ADHERENCE WITH IOP-lowering medications for glaucoma has been a long-term challenge for patients. A review of clinical research reveals a collection of disturbing statistics, says Jennifer L. Stone, O.D., associate optometrist of Total Vision, in Lutherville, Md. One study, based on prescription refill data, shows that patients may only have enough to cover an average of 56% of days in the first year of treatment. After 12 months of treatment, the majority of patients (more than 65%) discontinued therapy. Additionally, only 67% of patients are persistent in taking their medications for the entire first year of treatment.1
As a result of non-compliance, the risk of optic nerve damage becomes quite high, which can lead to vision loss and blindness, says Jim Thimons, O.D., F.A.A.O., medical director and founding partner of Ophthalmic Consultants of Connecticut, in Fairfield, Conn., and chairman of the National Glaucoma Society.
“On average, between 5% and 10% of patients with glaucoma who live long enough will suffer vision loss to the level of legal blindness,” he says. “For many, I think a significant component of their progression is due to non-compliance.”
Here, Drs. Stone, Thimons and others discuss how to increase compliance by evaluating obstacles to compliance; identifying non-compliant patients; and providing solutions, such as reviewing test results, educating patients, being mindful of follow-up visits and discussing IOP-lowering surgeries.
EVALUATE POSSIBLE OBSTACLES
The first step to increasing compliance is to know the obstacles your patients face. Although patients routinely report perfect compliance with daily eye medication regimens, studies reveal patients not only have poor instillation techniques but also forget to use or misuse their prescribed eye medications much more often than they recognize.2
“Life is complex, and distractions can occur; managing your health might not always be top of mind,” Dr. Thimons says.
Patients and doctors alike cite a myriad of reasons for medication non-adherence, such as lacking the motor skills or vision to adequately use drops. Dr. Stone says different bottle shapes and sizes can challenge some patients, such as those who have dexterity issues. Consequently, medication might be wasted during delivery.
Complex regimens can also be cumbersome, particularly for those who need to administer more than one type of medication daily and at multiple intervals.
“Elderly patients may become confused by dosing instructions,” Dr. Thimons says.
Because open-angle glaucoma is asymptomatic, patients may not realize the seriousness of their disease and importance of medication adherence. One study reports that 37.6% of glaucoma patients thought they could stop the medication at any time once symptoms were relieved.3
Furthermore, the cost of prescription drops can be too costly for some patients. (See “Provide Assistance.”)
“Without adequate prescription drug coverage, the most efficacious IOP-lowering medications can cost over $100 a bottle,” Dr. Stone says. “Patients may alternate days, use half doses or rely on samples to stretch their medications.”
IDENTIFY NON-COMPLIANT PATIENTS
Determining whether a patient is non-adherent is challenging, says Danica Marrelli, O.D., F.A.A.O., clinical professor at the University of Houston College of Optometry, in Houston.
“Unless the practitioner has a way of tracking pharmacy refills, the only way to assess adherence is by asking the patient if [he or she is] using the drops as prescribed,” she explains. “Unfortunately, patients do not always give a truthful answer.”
Financial issues is one potential roadblock leading to noncompliance. To combat this, connect your patients with assistance programs offered by pharmaceutical companies to aid with non-compliance related to financial issues. One website, Rxassist.org , provides a comprehensive list of these assistance programs.
When Andy Gurwood, O.D., professor at The Eye Institute of The Pennsylvania College of Optometry at Salus University, in Philadelphia, encounters a high IOP in a patient he has already diagnosed and successfully treated pharmacologically, he says he will instill the prescribed drops during his or her appointment to recheck effectiveness. If the IOP is successfully reduced, then it’s likely that the regimen still works.
“I am less suspicious that something that was working has stopped working and more inclined to think that the patient is omitting some instillations or doing them improperly,” he says.
Dr. Marrelli points out that sometimes patients with poor adherence will actually present with “good” IOP because they have been adherent in the few days leading up to the office visit, which she refers to as the, “floss before the dentist” syndrome. “Therefore, it’s always good to ask patients questions about their long-term adherence,” she says.
Because one of the obstacles is that patients may not understand the instructions, Dr. Gurwood says he will ask several questions before a patient leaves after his or her initial diagnosis. “Did you understand how we diagnosed you with glaucoma?” “Did we explain things to you clearly so that you understand the nature of the disease, its potential complications and your options?” and, “Do you have any questions?”
During follow-up visits, because Dr. Gurwood’s patients know him, he approaches things bluntly. For example: “So, are you taking your drops?” Softer approaches might include, “Are these drops working for you?” or, “Are you able to get them in?” If they admit to any missed dosages, he’ll ask “why” to identify the non-compliance issue.
Whenever Mark T. Dunbar, O.D., F.A.A.O., director of optometric services at Bascom Palmer Eye Institute, UHealth at the University of Miami Health System, has a patient encounter, he says he’ll ask whether the patient is using the drops, when the drops were last used and whether the patient had any difficulty remembering to take them.
