Will improvement of knowledge lead to improvement of compliance with glaucoma medication?

Barriers and enablers to medication adherence in glaucoma: A systematic review of modifiable factors using the Theoretical Domains Framework

PURPOSE

Nonadherence to medication reduces treatment effectiveness, and in chronic conditions it can significantly reduce health outcomes. In glaucoma, suboptimal adherence can lead to sight loss, which places a greater financial burden on society and reduces patients' quality of life. Interventions to improve adherence have so far had limited success and lack robust theoretical underpinnings. A better understanding of the determinants of medication adherence behaviour is needed in order to develop interventions that can target these factors more effectively. This systematic review aims to identify modifiable barriers and enablers to glaucoma medication adherence and identify factors most likely to influence adherence behaviour.

RECENT FINDINGS

We searched CINAHL, MEDLINE, PsycINFO, EMBASE, the Cochrane Library and sources of grey literature up to August 2022 for studies reporting determinants of glaucoma medication adherence. Data describing modifiable barriers/enablers to adherence were extracted and analysed using the Theoretical Domains Framework (TDF), a behavioural framework consisting of 14 domains representing theoretical factors that most likely influence behaviour. Data were deductively coded into one of the TDF domains and inductively analysed to generate themes. Key behavioural domains influencing medication adherence were identified by frequency of study coding, level of elaboration and expressed importance. Eighty-three studies were included in the final synthesis. Four key domains influencing glaucoma medication adherence were identified: 'Environmental Context and Resources', 'Knowledge', 'Skills' and 'Memory, Attention and decision processes'. Frequently reported barriers included complex eyedrop regimens, lack of patient understanding of their condition, forgetfulness and difficulties administering eyedrops. Whereas simplified treatments, knowledgeable educated patients and good patient-practitioner relationships were enablers to adherence.

SUMMARY

We identified multiple barriers and enablers affecting glaucoma medication adherence. Four theoretical domains were found to be key in influencing adherence behaviour. These findings can be used to underpin the development of behaviour change interventions that aim to improve medication adherence.

Does Diabetes Influence Adherence in Glaucoma Patients?

With chronic diseases, patient adherence plays a crucial role in delaying disease progression and in determining the success of therapy. Problems arise not only from low medication adherence, but also non-adherence to recommended follow-up examinations. Obtaining an accurate estimate of adherence is difficult, especially in glaucoma patients, due to the fact that most antihypertensive drugs are administered in the form of eye drops. There is great variability in the published adherence values for glaucoma patients. Most studies report an average medication adherence of approximately 70%, with around 50% of patients having good adherence (at least 80% of medication administered as planned). Furthermore, 6.8 - 31.4% of the eye drops do not end up in the patient's eye, which means there is even less active ingredient to achieve a therapeutic effect. Glaucoma patients also show low persistence and adherence to follow-up appointments. Since diabetes increases the risk for POAG and secondary glaucoma and given that diabetics have particularly low adherence, the question arose whether a diabetes diagnosis is associated with reduced adherence in glaucoma patients. Previous studies found no significant association between diabetes and reduced adherence in glaucoma patients, although a significant impact of elevated HbA_1c on adherence in glaucoma patients was found in one study. However, this connection still needs to be examined more closely in studies with larger samples.

Health literacy and ophthalmology: A scoping review

As of 2020, it is estimated that 43.3 million people are blind, and an additional 553 million have mild to severe vision impairment.50 At least 1 billion worldwide have a vision impairment that could have been prevented or has yet to be addressed.54 Poor health literacy may be a significant contributor to the prevalence of eye disease. With implications on disease burden, progression, and health outcomes, a greater understanding of the role health literacy plays in ophthalmology is needed. This is the first scoping review to assess the impact of health literacy on eye health outcomes and blindness, including ocular screening rates and/or follow-up rates, treatment adherence, and self-care practices. PubMed, Embase, and CINAHL databases were searched systematically through November 12, 2021, and we evaluated the association between health literacy and ophthalmic outcomes in 4 domains: clinical outcomes, treatment adherence rates, screening and/or follow-up rates, and self-care practices. There is evidence to suggest that health literacy is associated with ophthalmic outcomes in all these domains. To better understand how health literacy impacts eye health, further longitudinal studies examining the effect of health literacy (using standardized health literacy measures) on ophthalmic outcomes are needed. We believe a specific ophthalmic health literacy survey could help achieve this goal and help target interventions to ultimately improve outcomes among ophthalmology patients.

