Glaucoma patients not compliant with their drug therapy: clinical and behavioural aspects

Adherence and Persistence to Medical Therapy in Glaucoma: An Overview

Glaucoma is a group of progressive optic neuropathies characterized by loss of retinal ganglion cells and visual field deterioration. Despite the fact that the underlying pathophysiology of glaucoma remains unknown, elevated intraocular pressure (IOP) is a well-established risk factor, and the only factor that can be modified. Robust evidence from epidemiological studies and clinical trials has clearly demonstrated the benefits of IOP control in reducing the risk of glaucoma progression. IOP-lowering therapy by the means of eye drops remains a first-line treatment option. However, like other chronic and asymptomatic conditions, many patients with glaucoma have difficulties in maintaining high rates of adherence persistence to prescribed medications. On average, patients with chronic medical conditions take 30-70% of the prescribed medication doses, and on average 50% discontinue medications in the first months of therapy. The ophthalmic literature shows similarly low rates of adherence to treatment. Indeed, poor adherence is associated with disease progression and increased complication rates, as well as healthcare costs. The present review analyzes and discusses the causes of variability of the adherence to the prescribed drugs. The education of patients about glaucoma and the potential consequences of insufficient adherence and persistence seems fundamental to maximize the probability of treatment success and therefore prevent visual disability to avoid unnecessary healthcare costs.

The Effectiveness of a Nurse-led Glaucoma Education on Patient Knowledge and Compliance Motivation Levels: A 1-year Prospective Case Series

Purpose

To evaluate the impact of a nurse-led glaucoma education program on patient knowledge and compliance levels in an Asian population.

Materials and Methods

A 1-year prospective case series involving 69 adult glaucoma patients. Each patient attended a standardized nurse-led glaucoma education session. A questionnaire was administered by a single nurse-clinician and analyzed at three time points (preeducation for baseline, immediately posteducation, and at the 1-year follow-up) to evaluate for associations with patient knowledge and compliance motivation levels.

Results

A total of 64 patients were included in the final analysis. Patients with higher educational qualifications or who were employed had better baseline knowledge of glaucoma. Younger patients had higher baseline compliance motivation levels. Immediately posteducation, both median patient knowledge score and compliance motivation levels had a statistically significant increase. Patients on more glaucoma eye drops had greater immediate improvement in confidence in eye drop application. Patients with more positive Humphrey visual field mean deviation values had a greater immediate improvement in confidence in their understanding of glaucoma. A total of 34 patients were readministered the questionnaire at the 1-year time point. Median score for patient knowledge was highest at this point. Employed patients demonstrated better patient knowledge at baseline and at 1-year time point compared to unemployed patients. Unemployed patients experienced a significant improvement in scores from baseline to immediately posteducation, but improvement from immediately posteducation to the 1-year time point was insignificant was insignificant.

Conclusion

Our study has examined the effectiveness of a nurse-led glaucoma education program in an Asian population, demonstrating improvement in both patient knowledge and compliance motivation levels up to 1 year after intervention.

How to cite this article

Sng JJ, Ang BCH, Soo Hoo WC, et al. The Effectiveness of a Nurse-led Glaucoma Education on Patient Knowledge and Compliance Motivation Levels: A 1-year Prospective Case Series. J Curr Glaucoma Pract 2023;17(3):149-156.

Aiding Adherence to Glaucoma Medications: A Systematic Review

PURPOSE

To provide a comprehensive assessment of the strategies studied to date that focus on improving glaucoma medication adherence.

METHODS

A systematic review of the literature was conducted in MEDLINE (PubMed), Embase (Elsevier), and Scopus (Elsevier) from inception to March 1, 2021, of publications describing a device or strategy used to improve glaucoma medication adherence.

RESULTS

42 studies described by 50 papers were included. Five categories were identified: reminder systems, medication simplifications, behavioral change programs, education, and alternative engagement strategies.

