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Compliance With Medical Therapy In Glaucoma

Written by Ivan Goldberg, Clinical Associate Professor, University of Sydney Glaucoma Unit, The Sydney Eye Hospital and Sydney Hospital, Director, Eye Associates

Definition
Encompassing a spectrum from occasional forgetfulness to never following the recommended schedule, non-compliance is the intentional or accidental failure to follow a doctor’s directions in the self-administration of any medication. Drugs used to control glaucoma can only be effective if they reach the eye tissues regularly and appropriately. The latest medical advances are useless if the patient is not using them correctly.

Importance
Over 10% of visual loss from glaucoma may be caused by non-compliance. Because use of eye drops increases on the days before seeing the doctor, progressive visual loss may occur even if the doctor finds “safe” intra-ocular pressures (IOPs) at the times of consultations if the drops are not used properly between visits.

Techniques for Measuring Compliance
How do doctors know that a patient is not being compliant? Patient interview is often used. However, patients may complain, “how can you honestly expect me to remember what I have forgotten?” And there can be a wide divergence between compliance rates reported by patients and those measured objectively. One spectacular example involved children prescribed oral penicillin for streptococcal pharyngitis. Although 83% of the parents reported continued administration of the drug after 9 days of therapy, 82% of the children had no penicillin detectable in their urine. In another example, of glaucoma patients supposedly instilling pilocarpine drops four times daily, 99% claimed in interview to have instilled their drops at least 75% of the time, whereas a medication monitor hidden within the bottle detected that only 66% of the patients were at least this regular, 15% of patients instilling pilocarpine less than 50% of the time, and 25% of patients missing their medication altogether more than one day per month.

Perhaps this finding is not as startling as it might seem. In one study, even if patients were asked, 69% said they would not admit to problems with their medications; in another, 40% of defaulting patients said that they had never had any intention of following their doctor’s advice.

Dyscompliance
Not only must patients self-administer drops at the correct times and in the correct amounts, but they must also master a technique to do so. Techniques, below, summarises the actions required.

Elderly patients with arthritis and/or tremor can find this procedure impossible. In one survey, 27% of glaucoma patients failed to place the drop into the conjunctival sac, and of these, 25% were unaware that they had missed the eye. Those patients taught instillation techniques did better than those not tutored, particularly if the instructions were repeated periodically.

How Common is Non-Compliance?
Overall, at least one-third of patients will default from occasionally to often.

Factors Associated with Non-Compliance. These can be divided into:

The Patient
Missed appointments, an unstable home or family situation, dissatisfaction with the treatment, and a poor understanding of glaucoma and its treatment all correlate with non-compliance.

Most patients who admitted to defaulting were unable to explain what disease they had, or what were the aims of treatment. Of 62 patients in one glaucoma clinic who knew that glaucoma was associated with raised intra-occular pressure, and that regular drop instillation could prevent blindness, two-thirds were compliant; of those who did not grasp these concepts, only one-third followed their treatment.

Glaucoma has been regarded as one of the most important areas in which the patient’s viewpoint can alter significantly the therapeutic result. Patients often do not understand and do not retain what they have been told by their doctor, particularly if detailed information is provided immediately after a threatening diagnosis has been made. Such a situation may engender a shock-like state during which very little if anything is absorbed and digested mentally or emotionally. The language used may be too technical.

The Disease
Diseases that cause severe symptoms or disability promote compliance. As an asymptomatic, chronic disease requiring life-long, expensive treatment and supervision with no subjective improvement, glaucoma fosters non-compliance.

The Medical Program
The more complex the treatment program, the worse the compliance: more drugs, more frequent use and more side effects.

Longer treatment duration also makes compliance more difficult: patients may be willing to take drugs for a limited period, but when therapy is extended indefinitely, defaulting becomes more common. By its very nature as an incurable and life-long disease, glaucoma promotes non-compliance.

The Doctor-Patient Relationship
Poor communication between doctor and patient causes more defaulting; if the doctor is seen as warm, caring, friendly, accessible, active and thorough, patients are more likely to comply.

Strategies to Enhance Compliance
Explain Glaucoma
Patients who understand glaucoma and its treatment are more compliant with therapy and have more realistic expectations of both the doctor and the program. Misconceptions of the condition and its treatment are the rule among glaucoma patients, not the exception. In the long term, patient adherence with symptomatic, non-curative, costly medications cannot be expected without patient knowledge and understanding. Explanations must be simple, clear and repeated periodically.

Minimise Inconvenience

Try to fit the drops into your life-style. Discuss with your doctor your daily routine (eg times for waking, morning break, lunch, return from work, evening meal, bedtime) and link these with the drops.
If you have memory problems, with your doctor’s help, write out the schedule in large clear letters, labelling the bottles descriptively as well as by name (eg the lilac-top bottle).
If you have poor sight, use large coloured squares to match the bottle tops.
Remember that allergies to medications actually may be to the preservative.

Teach Instillation Techniques

Look up.
Gently pull the lower eyelid away from the globe to form a “cup”.
By looking at it, position the inverted bottle or dropper directly over the eye without touching anything with the tip.
Instil one drop (or more if the first is not felt - refrigerate the bottle if necessary to assist with this) into the conjunctival sac.
Look down; then release the eyelid.
Gently close the eye without blinking or squeezing the eyelids. Avoid rolling the eye around.
Simultaneously, press against the lacrimal sac (tear duct) with the tip of the index finger for at least two minutes.
Repeat for second eye, or combine technique so that both eyes treated simultaneously.

Use Compliance Aids
Openly communicate with your doctor. You should not feel guilty about any difficulties with treatment. Use aids such as instillation frames and other devices.

Conclusions
Even though cure is not yet within our reach, treatment is to preserve your sight and to maintain your quality of life. If you’re having difficulties, admit it firstly to yourself, and then to your doctor. Seek ways to improve your ability to comply to help preserve your sight.

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