Adherence to Therapy in Glaucoma Treatment—A Review

Glaucoma is a chronic disease and the second leading cause of irreversible vision loss worldwide, whose initial treatment consists of self-administered topical ocular hypotensive eyedrops. Adherence with glaucoma medications is a fundamental problem in the care of glaucoma patients as up to 50% of patients fail to receive the intended benefits of the treatment. The literature has identified many barriers to patients’ compliance, from factors depending on the type of medication administered, communication between physician and patients, to factors dependent on patients’ behaviour and lifestyle. Failure to take medication as prescribed increases the risk that patients will not receive the desired benefit, which often leads to a worsening of the disease. Our aim is to synthesize the methods used for measuring adherence of patients to glaucoma therapy and the interventions used for addressing adherence, laying emphasis on a patient-centred approach, taking time to educate patients about their chronic disease and to assess their views on treatment.

Patients’ adherence to topical antiglaucoma medications in a tertiary care hospital

Objectives

Adherence to glaucoma medications is a central factor to control intraocular pressure and manage glaucoma effectively. This study aims to assess the level of adherence of glaucoma patients to ocular hypotensive agents and determine factors contributing to non-adherence in the Aseer region.

Methods

This was a single-centre, prospective cross-sectional study carried out in Aseer Hospital, Saudi Arabia. Data were collected through a customized questionnaire adapted from the Morisky, Green and Levine Medication Adherence Questionnaire (MGLS).

Key findings

Of the 102 glaucoma patients, 63 (61.8%) were non-adherent to their glaucoma medications. About 48 (76.2%) of them reported that they have no background information about glaucoma. Older participants (37, 58.7%; >50 years) showed a low adherence level compared with the younger individuals. Contributing factors to non-adherence include forgetting the dose time (32, 50.8%), illiteracy (31, 49.2%; P = 0.313), economic problems (26, 41.3%; P = 0.286) and lack of information about prescribed medications (15, 23.8%; P = 0.188).

Conclusions

No significant relationship was found between medication adherence and patient’s demographic data or their background knowledge about glaucoma. Despite the need for improving the glaucoma patient’s knowledge of their disease and the importance of medication adherence, an additional strategy as alerts by smartwatches should be encouraged to improve the adherence level.

Patient-Reported Nonadherence with Glaucoma Therapy

Purpose: Effective glaucoma therapy relies to a great extent on the patients' ability to regularly self-administer eye drops. This study aimed to assess self-reported nonadherence and to identify potential barriers to adherence in glaucoma patients. Methods: Participants completed a 16-item questionnaire, designed to examine nonadherence rate and assess the therapy experience. Inclusion criteria stipulated treatment duration of at least 1 year. Nonadherence was defined as missing ≥5% of the prescribed pressure-lowering eye drops doses. Results: In total, 201 glaucoma patients aged 24-88 years were included. Mean treatment duration was 9.4 years. Nonadherence was reported by 30.3% of participants and 69.7% were reported to be adherent. Individuals who experienced side effects reported higher levels of nonadherence than those who did not (37.6% vs. 18.4%; P = 0.004). Eye drops with preservatives were used by 84.1% of participants, 11.9% were on combined preservative and preservative-free treatment, and 4.0% on preservative-free medication only. Self-reported nonadherence levels were 32.0%, 25.0%, and 12.5%, respectively, for each of these groups. Men reported higher rates of nonadherence than women (36.8% vs. 24.5%; P = 0.066). Age, social status, history of migration, severity of disease, and fear of blindness were not associated with significant differences in nonadherence levels. Conclusions: Nonadherence with glaucoma therapy is a significant barrier to therapeutic success for approximately one-third of patients. Nonadherence may be reduced if side effects are avoided. Preservative-free products may provide adherence benefits. The patient experience should be a key consideration when selecting appropriate treatments, to reduce nonadherence and optimize outcomes.

