Glaucoma and Compliance with Therapy: Strategies for and Barriers to Success

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Article initiated by:
Cody Blanchard, MD, Daniel B. Moore, MD
All contributors:
Alaa Malik, Ashlyn Burton, Ahmad A. Aref, MD, MBA, Daniel B. Moore, MD, Arsham Sheybani, MD, Lama Assi, MD MPH
Assigned editor:
Arsham Sheybani, MD
Review:
Assigned status Up to Date
 by Arsham Sheybani, MD on September 23, 2024.


Glaucoma is the leading cause of blindness worldwide, affecting more than 70 million people.[1] Early and consistent therapy is crucial for the preservation of remaining vision in patients with the disease. However, there are many factors that can lower compliance rates and cause non-adherence to treatment plans, which has reported rates of 30-80%.[2] [3]

Barriers to Eye Drop Administration

There are many barriers to adherence to regular eye drop therapy. These can occur at any stage of the process, from obtaining the eye drops to properly administering them on a daily basis. [4]

Obtaining Eye Drops

Cost is a significant barrier for many patients when accessing care, including obtaining glaucoma medications. This has been shown across different settings and patient populations.[5] [6] [7] [8][9] [10] In the United States, denial of early refills by pharmacies or insurance companies can be another barrier to obtaining eye drops. This often occurs when patients instill more than one drop at a time, thus running out of drops earlier than expected. As of August 2024, 21 states still do not have refill laws that require insurance companies to cover early refills for patients.[11]

Instilling Eye Drops Properly

Even when patients obtain their eye drops, many experience difficulties instilling them properly. Some patients may have physical limitations from rheumatological or neurologic disease which can limit their grip strength, neck extension, or ability to accurately aim the eye drops.[12] [13] [14] A contributing factor to poor drop administration is the significant variability between bottles in terms of the amount of force needed to produce a single drop.[12] This can lead to multiple drops being used (or wasted), and thus early exhaustion of drop supply.[13] Visual impairment from glaucoma or other ocular conditions can also lead to difficulties reading the print on the bottles.[10][15]

Administering Eye Drops Daily

Forgetfulness[10][16] and having other chronic conditions[17][18] [19] [20] [21] can also make it more challenging for patients to adhere to long-term eye drop therapy. Others do not see the necessity to use daily drops for a largely-asymptomatic disease. Many studies have found that patients diagnosed with glaucoma may not truly understand the potential for the disease to progress to severe vision loss without treatment.[5] [22] [23] [24] [6] [17][8] This can lead to a lack of trust and faith in the treating physician, which can increase the likelihood that patients will be non-adherent to their medications.[17][25] [26] [7] [27] Poor adherence cab also be attributed to poor health literacy in general, which is seen among patients dealing with a wide array of conditions, but especially glaucoma patients.[28] [29] [30] [31] Undesirable drop side effects may also lead to intentional non-adherence.[16]

Strategies and Interventions to Improve Adherence

The first step to address poor adherence is to identify the potential barriers for each patient.

Obtaining Eye Drops

For patients who are unable to afford eye drops, ophthalmologists can recommend generic medications instead of the more costly brand-name eye drops.[32] When counseling patients about using generics, ophthalmologists in the United States can inform them that the FDA requires that generics have the same active ingredients as brand-name eye drops. Although their side effect profiles may differ, their efficacy is often similar.

In states where there are no early eye drop prescription refill legislation, the American Academy of Ophthalmology encourages ophthalmologists to engage with their societies and lawmakers to ensure patients in their states are able to refill their eye drops early.[33]

Instilling Eye Drops Properly

Many aids have been designed to address issues with consistently administering a single drop. Some of the ones currently available on the market are described in the table below. Additionally, educational interventions which include observing patients instill drops and teaching them the proper techniques have been shown to improve the proportion of patients administering eye drops properly.[34][35] Taking the time to observe patients use eye drops in clinic may help them learn how to use eye drops properly.

