with patients by actively listening, addressing concerns, and involving patients in the decision-making process is very important. Regular follow-ups can also help maintain this relationship and provide opportunities to address any issues or barriers to compliance.

Improving patient compliance with doctor recommendations and treatments is essential for achieving better health outcomes. By simplifying treatment plans, enhancing patient education, and building strong patient-provider relationships, eye care providers can significantly improve adherence and ensure that patients receive the full benefits of their prescribed treatments. Ultimately, a collaborative and patient-centered approach is key to overcoming the challenges of dry eye non-compliance, which leads to better outcomes.

Kelly K. Nichols, OD, MPH, PhD, FAAO
Editor

Compliance With Dry Eye Management: The Most Challenging Part of Dry Eye

The dry eye landscape has changed dramatically over the last two decades. We have exciting therapeutics and interventional methodologies that provide us and our patients with targeted treatment. However, these are effective only if a patient adheres to therapy and stays compliant. 

Plan for Best Outcomes

Both adherence and compliance are terms we use when we talk about a patient’s follow-through with a prescribed treatment, but they differ with regard to the underlying philosophy and patient involvement. Adherence refers to the extent to which a patient’s treatment aligns with their goals—in other words, their buy-in. Compliance, on the other hand, refers to how well the patient follows what you prescribed. Said differently, compliance relates to whether the patient is “complying” with your instructions. Ultimately, I want patients to understand their journey and what’s possible so they can adhere to the plan and stay compliant for the best possible outcome. 

Setting expectations for patients is paramount in the patient journey. Helping patients understand the disease state, how the treatment can help them, what their experience may be like, and how to define success can be the right recipe to gain patient adherence.

Encourage Patients to Have Patience

Patients get frustrated for multiple reasons. We live in an instant gratification world. Dry eye disease (DED) doesn’t happen overnight, and it can’t be relieved right away or cured. If we do a good job of explaining how the patient got DED and what is exacerbating it, this can be the first step toward patient adherence. Dry eye disease is a multifactorial condition, however, so this is easier said than done. We’ve all had patients whose expectations were unmet and who stopped therapy because it didn’t result in the desired outcome. But how well were the desired outcomes explained and understood? Look for opportunities to better explain the disease state, diagnose early, and set proper expectations. 

Adverse effects such as burning and stinging upon instillation are quite common and can deter patients from staying on their therapy. If patients know that these adverse effects are normal and not harmful, it can be helpful and crucial to adherence. Reassure patients and set follow-up appointments to reinforce behaviors and answer questions. 

As we continue to learn more and as newer technologies become available to us, consider embracing interventional dry eye therapies. The more procedures we can do in-office, the less complicated patient routines need to be. Streamlining therapy plans and providing patients with written or video instructions can build better communication, which can translate to better adherence and compliance. 

Lastly, make sure you have protocols in place so that patients can access the therapy. There may be friction in this system, but I believe strongly in advocating on the patient’s behalf. Prior authorizations, peer reviews, and complicated pharmacy politics are extremely frustrating. I rely heavily on specialty pharmacies and stay in close contact with my local representatives so I can reduce the patient burden as much as possible. 

Set Clear Expectations

Dry eye management doesn’t end with a prescription—it begins there. Our role as clinicians is to be educators, advocates, and partners in our patients' journeys. By setting clear expectations, reinforcing the “why” behind each treatment, and minimizing barriers to access, we can transform compliance from a chore into commitment. Let’s challenge ourselves to not just prescribe therapies but also create connections, foster understanding, and champion adherence. When patients truly understand their disease, they don’t just follow a plan—they believe in it.

Take a moment to evaluate your current patient communication strategies. Are you setting the stage for long-term adherence? Identify one change you can implement this week—whether it’s refining how you explain DED, streamlining therapy instructions, or reducing access barriers. 

Preserve Eye Health With Pretreatment for Dry Eye Disease

Dry eye disease (DED) is a multifactorial condition characterized by a loss of homeostasis of the tear film (ie, tear film instability and hyperosmolarity), which results in damage to the epithelium and subsequent production of inflammatory mediators. As inflammation is a crucial component of DED, primary treatments include anti-inflammatory eye drops. The most familiar anti-inflammatory treatment is topical cyclosporine. The first commercially available preparation of cyclosporine 0.05% demonstrated improvements in blurry vision, decreased frequency of artificial tear use, reduced corneal staining, increased tearing (per the Schirmer I test), reduced inflammatory cytokine levels, increased goblet cell densities, and reduced HLA-DR expression. 