Clinical Pharmacist interventions in Refill Clinic at Tertiary Care Eye Specialist Hospital

Objective: To describe the role of Clinical Pharmacists in the Medication Refill Clinic area as a part of a multidisciplinary team in which he/she can provide education to patients and caregivers on the safe and appropriate use of medications, counsel on medication compliance, monitor and manage medication side effects, as well as screen for dangerous drug interactions. Methods: The data of this prospective, single-centered, chart review based study have been collected since the clinic launched in June 2011 till December 2013 in King Khalid Eye Specialist Hospital which is a Tertiary Hospital in KSA. Types of interventions documented during the patient–pharmacist visit are categorized as medication review and patient compliance. Key findings: Out of the total 16,417 patients, 3641 (22.2%) are noncompliant. The Clinical Pharmacist identified 18 intervention types. The most frequent interventions are as follows: Eye screening (24.8%), Counseling (13%), Physician/ER referral (12.4%), Therapeutic substitution/switch (10.8%), and Frequency changed (7%). Summary: This prospective analysis is a document evidence showing Clinical Pharmacist positive outcomes in the management of ophthalmic patients. Dissemination of this information would be valuable because it could raise the awareness of other Healthcare Professionals regarding Pharmacist as effective clinicians in care of ophthalmic patients.

A cross-sectional study on compliance with topical glaucoma medication and its associated socioeconomic burden for a Chinese population

AIM

To estimate the overall drug compliance for local Chinese glaucoma patients on long-term topical treatment.

METHODS

This was a retrospective cross-sectional study. Fifty-seven primary glaucoma patients from the subspecialty clinic of a publicly-funded tertiary care hospital in Hong Kong completed a questionnaire on compliance with topical glaucoma medication, attitude towards glaucoma and therapy and vision related quality of life. Noncompliance was defined as reporting missing more than or equal to 10% of the prescribed topical glaucoma medication during the 2wk immediately prior to the consultation. Relationships between noncompliance and demographics, attitude, disease and treatment status was studied. Cost was estimated with quality of life and direct medical cost involved with noncompliance. Multivariable logistic regression on noncompliance was performed on selected factors.

RESULTS

Compliance was calculated as 75% (95% CI: 64%-87%) among 57 subjects (mean age 69y, female 51%). No statistical significant relationship was established between noncompliance and any single factors or outcomes. Age (P=0.048) and forgetfulness (P=0.064) were found to be marginally significant predictive factors on noncompliance in multivariable logistic regression. Noncompliance might be related (P=0.130) to poorer self-rated vision-associated quality of life. The societal cost of noncompliance was estimated to be over 2510 life-years and US$ 3.7 million territory-wide.

CONCLUSION

The compliance of Chinese glaucoma patients in Hong Kong is comparable to other parts in the world, and carries detrimental impacts on individual and societal levels. Age and forgetfulness are two possible independent predictors for noncompliance.

Level of adherence to ocular hypotensive agents and its determinant factors among glaucoma patients in Menelik II Referral Hospital, Ethiopia

Background

Good adherence to ocular hypotensive agents is important to control intraocular pressure and hence to prevent progressive glaucomatous optic nerve head damage. Periodic investigation of adherence is crucial in glaucoma treatment. The purpose of this study was to assess level of adherence to ocular hypotensive agents and to identify factors affecting adherence among glaucoma patients at a tertiary public eye care center.

Methods

The study was a hospital-based cross-sectional study that was conducted in Menelik II Referral Hospital from June 1, 2015 to July 31, 2015. A systematic random sampling technique was used to select 359 study participants from the source population. The study patients were interviewed and their medical charts were reviewed using a pretested structured questionnaire. Adherence was assessed using Morisky Medication Adherence Scale - 8 and adherence determinant factors were identified using multivariate binary logistic regression analysis. The association was declared statistically significant at p < 0.05.

Results

Among the 359 study glaucoma patients, 42.6 % were adherent to their prescribed hypotensive agents. Higher educational level (AOR = 4.60, 95 % CI: 1.01–21.03, p < 0.049), being self - employed (AOR = 6.14, 95 % CI: 1.37–27.50, p < 0.018) and taking lesser frequency of drops (AOR = 2.89, 95 % CI: 1.25–6.66, p < 0.013) were significantly associated with adherence, whereas being a farmer (AOR = 0.07, 95 % CI: 0.01–0.75, p < 0.028), having very low monthly family income (AOR = 0.22, 95 % CI: 0.06–0.77, p < 0.019) and self - purchasing of medications (AOR = 0.30, 95 % CI: 0.10–0.93, p < 0.036) were significantly associated with non-adherence.

Conclusions

The study has identified the adherence level to the prescribed ocular hypotensive agents to be sub-optimal and is influenced by different factors among glaucoma patients of the public tertiary center. We recommend glaucoma care providers to pay due attention on the importance of adherence.

