Glaucoma is a group of diseases that are characterized by progressive optic nerve damage and vision loss that ultimately ends in irreversible blindness. It is the leading cause of blindness in African Americans and the second leading cause of legal blindness in the United States. The most significant and only treatable risk factor is an elevated intraocular pressure, or IOP. Thus, therapy is centered on lowering IOP, which can be accomplished with medical therapy in the form of eye drops (or less commonly oral medications), glaucoma laser therapy or surgery.
There are many effective medications currently available to lower IOP, and the majority of disease can be managed with their proper use. However, compliance with medications is quite problematic and is a major obstacle in glaucoma treatment. Glaucoma is a chronic disease with few symptoms until late in the disease, and treatment is designed to prevent worsening rather than to improve visual function. Due to the fact that an immediate benefit is not felt by the patient, glaucoma is by nature a disease where compliance is a problem. The video shown with this article illustrates many of the most common causes for non-compliance with glaucoma medical therapy from a patient perspective. It does so in a light-hearted manner, but the consequences of poor compliance are serious and permanent.
The first problem with glaucoma treatment compliance is targeting the drop to the right spot on the eye. The ideal location for instillation of an eye drop is in the eyelid cul-de-sac, or directly onto the surface of the eye. However, patients with glaucoma are often unable to see well enough to tell if the drop is centered over their eye. This results in many missed glaucoma eye drops over time and can lead to suboptimal treatment or costly wasting of medication.
The second issue shown is applying the correct amount of pressure to the bottle to release only one drop at a time. Many patients, especially those with arthritis, find it difficult to squeeze a small bottle carefully. Some dropper bottles have a special design with a certain area to press to release the drop, while others are designed for the drop to come out when turned upside down with minimal or no pressure. This can be especially confusing when multiple different bottles with various designs are used.
Next is difficulty in holding the eyelid open during installation. Some patients are simply unable to hold open their lids due to coordination or mobility problems, and others may be unable to control reflex blinking. Another person may help with this, but I don’t recommend soliciting your household pets as shown in the video!
The pirates in the next sequence illustrate the potential for injury with the tip of the bottle. This can lead to eye damage, or contamination of the medicine with a resulting infection.
The next two scenarios highlight the difficulty in monitoring glaucoma drops. This can be especially difficult with a multiple eye drop regimen or using a drop more than once a day. Studies of compliance with medications have shown that proper usage drops significantly when a medication has to be used more than once a day. A landmark study of a four-times-a-day glaucoma medication measured the number of times it was used with a measuring device on the bottom of the bottle. Investigators found that 30% to 60% of patients were not using the medication correctly. Even more surprising was that patients reported proper usage 97% of the time, indicating that they were not aware of their non-compliance.
The issue of trust is a complex one, and is equally applicable to medications and the treating physician. As stated previously, there is no immediate benefit of medication that can be noticed by the patient and therefore there is little in the way of positive feedback that encourages compliance. Patients must trust that their physician will prescribe the correct medication, and be able to determine if it is working or not.
The senior citizen robbing the liquor store is a reminder of the costs of medical treatment. In many cases, insurance companies and Medicare cover little or none of the costs of chronic medications including glaucoma, forcing patients to make difficult financial decisions.
Side effects of glaucoma medications are another issue in patient compliance. They can range from minor and localized effects such as redness and irritation, to more serious systemic effects such as shortness of breath, fatigue, low blood pressure or heart rate.
The final problem illustrated here is following the complexity of the treatment regimen. Many glaucoma patients require multiple medications with multiple daily uses to control their IOP. This is particularly confusing when they are using medications for other conditions such as high blood pressure, diabetes and heart disease, to name a few.
Now that these problems have been identified, what can patients do to circumvent them? The first is to find an ophthalmologist (eye physician, MD) that is knowledgeable about glaucoma and its different treatment options. This includes medications, laser and surgical alternatives. Next, one must establish trust in this relationship, which includes the ability to ask questions if appropriate. One may also ask ancillary personnel such as the technician or pharmacist. The patient must educate themselves about the disease and understand the goals of treatment, the importance of compliance and the different available alternatives. Know about potential side effects and tell your physician if you are experiencing them. Also, remember to let other treating physicians know what eye medications you are taking, as these could cause systemic side effects or interact with other medications. Along with your ophthalmologist, critically evaluate glaucoma medications to see if they are effective, instead of simply adding more drops if the IOP is not controlled.
Finally, look for alternative therapies for glaucoma such as selective laser trabeculoplasty or SLT (Lumenis, Inc., Santa Clara, CA). This is an office based glaucoma laser surgery procedure that targets the drainage system in the eye in order to make it easier for the outflow of fluid (aqueous humor) and consequently lowers IOP. It has an excellent safety record and is equivalent in efficacy to medications. It can be used as a primary therapy, in addition to one or more medications, or as replacement therapy to reduce medication use. It is a standard procedure that is covered by Medicare and other insurances and is not experimental. It should also be differentiated from other types of lasers for other eye conditions such as retinal disease, narrow angle glaucoma and lens opacity after cataract surgery.
The SLT laser is a non-thermal, or cold laser, and is therefore not painful during application, taking about 5 minutes. There may be minor discomfort or blurred vision following the procedure for a few hours. The major risk is transient elevation of IOP occurring in about 5% of patients, typically within one hour and lasting less than 24 hours. The success rate of the laser is about 80%, lasts 2 to 5 years, and can be repeated when it wears off. Unlike medications, patient compliance is not an issue.
For more information on SLT, visit: www.glaucomaslt.com.
As a final recommendation to patients, take responsibility for the treatment of your glaucoma! This entails understanding the disease and treatment as well as the consequences of not treating or not complying with the treatment regimen. If you have concerns about your treatment or questions about surgical alternatives, ask your doctor. If you are still concerned, seek a second opinion. Remember that you only have one pair of eyes, and that although your ophthalmologist can help you take care of them, the ultimate responsibility rests with you.