CONCLUSION

Most studies (40 of the 42) addressed the question of improved adherence directly, with 26 finding improved adherence. Notably, 14 examined the clinical effects of the intervention, either in terms of intraocular pressure (IOP) or visual fields. Only three found an improvement in IOP. None demonstrated a between group difference in visual field progression.

Psychometric Properties of the Glaucoma Treatment Compliance Assessment Tool (GTCAT) in a Brazilian Population

PURPOSE

To determine the psychometric properties of a reduced version of the Glaucoma Treatment Compliance Assessment Tool (GTCAT), which was translated to Brazilian Portuguese.

PATIENTS AND METHODS

We translated into Portuguese the GTCAT using validated techniques and administered it to a group of glaucoma patients using at least 1 ocular hypotensive eye drop medication. We used principal components analysis to determine construct validity, Rasch analysis, and Cronbach α for internal consistency reliability, frequency analysis for floor and ceiling effects, and Spearman ρ for test-retest reliability.

RESULTS

We included 76 glaucoma patients. Principal component analysis loaded 14 questions into 7 components that were consistent with the Health Belief Model. The components were related to "barriers due to lack of drops," "self-efficacy," "experience of negative effects of the disease," "well-being," "general glaucoma knowledge," "glaucoma symptoms," and "cues-to-action." No statements had floor or ceiling effects, and all statements had acceptable test-retest reliability. Components had internal consistency Cronbach α reliability between 0.125 and 0.794. and average Spearman ρ reliability was 0.73, ranging from 0.44 to 1.00. According to Rasch analysis, the mean (±SD) of the person measures was 0.24±0.15 logits, person separation index was 0.58, and person reliability 0.25.

CONCLUSIONS

The Portuguese-translated version of the GTCAT showed acceptable psychometric properties. With further refinement, clinicians and researchers could use it to better investigate glaucoma adherence issues in the Brazilian population.

Psychometric Properties of the Reduced Version of the Glaucoma Treatment Compliance Assessment Tool (GTCAT)

PURPOSE

To measure the psychometric properties of a reduced, 27-statement version of the Glaucoma Treatment Compliance Assessment Tool (GTCAT).

METHODS

We administered the GTCAT to 183 participants who were using a single bottle of an ocular hypotensive agent, and objectively measured adherence with Medication Event Monitoring System devices over 60 days. Adherence was the number of days with correctly timed bottle openings divided by the total number of study days. Using the 47-statement GTCAT, we created a reduced GTCAT by removing statements that: (1) did not load using Principal Components Analysis (PCA); (2) did not have a univariable association with adherence; or (3) were highly correlated (.75 or higher) with another statement. We assessed the construct validity of the remaining statements using PCA and assessed the predictive validity using multiple logistic regression analysis.

RESULTS

We removed 20 statements because they did not appear in the PCA analysis; were not predictive of adherence; and/or had high correlation. PCA of the reduced GTCAT (27 statements) extracted 5 components of the Health Belief Model (knowledge, susceptibility, cues-to-action, self-efficacy, and barriers). Multiple regression showed that the 27 statements predicted adherence (Rsq = .11, p = .03).

CONCLUSIONS

The reduced version of the GTCAT is associated with adherence, which suggests that after external validation, future glaucoma medication adherence studies could use the reduced version to efficiently measure health behaviors and determine the benefit of the GTCAT to develop personalized interventions in glaucoma adherence.

Comparison of Two Fixed Beta-Blocker-Pilocarpine Combinations

Purpose

To compare the efficacy and safety of a newly developed ophthalmic solution containing carteolol 2% and pilocarpine (2% (CBS341A) with a timolol 0.5% and pilocarpine 2% fixed combination.

Patients and Methods.

A randomized, double-masked, multicenter study was conducted in 209 patients with primary open-angle glaucoma or ocular hypertension, whose intraocular pressure (IOP) was higher than 21 mm Hg on bet-blocker twice a day alone. The test medications were administered twice daily for 4 months. IOP was measured at 9 and 11 a.m. at the beginning of the study (with beta-blocker alone) and after one and four months of treatment. Adverse effects were recorded.