[Is there a need for a therapeutic education with patients suffering with open-angle glaucoma? Preliminary inquiry regarding knowledge and patient adherence]

PURPOSE

To evaluate the knowledge and compliance of patients with open-angle glaucoma in order to propose an approach by therapeutic education, validated for other chronic pathologies.

METHODS

A questionnaire-based interview of all patients in the waiting room of the glaucoma center is performed by the same health care professional.

RESULTS

Out of 200 patients, 73% know they will need to be treated throughout their lives and 95% are aware of the risk of blindness in the absence of appropriate treatment. However, 16% respond that they can be cured, and 54% believe that treatment can save their eyesight. Knowledge increases with the length of follow-up of patients at the glaucoma center beyond one year, but the progress is still insufficient in their confidence that treatment can save their eyesight (36% to 57%), and in the decrease in the number of patients who forget their treatment (56% to 30%).

CONCLUSION

Cognitive knowledge is insufficient to encourage the patient to comply with treatment. It is necessary to consider therapeutic patient education (TPE) techniques, such as described by WHO, in group and/or individual sessions, aimed at building the patient's confidence that treatment can delay the progression of the disease and blindness, strengthening his/her capacity to properly administer the eye drops, managing his/her treatment and coping with frequent side effects. Within this framework, our knowledge of the patients' representations of their glaucoma and its treatment must improve.

Short-term effects of relaxation music on patients suffering from primary open-angle glaucoma

Purpose

To evaluate whether additive relaxation music (RM) has an adjuvant short-term effect on physiological and psychological parameters in patients with primary open-angle glaucoma.

Methods

Prospective, randomized clinical trial. Patients in the therapy group (TG) received a 30-minute RM via headphones, whereas members of the control group (CG) did not. Best corrected visual acuity, intraocular pressure, visual field testing, short- and long-term mental states, and blood levels of different stress hormones were analyzed and compared.

Results

A total of 25 (61%)/16 (39%) patients were assigned to the TG/CG. Best corrected visual acuity, daily intraocular pressure, and short-term mental state (KAB) development were significantly better in the TG in comparison to controls. Visual field testing, long-term mental well-being (profile of mood states), and adrenalin, cortisol, and endothelin-I blood levels did not differ significantly between both groups.

Conclusion

Additive RM applied on a daily basis can positively impact various physiological and psychological parameters in the short term.

Level of knowledge about glaucoma in Vienna

BACKGROUND

Glaucoma is a chronic and serious disease calling for consistent lifelong therapy. The patient's compliance requires that he/she be well informed about the disease. The purpose of the present study was to determine the level of knowledge about glaucoma, and compare young patients with older ones as well as glaucoma patients with nonglaucoma ones.

METHODS

A total of 1110 questionnaires were distributed to patients and their relatives at the outpatient eye clinic of Hietzing Hospital (Vienna), of which 1041 were returned. The questionnaire comprised 18 questions. Patients were divided into two groups: group 1 consisted of those aged 18-60 years, while group 2 consisted of those older than 61 years.

RESULTS

In total, 941 questionnaires were evaluated; 72.8% of the respondents were older than 60 years, and one-half of the respondents had glaucoma (51%). The majority of patients had "moderate knowledge" of the disease (41.87%), followed by "poor knowledge" (32.52%). Glaucoma patients had considerably better knowledge of the disease (p < 0.01) than did nonglaucoma patients. Younger patients were significantly better informed than older ones (p < 0.01). Nonglaucoma patients with a positive diagnosis of glaucoma among their circle of friends or family were significantly better informed (p < 0.01) than those without such persons in their circle of friends.

CONCLUSION

Persons with glaucoma are much better informed about the disease than nonglaucoma patients, but the general level of knowledge is very low. Notably, younger patients were better informed than older ones. The present study, comprising a large number of patients, revealed poor knowledge of glaucoma among patients with the disease and especially among nonglaucoma patients in Vienna.

Assessing the adherence behavior of glaucoma patients to topical eye drops

PURPOSE

The goal of this study was to determine the adherence of glaucoma patients to their topical glaucoma medication. Furthermore, the relationships between the adherence behavior and the patients' demographic data, clinical characteristics, and their knowledge about glaucoma were evaluated.

METHODS

This was a prospective study of 123 patients with primary open-angle glaucoma who were given two standardized questionnaires. The first questionnaire at time point T1 comprised a knowledge assessment and the self-reported adherence measures Adherence to Refills and Medication Scale 2 (ARMS2), visual analogue scale for adherence (VAS-AD), and missed doses in the past 14 days. Two months later at time point T2, a second questionnaire reevaluated the adherence measures ARMS2, VAS-AD, and missed doses in the past 14 days.

