patient adherence – a fault line in glaucoma management · patient adherence-a global fault line...
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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.