Table 1: Eye Drop Administration Aids

1: On product official websites, updated August 25, 2024.
Device Mechanism Characteristics Compatible bottles Cost1
AutoDrop Eye Drop Guide Holds the lower lid in place and draws the patient’s gaze away from the dropper for accurate drop delivery Reusable Most bottles (contact Owen Mumford for a full up-to-date list) $8.99
AutoSqueeze Bottle Aid Clips onto eye drop bottle to provide extra leverage when squeezing, making it easier for those with dexterity and hand strength issues Reusable

Can be used in conjunction with the AutoDrop Eye Drop Guide

Most bottles (contact Owen Mumford for a full up-to-date list) $8.99
GentleDrop Rests on the nose to align bottle with eye and successfully deliver drop, reducing the risk of waste Reusable and washable Traditionally-shaped 5-15 mL bottles (check compatibility here) $18.99
Nanodropper Adaptor Adaptor twists onto bottle to reduce volume of drop by over 60% , reducing waste, side effects, and costs For single bottle use only Most multi-dose eye drop bottles (check compatibility here) $19.99
Opticare Eye Drop Dispenser Helps target the eye by resting around it and makes squeezing the bottle easier with its texture and shape (may help with arthritic and shaking hands) Reusable Most traditionally-shaped 2.5-10 mL bottles (check compatibility here) £8.50

Other ongoing projects include establishing a smart electronic eye drop bottle that measures the number of single- and multiple-drop deliveries, thus providing a potential solution for remote glaucoma eye drop monitoring. This device is currently under development at University of California – San Diego.[36]

Administering Eye Drops Daily

Improving patient engagement can help with treatment adherence. Incorporating discussions of beliefs about glaucoma and treatment methods can help address misinterpretations of the disease and build trust in the patient-physician relationship, especially when patient-centered communication is used, leaving the patient feeling like an active participant in their own healthcare.[10][37] [38] [39]

Another method to improve adherence involves improving health literacy as a whole among patients with glaucoma, especially among those newly diagnosed or those struggling with non-adherence. This has been achieved using videos discussing glaucoma, including the anatomy of the eye and examples of what vision loss in glaucoma looks like, and also the potential treatment options available and instructions for their use.[29][40] [41] [42]

Strategies for unintentional non-adherence include personalized mail and phone call reminders of appointments and medication administration times.[40][43] One important development in this area includes the development of the EyePhone© App, which provides notifications and reminders of patients' medical treatment, and it has been found to significantly increase glaucoma treatment adherence and improve quality of life.[44]

Alternatives to Daily Eye Drop Use

Despite the availability of a number of strategies to improve eye drop adherence, some patients may continue to struggle with consistent use of eye drops as instructed. It is important to recognize these patients early on to ensure that they can still receive the glaucoma care they need. These patients may be good candidates for sustained-release glaucoma implants, including the FDA-approved bimatoprost and travoprost intracameral implants. Moreover, it is important to recognize the shift in treatment protocol for glaucoma away from the medication-first model to the early and repeated use of selective laser trabeculoplasty (SLT). SLT involves the use of a Nd:YAG laser to improve drainage through the trabecular meshwork, thus lowering intraocular pressure (IOP). In a recent systematic review, SLT was proven to be effective at lowering IOP with high success rates, even after a single treatment, and has the added benefit of being independent of a patient’s capacity to remain compliant with a treatment plan.[45] The Clarifying the Optimal Application of SLT Therapy (COAST) Trial is being initiated to determine the utility of low-energy SLT conducted annually as primary treatment for mild to moderate open angle glaucoma.[46]

Conclusion

In summary, treatment non-adherence is frequently seen among glaucoma patients, and is associated with difficulty affording and administering eye drops, as well as lack of understanding of the threat to vision from glaucoma and mistrust of the treatment plan. There are many interventions to address these barriers, including devices and educational interventions. At the same time, it is important to recognize that there are alternatives to eye drops, even as first-line therapy with SLT treatment. Future therapeutics will likely also consider the difficulties and barriers to frequent eye drop administration.

