As eyecare providers, we understand the importance of routine eye examinations and the gravity of ocular disease.
Conditions causing irreversible vision loss, such as macular degeneration, diabetic retinopathy, and glaucoma, may or may not be straightforward to diagnose, yet are always difficult discussions for the patient and provider.
Additionally, patients feel the financial and psychological pressure associated with disease prognosis, intervention, and follow-up care.
In 2019 a cross-sectional survey conducted in the United Kingdom found that sight is the most valued sense. People in this survey also preferred a shorter lifespan with excellent vision over a longer lifespan with complete sight loss.1
Clearly, vision is a high-valued sense and people have a deeply rooted fear of going blind. Despite the fear of permanent vision loss being higher than any other sense, patient non-compliance is an ongoing struggle in optometry.
Glaucoma: A brief overview
Glaucoma persists as the second-leading cause of blindness worldwide and is among the leading causes of irreversible blindness.2 The most common form of glaucoma is primary open-angle glaucoma (POAG). About 3 million Americans are currently diagnosed with glaucoma.3
Glaucoma risk factors
Risk factors include age, race, family history, past medical history, previous ocular disease/trauma, and steroid use. Any individual above the age of 60 is at an increased risk of the development of glaucoma.
Race also plays a role in the likelihood of a glaucoma diagnosis, as African Americans as young as the age of 40 are at a higher risk for the development of glaucoma.3 In addition, individuals of Japanese descent are more likely to develop normal-tension glaucoma, and those of Asian/Native Alaskan descent are at higher risk for angle-closure glaucoma.4
Glaucoma treatment options
With advances in technology, the options for initial and continuing treatment of glaucoma continue to widen. Topical anti-hypertensives and selective laser trabeculoplasty (SLT) remain among first-line treatment options.
For patients with mild to moderate glaucoma, other options include minimally invasive glaucoma surgery (MIGS), targeting the trabecular meshwork and ciliary body.
In cases of advanced or fast-progressing glaucoma, procedures such as aqueous drainage valve implants or surgery allowing direct outflow from the anterior chamber to the sclera may be indicated to maintain target intraocular pressure (IOP).
Non-compliance is not a surprise in glaucoma patients
Non-compliance is the inability to conform to a regulation or request. In the glaucoma world, patient non-compliance translates to the failure to administer topical anti-hypertensives in the daily routine as prescribed by an eyecare provider.
This inability may be deliberate, such as in the case of a recently diagnosed 65-year-old male “declining” to begin a prostaglandin. It may also be involuntary non-compliance, as in the case of an 85-year-old woman in a long-term care facility where she is unable to physically instill the drops herself.
Due to the infinite spectrum of involuntary and voluntary reasons for not using a drug as prescribed, some practitioners prefer the phrase “non-adherence” as it offers a subjectively modest alternative wording to avoid negative connotations patients may experience. Ultimately, the practitioner may decide on the preferred phrasing regarding patient education.
Despite differences in phrasing preferences, eyecare practitioners all face the same problem as a result—glaucoma progression. This poses a huge hurdle for the provider in battling irreparable vision loss.
Current studies estimate that between 24 to 59% of glaucoma patients fail to receive the full effect of treatment secondary to non-compliance.5 Additionally, patients may not admit to non-compliance in an attempt to please their doctor.
The range of reasons for non-compliance
Barriers patients face to taking topical medications as prescribed are multifactorial. From the provider’s standpoint, perceived reasons for patient non-compliance include poor patient education on understanding the treatment, poor education on drop instillation, or poor communication between pharmacies to fill the medication timely and continually.
The Glaucoma Adherence and Persistency Study further explored the average eyecare provider’s perspective on non-compliance. The top three perceptions of non-compliance from a prescriber’s opinion were identified as:
- Cost to the patient
- Patient forgetfulness
- Fear/denial of glaucoma and its threat to vision loss.
Other factors included a comprehensive understanding of glaucoma and drop regimen complexity.6 Conversely, data from this study suggests that the perception of physician behavior is an identifiable factor in patient non-compliance. Patients who had knowledge of future expectations for the treatment of their glaucoma were more likely to comply with prescribed medications.6
Secondly, patients who had telephone appointment reminders tended to comply with medications more closely than those who did not receive reminders about their upcoming glaucoma follow-up.
Lastly, patients who believed in vision loss because of non-compliance had higher levels of compliance than those who did not believe in vision loss consequences.6 Other barriers such as cost and side effects of medication also play a role.
Step for improving compliance in glaucoma patients
Limited compliance with prescribed medication is not unique to eyecare. All primary and specialty care providers experience levels of pushback on prescribed medications. The psychology surrounding non-compliance is a topic that deserves increased attention in the medical field.