RESULTS

There was a good correlation among all the three adherence measures at T1 and T2. The mean values of ARMS2 were in the lower range, with 3.38 at T1 and 2.8 at T2. The VAS-AD detected that 18.5% of patients always took their eye drops correctly, and 77.9% of patients reported not to have missed a single dose in the past 14 days. There was no significant correlation between the patients' demographic data or knowledge about glaucoma and the adherence measures ARMS2 or VAS-AD. Among the clinical characteristics, only single-eye blindness showed a significant correlation with VAS-AD.

CONCLUSION

In this study, no general relationships were found between medication adherence and the patients' demographic data, clinical characteristics, or knowledge about glaucoma. It may be assumed that more individualized strategies are required to optimize adherence behavior.

Adherence improvement in Dutch glaucoma patients: a randomized controlled trial

PURPOSE

To study the effect of patient education and the TravAlert(®) -Eyot(®) drop guider on intraocular pressure (IOP) and adherence in patients with primary open angle glaucoma (POAG) or ocular hypertension (OHT) monitored with the TravAlert(®) dosing aid.

METHODS

Multicentre, randomized, controlled clinical trial among 18 Dutch hospitals. Patients were randomized to one of the four study arms: (1) use of the dosing aid, (2) use of the dosing aid with the drop guider, (3) use of the dosing aid together with patient education or (4) use of the dosing aid and drop guider together with patient education. IOP was recorded at baseline and after 3 and 6 months. Data on adherence generated by the dosing aid were collected and studied at the end of the study.

RESULTS

Mean IOP dropped from 20.3 ± 5.7 mmHg at baseline to 16.3 ± 4.0 mmHg (right eye) after 6 months and from 20.2 ± 5.9 mmHg to 16.4 ± 4.1 mmHg (left eye). The mean adherence rate was 0.91 ± 0.1. IOP and adherence rate were not statistically different between the study arms. Patients with 'drug holidays' had a significantly higher mean IOP after 6 months. Patients who used the drop guider were less adherent. A lower adherence level was also associated with new patients with glaucoma and patients with a lower level of knowledge on glaucoma.

CONCLUSION

Patient education is especially useful for new patients with glaucoma. The use of a drop guider does not improve adherence. Especially patients with 'drug holidays' are at risk for developing uncontrolled IOP levels.

Determinants of medication adherence to topical glaucoma therapy

INTRODUCTION/PURPOSE

To determine the associations between medical, demographic, socioeconomic, and ocular factors and adherence to topical glaucoma ocular hypotensive therapy.

METHODS

One hundred sixteen patients with ocular hypertension or open-angle glaucoma from 2 tertiary glaucoma services participated in this prospective study. Adherence to ocular hypotensive therapy was measured using an electronic dose monitor (Travatan Dosing Aid, Alcon Laboratories Inc., Fort Worth, TX) and collected data at 3 months after enrollment. We used 3 different definitions of adherence: 1) Definition 1: the proportion of days taking the prescribed number of drops within 3 hours of the prescribed dosing time; 2) Definition 2: the proportion of days taking any drops within 3 hours of the prescribed dosing time; and 3) Definition 3: the proportion of days taking any drops within 6 hours of the prescribed dosing time. Univariate and multivariate models were used to determine the association between the 3 adherence definitions, medical, demographic, socioeconomic, and ocular factors at 3-month follow-up. The main outcome measures for this study were risk factors for poor objective medication adherence.

RESULTS

Adherence, using Definition 1, Definition 2, and Definition 3, was 64%, 75%, and 80%, respectively. Age, total number of other eye diseases, and race were significantly associated with full treatment adherence (Definition 1), with race alone significantly predicting 11% of full treatment adherence. For Definition 2, age, income, level of education, and total number of eye diseases were significantly associated with partial adherence (3 h), again race alone significantly predicted 15% of partial adherence (any drops within 3 h). For Definition 3, race, income, level of education, and total number of other eye diseases significantly predicted partial adherence (any drops within 6 h), both race and income predicted 19% of partial treatment adherence. Significant differences for adherence rates between patients of European descent and those of African descent were found for all 3 definitions with those who were less adherent more likely to be of African descent.

