NOTE: Always remind patients to wash their hands and avoid directly touching their eyes.

Glaucoma’s insidious nature of progression without early symptoms makes the stringent adherence of patients to their IOP-lowering drops crucial. That said, achieving optimal patient adherence remains a formidable challenge in practice.

While obtaining 100% medication adherence from all our glaucoma patients is not possible, I have found that employing the following multifaceted approach has enabled me to increase it.

Educating on the Stakes

I have experienced that providing patient education on the direct link between their nonadherence to IOP-lowering drops and their risk of blindness as a result can motivate patients to adhere. Before the patient can grasp this connection, however, I have found that it’s imperative to explain the nature of their glaucoma first and ask whether they need additional information to understand its seriousness:

• Primary open-angle glaucoma (POAG). “You have an ocular disease called primary open-angle glaucoma. This is characterized by a slow clogging of the drainage canals in your eye. These canals prevent a fluid that nourishes your eye from over accumulating and, thus, increasing pressure within your eye. Increased pressure is not desired, as it can damage your optic nerve, causing irreversible vision loss. The optic nerve is the part of your eye that delivers visual information to your brain. There is no cure for primary open-angle glaucoma, though there are interventions that can prevent the vision loss it causes. Do you have any questions?”
• Normal-tension glaucoma. “You have an ocular disease called normal-tension glaucoma. This is characterized by a damaged optic nerve despite an eye pressure measurement that falls within the normal range. The optic nerve is the part of your eye that delivers visual information to your brain. Eye pressure is related to the ability of your eye’s drainage canals to filter out a fluid that nourishes the eye, so this fluid doesn’t accumulate and cause optic nerve damage. There is no cure for normal-tension glaucoma, though there are interventions that can prevent vision loss. Do you have any questions?”

There are obviously many other types of glaucoma that each require their own individual conversations. The above are just two examples.

To make the association between patient nonadherence to IOP-lowering drops and permanent vision loss, I do so verbally and by using visual aids.

Verbal Messaging

“This medication(s) is intended to lower your eye pressure. It must be used daily to maintain its effectiveness. Inconsistencies in following this treatment regimen can lead to fluctuating eye pressure levels, which may accelerate damage to your optic nerve and cause irreversible vision loss. What’s more, a lack of compliance to this treatment regimen can result in the need for more aggressive interventions, including surgeries and hospitalizations, which can create higher patient costs. The bottom line is that this medication doesn’t work if it’s in the bottle; you have to use it as prescribed.”

Pro tip. I also educate the patient on proper drop instillation and possible side effects, such as headaches, that they can expect from the drops. In doing so, I preemptively address these additional reasons for nonadherence.

Regarding proper drop instillation, I demonstrate to patients to pull their lower lid down, creating a “pocket” that can be seen via mirror and then without touching the lid or eye, instill the drop into that pocket and release the lid.

A study on glaucoma medication adherence and communication between the eye care provider and the patient shows that education on eye drop administration was the lone provider communication variable significantly linked with patient adherence to their IOP-lowering drops.¹

Visual Aids

I use diagrams,² eye models, and digital apps to show how glaucoma can progress to cause irreversible blindness without proper medication use. Using visual aids reinforces the importance of the verbal education (See photos).

Inquiring About Routine Activities

I ask my patients about their routine activities of daily life, as research shows that integrating their IOP-lowering drops into these activities can create habitual medication-taking behaviors.³

As an example, if the first thing a patient does upon waking is make coffee, I recommend that the patient keep their IOP-lowering drops near their coffee maker as a reminder to take them in the morning. Something else to keep in mind: The physical placement of medication can act as a visual cue to take it.

Simplifying Medication Regimens

Complex medication schedules can be a significant barrier to patient adherence, resulting in dosing errors or missed doses, despite the best of intentions.

I have found the following can overcome complex medication regimens:

• Combination IOP-lowering drops (if applicable to the patient).
• Long-acting IOP-lowering drops (if applicable to the patient).
• Selective laser trabeculoplasty, which is shown to decrease and, in some cases, remove the need for IOP-lowering drops.⁴ (SLT is covered by health insurance, especially if topical medical therapy has been attempted and failed. Also, the cost may be significantly less to the patient in cases where they are unable to instill just one drop and need three-to-four for each eye, every day, requiring multiple bottles every month.)

Leveraging Technology

I recommend the following adherence-aiding technology to my patients:

• Automated medication reminders. Alarms/timers on phones, medication-reminder apps (search on Apple or Android), or a virtual assistant can encourage patients to take their medications at prescribed times.
• Drop administration tools. Devices comprised of applicators, cups, rubber thimbles, and more are available for patients to purchase to facilitate proper drop instillation.
• Telemedicine check-ins. Scheduling these helps my patients adhere to their IOP-lowering drops, as these check-ins require accountability and provide opportunities for addressing any questions or concerns, such as intolerable side effects, that may affect patient adherence.

In addition, switching to a preservative-free IOP-lowering drop may be beneficial for patients who report poor adherence due to ocular dryness.⁵

Providing Financial Assistance Resources

To thwart possible financial or economic constraints that can be obstacles to patient adherence, I provide the following to my glaucoma patients:

• A sample of their drops;
• An associated manufacturer discount card (if available);
• The names of discount pharmacies;
• The names of financial support resources (e.g., Glaucoma Research Foundation, Prevent Blindness, and Bright Focus Foundation); and
• A list of patient assistance programs provided by the drug manufacturers themselves.

Another option, when appropriate, is to consider generic alternatives. That said, because generic medications have significant variability in ease of use, formulation, efficacy, and tolerability, this option may not be ideal for all patients.⁶

Working in Concert

The effective management of glaucoma extends beyond prescribing treatments, to actively ensuring that patients adhere to their medication regimens. Through a combination of patient education, inquiring about routine activities, simplifying medication regimens, leveraging technology, and providing financial assistance resources, I have been able to significantly enhance the likelihood of patient adherence, which enables them to maintain their quality of life. OM

References

1. Sleath B, Blalock SJ, Carpenter DM, et al. Ophthalmologist-patient communication, self-efficacy, and glaucoma medication adherence.Ophthalmology. 2015;122(4):748-754. doi:10.1016/j.ophtha.2014.11.001

2. Newman-Casey PA, Niziol LM, Gillespie BW, Janz NK, Lichter PR, Musch DC. The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study.Ophthalmology. 2020;127(4):477-483. doi:10.1016/j.ophtha.2019.10.022.

3. Zaharia AC, Dumitrescu OM, Radu M, Rogoz RE. Adherence to Therapy in Glaucoma Treatment-A Review.J Pers Med. 2022;12(4):514. Published 2022 Mar 22. doi:10.3390/jpm12040514.

4. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension.Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009.

5. Wolfram C, Stahlberg E, Pfeiffer N. Patient-Reported Nonadherence with Glaucoma Therapy.J Ocul Pharmacol Ther. 2019;35(4):223-228. doi:10.1089/jop.2018.0134.

6. Tatham AJ. The Use of Generic Medications for Glaucoma. J Ophthalmol. 2020;2020. doi: 10.1155/2020/1651265.

Justin Holt, OD, practices full-scope optometry in Northern California. He is in group practice at Anderson Eye Care. Email him at dr.justinholt@gmail.com.