Results

Both combinations caused a similar, statistically significant decrease in IOP. At four months, in the CBS341A group a 2.4 mm Hg (9%) reduction in IOP was achieved at 9 a.m. and 4.1 mm Hg (17.3%) at 11 a.m. compared with respectively 3 mm Hg (11%) and 4.5 mm Hg (19.5%) in the timolol-pilocarpine group. No statistical difference was observed between the two groups in safety and efficacy.

Conclusions

The carteolol-pilocarpine combination appears as safe and as effective as the timolol-pilocarpine combination in the medical treatment of primary open-angle glaucoma or ocular hypertension.

Strategies to Improve Glaucoma Compliance Based on Cross-Sectional Response-Based Data in a Tertiary Healthcare Center: The Glauco-Jung Study

Purpose: To elucidate compliance rates among glaucoma patients in a tertiary healthcare center, reasons for noncompliance and response-based-solutions to improve compl iance in the same cohort.

Materials and methods: In the Glauco-Jung study, a cross-sectional descriptive epidemiological one, information was obtained from 500 patients from 1st January, 2014 to 30th June, 2014. Patients were intercepted at entry point where they get their intraocular pressure (IOP) checked, wherein they were asked to fill an exhaustive questionnaire. At the same setting, they were also asked to demonstrate how they (or their relatives or helpers) instill eyedrops, following which any irregularities were brought to notice and corrected. Finally, they were also asked any suggestions to improve compliance to medications.

Noncompliance rates were determined based on the number of patients who did not instill anti-glaucoma medications as per prescribed dosage or frequency schedule. Noncompliance rates were then evaluated by the Chi-square test for any association with distributions based on various parameters.

Results: In case of a positive association, correlation coefficient was further calculated to know the strength of this association. No association was observed in distributions based on diet, associated co-morbidities, daily dosage frequency and side-effects experienced by patients. Positive association was noted in distributions based on age, sex, duration of treatment, social structure and number of medications (p < 0.05); but correlation coefficients were very weak (c < 0.3). Cost of medications not only had positive association but also had a very strong correlation coefficient (c = 0.9188), proving that cost of medications had a modest bearing on compliance rates.

Conclusion: The Glauco-Jung study concluded that besides availability of medications at reasonable cost, simplification of treatment regimen and interactive health education appear to be the most important factors for improving compliance so that patients do not feel guilty or inadequate because they have problems while administering their eyedrops.

How to cite this article: Gupta VS, Sethi H, Naik M. Strategies to Improve Glaucoma Compliance Based on Cross-Sectional Response-Based Data in a Tertiary Healthcare Center: The Glauco-Jung Study. J Curr Glaucoma Pract 2015;9(2):38-46.

Psychometric properties of the Glaucoma Treatment Compliance Assessment Tool in a multicenter trial

PURPOSE

To assess the psychometric properties of a new version of the Glaucoma Treatment Compliance Assessment Tool, a survey evaluating health behavior and glaucoma adherence using constructs from the Health Belief Model.

DESIGN

Psychometric analysis.

METHODS

We administered the 47-statement Glaucoma Treatment Compliance Assessment Tool to 201 participants who were using a single bottle of an ocular hypotensive agent, and objectively measured adherence with medication event monitoring system devices over 60 days. Adherence was the percentage of days with correctly timed bottle openings. We used principal components analysis to determine construct validity, Cronbach's alpha for internal consistency reliability, frequency analysis for floor and ceiling effects, and Spearman rho for test-retest reliability. We determined predictive validity using univariate and multiple regression.