Efficacy of Pretreatment for DED

Original studies demonstrated that pretreating with preservative-free fluorometholone 0.1% eye drops and subsequently switching to cyclosporine 0.05% eye drops was effective in decreasing ocular inflammation.¹ In patients with moderate to severe DED who were unresponsive to cyclosporine 0.05%, switching to cyclosporine 0.1% improved objective signs, albeit with lower treatment tolerability, over the short term.² In patients with Sjögren’s syndrome (SS)–associated DED, switching from cyclosporine 0.05% to cyclosporine 0.1% improved ocular symptoms and conjunctival staining.³

The purpose of this study was to compare the clinical outcomes and the effect of cyclosporine 0.1% after no pretreatment, fluorometholone 0.1%, or cyclosporine 0.05% pretreatment in patients with DED (specifically SS-associated DED).⁴ The study included 137 patients (274 eyes) diagnosed with DED who were retrospectively recruited. Thirty patients (group 1, 60 eyes) were not pretreated, while 68 patients (group 2, 136 eyes) were pretreated with fluorometholone 0.1%, and 39 patients (group 3, 78 eyes) were pretreated with cyclosporine 0.05% before treatment with cyclosporine 0.1%. All study participants were assessed with the Ocular Surface Disease Index Questionnaire (OSDI) score, Schirmer I test result, noninvasive tear film break-up time (NItBUT), corneal staining score, matrix metalloproteinase-9 (MMP-9) grade, meibography, meibum quality and expressibility scores, and tear meniscus height. The patients were examined before treatment and at 1, 2, and 3 months after treatment.

Results

The results demonstrated that all dry eye signs and symptoms of all patients at 1, 2, and 3 months were significantly improved compared with those recorded before treatment with cyclosporine 0.1%. Most notably, the OSDI score, Schirmer I test result, NItBUT, corneal and conjunctival fluorescein score, and MMP-9 grade in group 3 were significantly improved compared with those in groups 1 and 2 at all time periods after treatment with cyclosporine 0.1%. The highest percentage of discontinuation was in the non-pretreatment group. 

The authors concluded that pretreatment with cyclosporine 0.05% can improve the effect of cyclosporine 0.1%. This is thought to be secondary to a better ability to decrease ocular inflammatory signs and symptoms compared with fluorometholone 0.1% and no pretreatment. Interestingly, the use of a lower concentration of cyclosporine was more effective than the use of fluorometholone. With the potential increased risk of complications with the use of long-term steroids (eg, increased IOP, cataract development) the use of a lower dose of cyclosporine has definite advantages. Adopting a steroid or lower concentration of cyclosporine eye drops as pretreatment can also increase the compliance of patients with the use of cyclosporine 0.1% eye drops compared with no pretreatment.

Clinically, many of us have used a pre- or concurrent treatment of a steroid with cyclosporine 0.05%. With the added benefits of the treatment with a higher concentration of cyclosporine (0.1%) but lower tolerability, the use of a steroid would seem to make sense to increase the success of treatment, as was seen with cyclosporine 0.05%. I think the clinical usefulness of pretreating with cyclosporine 0.05% and then transitioning to the 0.1% formulation will be a selling point to those patients who are reluctant to use a topical steroid because of the potential side effects and may aid in improving compliance.

References:

1. Jee D, Park M, Lee HJ, Kim MS, Kim EC. Comparison of treatment with preservative-free versus preserved sodium hyaluronate 0.1% and fluorometholone 0.1% eyedrops after cataract surgery in patients with preexisting dry-eye syndrome. J Cataract Refract Surg. 2015;41:756-763. doi:10.1016/j.jcrs.2014.11.034.
2. Chan YH, Sun CC. Efficacy and safety of topical cyclosporine 0.1% in moderate-to-severe dry eye disease refractory to topical cyclosporine 0.05% regimen. Taiwan J Ophthalmol. 2023;13:68-74. doi:10.4103/tjo.TJO-D-22-00140.
3. Kim J, Moon TK, Yoon HJ, Ji YS, Yoon KC. Efficacy of switching from cyclosporine A 0.05% anionic emulsion to cyclosporine A 0.1% cationic emulsion in patients with dry eye associated with Sjögren’s syndrome. J Ocul Pharmacol Ther. 2021;37:472-478. doi:10.1089/jop.2020.0146.
4. Donghyun J, Han SY, Kim HS, Kim EC. Comparison of the effect of and compliance with cyclosporine 0.1% after various pretreatments in dry eye disease. J Ophthalmol. 2025;2025:1–8. doi:10.1155/joph/6744482

Comparison of the Effect of and Compliance With Cyclosporine 0.1% After Various Pretreatments in Dry Eye Disease

Donghyun Jee, Su Yeon Han, Hyun Seung Kim, and Eun Chul Kim
J Ophthalmol. 2025 Jan 7:2025:6744482. doi: 10.1155/joph/6744482

Purpose: We sought to compare the effect of cyclosporine 0.1% after various pretreatments in patients with dry eye disease. 