CONCLUSIONS

Electronic dose monitors provide important information regarding adherence to topical ocular hypotensive medications in glaucoma patients. Electronic dose monitors show low adherence in a significant number of participants. Future studies are needed to determine the reasons for these differences in health behaviors related to glaucoma treatment, which should guide treatment of poor adherence with glaucoma therapy.

A proposed methodology for the assessment of glaucoma awareness in Greece: introduction of the EIT-8G scale

PURPOSE

To develop a reliable and practical questionnaire for glaucoma awareness and evaluate the impact of potential determinants.

METHODS

Patients with primary open-angle, pigmentary, and exfoliation glaucoma, as well as healthy controls, were recruited. The instrument included questions about demographic characteristics, as well as 8 questions assessing the participant's familiarity with glaucoma. Rasch analysis was used for the validation of the questionnaire. The effect of demographics as potential determinants of awareness was examined with a multivariate logistic regression analysis. Bonferroni-corrected statistical significance was tested with the Mann-Whitney U test or one-way analysis of variance. Association between demographics and questionnaire scores was examined with Spearman correlation.

RESULTS

As indicated by power analysis, responses from 175 patients (mean age 65.5 years) and 314 controls (mean age 43.3 years) were analyzed. Rasch analysis indicated no multidimensionality and good item-person targeting. Mean ± SD awareness scores for the glaucoma and control groups were 4.43 ± 2.10 and 4.20 ± 2.11, respectively (p=0.207). Sex and residence were not predictors of disease awareness, whereas educational level was only a determinant in the control group (p<0.001). Income was a predictor only for patients (r=0.357, p<0.001), whereas family history was predictive for both groups (p<0.001). Logistic regression analysis revealed that only family history was associated with increased awareness (Chi(2)=4.61, p=0.03, odds ratio 1.98).

CONCLUSIONS

This study introduces a practical and valid instrument for the assessment of glaucoma awareness.

Individualised patient care as an adjunct to standard care for promoting adherence to ocular hypotensive therapy: an exploratory randomised controlled trial

PURPOSE

To evaluate the impact of individualised patient care, as an adjunct to standard care, on adherence to ocular hypotensive therapy.

METHODS

A two-arm, single-masked exploratory randomised controlled trial recruited patients newly prescribed ocular hypotensive therapy. The intervention involved an individual assessment of health-care needs and beliefs and a 1-year follow-up period according to need. The primary outcome was refill adherence, measured by collating prescription and dispensing data for 12 months. Secondary outcomes included self-reported adherence, glaucoma knowledge, beliefs about illness and medicines, quality of care, intraocular pressure (IOP) fluctuation, and changes in clinical management assessed at 12 months. The strength of the intervention was measured following withdrawal by reviewing clinical outcomes for a further 12 months.

RESULTS

In all, 127 patients were recruited (91% response rate). Intervention-arm patients collected significantly more prescriptions than control-arm patients. Self-report adherence was significantly better in the intervention-arm for patients who forgot drops and those who intentionally missed drops. The intervention group demonstrated significantly more glaucoma knowledge, expressed a significantly stronger belief in the necessity of eye drops and believed that they had more personal control over managing their condition. Control-arm patients had more IOP fluctuation and changes in clinical management. However, this finding only reached significance at 24 months.

CONCLUSION

Modelling patient care according to health-care needs and beliefs about illness and medicines can have a significant impact on improving adherence to therapy for this patient group, with the potential benefit of improving clinical outcomes.

Preliminary survey of educational support for patients prescribed ocular hypotensive therapy

PURPOSE

to establish the impact of educational support on patients' knowledge of glaucoma and adherence, in preparation for an intervention study.

METHODS

structured observation encapsulated the educational support provided during clinical consultations and patient interviews captured the depth of glaucoma knowledge, problems associated with glaucoma therapy, and adherence issues.

RESULTS

one hundred and thirty-eight patients completed the study. Education was didactic in nature, limited for many patients and inconsistent across clinics. Patients showed generally poor knowledge of glaucoma with a median score of 6 (range 0-16). A significant association was found between educational support and knowledge for newly prescribed patients (Kendall's tau=0.30, P=0.003), but no association was found for follow-up patients (Kendall's tau=0.11, P=0.174). Only five (6%) patients admitted to a doctor that they did not adhere to their drop regimen, yet 75 (94%) reported at interview that they missed drops.

CONCLUSIONS

although important, knowledge alone may not sufficiently improve adherence: a patient-centred approach based on ongoing support according to need may provide a more effective solution for this patient group.