Patient compliance with glaucoma medication remains a major problem. A study published in Ophthalmology in 2009, found that nearly 45% of patients using an electronic monitoring device (for the study’s purposes), and who knew they were being monitored, used their drops less than 75% of the time. In addition, patients reported far higher medication use than their actual behavior. This raises concerns as to whether patients are truly compliant, how to identify compliance concerns, and how to boost adherence to prescribed regimes.

“In our practice, we’re fortunate because the staff plays just as much if not more of a role than the physician does when it comes to compliance,” says Michael J. Siegel, MD, partner at Glaucoma Center of Michigan and co-chief of the glaucoma service, as well as assistant professor of ophthalmology at Oakland University/William Beaumont School of Medicine. “In fact, since the staff spends time with patients before I even see them, they are usually the first ones to catch compliance concerns — and we rely on them for that important task.”

Here, physicians and allied health professionals discuss steps they take to address the challenge of patient noncompliance with glaucoma therapy.

Identify “red flags.”

Justin Schweitzer, OD, FAAO, Vance Thompson Vision in Sioux Falls, SD, says the staff can identify compliance “red flags” using “open-ended questions,” such as, “What medications are you taking?” followed by, “What is the color of the bottle cap on the glaucoma medications you are taking?”

“If it’s a chronic medication that they’re supposed to be taking every day and they don’t know the color of the bottle cap, they probably aren’t taking it,” Dr. Schweitzer says. “The staff might also ask, ‘What time do you take the medication?’”

Dr. Schweitzer admits that identifying non-compliant patients can take a little bit of sleuthing via intentional questions that could identify the need for concern. He says staff also look at e-prescribing notes to see how many times the medication was filled.

Uncover the “why,” and remain calm.

Carey Church, COA, of Glaucoma Center of Michigan, says it’s important to get to the bottom of why patients are non-compliant to help correct issues. For example, sometimes it’s a struggle with memory or a cost issue, whereas other times patients dislike the drops and skip them intentionally. (See, “Barriers to compliance,” page 21.) Regardless of the reason, avoid becoming upset with the patient.

“Honestly, it doesn’t help to get upset,” Dr. Siegel says. “I’ve worked at places where patients are berated for noncompliance, and it doesn’t solve the issue — if anything, it’s a setback. I’d rather patients were honest and upfront. So, we work hard to create an environment where they feel safe and where they can admit they haven’t been taking their prescribed medication so that we can get them back on track.”

Understand options to help compliance.

Those interviewed for this article explained some of the methods their practices use to help patients maintain compliance with glaucoma therapies, including:

• Accommodate the patient’s routine. “The key is to make it easy for the patient,” Dr. Schweitzer says. “Most of the time, we’re prescribing first-line agents, which are always taken at night, before bed. If a patient has a routine nighttime ritual, then perhaps the drops should be kept near where that ritual occurs. If they read a book every night, perhaps they should be kept on the nightstand. When you can fit it into their routine, patients are more likely to comply.”
• Simplify dosing regimens. While an additional drop may help lower IOP, complex dosing regimens have been shown to contribute to noncompliance. Options to simplify dosing include prescribing a drop that requires less frequent dosing or prescribing a combination drop.Ms. Church says that helping to get combination therapies approved by insurance companies is one of the biggest frustrations their practice currently faces. It’s simply not always feasible.
  “I’d love to have every patient on a combination therapy, but it’s not always possible,” adds Dr. Siegel. Regarding multiple drops, he says: “It’s a huge problem from a compliance standpoint and an issue we’d love to see change. Samples will only take you so far.”
• Address side effects, particularly ocular surface disease. Long-term installation of glaucoma drops can compromise the ocular surface, especially among the elderly, for which dry eye disease is more prevalent.“You must address dryness in the glaucoma population — it isn’t always an option to just stop their medications,” Dr. Schweitzer says. “There are prescribed therapies out there [for dry eye], but oftentimes you don’t want to add more drops to their regimen due to making compliance even more difficult. Options to consider are neurostimulation, thermal pulsation, devices that aid in meibomian gland clearance, and nutraceuticals.”
• Help reduce medication costs. Where the patient has issues with the cost of the medication, “we work very hard with getting patients coupons that will help reduce the expense as well as calling different pharmacies or working directly with drug companies,” Ms. Church says. “We are always signing up with pilot programs if we think it could help reduce the cost burden for our patients and improve compliance.”
• Considering surgical options. Surgery to lower IOP may reduce or even eliminate the patient’s burden of taking drops. Recently, the LiGHT study demonstrated the benefits of selective laser trabeculoplasty, or SLT, as a first-line treatment for patients who have glaucoma.
• Share what works. Kasey Mashburn, COA, lead ophthalmic technician with Sacramento Eye Consultants in California, says that listening to patients’ experiences and sharing their “best tips for compliance,” such as using a reminder, is also effective.“Patients have relayed tips like using phone alarms, taping the top of the box to their coffee machine, or associating it with a task they do every day,” Ms. Mashburn says.

Education is key.

A 2017 study in the Expert Review of Ophthalmology reported the interventions that improve adherence to glaucoma therapy include “face-to-face” counseling along with education about glaucoma. The education should come from both the doctor and the staff, with the staff reiterating the compliance message, says Dr. Schweitzer.

That messaging should emphasize that glaucoma is progressive and irreversible. It should stress the importance of attending each office visit, regardless of whether the patient experiences any symptoms. Education must also deliver the message of how important it is to take medications as prescribed.

Ms. Church adds that compliance education should be part of every visit. She has seen some patients mistakenly assume after finishing a single bottle that they are “cured” or others who make mistakes with dosing.

“You can never assume that the patient fully understands what they’re supposed to be doing even if they’ve already been taking the medication,” she says. “Patients should be reminded about medication details, such as properly spacing drops or what to do if they miss a dose. Never assume a patient knows all those little details. And even if they do, it never hurts to provide reminders.” OP