Improving compliance with glaucoma treatment requires patient-focused approach

Regardless of lifestyle and patient-dependent factors, glaucoma specialists must monitor patients for disease progression.

Issue: November 15, 2006

ByErin L. Boyle

NEW YORK — Patients’ adherence to glaucoma drug regimens can be improved using strategies that address the patients’ behavioral and cognitive needs, according to a physician speaking here.

Robert D. Fechtner, MD, discussed issues relating to glaucoma therapy compliance in a presentation at the New Frontiers in Glaucoma meeting held by Columbia University’s College of Physicians and Surgeons.

He said adherence to treatment regimens increases when patients can directly correlate some regular activity to their therapy. For instance, linking instillation of their medications with a common behavioral task such as brushing their teeth can help improve adherence.

Patients also need to feel that using their glaucoma medications has some effect, Dr. Fechtner said. Educating patients about the importance and benefits of regular use of their drugs or medications can help in this regard.

In addition, patients should understand that they can admit that they have not been compliant with prescribed treatment and have not recently taken their drops, he noted.

“There’s an imbalance of power in the physician-patient relationship. Our patients want to please us,” Dr. Fechtner said. “We need to give them permission for what we all expect; people have difficulties taking their eye drops.”

Forgetfulness is the most common reason patients cite for not using their glaucoma medications, which Dr. Fechtner called an “easy excuse.” He recommended devices such as alarm clocks and dosing tools to both remind patients of their medications and record their drop-taking habits.

The following are additional highlights from the New Frontiers in Glaucoma meeting.

These items appeared first on the OSN SuperSite as daily news reports filed on location at the meeting. Look to upcoming issues of OSN for expanded coverage of selected items.

Learning about patients’ lives aids treatment

Developing a more personal relationship with glaucoma patients can help physicians better treat their disease, according to Henry D. Jampel, MD, MHS.

Because glaucoma in its early stages is largely asymptomatic, many patients go through stages of anxiety, depression, denial or hypochondria after they are diagnosed with the disease, Dr. Jampel said.

“Much of my day is spent with patients whom I’m reassuring that they are doing well,” he said. “My visit is their insurance policy that they are not going blind, and I believe many of them take comfort from that interaction.”

Dr. Jampel noted that he often sees the same patients for years because of glaucoma’s chronic nature. He recommended learning about patients’ lives because developing a good personal relationship with patients is key to their treatment.

“Behind all our patients are interesting individuals,” Dr. Jampel said. “If we learn one or two things about them that you can ask them when you see them, that’s a great start. If you can’t remember those things, write them down on their charts.”

Lifestyle factors can affect IOP

Glaucoma patients should be educated about lifestyle factors that affect IOP, noted Louis R. Pasquale, MD.

Studies have shown that practicing head-down yoga positions, wearing tight neckties, playing wind instruments and consuming caffeine can increase IOP, while behaviors such as exercise, moderate alcohol consumption and marijuana use appear to decrease IOP, he said.

While these factors can affect IOP, they do not seem to cause or reduce the risk of primary open-angle glaucoma, he added.

As an example, Dr. Pasquale described the case of a 56-year-old man with an IOP of 24 mm Hg that suddenly dropped to 20 mm Hg. The patient told Dr. Pasquale that he had started drinking decaffeinated coffee and was wearing his necktie looser. The patient wondered if these changes had been factors in his IOP reduction and whether he should continue with them. Both of these are difficult questions to answer, Dr. Pasquale said.

“We get uncomfortable because we really don’t know the answers to these questions. But you may want to talk to patients about these things so they are aware,” he said.

But in addition to lifestyle factors and medication compliance, glaucoma patients need to be aware of less recognized complications of their disease. These patients are at a higher risk of falls and fractures, according to Anne L. Coleman, MD, PhD.

Dr. Coleman cited a study in which she participated that included 4,216 women with osteoporosis. The study found that, with binocular visual field loss, the chances of falls and fractures increased. Of the women in the study, 2,069 had two or more falls in 3.9 years of follow-up, Dr. Coleman said.

“The reason why hip fractures are so serious is because it is one of the most expensive diseases ... in the elderly population for the U.S. government,” she said.

Investigators have suggested that the increased risk of falls might be associated with medications for glaucoma treatment, such as beta-blockers, but no concrete link of this type has been established, Dr. Coleman said. She said patients should be counseled regarding their increased risk of falling and fractures.

Image regularly to chart glaucoma progression

Regardless of lifestyle and patient-dependent factors, glaucoma specialists need to monitor patients for disease progression. To that end, stereoscopic optic disc photos should be obtained regularly, according to Mark Sherwood, MD.

“We need to take regular disc photos because glaucoma is a long-term disease. You’re looking for subtle, not gross, changes,” he said, noting it is important to take a baseline stereo photo and then repeat photos annually. The photos can then be carefully compared, noting any changes, however small.

Close attention should be given to the neuroretinal rim thickness in each quadrant, the curvature and bayoneting of disc vessels, the position of the vessels in relation to the neuroretinal rim and disc margin, the depth of the optic cup, and the appearance of any disc hemorrhages or peripapillary atrophy, he noted.

U.S. medical education emphasizes well-rounded background

In addition to the basics of surgery, ophthalmology residents in the U.S. are taught patient care, professionalism and aspects of glaucoma and its treatment.

Richard K. Parrish II, MD, also discussed aspects of current medical education. He said the Accreditation Council for Graduate Medical Education (ACGME) advocates “competency based education,” focusing on teaching patient care, interpersonal skills and communication, medical knowledge, professionalism, practice-based learning and improvement, and systems-based practice.

In addition, the “non-official” competencies in glaucoma — not explicitly included in the ACGME’s Mission in Ophthalmic Education — include learning about primary open-angle glaucoma, primary acute angle-closure glaucoma, chronic angle-closure glaucoma and glaucoma associated with retinal vascular disease. Students also learn patient care diagnosis skills, including the use of the gonioscopy, examination of the optic nerve and interpretation of automated visual fields, Dr. Parrish said.