Patient and Provider Perspectives on Glaucoma Treatment Adherence: A Delphi Study in Urban Alabama

Alternatives to Topical Glaucoma Medication for Glaucoma Management

Topical glaucoma medications have favorable safety and efficacy, but their use is limited by factors such as side effects, nonadherence, costs, ocular surface disease, intraocular pressure fluctuations, diminished quality of life, and the inherent difficulty of penetrating the corneal surface. Although traditionally these limitations have been accepted as an inevitable part of glaucoma treatment, a rapidly-evolving arena of minimally invasive surgical and laser interventions has initiated the beginnings of a reevaluation of the glaucoma treatment paradigm. This reevaluation encompasses an overall shift away from the reactive, topical-medication-first default and a shift toward earlier intervention with laser or surgical therapies such as selective laser trabeculoplasty, sustained-release drug delivery, and micro-invasive glaucoma surgery. Aside from favorable safety, these interventions may have clinically important attributes such as consistent IOP control, cost-effectiveness, independence from patient adherence, prevention of disease progression, and improved quality of life.

Challenging the "Topical Medications-First" Approach to Glaucoma: A Treatment Paradigm in Evolution

Topical glaucoma medications are effective and safe, but they have numerous well-documented limitations that diminish their long-term utility and sustainability. These limitations can include high rates of nonadherence (with associated glaucoma progression), concerning side effects, inconsistent circadian intraocular pressure (IOP) control, complex dosing regimens, difficulty with self-administration, costs, and decreased quality of life. Despite these limitations, topical medications traditionally have been first-line in the glaucoma treatment algorithm, as no other minimally invasive treatment alternatives existed. In recent years, however, novel interventional therapies-including sustained-release drug-delivery platforms, selective laser trabeculoplasty, and micro-invasive glaucoma surgery procedures-have made it possible to intervene earlier without relying on topical medications. As a result, the topical medication-first treatment approach is being reevaluated in an overall shift toward earlier more proactive interventions.

Pharmacokinetic and Ocular Toxicity Evaluation of Latanoprost Ophthalmic Solution, 0.005%, with Preservative Level Reduced to Below the Limit of Quantitation

Purpose: The systemic and ocular pharmacokinetics (PK), and ocular toxicity of benzalkonium chloride (BAK)-free TearClear latanoprost ophthalmic solution, 0.005% formulation (TC-002) were evaluated. TC-002 is designed to selectively capture BAK at the time of drug administration; therefore, the dose delivered to the eye contains no quantifiable level of preservative. Methods: The systemic and ocular PK of TC-002 were compared to a BAK containing reference listed drug (RLD, Xalatan™) over a 24-h period, after a single topical ocular dose to 1 eye of male Dutch Belted (DB) rabbits (n = 3/timepoint). Latanoprost acid concentrations were measured in plasma and ocular tissues. The ocular toxicity was evaluated in a separate study and included toxicokinetic evaluation of TC-002 after once daily topical ocular dosing into each eye of DB rabbits (n = 8/group) for at least 28 days. Toxicity endpoints included ophthalmic and clinical evaluations, necropsy, and microscopic evaluation of ocular tissues. Results: Average ratios of Cmax values for TC-002/RLD ranged from 0.6 to 1.6, and Cmax and area under the concentration-time curve of last observed concentration (AUClast) exposures to latanoprost acid were similar (<2-fold) between the 2 treatments. In the 28-day study, the Tmax was achieved in both groups in <0.5 h. There were no abnormal ocular findings. Conclusions: TC-002 with no quantifiable preservative or BAK-containing RLD exhibited similar ocular and systemic PK profiles. TC-002 was well tolerated and comparable to RLD. TC-002 retains the safety and PK characteristics of RLD without the added concern of long-term exposure of the eye to preservatives.

Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting

Purpose

To explore barriers and facilitators to completing scheduled outpatient appointments at an urban academic hospital-based ophthalmology department.