RESULTS

The mean (±SD, range) adherence percentage was 79.9% (±18.5%, 20.3%-100.0%). Principal component analysis loaded 24 questions into 6 components that were consistent with the Health Belief Model. All 6 components had Cronbach's alpha reliability between 0.601 and 0.797. No statements had floor or ceiling effects, and all statements had acceptable test-retest reliability. Multiple regression analysis showed 4 Health Belief Model statements, white race, older age, and married marital status to be associated with higher adherence (adjusted R(2) = 0.27, P < .001).

CONCLUSIONS

The newest version of the Glaucoma Treatment Compliance Assessment Tool showed acceptable psychometric properties. With further refinement, clinicians and researchers could use it to examine factors related to adherence and measure improvement in adherence with a change in health behavior attitudes.

The eye drop chart: a pilot study for improving administration of and compliance with topical treatments in glaucoma patients

Aim

In order to improve patient education, compliance, and administration of eye drops prescribed for patients suffering with glaucoma within a UK ophthalmology department, an eye drop chart (EDC) was designed, developed, and piloted with patients attending the glaucoma clinic over 1 month.

Methods

A cross-sectional prospective pilot study of 25 patients using an administration aid and a self-reported questionnaire. Chi-square tests were used to compare responses pre- and postintervention.

Results

Results demonstrated an impressive improvement in nine of eleven categories assessed regarding drop administration and compliance. Patients stating that they always wash their hands increased significantly from 64% (13 participants) to 92% (23 participants) (P=0.029), and those who always shake the bottle improved from 40% (10) to 84% (21) (P=0.001). Punctal occlusion techniques improved from 44% (11) to 72% (18) (P=0.015). Finally, patients who always discarded the bottle after 28 days of use rose from 68% to 92%, though the difference was not significant (P=0.09). Only the number of drops being administered to the eye and the length of time left between the application of drops remained relatively unchanged. Sixty-four percent reported finding EDC helpful or useful, 52% had positive responses when asked if they would continue using EDC, and 88% would recommend it to a friend.

Conclusion

Although there are limitations to the data as they are subjective, descriptive, and limited to sample size of 25, the results of this pilot study have shown promise. The EDC appears to be a cost-effective way at improving patients’ use of topical ocular medications.

Psychometrics of a new questionnaire to assess glaucoma adherence: the Glaucoma Treatment Compliance Assessment Tool (an American Ophthalmological Society thesis)

PURPOSE

To report the psychometrics of the Glaucoma Treatment Compliance Assessment Tool (GTCAT), a new questionnaire designed to assess adherence with glaucoma therapy.

METHODS

We developed the questionnaire according to the constructs of the Health Belief Model. We evaluated the questionnaire using data from a cross-sectional study with focus groups (n = 20) and a prospective observational case series (n=58). Principal components analysis provided assessment of construct validity. We repeated the questionnaire after 3 months for test-retest reliability. We evaluated predictive validity using an electronic dosing monitor as an objective measure of adherence.

RESULTS

Focus group participants provided 931 statements related to adherence, of which 88.7% (826/931) could be categorized into the constructs of the Health Belief Model. Perceived barriers accounted for 31% (288/931) of statements, cues-to-action 14% (131/931), susceptibility 12% (116/931), benefits 12% (115/931), severity 10% (91/931), and self-efficacy 9% (85/931). The principal components analysis explained 77% of the variance with five components representing Health Belief Model constructs. Reliability analyses showed acceptable Cronbach's alphas (>.70) for four of the seven components (severity, susceptibility, barriers [eye drop administration], and barriers [discomfort]). Predictive validity was high, with several Health Belief Model questions significantly associated (P <.05) with adherence and a correlation coefficient (R (2)) of .40. Test-retest reliability was 90%.

CONCLUSION

The GTCAT shows excellent repeatability, content, construct, and predictive validity for glaucoma adherence. A multisite trial is needed to determine whether the results can be generalized and whether the questionnaire accurately measures the effect of interventions to increase adherence.

