Increasing Glaucoma Treatment Compliance

A Visual Field test is use to detect glaucoma damage and monitor
for progression.  In many cases, early damage that shows up
on this test is not noticeable to the patient in their daily life.
Glaucoma damage would go entirely undetected if left untreated until
the disease had resulted in permanent peripheral field loss
via 

Glaucoma is a really difficult disease (read here for more details on what glaucoma is!).  Imagine that you have to tell a person that they have a disease where they have to take an eye drop every single day for the rest of their life.  The drops aren't going to make you feel any better; the disease is painless, and if you have had vision loss already they won't give you the vision back.  You can see how there is little incentive to use those drops every day.  This is a conversation that eye care professionals have very frequently, and for many of us, we have to have it every time our patients return for their follow-up appointments because they are routinely missing their drops!

One thing we do know; even if your patient reports good compliance with their glaucoma medication, they probably aren't taking it as often as they tell you.  Studies estimate that as high as 25% of patients prescribed glaucoma medication actually take NONE of the drops prescribed.  Only 25 to 35% of patients in the same study had full compliance.  This means that most people have "partial compliance" - -getting the drop in irregularly.  Usually they remember when it gets closer to their next appointment (just like flossing your teeth before you see the dentist!).  When the patient has their pressure checked, it may read normally if they have used their drops more regularly over the past few days, but their peripheral vision or optic nerve scans may show increased damage.  What is the doctor left to think??  Well, if your doctor thinks you are getting your drops in regularly and you are still having progression of glaucoma, they are going to prescribe more drops!

We all know that the more drops you prescribe, the less likely a patient is going to be able to afford their glaucoma treatment and remember to get the drops in.  If a patient can have good control of glaucoma with just one drop, it is definitely ideal.  Before adding more drops to a patient's regimen, I always like to investigate to see if they are using the drops regularly by asking these questions:

• How often do you miss your drops?   If they say a few times, does that mean a few times a month?  Or a few times a week?  It makes a big difference to get these details!
• When did you last use your drop?  Did they get it in last night or this morning?  Or was it a few days ago?
• What is the name of your drop?  Not everyone is going to remember this, so it also works to have them bring their drops in to their appointment.  I love looking at the drops because you can see how much is left in there and when their last refill was.  If they have a full bottle and the refill date was a few months ago, you know they aren't using their drops.  Sometimes they are using a drop by mistake that isn't even the one for glaucoma.  They could have had an old antibiotic, or worse a steroid! that they have been using daily by mistake!
• What grade would you give yourself on using your drops?  Asking a person to take accountability for themselves can sometimes lead to more honest answers.  If they tell you they get their drop in regularly, and then give themselves a "B" you need to know why.
• Ask them to show you how they put their drop in.  I don't do this often, but if I am getting concerned that a patient might be having trouble, it is a really good idea.  Sometimes they will miss their eye altogether when they try to put the drop in.  I heard a story at the VA Hospital where I interned about a patient who put the drop on his tongue when the doctor asked him to demonstrate.  No wonder his pressure was so high that day!

Increase Compliance by Changing How You Prescribe

For years, we have been making it hard for patients to remember to put drops in by telling them to use them "at bedtime".  The most popular glaucoma drops called prostaglandin analogues (like Xalatan, Lumigan, and Travatan) have been dosed as "bedtime" drops traditionally.  If you instead tell the patient to use them "at dinner" or when brushing their teeth, it is a lot easier for them to remember.  How often do you fall asleep before you mean to, watching TV or reading in bed?  The drop is going to work a lot better if they can get it in before they pass out for the night!

Helping your patient comply with their drops can save not just their vision from permanent damage, but  their money if it means you don't have to add more drops to their daily regimen.  Many patients HATE using the drops due to price, convenience, and side effects like redness, and they ask me about surgical options.  Even the lowly-invasive laser surgeries like SLT may not work in as high as 30% of glaucoma patients (as reported at a local continuing education seminar), and they often still need to use drops afterwards.  If we can control progression of glaucoma with just one drop a day, it is a great option for both the patient's health and their personal finances.