Methods

Potential participants were stratified by neighborhood Social Vulnerability Index (SVI) (range, 0-1.0, higher scores indicate greater vulnerability), and semistructured interviews were conducted with individuals 18 years and older with an SVI of greater than 0.61 (n = 17) and providers delivering care in the General Eye Clinic of the University of Illinois Chicago (n = 8). Qualitative analysis informed by human-centered design methods was conducted to classify barriers and facilitators into three domains of the Consolidated Framework for Implementation Research: outer setting, inner setting, and characteristics of individuals.

Results

There were four main themes-transportation, time burden, social support, and economic situation-all of which were within the outer setting of the Consolidated Framework for Implementation Research; transportation was most salient. Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition.

Conclusions

A lack of resources outside of the health system presents significant barriers for patients from neighborhoods with high SVI. Future efforts to improve adherence should focus on resource-related interventions in the outer setting. Improving access to eye care will require community-level interventions, particularly transportation.

Translational Relevance

Understanding the barriers and facilitators within the Consolidated Framework for Implementation Research provides useful guidance for future interventions, specifically to focus future efforts to improve adherence on resource-related interventions.

Identifying and addressing common contributors to nonadherence with ophthalmic medical therapy

PURPOSE OF REVIEW

To discuss common reasons for nonadherence and review existing and emerging options to reduce nonadherence with ocular medical therapy and optimize therapeutic outcomes.

RECENT FINDINGS

Nonadherence can arise from patient-related issues (e.g. physical, cognitive) and healthcare-related issues (e.g. cost, access to care). Multiple strategies have been developed and evaluated to overcome these barriers to adherence. Identifying nonadherence and its cause(s) facilitates the development of strategies to overcome it.

SUMMARY

Many common causes of nonadherence can be mitigated through a variety of strategies presented.

Whitecoat Adherence in Patients With Primary Open-Angle Glaucoma

Purpose

Whitecoat adherence refers to improved medication adherence in the days surrounding clinic visits. This may lead to clinical measures that are not representative of those outside of clinical encounters. In glaucoma, whitecoat adherence to prescribed hypotensive therapy may lead to intraocular pressure readings within the target range, which may impact clinical decision-making. We aimed to quantify and identify factors associated with whitecoat adherence.

Methods

In this cohort study, patients with primary open-angle glaucoma were selected from an ongoing longitudinal NIH-funded study if they used hypotensive eyedrops, had a clinic visit during the parent study, and had adherence data during the 28 days evenly bracketing the clinic visit. Adherence within the implementation phase was measured using Medication Event Monitoring System (MEMS) caps. Wilcoxon tests were used to compare mean adherence between the following periods: Pre14-4 (days 14 to 4 preceding the clinic visit) and Pre3-1 (days 3 to 1 preceding the visit); Post1-3 (days 1 to 3 following the clinic visit) and Post4-14 (days 4 to 14 following the visit). Analyses were performed in the full sample and in patients with optimal (≥80%, n = 49) and suboptimal adherence (<80%, n = 17).

Results

Sixty-six patients were included, of which 51.5% were female. Mean age was 70.8 ± 8.1 years. In the 6 months evenly bracketing the clinic visit, mean and median adherence were 86.3% (standard deviation = 17.7) and 95.6% (interquartile range = 21.2), respectively. Overall, mean adherence increased from Pre14-4 to Pre3-1 (85.5% ± 21.2 to 88.5% ± 23.2, p = 0.01) and decreased from Post1-3 to Post4-14 (87.0 ± 23.9 to 84.9 ± 23.3, p = 0.02). In patients with optimal adherence, adherence increased from Pre14-4 to Pre3-1 (94.0 ± 11.7 to 97.7 ± 7.4, p = 0.001) and from Post1-3 to Post4-14 (95.2 ± 12.0 to 95.4 ± 5.7, p = 0.007). Whitecoat adherence was not observed in patients with suboptimal adherence.

Conclusion

We documented the presence of whitecoat adherence in this cohort. Due to its potential impact on clinical outcomes and decisions, providers should remain vigilant for this phenomenon and prioritize it during patient-provider discussions.