Eye drop instillation technique in patients with glaucoma

AIMS

To evaluate the technique of eye drop instillation in patients with glaucoma and assess factors associated with a good technique.

METHODS

A cross-sectional observational study of 85 participants using self-administered topical medication for glaucoma or ocular hypertension. Patients were asked to demonstrate how they normally instil eye drops using a 5-ml bottle of sterile artificial tear solution. The procedure was recorded and assessed by two masked graders. Whether the patient had been previously shown how to instil drops, the number of eye medications used, and self-perceived difficulty of using drops were also recorded. Univariable logistic regression was performed to relate each variable to drop technique and variables with P<0.2 were included in a multivariable logistic regression analysis.

RESULTS

54.1% (46/85) of patients had a poor drop technique, 11.8% (10/85) missed the eye, 15.3% (13/85) touched the tip of the bottle to the bulbar conjunctiva or cornea, and 27.1% (23/85) touched the eyelid or lashes with the bottle tip. 81.2% (69/85) could not recall being shown how to instil eye drops. In the multivariable model, previous instruction regarding drop instillation technique was significantly associated with good technique (adjusted OR=8.17, 95% CI 2.02-33.05, P=0.003) and increasing age was associated with poor technique (adjusted OR=0.95, 95% CI 0.91-0.99, P=0.017).

CONCLUSIONS

Education relating to eye drop instillation technique is significantly associated with a patient's ability to instil drops correctly. The assessment of a patient's ability to instil eye drops correctly should be a routine part of the glaucoma examination.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity.

MAIN RESULTS

Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive.

AUTHORS' CONCLUSIONS

Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

Patterns of adherence behaviour for patients with glaucoma

AIMS AND PURPOSE

Adherence to long-term treatment regimens for primary open-angle glaucoma holds a challenge for both clinicians and patients. The study aims were to (i) establish the magnitude of travoprost non-adherence using an Electronic Adherence Monitor (EAM), (ii) compare electronic with patient self-reported adherence, and (iii) explore the application of a previously reported method of graphically presenting adherence data to a larger cohort over a longer monitoring period.

METHODS

A cohort study of patients using travoprost for glaucoma or ocular hypertension was conducted. All participants used an EAM and adherence data were collected prospectively for 2 months. Self-reported adherence was obtained using the Morisky Medication Adherence Scale (MMAS); patients also reported frequency of missed doses. Potential predictors of adherence were collected via a structured interview. EAM-recorded interdose intervals were plotted graphically.

RESULTS

Of 100 patients invited to participate, 98 consented and EAM data were collected successfully from 88 participants. The median EAM adherence score for the cohort was 88.9% (interquartile range: 71.2, 92.2). When dichotomised (≥80%: adherent; <80%: non-adherent), EAM identified 36.7% as non-adherent and MMAS 12.2%. EAM data were used to classify five types of adherence behaviour including a category representing levels of ≥97% maintained by 21% of participants.

CONCLUSION

EAM revealed good adherence to glaucoma monotherapy but poor agreement with patient self-reported adherence. An adherence category of persistent and exceptionally high adherence to travoprost over a 2-month period was identified.

Patient satisfaction with topical ocular hypotensives

BACKGROUND

The aim of this study is to assess patient satisfaction, convenience of use, ease of administration, side effects and treatment burden of topical ocular hypotensives.

DESIGN

Prospective, observational cohort.

PARTICIPANTS

Two thousand five hundred and forty-one patients with glaucoma or ocular hypertension.

METHODS

The Treatment Impact Patient Satisfaction Scale (TIPSS) was administered by mail to all patients with glaucoma or ocular hypertension registered with Glaucoma New Zealand during a 3-month study period. The questionnaire assessed patient demographics; topical ocular hypotensive use including number of medications, frequency of administration, ease of use, class of medication, and presence/severity of side effects; impact on quality of life; and patient satisfaction. Univariate and multivariate analyses were performed to identify determinants of patient satisfaction.

