Eyeworld

I REVOLUTION IN GUCOMA MEDICATIONS N FOCUS 62 | EYEWORLD | MAY 2020 Glaucoma patients have a higher rate of ocular surface disease than the general population, he said. According to Alan Robin, MD, adherence is multifactorial, and one of the problems that ophthalmologists may have is they often only think about the eyes and may forget about sys- temic conditions requiring medications. "I think adherence is a significant issue in all of med- icine," he said. "We forget that most patients are on a multitude of other medications, [so] by the time you add an eye drop, you're the fifth or sixth medicine that they have to remember to take." In addition, the mean age of glaucoma patients is around 65, Dr. Robin said. Even if these patients have a $20–30 deductible, if they're on five medications, that adds up, espe- cially to those on fixed or limited incomes. One of the biggest barriers to adherence, Dr. Robin said, is the communication of the physicians themselves, with many not telling patients the names of the medications, dosing schedules, goals, etc. "Our communication skills have to be improved," he said. Another major issue is level of patient understanding, including the level at which doctors describe the optic nerve. "Most patients don't understand what we are saying," he said, adding that when he's having a conversation with a patient, he will ask about social history, profession, and schooling to get an idea of the patient's health literacy. "We often talk at a level far above their ability to understand." Who is nonadherent to glaucoma medical therapy? "We should remember that all patients may struggle with adherence, being careful to not make assumptions about how well a patient is or is not doing with glaucoma medications," Dr. Muir said. "Doctors can consider leading the conversation with a statement that softens the guilt that a patient who is struggling might experience and following with an open-ended question," she said. "An example might be, "It is hard to take eye drops every day. How is that going for you?"' There is evidence that patients P hysicians face a number of challenges when treating patients with glaucoma, including adherence to the chosen medical therapy. Whether it's patient compliance, ability to administer med- ications, or an issue with obtaining the medication, there are many obstacles impacting this. Experts discussed with EyeWorld some of the biggest barriers, how they address these, and how to handle ocular surface disease, a frequent consequence of glaucoma medical therapy. Barriers to adherence Barriers to adherence in glaucoma medical therapy differ from patient to patient, said Kelly Muir, MD. Common barriers include cost, side effects, forgetfulness, not understanding the need for chronic therapy, competing priorities, and concurrent health conditions that make it difficult to physically administer the drops or remember to take them. "Patients may also have difficulty adhering to glaucoma medications because they don't appreciate any improvements in their vision or other ocular symptoms when taking medica- tions," said Dana Wallace, MD. "In fact, [the medications] may actually make their eyes feel worse by leading to redness and burning." Robert Noecker, MD, said the first barri- er is cost. "In this day and age, I think people acquiring the medications and paying for them over time is the biggest barrier," he said. Pa- tients may have the same medication for years, then the price might increase unexpectedly. When this happens, Dr. Noecker said it can lead to patients cutting back on the recommended dosage. Another barrier he described was "people being people." Patients have to follow a routine, Dr. Noecker said. For this reason, he strives for optimal therapy or drop minimization therapy. He also likes to use SLT. Dr. Noecker finds that many mild glaucoma patients are successful us- ing one drop a day. "Once you add on multiple bottles, I think life gets in the way," he said. The last barrier to adherence that Dr. Noecker mentioned was ocular surface issues. Barriers to adherence in glaucoma medical therapy by Ellen Stodola Editorial Co-Director At a glance • There are many potential barriers to adherence in glaucoma medical therapy. Patient access issues like cost and ability to effectively deliver the medication are common. • To address some adherence barriers, physicians suggested combination medications, patient education, and drop and refill reminders. • Using preservative-free med- ications may help glaucoma patients who also have ocular surface disease.

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