BLOG: 5 reasons patients struggle with eye drops and how to help them
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Optometrists prescribe eye drops to patients every day for a variety of conditions, including chronic, progressive diseases like glaucoma, and we give the most basic of instructions: “Put a drop in each eye, twice a day.” Simple, right?
But there are many reasons why our patients might struggle to comply. Depending on the specific challenge, there may be a quick and easy adjustment that makes it easier for patients to instill their drops. When those fail or we judge them unlikely to succeed, we should strongly consider alternative options, such as laser, surgical intervention or injection of a sustained-release medication to manage IOP without drops.
Here are five reasons patients fail with drops and the types of assistance or non-drop alternatives that can benefit them.
Cognitive challenges
Some patients don’t have the cognitive capacity to understand instructions, due to dementia, a history of drug or alcohol dependence, or low health literacy. The medical history may hold clues to this, such as a diagnosis of Alzheimer’s disease, but I also try to gauge whether the patient seems to fully comprehend the conversation in the exam room.
If not, I ask whether they have help at home, and I provide a memory aid, such as a visual drop checklist by day.
Physical challenges
Some patients understand the instructions just fine, but they struggle to instill drops due to arthritis or other conditions that cause weakness or deformity of the hands.
Patients who have suffered a stroke or who have Parkinson’s disease may have lost the fine motor skills needed to instill drops as intended. For these patients, there are a number of assistive devices available. The AutoSqueeze (Owen Mumford) is similar to large plastic pliers that provides a wider grip and better leverage for those who struggle with fine motor skills. The same company also makes the AutoDrop, a cup that is placed over the eye to help shaky or weak hands direct the drops correctly.
Poor technique
A lot of patients try to instill drops while looking in the mirror and end up jabbing themselves in the eye with the bottle tip or blinking the drop onto their cheek without getting any in the eye.
Although I sometimes ask patients to demonstrate how they put in drops, I’ve actually found it more helpful to demonstrate good technique myself. I lie down on the floor and demonstrate resting the bottle on the bridge of my nose, tilting it a little toward the eye and squeezing the drop into the corner of the eye (with the other eye open). Patients can do this while lying in bed or on a couch.
Lack of motivation
Some patients simply can’t grasp the severity of glaucoma progression and the role they can play in disease prevention. They may lack the motivation or the willpower to consistently follow a habit when they don’t see immediate benefit to their actions.
When I talk about “vision loss” they think it doesn’t apply to them because they can see. It is worth modifying your messaging with these patients to see if a different way of talking about it gets through, but these are prime candidates for non-drop options.
Frugality
Finally, we have patients who purposely skip drops because they want or need to save money. In some cases, there may be manufacturer patient assistance programs to help them.
Another alternative, especially for very expensive drops like Rhopressa (netarsudil ophthalmic solution 0.02%, Alcon) or Rocklatan (netarsudil and latanoprost ophthalmic solution 0.02%/0.05%, Alcon), is a volume-reducing adaptor called the Nanodropper. This dropper top reduces the drop size by about one-third. A typical 1 nL drop is larger than the eye can absorb, so this device delivers a controlled, smaller drop. It is better than skipping the drop altogether, and I have found that it still delivers an effective amount of the drug.
Considerations for surgery
Alternatives should be considered at any point in the patient’s journey, but especially when they are ready for cataract surgery. My standard of care for any patient with cataracts and glaucoma is to ensure they get trabecular micro-bypass stents implanted at the time of surgery to reduce their dependence on drops.
Even compliant patients may progress or encounter new challenges to adhering to their drop regimen. If a MIGS procedure can reduce or eliminate drops for them before that happens, so much the better.
For more information:
Nicole Albright, OD, is clinic director at Moses Eyecare Center in Merrillville, Indiana, where she also serves as externship coordinator for optometry students at Indiana University and Chicago College of Optometry. She practices full-scope optometry, with a focus on specialty lenses, perioperative care and ocular disease management.
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