However, there are studies that have categorized methods for improving compliance into four categories:8
- Patient education
- Improved dosing schedules
- Increasing clinic hours to decrease wait times
- Improved communication between physician and patient
Notably, these above points are all modifiable factors of the eyecare provider. This mindset of a proactive approach instead of placing passive blame on patients is important to highlight.
Patient education, communication, and clinic hours
Patient education begins in the exam room, but does not have to end when the exam is over. Supplemental resources are an excellent way to ensure your patient’s questions are being answered. Thorough disease explanations, such as pamphlets and guides to websites, are ways for patients to have improved knowledge of their condition.
Oftentimes, patients call back after an appointment with follow-up questions that are frequently simple to answer. Doctors should take the time to train technicians and staff to triage the most commonly asked questions, and to know when a conversation with the doctor is needed. Simple telephone communication between patients, the doctor, and staff goes a long way.
Whether it is for a low-risk glaucoma suspect who is returning in 6 months for repeated testing, or a recently diagnosed POAG patient returning in 5 weeks for an IOP check, open communication can close the bridge between patient compliance and non-compliance. A patient is more likely to comply with treatment when the consequences of vision loss are understood.8
While clinic hours are linked to a provider’s availability, it is important to note that we shouldn’t be expected to increase clinic hours to improve compliance, but rather improve communication during clinic hours.
As mentioned above, phone call triaging with staff is extremely helpful in assisting patients with pharmacy authorizations, dosing questions, and refill requests. It is also helpful to have phone call reminders for patient’s to be aware of upcoming appointments.
Reducing drop burden with SLT
Drop burden is another hurdle that the prescriber can minimize to meet both IOP and patient goals. Every time a prescription is added, compliance drops. This can be due to either patient forgetfulness or unwanted side effects. Burning with drop instillation and conjunctival hyperemia are notorious reasons for non-compliance.
Perhaps the most underutilized technology available to decrease drop burden is SLT. SLT is a treatment available for patients as first-line treatment or as an adjunct. The Laser in Glaucoma and Ocular Hypertension (LiGHT) trial exemplified SLT as recommended first-line therapy in patients.9
Its primary endpoints were health-related quality of life, and secondary outcomes clinical effectiveness and adverse events. Of note, 6-year data is now available regarding comparing the treatment of SLT to anti-hypertensive drops, and the results remain promising.
The biggest takeaways are that SLT is safe to treat both open-angle glaucoma and ocular hypertension, and reduces the need for incisional glaucoma surgery.9 Moreover, eyes assigned to topical therapy were more likely to have disease progression—although the difference between quality-of-life endpoints was not statistically different.9
Addressing ocular surface disease in glaucoma patients
Preservatives such as benzalkonium chloride (BAK) are toxic to the cornea over time and can worsen ocular surface disease, which can add more flame to the fire of non-compliance. Luckily, there are several options to minimize this.
Compounded fixed-combination drops are an excellent option to minimize the dosage and number of preservatives exposed to the cornea. ImprimisRx and OSRX are two companies that offer this. Options include combining aqueous suppressants, alpha-adrenergic agonists, carbonic anhydrase inhibitors, and prostaglandins, all in one drop!
The role of MIGS in glaucoma management
MIGS also deserves its moment for glaucoma control. Of recent note, trabecular-bypass stents, such as the iStent infinite, are FDA-approved as standalone procedures to improve aqueous outflow.
Once reserved for at the time of cataract surgery, these stents are placed in the nasal quadrant of the trabecular meshwork. However, now, it is approved as a standalone procedure. This achieved FDA approval for clinically significant IOP reduction in patients with uncontrolled open-angle glaucoma.10
Introducing intracameral bimatoprost
Another newer option to decrease the drop burden is intracameral bimatoprost (10mcg). This pellet contains a slow release of medication for up to 6 months and is injected into the anterior chamber of the eye.
While a temporary solution, this may offer a brief suspension of topical medication instillation burden. Patients who struggle to administer their own medications due to dexterity and mobility limitations are also excellent candidates for this option.
In conclusion
Glaucoma is a lifelong, incurable disease. Paramount efforts are needed from both doctor and patient to ensure the highest efficacy of prescribed treatment.
As technology expands and innovations in glaucoma care evolve, we cannot forget the simple fact that if a patient is not motivated or understanding, time and treatment effort are lost for both parties.
Doctors can make a difference by remembering the importance of the basics: patient education, a simple regimen for treatment, and trust between patient and doctor.
Through open communication outside of the exam and between doctors, staff, and patients, glaucoma can be viewed again as a treatable disease and not a doomsday diagnosis.
Further, options such as SLT, combination anti-hypertensive medications, MIGS, and injectable drug implants can decrease drop burdens that patients face. Through these methods mentioned above, we can continue to provide top care without cutting corners on glaucoma management.
