Poor office visit follow-up compliance could affect glaucoma surgical success

Clinicians should educate patients about possible implications of missing follow-up appointments.

Steven J. Gedde

Physicians should emphasize the necessity of good compliance with follow-up office visits for glaucoma patients, especially those who have undergone surgery, for tracking progression, potential complications and surgical success.

Steven J. Gedde, MD, said that there are two key reasons why follow-up visits are important after glaucoma surgery. Notably, if glaucoma patients are not seen, surgical complications might be missed. Secondly, patient follow-up affects surgical success.

“I tell patients that the ultimate success of surgery is not only dependent on what occurs in the operating room, but also on the follow-up care. That’s especially true for trabeculectomy,” Dr. Gedde told Ocular Surgery News. “If patients are not showing up for visits, this can adversely affect the outcome after surgery.”

Noncompliance issues

Many patients do follow up after surgery; surgery inspires some patients to be more conscientious about their compliance, Reay H. Brown, MD, said. When patients undergo glaucoma surgery, they sometimes finally understand the severity of their disease.

A 1998 study by Kosoko and colleagues looked at office visit compliance and found that patients did not attend follow-up visits because they felt their disease was not serious enough. When surgery is considered an option in glaucoma treatment, patients often realize how truly serious the disease is, Dr. Brown said.

Following surgery, physical changes in patients’ eyes can also change their view of the disease.

“The eye usually feels differently, it may look a little different, and so the patient has some reminders that something is going on [after surgery],” Dr. Brown said. “Although there certainly are patients who will disregard every voice telling them to come back, an intervention like laser treatment is a strong reminder of the importance of compliance. Patients are being told, ‘You’re in trouble.’ Anyone who wants to help his/her vision is going to respond to that.”

Overall office visit compliance can be low in some instances, studies have shown. A 2007 study by Ngan and colleagues found that nearly half of normal-tension glaucoma patients examined lacked appropriate follow-up.

“The whole point of follow-up is to detect glaucoma progression, so this is really the most crucial thing of all,” Nils Loewen, MD, PhD, said. “Someone who is noncompliant will not be known to progress.”

Compliance after trabeculectomy

Because of trabeculectomy’s complications profile, physicians must be especially diligent in ensuring patients return for follow-up visits following filtration surgery. In Ngan and colleagues’ study examining noncompliance risk factors in normal-tension glaucoma cases, 46% of patients were noncompliant with follow-up visits, and those patients were significantly younger than those who made regular visits.

Dr. Loewen said that patients in his practice most at risk for scarring issues after trabeculectomy tend to be younger, and those patients also tend to be less compliant.

“If you don’t micromanage the wound-healing response, then trabeculectomies can fail rapidly and you cannot rescue the bleb,” he said. “If it scars down, well, there’s no way of getting rid of the scar tissue other than by more surgical means. Sometimes you are able to do a laser suture lysis even a month or two out and aggressively push against the eye, for instance, to break the adhesions, but that’s not the rule.”

He said physicians should develop good communication with their patients and know which patients are compliant in other areas of their glaucoma care. Patients with medical therapy compliance issues might be better candidates for procedures other than trabeculectomy. For instance, those patients might have better postop results with tube shunt surgery, especially if they are younger.

Dr. Gedde said that patients who have had problems with compliance with glaucoma medications might have issues taking postop medications such as steroids following trabeculectomy. This may influence his selection of a glaucoma procedure.

“If I have a [medically] noncompliant patient, that very well might be the reason why they are in need of glaucoma surgery. That may impact the glaucoma surgery I choose, and I often favor tube shunt surgery over trabeculectomy in these cases,” Dr. Gedde said.

Improving noncompliance

Physicians can assist patients in improving office visit compliance. Providing patients with visual reminders, including postoperative schedules, or phoning patients who have missed visits to reschedule can help them be more compliant about follow-up.

Dr. Loewen gives patients a sheet detailing postop follow-up by day, week and month, including color-coded instructions for eye drops and follow-up visits. He said that in his experience, giving patients a visual aid encourages follow-up visit compliance.

“It allows you to visualize where you are in this whole roller coaster of postoperative care. I think that helps to make them look forward even to a follow-up visit,” he said. “I think that’s a motivator, giving them a good handout that gives them an overview of what the plan is.”

Dr. Gedde’s office issues a letter to patients who have not returned to the office. He also calls patients and tells them that it is critically important that they come in for their visit. He said there are real reasons that patients sometimes miss appointments, such as older patients who cannot find transportation or simply forget their appointments.

He said physicians should be clear with glaucoma patients about how their surgical success could be adversely affected by missed office visits.

“In encouraging compliance, education is key,” he said.

Dr. Loewen said instructional videos might help patients realize the need for follow-up visits. He likened the videos to public service announcements for wearing seat belts, visually educating patients about severe risks they are not aware of or underestimate because even advanced glaucoma may not be noticeable.

New surgical options should also reduce the need for additional office visits following surgery, Dr. Brown said. Both tube shunts and nonpenetrating glaucoma surgery procedures and techniques have reduced complications.

“Ultimately, some of the internal drainage procedures are going to be successful, and we’ll figure out how to tap into that,” he said. “The follow-up will be much less, because patients won’t have a hole in the eye and we won’t need to be checking so often for serious complications like hypotony and infection.” – by Erin L. Boyle

References:

• Kosoko O, Quigley HA, Vitale S, Enger C, Kerrigan L, Tielsch JM. Risk factors for noncompliance with glaucoma follow-up visits in a residents’ eye clinic. Ophthalmol. 1998;105(11):2105-2111.
• Ngan R, Lam DL, Mudumbai RC, Chen PP. Risk factors for noncompliance with follow-up among normal-tension glaucoma suspects. Am J Ophthalmol. 2007;144(2):310-311.

• Reay H. Brown, MD, can be reached at Atlanta Ophthalmology Associates, 993-D Johnson Ferry Road NE, Suite 250, Atlanta, GA 30342; 404-252-1194; e-mail: reaymary@comcast.net.
• Steven J. Gedde, MD, can be reached at Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL 33136; 305-326-6435; e-mail: sgedde@med.miami.edu.
• Nils Loewen, MD, PhD, can be reached at Department of Ophthalmology and Visual Science, Yale University School of Medicine, 40 Temple St., Suite 3D, Room 375, New Haven, CT 06510-2715; 203-737-5746; e-mail: nils.loewen@yale.edu.