References

  1. ↑ Parihar JK. Glaucoma: The 'Black hole' of irreversible blindness. Med J Armed Forces India. 2016;72(1):3-4.
  2. ↑ Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol. 2008;53 Suppl1:S57-68.
  3. ↑ 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):953-961.
  4. ↑ Davies I, Williams AM, Muir KW. Aids for eye drop administration. Surv Ophthalmol. 2017;62(3):332-345. doi:10.1016/j.survophthal.2016.12.009
  5. ↑ 5.0 5.1 friedman ds, hahn sr, gelb l, et al. doctor-patient communication, health-related beliefs, and adherence in glaucoma results from the glaucoma adherence and persistency study. ophthalmology. 2008;115(8):1320-1327, 1327.e1321-1323.
  6. ↑ 6.0 6.1 subathra gn, rajendrababu sr, senthilkumar va, mani i, udayakumar b. impact of covid-19 on follow-up and medication adherence in patients with glaucoma in a tertiary eye care centre in south india. indian j ophthalmol. 2021;69(5):1264-1270.
  7. ↑ 7.0 7.1 Killeen OJ, Pillai MR, Udayakumar B, et al. Understanding Barriers to Glaucoma Treatment Adherence among Participants in South India. Ophthalmic Epidemiol. 2020;27(3):200-208.
  8. ↑ 8.0 8.1 Meier-Gibbons F, Töteberg-Harms M. Influence of Cost of Care and Adherence in Glaucoma Management: An Update. J Ophthalmol. 2020;2020:5901537.
  9. ↑ Blumberg DM, Prager AJ, Liebmann JM, Cioffi GA, De Moraes CG. Cost-Related Medication Nonadherence and Cost-Saving Behaviors Among Patients With Glaucoma Before and After the Implementation of Medicare Part D. JAMA Ophthalmol. 2015;133(9):985-996.
  10. ↑ 10.0 10.1 10.2 10.3 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.
  11. ↑ American Academy of Ophthalmology. Advocacy: Eyedrop Prescription Refill Map. American Academy of Ophthalmology. Published August 2023. Accessed August 25, 2024. https://www.aao.org/advocacy/eyedrop-refills/eyedrop-prescription-refill-map
  12. ↑ 12.0 12.1 Moore DB, Hammer JD, Akhtari R, Beck J, Sanders S, Kryscio RJ. Squeeze Me if You Can: Variability in Force Requirements to Extract a Drop From Common Glaucoma Bottles. J Glaucoma. 2016;25(9):780-784.
  13. ↑ 13.0 13.1 Moore DB, Walton C, Moeller KL, Slabaugh MA, Mudumbai RC, Chen PP. Prevalence of self-reported early glaucoma eye drop bottle exhaustion and associated risk factors: a patient survey. BMC Ophthalmol. 2014;14:79.
  14. ↑ Hennessy AL, Katz J, Covert D, et al. A video study of drop instillation in both glaucoma and retina patients with visual impairment. Am J Ophthalmol. 2011;152(6):982-988.
  15. ↑ Sleath B, Ballinger R, Covert D, Robin AL, Byrd JE, Tudor G. Self-reported prevalence and factors associated with nonadherence with glaucoma medications in veteran outpatients. Am J Geriatr Pharmacother. 2009;7(2):67-73.
  16. ↑ 16.0 16.1 Gatwood J, Brooks C, Meacham R, et al. Facilitators and Barriers to Glaucoma Medication Adherence. J Glaucoma. 2022;31(1):31-36. doi:10.1097/IJG.0000000000001965
  17. ↑ 17.0 17.1 17.2 kanu ln, jang i, oh dj, et al. glaucoma care of prison inmates at an academic hospital. jama ophthalmol. 2020;138(4):358-364.
  18. ↑ Stringham J, Ashkenazy N, Galor A, Wellik SR. Barriers to Glaucoma Medication Compliance Among Veterans: Dry Eye Symptoms and Anxiety Disorders. Eye Contact Lens. 2018;44(1):50-54.
  19. ↑ Jones JP, Fong DS, Fang EN, Mesirov CA, Patel V. Characterization of Glaucoma Medication Adherence in Kaiser Permanente Southern California. J Glaucoma. 2016;25(1):22-26.
  20. ↑ Asefzadeh B, Rett D, Pogoda TK, Selvin G, Cavallerano A. Glaucoma medication adherence in veterans and influence of coexisting chronic disease. J Glaucoma. 2014;23(4):240-245.
  21. ↑ Lee BW, Murakami Y, Duncan MT, et al. Patient-related and system-related barriers to glaucoma follow-up in a county hospital population. Invest Ophthalmol Vis Sci. 2013;54(10):6542-6548.
  22. ↑ lacey j, cate h, broadway dc. barriers to adherence with glaucoma medications: a qualitative research study. eye (lond). 2009;23(4):924-932.
  23. ↑ tsai jc, mcclure ca, ramos se, schlundt dg, pichert jw. compliance barriers in glaucoma: a systematic classification. j glaucoma. 2003;12(5):393-398.
