PATIENT ADHERENCE

-A GLOBAL FAULT LINE IN GLAUCOMA MANAGEMENT- AUSTIN R. LIFFERTH OD, FAAO

VETERANS AFFAIRS OUTPATIENT CLINIC

THE VILLAGES, FLORIDA

BACKGROUND The benefit of treatment for a patient is largely proportional to the patient’s level of adherence in regards to their treatment1. Patient nonadherence is a very common problem for patients with glaucoma2. Patient nonadherence is caused by a variety of associated patient barriers3 and it results in poor intraocular pressure control, larger visual field defects, and glaucomatous progression4-8 .

Ineffective eye drop instillation technique is one of the most significant patient barriers that negatively affects patient adherence3,9-11 and, unfortunately, it continues to represent an overlooked fault line in glaucoma management. The purpose of this presentation is to better appreciate this underestimated patient barrier as well as to identify the associated potential complications resulting from ineffective eye drop instillation techniques.

METHODS Four consecutive patients with longstanding glaucoma were simply asked to demonstrate putting in their eye drops while in the clinic. With their informed consent, their technique was recorded and reviewed.

RESULTS DISCUSSION Safely and successfully instilling eye drops is difficult to perform - even for the most proficient patients – and is commonly underestimated by their eye care providers.

Ineffective eye drop instillation technique is a significant patient barrier that negatively affects patient adherence and it is also associated with the following observed complications/risks:

CONCLUSION

The full benefit of the recommended

treatment for a patient depends

much on the full adherence from the

patient.

As eye care providers, our proactive

perspective and our approachable

attitude regarding this specific

barrier can positively influence

patient behavior and help improve

patient adherence2,12.

Simple and routine in-office

demonstration of proper eye drop

instillation techniques (especially

within the first year of treatment13)

will increase adherence, increase

independence, reduce medication

waste, minimize adverse effects,

prevent injury, limit contamination,

and maximize the therapeutic effect

of the medication.

In their own words, these patients

reported the following:

• “I have trouble putting my drops

in, so my daughter has to do it for

me…” (top row)

• “Sometimes I’ll miss, and the drop

will land on my cheek…” (second

row)

• “It’s hard for me to keep my eyes

open and find my eyes…” (third

row)

• “I always get more than one drop ,

and it runs down my face…”

(bottom row) REFERENCES

1. Ozcan K, Sinan B, Murat U. Review on the Eyedrop Self-Instillation Techniques and Factors Affecting These Techniques in

Glaucoma Patients. Scientifica, Vol 2016 (2016).

2. Liebmann J, Weinreb R, World Glaucoma A. Medical Treatment Of Glaucoma : The 7Th Consensus Report Of The World Glaucoma

Association. Amsterdam: Kugler Publications; 2010. p 282.

3. Newman-Casey P, Robin A, Lee P, et al. Original article: The Most Common Barriers to Glaucoma Medication Adherence. A Cross-

Sectional Survey. Ophthalmology. July 1, 2015;122:1308-1316.

4. Jean-Philippe N, Christophe B, Jean-Paul R, et a. Measurement of treatment compliance using a medical device for glaucoma

patients associated with intraocular pressure control: a survey. Clinical Ophthalmology, Vol 2010, Iss Default, Pp 731-739 (2010) .

5. Sleath B, Blalock S, Robin A, et al. Original article: The Relationship between Glaucoma Medication Adherence, Eye Drop

Technique, and Visual Field Defect Severity. Ophthalmology. January 1, 2011;118:2398-2402.

6. Schwartz G, Quigley H. Adherence and Persistence with Glaucoma Therapy. Survey Of Ophthalmology. January 1,

2008;53(Supplement):S57-S68.

7. Olthoff C, Schouten J, van de Borne B, Webers C. Original article: Noncompliance with Ocular Hypotensive Treatment in Patients

with Glaucoma or Ocular Hypertension. An Evidence-Based Review. Ophthalmology. January 1, 2005;112:953-961.e7.

8. Stewart WC, Chorak RP, Hunt HH, Sethuraman G. Factors associated with visual loss in patients with advanced glaucomatous

changes in the optic nerve head. Am J Opthhalmol. 1993; 116: 176-181.

9. A.J. Winfield, D. Jessiman, A. Williams, L. Esakowitz. A study of the causes of non-compliance by patients prescribed eyedrops. Br

J Ophthalmol, 74 (1990), pp. 477–480.

10.Kholdebarin R, Campbell RJ, Jin Y-P, Buys YM. Multicenter study of compliance and drop administration in glaucoma. Can J

Ophthalmol. 2008;43(4):454-461.

11.Stone J.L., Robin A.L., Novack G.D., et al: An objective evaluation of eyedrop instillation in patients with glaucoma. Arch

Ophthalmol 2009; 127: pp. 732-736.

12.Friedman D, Hahn S, Quigley H, et al. Original article: Doctor–Patient Communication, Health-Related Beliefs, and Adherence in

Glaucoma. Results from the Glaucoma Adherence and Persistency Study. Ophthalmology. January 1, 2008;115:1320-1327.e3.

13.Newman-Casey P, Blachley T, Lee P, Heisler M, Farris K, Stein J. Original article: Patterns of Glaucoma Medication Adherence

over Four Years of Follow-Up. Ophthalmology. October 1, 2015;122:2010-2021.

Risks related to poor eye

drop instillation technique

Increased risk of ocular

injury

Decreased independence

Increased risk of waste

Increased risk of

periorbital dermatitis

Increased risk of dropper

contamination and ocular infection

Decreased bioavailability

due to excessive

drops

Patient Nonadherence

Increased or unstable IOP

Progressive glaucomatous ONH damage

Progressive visual field

defects

All patients with longstanding

glaucoma (and presumed proficiency

in putting in their eye drops) showed

difficulty instilling their eye drops

while in the clinic.