One of the most difficult things that we often face in practice is the non-compliant patient. This is particularly true when we deal with patients who have glaucoma. Due to its lack of symptoms until late in the disease process, it's often difficult to convince patients of the importance of using their medications as prescribed. This, combined with glaucoma's chronic nature, provides the perfect framework for non-compliance. It's a situation that can prove disastrous, so it's imperative that we doctors find ways to prevent it.

There's always an excuse

There are many reasons patients give for non-compliance, including forgetfulness, lack of understanding, lack of support (either social or financial) and pre-conceived medical beliefs. Further, when dealing with medications, other factors may arise, such as side effects, costs and complexity of the treatment regimen. Lastly, difficulties in the patient-provider relationship and poor communication can derail compliance.

Head 'em off at the pass

Here are some things to consider when trying to keep glaucoma patients compliant with their therapy.

Ask the patient at each visit if they are having problems or concerns with their medications. Start with open-ended questions, such as "Are you having any problems or concerns with your current eye medications?"

It may help the patient to open up with you. It also may take a few visits until the patient gets sufficiently comfortable with the provider to discuss some of his concerns, so it's important to ask at each encounter you have with the patient. For instance, a patient suffering from decreased libido from a beta-blocker may be hesitant to admit this to the doctor until he's established a greater level of trust and rapport. Also be sure to ask about specific side effects that are common with a particular medication, such as eyelash growth or iris color change with prostaglandins.

Ask the patient to repeat his treatment regimen. It is important to ask patients which drops they are using and how often. They may not know the exact name of the drop, but should be familiar with the bottle size or color. This way you can clarify and remedy any misunderstandings about dosage. Also, periodically ask patients to demonstrate how they instill their drops. Offer techniques that may help if they are doing so incorrectly.

Provide written instructions on proper drop administration with the patient's specific drug regimen. This serves as a handy reference for the patient after they leave your office and may prevent them from calling back because they forgot which drop to use when and how often. Further, because written instructions may contain your practice information, they can also be a valuable tool to help grow your practice through referrals and word-of-mouth.

Provide patient education, preferably in writing. It's important to educate the patient on the reasons for treatment despite an absence of obvious symptoms, such as pain or decreased vision. Further, general information concerning glaucoma, again in writing, in the form of brochures or pamphlets, is also valuable. Several software programs are available that can provide quality patient education in terms the patient can understand, and can also be customized with his individual medications, dosages, and your practice information.

Provide positive feedback if IOP is within target. We all like a pat on the back from time to time as acknowledgment for doing a good job. Your patients are no exception. Therefore, make it a point to tell your patient if you are pleased with his current IOP control, and if they appear to be remembering to use their medications as prescribed. Not only will this help build rapport, it will also strengthen their desire to continue with the treatment as they can begin to see that it is making a difference.

Encourage your patient to acknowledge missed doses. This is especially important if you are considering adding another medication or changing therapy. Acknowledge to the patient that you understand it may be difficult to recall their medications all the time, but that it's very important for them to confide in you if they are using them, so that you don't recommend a change unnecessarily. This is especially important in your older patients, who may have memory or cognitive impairments, and may also be on multiple medications, not just for their glaucoma but for systemic reasons as well.

Keep in mind that compliance may increase just prior to an exam. Just like you probably floss your teeth before a dentist appointment, compliance may increase right before an exam. This may be done in an attempt to make the doctor happy, or simply because they remembered to start using the drops due to their appointment reminder. Whatever the reasoning, you may get a good IOP reading that leads to a sense of false security. Again, it's important to encourage the patient to be honest regarding administration of his drops, especially if you're considering altering the treatment.

Use the least number of medications to achieve your desired response. Studies show that patients who take only one eye drop per day report approximately 49% compliance with their medications compared with 39% compliance for twice daily dosing. And, more than one medication further decreases compliance to about 32%. Therefore, it is important to use the least number of medications, with the easiest dosing regimen possible, to achieve the desired response. A decreased number of medications also means decreased cost for the patient, as well as decreased potential side effects and drug interactions.

Switch medications first, add additional medications second. If a patient demonstrates a poor IOP response to a specific mediation, resist the temptation to automatically add medications. For example, if a patient does not achieve the desired IOP reduction, such as the 25% or so we come to expect with a prostaglandin, try a different class of medication or another prostaglandin before simply adding a second medication. As stated above, additional medication will only hinder compliance. There is plenty of literature that suggests some patients may respond better to one prostaglan-din than another. Further, not all patients will respond equally to all classes of medications.

Consider combinations in patients who need more than one medication. In a patient who requires a greater reduction in IOP than can be achieved with a single medication, consider using a combination, such as Cosopt (dorzolamide hydrochloride 2% plus timolol maleate 0.5%, Merck). Again, a smaller number of drops per day will help to increase compliance. In fact, one study revealed that almost half the patients surveyed stated they would be willing to pay more for an eye drop that included two medicines in a single bottle. While this is the only combination currently commercially available, several companies are working on plans to develop combination beta-blockers and prostaglandins.

Adjust the treatment regimen to fit the patient's lifestyle. For example, we know that prostaglandins tend to get the best IOP response if taken in the evening. However, if you have an elderly patient who falls asleep watching television every night before administering his medication, it's perfectly legal to recommend taking the drop in the morning. Studies have demonstrated that the IOP response with morning administration of prostaglandins is still very good. Simply explain to the patient that while the evening administration has been shown to be more effective, you would prefer the patient to remember using the drop consistently, regardless of the time, rather than not at all.

Encourage patients to become active in their treatment plans. Just as it is important to let the patient know when you are pleased with the IOP control, it is equally important to let them know when you are not pleased, and when you feel that it's necessary to make a change in their treatment regimen. If possible, let the patient feel that they are part of the decision-making process by allowing them to have input into the different strategies you are considering. This will go a long way in establishing patient-provider rapport and increasing compliance.

Demonstrate field loss on a visual field. Showing the patient with field loss the gray scale on the visual field printout can often be a powerful patient education tool. This is especially true if you can demonstrate some worsening over time attributable to non-compliance. The "black spots," showing areas that the patient is unable to see is powerful, especially since most patients do not notice this field loss until late in the disease process. Conversely, showing fundus photos of the optic nerve head is of little value, as the patient generally cannot appreciate or understand the difference between healthy and unhealthy appearing nerves.

Discuss alternative treatments with the patient. When you can't obtain appropriate control of IOP with topical medications alone, consider other treatment modalities, such as argon laser trabeculoplasty, selective laser trabeculoplasty and trabeculectomy. Don't look at these as punishment for non-compliance, but rather as alternatives. Discuss all therapies with patients, including your recommendations.

It's worth the effort

Convincing glaucoma patients, especially those with no noticeable field loss or other symptoms, of the importance of proper compliance is a true challenge. Some of these strategies may help decrease non-compliance and lead to better treatment outcomes.  Moreover, connecting with these patients on a personal level to help them avoid complications from their glaucoma can be very rewarding.

References available on request.

Dr. Ferrucci is Chief of Optometry at the Sepulveda Veterans' Affairs Ambulatory Care Center and Nursing Home, and an Assistant Professor at the Southern California College of Optometry. He has also published several articles in optometric journals.