Glaucoma compliance a complex issue with many contributing factors

From drop amount permitted by insurance companies to glaucoma patients’ difficulty, glaucoma medical therapy adherence is a challenge to maintain.

Alan L. Robin

To realistically address glaucoma compliance issues, physicians must work together with patients in acquiring, administering and remaining adherent to eye drops, a glaucoma expert said.

“Adherence to medication is very complex,” Alan L. Robin, MD, told Ocular Surgery News. “You really have to communicate with patients better. We have to listen to them. We have to ask them the right questions. We have to educate them. And as we listen, we also have to watch.”

At Hawaiian Eye 2010, Dr. Robin said research has shown that in industrialized countries, 50% of people screened for glaucoma do not realize that they have the disease. In a follow-up interview with OSN, he spoke about the many issues that physicians and patients face in both encouraging and practicing medical adherence. Those issues include older patients who are on multiple medications, which can reduce compliance; patients who cannot find transportation or assistance to refill their eye drop prescriptions; and patients who have visual loss from glaucoma and difficulty seeing the bottle to administer drops.

The disease’s asymptomatic nature also causes problem with adherence, because patients do not realize that they are experiencing visual loss.

“I think it’s different for, let’s say, a diabetic who needs a chronic medicine, because people are more aware of their highs and lows in diabetes, getting headaches, feeling weak. In glaucoma, you really don’t feel anything until it’s too late,” Dr. Robin said.

Administering drops

A major issue in medical compliance is patients’ application of drops. A standardized technique for patients to use eye drops does not exist, despite the fact that medical therapy is first-line treatment in glaucoma, Dr. Robin said.

In Dr. Robin’s practice, he and his technicians watch how each patient administers his or her drops. Patients are instructed to apply their drops in the same manner that they do at home. At the Hawaiian Eye 2010 meeting, he showed videos of patients attempting to use their eye drops. Some patients could not get drops into their eyes, while others flooded their eyes with too much medication.

Dr. Robin is now creating educational videos on the most effective ways of administering drops. But doing so is only one step forward in a long journey to obtain full medical compliance, he said.

“Eye drop medications have been around a long time, and their success relies upon an individual actually remembering to take the drops and then getting the drop in the eye. This rarely happens. People want quick fixes and it’s a new generation — ‘let’s fix it, give me something’ — and I think we have to address that.”

Drop quantities

Another compliance issue is the supply of eye drops that insurance companies allow patients to obtain. Many insurance companies have a policy that an empiric number of drop bottles must last 90 days. However, daily eye drop usage is not an exact measurement, such as daily prescribed pills can be, Dr. Robin said.

“We know how many drops may be in a bottle or what the volume of an eye drop bottle is, but the angle at which you administer a drop, and the force that you squeeze the bottle and the temperature of the air when you squeeze the bottle all change how many drops there are per bottle. And if you make it even more complex and deal with the issue of somebody getting multiple drops at a time, a 90-day supply isn’t going to last 90 days,” Dr. Robin said.

Some patients run short of medicine early in their medical therapy and cannot afford an additional bottle of eye drops. Some patients have taken to a “pill-splitting” technique of using one drop every other day of a once-daily medication to lengthen medication use, he said.

Dr. Robin recommended that physicians ask their patients to contact Medicare at 1-800-633-4227, enter their Medicare information, say “drug problem” to the automated system and request an agent. Patients should explain their eye drop shortage situation to the Medicare agent, and explain that although their physician has tried to solve the problem, they are still being denied the medication.

Patient’s story

Dr. Robin presented a filmed example of a glaucoma patient at Hawaiian Eye 2010. The patient, a man in his 50s, was blind in one eye from glaucomatous damage.

The patient said that his original physician did not fully express glaucoma’s threat to his vision. He had taken his eye drops regularly for 5 years, but then stopped. He is now mostly compliant, occasionally lapsing in his eye drop use.

“There are a couple of … messages from him,” Dr. Robin said. “How you talk to a patient makes a difference. How you describe what’s going on. What are the ethical questions when you’re dealing with somebody with glaucoma — should you mention the fact that you could go blind? Is that something that you should mention to somebody? I think you should.”

“Here he is with one eye [with sight], knows that he has lost his first eye from glaucoma and he is very intelligent,” Dr. Robin said. “I think if you couple that with the videos that I had of people putting drops in their eyes, you have an issue that you have to take eye drops out of patients’ hands. You have to create delivery systems or operators to do something to help prevent people from going blind.”– by Erin L. Boyle

• Alan L. Robin, MD, can be reached at 6115 Falls Rd., Suite 333, Baltimore, MD 21209; 410-377-2422; fax: 410-377-7960; e-mail: arobin@glaucomaexpert.com.