“It’s important to have this discussion, and to encourage the patient to acknowledge any challenges,” he says.
Once you have identified the obstacles for your specific patient, utilize one or more of the following solutions to aid in compliance.
• Review the test results. Reviewing test results that illustrate changes in the patient’s vision or eye health can also increase compliance.
“Some patients don’t follow through with treatment because they don’t believe they have glaucoma,” Dr. Gurwood says. “In the early stages of disease, they can’t tell they’re losing vision and in cases of open-angle glaucoma, they don’t feel anything. So, they may not believe what you are telling them is true, [and this belief] is supported by studies.4,5 That’s why a good explanation and examples are necessary.”
During his explanation, he says he will show them models or pictures of the eye, their clinical data and how he arrived at his diagnosis.
Dr. Marrelli says she will show patients their VF test results to illustrate where vision has been lost.
“Showing changes over time can be helpful to emphasize the importance of adherence,” she adds. “Conversely, showing a stable VF to adherent patients can reinforce that they are doing their part in controlling their glaucoma.”
• Educate the patient: After an open-angle glaucoma diagnosis, Dr. Gurwood says he will provide a thorough overview of the disease and its consequences.
“This sets the stage for understanding the disease’s course and the potential complications that will ensue if it’s left untreated,” he says. “I involve patients in the decision-making process as their treatment is formulated. This leads to better compliance and follow through.”
Patients need to know that the purpose of the eye drops is more than just lowering eye pressure; the ultimate goal is to slow down the progression of the glaucoma to maintain functional vision, Dr. Marrelli says. Answers to questions such as, “What do you think will happen if you don’t use your eye drops?” or even, “What is your understanding of glaucoma?” can be a real eye opener to patients, she says.
Dr. Stone recommends patients build a daily routine around administering their eye drops.
“Link drops with a daily habit, such as having morning coffee or reading the newspaper before bedtime,” she says.
Educational resources can provide facts and descriptions, which help support and corroborate explanations, Dr. Gurwood says. Pamphlets can serve to remind patients about the complications of neglected disease, reinforcing good habits, compliance with medications and follow-up.
Numerous medication reminder apps on smartphones can be used to remind patients of when to instill drops and attend appointments. For patients without smartphones, Dr. Marrelli recommends they set an alarm clock to sound at the same time every day. She says she also advises patients to ask a family member to help with reminders or administer drops, if needed.
• Be mindful of follow-up visits. Telling patients up-front how frequently they will need follow-up appointments works well in instilling compliance for Dr. Dunbar. “This way, they can mentally understand the big picture,” he says.
Missing follow-up visits is actually a good indicator of poor medication adherence, says Dr. Marrelli, so she will take note of missed appointments, and stress adherence to both follow-up visits and daily drop administration when seeing the patient again. She says she will schedule frequent follow-up visits with patients in the early months following diagnosis to stress adherence and to see how they’re doing with their medications.
Dr. Gurwood says he is mindful of how many refills he provides on the prescription. He says this provides an additional incentive for patients to maintain their appointments and meet the best possible outcome for their eye health.
• Discuss IOP-lowering surgeries. Dr. Marrelli says she discusses IOP-lowering surgery during the initial glaucoma diagnosis. She says she tells patients that drops, lasers and incisional surgery are all options. She’ll mention that surgery has more risks than medications, so it’s only used when medication and lasers are insufficient. If a patient is non-adherent, she says she’ll mention medication alternatives again.
“I try not to use surgery as a scare tactic, but I think bringing up surgery is a wake-up call to the seriousness of the disease,” she says. “In some cases, that discussion can motivate better adherence.”
That said, Dr. Dunbar says it’s important to acknowledge that not everyone is good at remembering to take eye drops, or issues at play can make it difficult. If that’s the case, he says he lets patients know that it’s OK, and that other effective options exist.
Consider the reasons for medication non-compliance and methods to improve adherence to IOP-lowering therapies when helping open-angle glaucoma patients adhere to eye drop prescriptions. OM
- Reardon G, Kotak S, Schwartz GF. Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systemic review. Patient Prefer Adherence. 2011; 5: 441-463.
- Stone JL, Robin AL, Novack GD, Covert DW, Cagle GD. An objective assessment of eyedrop instillation in patients with glaucoma. Arch Ophthal. 2009; 127(6): 732-736.
- Mohindroo C, Ichhpujani P, Kumar S. How ‘drug aware’ are our glaucoma patients? J Current Glaucoma Practice. 2015; 9(2): 33-37.
- Kim YK, Jeoung JW, Park KH. Understanding the reasons for loss to follow-up in patients with glaucoma at a tertiary referral teaching hospital in Korea. Br J Ophthalmol. 2017; 101(8): 1059-1065.
- Masoud M, Sharabi-Nov A, Pikkel J. Noncompliance with ocular hypertensive treatment in patients with primary open angle glaucoma among the Arab population in Israel: A cross-sectional descriptive study. J Ophthalmol. 2013. DOI: 10.1155/2013/405130.