...to acquire medication compliance

While patient adherence to topical treatment in glaucoma significantly delays¹, slows², and minimizes the severity³ of visual loss in glaucoma, many patients are non-compliant to their prescribed treatments. As a result, they often will have increased or unstable IOP levels with associated progressive glaucomatous optic nerve damage and VF defects. Fortunately, doctors can increase the likelihood of patient adherence to anti-glaucoma medications by using the three R’s: realizing, recognizing, and removing.

1 REALIZING

We must first realize the pre-valence of non-adherence — the inability to take the prescribed medication in the prescribed manner more than 80% of time⁴ — among our glaucoma patients. Doing so increases our awareness of the problem, placing it on our radars when we see our glaucoma patients. Studies show that between office visits, patient medication adherence ranges from 5% to 80%⁵ with associated persistence rates (how often they fill the medication as directed) of less than 50% within a year of treatment.⁶ Clinically, this means that based on epidemiological data and conservative adherence estimates of 25%, approximately 19 million of the estimated 76 million people who have glaucoma are non-adherent to treatment.⁴

2 RECOGNIZING

Second, we need to recognize those patients who are more likely to be non-compliant to their glaucoma medications. With that said, studies reveal that patients who have low health literacy scores, low self-efficacy (the confidence to adhere to and administer their eye drops correctly), and low social support are more likely to be less adherent to their medications.⁴ Furthermore, race, unmarried patients, and those who have a negative affect/depression (more common in glaucoma patients^7-8) are more likely to miss doses.² Other links to medication non-adherence are multiple medication use,⁹ forgetfulness (ranked No.1 among all glaucoma patients), skepticism that glaucoma leads to vision loss and/or that glaucoma medications can prevent vision loss, and general insufficient knowledge about the disease — with many of these barriers co-existing among glaucoma patients.¹⁰

3 REMOVING

The common factor among all these barriers is that they can be removed, or at least significantly mitigated, via patient-tailored education. Studies show that patients who receive tailored education (e.g., instillation technique, purpose of medications, the nature of the disease, memory aids, etc.) have both higher self-efficacy, and a significant increase in adherence.^4,11,12 In short, we should provide patient re-education at each visit.

Related to these efforts, and on a personal note, I have found that if I must write the drop schedule so that the patient can remember and/or understand it better, I am prescribing too many drops and should proactively consider other readily available and successful procedures, such as selective laser trabeculoplasty and MIGS,¹¹ when and where appropriate.

Regardless of the barriers, and when talking with patients about potential barriers, we should strive to be specific, open and nonjudgmental, and, above all, encouraging.¹³

REVIEW

Because “physician attitude has been shown to play a large role in patient adherence,”⁴ taking time as providers to Realize, Recognize, and Remove potential barriers to adherence can positively affect the stability and the course of glaucomatous disease in the lives of our patients. OM

References

1. Shu YH, Wu J, Luong T, et al. Topical Medication Adherence and Visual Field Progression in Open-angle Glaucoma: Analysis of a Large US Health Care System. J Glaucoma. 2021;30(12):1047-1055. doi: 10.1097/IJG.0000000000001943. 
 
2. Newman-Casey PA, Niziol LM, Gillespie BW, et al. The Association between Medication Adherence and Visual Field Progression in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2020;127(4):477-83. doi: 10.1016/j.ophtha.2019.10.022. 
 
3. Sleath B, Blalock S, Covert D, e al. The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology. 2011;118(12):2398–2402. doi: 10.1016/j.ophtha.2011.05.013. 
 
4. Achilleos M, Merkouris A, Charalambous A, Papastavrou E. Medication adherence, self-efficacy and health literacy among patients with glaucoma: a mixed-methods study protocol. BMJ Open. 2021;11(1):e039788. doi: 10.1136/bmjopen-2020-039788. 
 
5. Olthoff CM, Schouten JS, van de Borne BW, Webers CA. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension an evidence-based review. Ophthalmology. 2005;112(6):953-61. doi: 10.1016/j.ophtha.2004.12.035.
 
6. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. 
Surv Ophthalmol. 2008 Nov;53 Suppl1:S57-68. doi: 10.1016/j.survophthal.2008.08.002.
 
7. Çakmak H, Altinyazar V, Yilmaz SG, et al. The temperament and character personality profile of the glaucoma patient. BMC Ophthalmol. 2015;15:125. doi: 10.1186/s12886-015-0117-9.
 
8. Tan Z, Tung TH, Xu SQ, Chen PE, Chien CW, Jiang B. Personality types of patients with glaucoma: A systematic review of observational studies. Medicine (Baltimore). 2021 Jun 11;100(23):e25914. doi: 10.1097/MD.0000000000025914.
 
9. Wilensky J, Fiscella RG, Carlson AM, Morris LS, Walt J. Measurement of persistence and adherence to regimens of IOP-lowering glaucoma medications using pharmacy claims data. 
Am J Ophthalmol. 2006 Jan;141(1 Suppl):S28-33. doi: 10.1016/j.ajo.2005.09.011.
 
10. Newman-Casey PA, Robin AL, Blachley T, et al. The Most Common Barriers to Glaucoma Medication Adherence: A Cross-Sectional Survey. Ophthalmology. 2015;122(7):1308-1316. doi: 10.1016/j.ophtha.2015.03.026.
 
11. Meier-Gibbons F, Berlin MS, Töteberg-Harms M. Influence of new treatment modalities on adherence in glaucoma. Curr Opin Ophthalmol. 2019 Mar;30(2):104-109. doi: 10.1097/ICU.0000000000000551. 
 
12. Newman-Casey PA, Niziol LM, Lee PP, Musch DC, Resnicow K, Heisler M. The Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Pilot Study on Glaucoma Medication Adherence. Ophthalmol Glaucoma. 2020;3(4):228-237. doi: 10.1016/j.ogla.2020.04.013. 
 
13. Budenz D. A clinician's guide to the assessment and management of nonadherence in glaucoma. Ophthalmology. 2009 Nov;116(11 Suppl):S43-7. doi: 10.1016/j.ophtha.2009.06.022.

DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Email him at glaucomaqd@yahoo.com.