  24. ↑ sleath b, blalock sj, robin a, et al. development of an instrument to measure glaucoma medication self-efficacy and outcome expectations. eye (lond). 2010;24(4):624-631.
  25. ↑ Stryker JE, Beck AD, Primo SA, et al. An exploratory study of factors influencing glaucoma treatment adherence. J Glaucoma. 2010;19(1):66-72.
  26. ↑ Lunnela J, Kääriäinen M, Kyngäs H. The views of compliant glaucoma patients on counselling and social support. Scand J Caring Sci. 2010;24(3):490-498.
  27. ↑ Muir KW, Alder B, Thomas A, Crowell SS, Stinnett SS, Lee PP. Trust in the provider and glaucoma-related blindness. ISRN Ophthalmol. 2012;2012:393917.
  28. ↑ Muir KW, Santiago-Turla C, Stinnett SS, et al. Health literacy and adherence to glaucoma therapy. Am J Ophthalmol. 2006;142(2):223-226.
  29. ↑ 29.0 29.1 Muir KW, Ventura A, Stinnett SS, Enfiedjian A, Allingham RR, Lee PP. The influence of health literacy level on an educational intervention to improve glaucoma medication adherence. Patient Educ Couns. 2012;87(2):160-164.
  30. ↑ Juzych MS, Randhawa S, Shukairy A, Kaushal P, Gupta A, Shalauta N. Functional health literacy in patients with glaucoma in urban settings. Arch Ophthalmol. 2008;126(5):718-724.
  31. ↑ Tsai JC. A comprehensive perspective on patient adherence to topical glaucoma therapy. Ophthalmology. 2009;116(11 Suppl):S30-36.
  32. ↑ Swamy N R. Medication Affordability: What Can We Do? Review of Ophthalmology. Published March 5, 2023. Accessed August 25, 2024. https://www.reviewofophthalmology.com/article/medication-affordability-what-can-we-do
  33. ↑ American Academy of Ophthalmology. Advocacy: Eyedrop Refills. American Academy of Ophthalmology. Published August 2023. Accessed August 25, 2024. https://www.aao.org/advocacy/eyedrop-refills
  34. ↑ Lampert A, Bruckner T, Haefeli WE, Seidling HM. Improving eye-drop administration skills of patients - A multicenter parallel-group cluster-randomized controlled trial. PLoS One. 2019;14(2):e0212007. Published 2019 Feb 21. doi:10.1371/journal.pone.0212007
  35. ↑ Lazcano-Gomez G, Castillejos A, Kahook M, Jimenez-Roman J, Gonzalez-Salinas R. Videographic Assessment of Glaucoma Drop Instillation. J Curr Glaucoma Pract. 2015 May-Aug;9(2):47-50. doi: 10.5005/jp-journals-10008-1183. Epub 2015 Sep 25. PMID: 26997834; PMCID: PMC4750026.
  36. ↑ Aguilar-Rivera M, Erudaitius DT, Wu VM, et al. Smart Electronic Eyedrop Bottle for Unobtrusive Monitoring of Glaucoma Medication Adherence. Sensors (Basel). 2020;20(9).
  37. ↑ Hahn SR. Patient-centered communication to assess and enhance patient adherence to glaucoma medication. Ophthalmology. 2009;116(11 Suppl):S37-42.
  38. ↑ Mansukani SS. Improving adherence to drug-treatment regimens for glaucoma. Manag Care. 2002;11(11 Suppl):49-53.
  39. ↑ McDonald JE, Dickinson JK. A Novel Approach to Helping People with Glaucoma Use Their Drops Routinely. Optom Vis Sci. 2019;96(5):331-334.
  40. ↑ 40.0 40.1 Okeke CO, Quigley HA, Jampel HD, et al. Interventions improve poor adherence with once daily glaucoma medications in electronically monitored patients. Ophthalmology. 2009;116(12):2286-2293.
  41. ↑ Davis SA, Carpenter DM, Blalock SJ, et al. Glaucoma Patient Preferences for Video Education on Eye Drop Technique. Optom Vis Sci. 2019;96(5):325-330.
  42. ↑ Schneider KJ, Hollenhorst CN, Valicevic AN, et al. Impact of the Support, Educate, Empower Personalized Glaucoma Coaching Program Pilot Study on Eye Drop Instillation Technique and Self-Efficacy. Ophthalmol Glaucoma. 2021;4(1):42-50.
  43. ↑ Pizzi LT, Tran J, Shafa A, et al. Effectiveness and Cost of a Personalized Reminder Intervention to Improve Adherence to Glaucoma Care. Appl Health Econ Health Policy. 2016;14(2):229-240.
  44. ↑ Leshno A, Gaton D, Singer R, et al. A novel EyePhone(c) App for improving adherence to glaucoma therapy. Graefes Arch Clin Exp Ophthalmol. 2021;259(5):1253-1262.
  45. ↑ Toteberg-Harms M, Meier-Gibbons F. Is laser trabeculoplasty the new star in glaucoma treatment? Curr Opin Ophthalmol. 2021;32(2):141-147.
  46. ↑ Realini T, Gazzard G, Latina M, Kass M. Low-energy Selective Laser Trabeculoplasty Repeated Annually: Rationale for the COAST Trial. J Glaucoma. 2021;30(7):545-551.
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