Eyeworld

I MAY 2020 | EYEWORLD | 63 Medication tolerance and OSD Unfortunately, any medication that includes a preservative can lead to ocular irritation. "I find the highest rates of irritation in alpha-2 agonists (especially generics), prostaglandin analogues, and rho kinase inhibitors," Dr. Wallace said. She finds that preservative-free formula- tions are often the best tolerated in patients with ocular surface disease. Dr. Wallace said she is quick to offer SLT to this group of patients and is also looking forward to incorporating sustained-release bi- matoprost (Durysta, Allergan) into her practice. "If patients have ocular surface disease and are planning to have cataract surgery, I recommend MIGS procedures to decrease their medication burden," Dr. Wallace said. "These patients may also need to consider other glaucoma surgeries, particularly if their medication burden is high and they have more advanced stages of glaucoma." Dr. Muir thinks that it's important to consider not just the individual medication but the quantity of drops that the patient's eyes with more advanced disease may struggle with the physical task of drop administration due to visual impairment, so it may be particularly im- portant to assess this skill in the office for these patients, Dr. Muir said. Dr. Wallace said uninsured patients or those with poor medication coverage have higher rates of nonadherence. "While elderly patients often have high refill rates, age and accompa- nying physical difficulties can make administra- tion of medication difficult," she said. "Other groups that have high rates of nonadherence are those with low health literacy and lack of social support." Methods to improve adherence One thing that Dr. Robin thinks would help improve adherence is to simplify regimens. "We're fortunate now that we have some won- derful medications available and many are com- bination medicines," he said. "If one doesn't work, rather than adding to it, trying a different one or a fixed combination product might be effective." Dr. Robin thinks that the number of times a day the patient takes a medication makes a difference as well. Multiple studies have found that patients remember more often first thing in the morning rather than midday or end of the day, he added. Dr. Muir said taking the time to educate patients about glaucoma and the natural course of the disease if left untreated can help im- prove adherence. She also stressed the impor- tance of communicating clearly and verifying patient understanding, asking about barriers in a nonjudgmental way and addressing each barrier specifically. When possible, prescribing a regimen that requires the least number of drops per day and suits the patient's lifestyle and competing commitments can help. Suggesting generic alternatives to brand name medicines, when appropriate, also helps reduce the cost burden to the patient. Ensure that patients can accomplish the physical task of administering drops by asking them to demonstrate for you. She also suggested involving companions in education efforts. continued on page 64 About the doctors Kelly Muir, MD Associate professor of ophthalmology Duke University School of Medicine Durham, North Carolina Robert Noecker, MD Ophthalmic Consultants of Connecticut Fairfield, Connecticut Alan Robin, MD Associate professor of ophthalmology and international health Johns Hopkins University Baltimore, Maryland Dana Wallace, MD Thomas Eye Group Sandy Springs, Georgia

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