Methods: Two hundred seventy-four eyes of 137 patients diagnosed with dry eye disease were retrospectively enrolled. Thirty patients (Group 1, 60 eyes) were not pretreated, while 68 patients (Group 2, 136 eyes) were pretreated with fluorometholone 0.1%, and 39 patients (Group 3, 78 eyes) were pretreated with cyclosporine 0.05% before treatment with cyclosporine 0.1%. The Ocular Surface Disease Index Questionnaire (OSDI) score, Schirmer I test result, noninvasive tear film break-up time (NItBUT), corneal staining score, matrix metalloproteinase-9 (MMP-9) grade, meibography result, meibum quality and expressibility scores, and tear meniscus height were examined before treatment and at 1, 2, and 3 months after treatment. 

Results: All dry eye signs and symptoms of all Groups at 1, 2, and 3 months were significantly improved compared to those before treatment with cyclosporine 0.1% (p < 0.05). Notably, the OSDI score, Schirmer I test result, NItBUT, corneal and conjunctival fluorescein score, and MMP-9 grade in Group 3 were significantly improved compared to those in Groups 1 and 2 at 1, 2, and 3 months after treatment with cyclosporine 0.1% (p < 0.05). The percentages of cases with treatment discontinuation in Groups 1, 2, and 3 were 20.0%, 7.4%, and 10.0%, respectively. 

Conclusion: Pretreatment with cyclosporine 0.05% can augment the anti-inflammatory effect of cyclosporine 0.1%. Pretreatment with a steroid or a lower concentration of cyclosporine can increase compliance in patients using a cyclosporine 0.1% eye drop.

Drop-out Rates in Clinical Trials Compared to the Real-world Experience

I started clinical trials nearly 7 years ago. Since that time, my colleagues and I have completed dozens of studies that led to 8 United States Food and Drug Administration (FDA) approvals. Throughout this period, I have maintained a private practice where I see patients for routine medical and emergency eye exams. While there are many vast differences between clinical trials and private practice, one of the trends I have noticed is greater patient compliance and willingness to return to the clinic as prescribed among the research patients as opposed to the patients in my primary care clinic.

When I think about it, there are myriad reasons for this. First of all, my research patients are being paid for their time and efforts to be in the clinical trial. In my opinion, this is the largest driver of patient retention and motivation to stay in the study for the entire duration of the trial. While the trial is always completely voluntary, the vast majority of patients will complete all of the visits and maintain strict adherence to the investigational product as directed. I contrast this with my primary care clinic, where patients come to me with an issue (eg, dry eye), pay a copay, and then go pay for a prescription drug, often at a wide range of cost. My research model flips the paradigm upside down. Patients have free access to me, do not pay any copays, get paid for the participation, and can use the drugs (or perhaps the placebo) for free.

As a result of the frequency with which I see my research patients, I can establish a high level of trust and rapport with them. I know all of them on a first-name basis, since many of my research patients enroll in multiple clinical trials throughout the year. As opposed to my primary care clinic, where I will most likely not see any given patient more than quarterly (assuming I am treating a pathology), it isn’t uncommon for me to see my research patients 5 to 7 times during a single clinical trial over the course of several weeks. The more interaction I have with my research patients, the more they open up and want to be involved in the research that is taking place.

The third reason why patients often do not drop out of trials (and do come as directed) is that in many cases they are receiving an “experimental” treatment. We have done plenty of first-in-human trials, and patients who participate in these studies want to come back to make sure they are not experiencing any adverse events that might affect the health of their eyes. I am very happy to report that the occurrence of such events has never happened in my clinic. With the exception of the occasional burning and stinging upon instillation (almost universal with any eye drops), my patients have yet to have any drug-dependent side effects driving them out of the trials. The most common reason for drop out is schedule interference or that the patient moves away. 

I feel fortunate to offer opportunities to patients in my community to participate in clinical trials. It is a privilege that I and my colleagues do not take lightly. I frequently tell my coordinators that our local efforts have worldwide implications. Working with sponsors and patients synergistically is my top priority. I hope that it continues for years to come.

This editorial content was supported via unrestricted sponsorship.