Article Date: 11/1/2007



Almost half of patients may not adhere to their glaucoma medication regimen. What can you do?

BY JIM THOMAS, editorial director

How daunting is the challenge of keeping glaucoma patients compliant with their therapies? Research provides clues:

► As many as 47% of patients who receive glaucoma therapy do not adhere to their doctor's prescribed regimen of treatment, reports a study published in Ophthalmology (May 2005).

► The same study reports that 90% of doctors believe that patients are compliant with their glaucoma medications.

► In a 1990 study on glaucoma therapy non-compliance, published in the British Journal of Ophthalmology, 69% of patients admitted having difficulty in administering their drops, yet 69% said they would not admit problems to their doctor, even if the doctor asked.

"Whenever we talk about patient compliance, we're making an assumption right from the start that we believe patients when they tell us what they're doing, or not doing," says Kimberly K. Reed, O.D., associate professor of optometry at Nova Southeastern University.

So against these odds, how do doctors keep addressing patient non-compliance with therapy?

The first step: education

The optometrists interviewed for this article all agreed that education is the single most important step in getting patients to adhere to the prescribed glaucoma therapies. Andrew Gurwood, O.D., professor of clinical sciences at the Pennsylvania College of Optometry, asserts that involving the patient in the education process is critical. "They must participate in the therapy and agree with the approach. They must understand the consequences and benefits [of adherence to therapy]. In most instances, this approach works well — barring other obstacles like the inability to squeeze or aim the bottles," he says.

Dr. Gurwood uses model eyes and posters to educate patients and reinforce the importance of adherence to therapy. Sheldon H. Kreda, O.D., who practices in a primary-care setting in Lauderhill, Fla., says he uses computer graphics presented during the consultation in the exam room, and he provides patients with handouts. Dr. Reed says she shows patients the results of their visual field tests.

"The 'dark spots' on a visual field are very dramatic and often get the patient's attention very quickly," she says. "At our teaching facility, we also have a number of models, posters and teaching aids that are useful when describing the pathology as well as the mechanism of action for various treatments."

"We are not the glaucoma police", says Dr. Gurwood.

Dr. Reed says she provides patients with a medication sheet that includes instructions for all medications, such as the time of day for taking the medication, the bottle characteristics and what to do if the patient misses a dose.

Staff can play an important role in assuring patient compliance. (For example, Dr. Kreda's staff demonstrates the eye drop training to patients.) In these instances, intra-office communication is essential. Staff might notice the patient who has difficulty in instilling drops or understanding the therapy regimen. Also, some patients may be reluctant to inform the doctor of their non-compliance, yet will tell staff more readily.

Facing non-compliance

The best in-office education and training doesn't guarantee adherence. "Age contributes to a patient's ability to instill drops," says Dr. Kreda. "Education and economic class contributes to the affordability and understanding of the therapies. The doctor-patient relationship also affects compliance."

The study published in the British Journal of Ophthalmology found patients face a number of physical barriers that affect adherence, including:

► missing while directing the bottle (36% frequently and 13% occasionally);

► squeezing the bottle (20%);

► problems reading labels and identifying bottles (14%);

► poor visibility of the tip dropper (13%);

► blinking (12%);

► prodding the eye with the tip of the dropper (9%).

The study explains that older patients experience problems in raising their arms, tilting their heads and holding and squeezing bottles. Dr. Reed also notes that every patient is different and "non-compliance comes in all shapes, sizes, ages, colors and backgrounds."

When Dr. Kreda finds that a patient has been non-compliant with glaucoma therapy, he says he reviews the visual aids with the patient and stresses that while no symptoms are associated with non-compliance, improper treatment has consequences.

When addressing non-compliance, Dr. Reed says she tries to understand the patient. "Patients may not be comfortable in admitting that last month they had to choose between getting their car fixed or buying glaucoma medication, because of finances," she says. "But, in many cases, it comes down to that level of decision making. Patient assistance programs address these issues, but the patient has to inform you of his financial need."

As many patients will not admit "non-compliance," doctors can remove the stigma through communication. Rather than ask, "have you been taking your medication?" which usually elicits a "yes" response, ask, "how often do you typically miss taking your medication?" This question can lead the doctor to the reason(s) for non-compliance.

None of the doctors interviewed used surgery as a threat to facilitate glaucoma therapy adherence. Says Dr. Gurwood: "That will get patients not to trust you."

However, Dr. Reed recommends you include surgical information as part of patient education. "I always inform the patient about all his options for treatment, including surgery as a first-line therapy," she says. "I believe that patients deserve complete informed consent before I initiate therapy of any sort. It's a disservice to patients not to inform them of surgical options, as surgery is a viable means of managing glaucoma."

Living with non-compliance

In the end, optometrists may best deal with glaucoma therapy non-compliance by understanding — and maintaining — their role in the doctor-patient relationship.

"Doctors are not the glaucoma police. They are the keepers of trust, the investigators of health, the advisors for wellness," says Dr. Gurwood. "It is always up to the patient to take or discard the advice physicians give. It is up to the doctors to provide a sound and trustworthy platform so patients are encouraged and persuaded to follow through." OM

OM welcomes you to share your tips for patient compliance with glaucoma medications. E-mail them to We will publish them in a future issue.

Optometric Management, Issue: November 2007