MAIN OUTCOME MEASURES

Patient satisfaction.

RESULTS

Almost 80% of respondents were either 'very satisfied' or 'satisfied' with topical ocular hypotensives. Factors that were predictive of patient satisfaction included satisfaction with frequency of eye drop use {odds ratio (OR) 2.4 (95% confidence interval [CI] 1.8-3.1); P < 0.001}, subjective convenience (OR 2.6 [95% CI 2.0-3.4]; P < 0.001) and ease of administration (OR 2.5 [95% CI 2.0-3.3]; P < 0.001). Male gender was associated with lower satisfaction (OR 0.6 [95% CI 0.5-0.9]; P = 0.01). Factors that were not predictive of patient satisfaction included age, duration of eye drop use, class of medication and the presence of side effects.

CONCLUSIONS

Patients with glaucoma and ocular hypotension are satisfied with topical ocular hypotensives. Efforts to improve patient satisfaction should focus on convenience and ease of administration.

Comparison of the latanoprost 0.005%/timolol 0.5% + brinzolamide 1% versus dorzolamide 1%/timolol 0.5% + latanoprost 0.005%: a 12-week, randomized open-label trial

Objective

To compare the safety and effectiveness of fixed-combination regimes (latanoprost– timolol and brinzolamide 1% compared to dorzolamide 1%/timolol and latanoprost) in open-angle glaucoma patients after switching from a combination of three topical antiglaucoma eye drops.

Methods

We conducted an open, randomized 12-week multicenter prospective study. We randomly allocated 39 patients who had been treated with three antiglaucoma eye drops (prostaglandin F_2α analogues plus beta-blockers and carbonic anhydrase inhibitors) into two groups. Group A (n = 20) were treated with latanoprost–timolol and brinzolamide 1% therapy and Group B (n = 16) were treated with dorzolamide 1%/timolol and latanoprost. Thirty-six patients completed all 12 weeks of this study. The major clinical parameters measured were intraocular pressure (IOP), conjunctive hyperemia, superficial punctate keratopathy and hyperpigmentation of eyelid at baseline, 4, and 12 weeks. Additionally noted were adverse events and patient preferences, measured using a questionnaire at study initiation and at 12 weeks.

Results

At baseline, IOPs were (Group A: 14.1 ± 2.9 mmHg, B: 14.5 ± 2.9 mmHg; P = 0.658), (Group A: 13.8 ± 2.6 mmHg, B: 14.3 ± 2.8 mmHg; P = 0.715) at 4 weeks, and (Group A: 14.1 ± 2.7 mmHg, B: 14.2 ± 2.7 mmHg; P = 0.538) at 12 weeks. Among the groups, there was no significant difference at any time point after baseline (P = 0.923, 0.951, respectively). All adverse events were not remarkably different after therapy. In regards to patient preference before and after switching therapy, 10 patients (50%) in Group A and 10 patients (63%) in Group B preferred using fixed-combination eye drop therapy.

Conclusions

Effectiveness and safety were maintained in both groups after switching therapy. Overall, patients generally preferred using a fixed-combination therapy.

Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review

PURPOSE

This study summarizes findings from objective assessments of compliance (or adherence) and persistence with ocular hypotensive agents in patients with glaucoma and ocular hypertension.

DESIGN

Systematic literature review.

METHODS

A PubMed and reference list search was conducted across publication years 1970-2010, using these terms and variants: "compliance," the equivalent term "adherence," and "persistence" in patients with these conditions and therapies. Summaries of selected studies were stratified by measurement method (electronic monitor, prescription fills review, medical chart review). Measures of central tendency across studies were calculated for commonly-reported compliance or persistence measures.

RESULTS

Fifty-eight articles met all inclusion/exclusion criteria: measurement of compliance-electronic monitoring (seven studies reported in 14 articles), measurement of compliance/ persistence-prescription records (36 studies in 38 articles), and measurement of persistence- medical chart review (six studies in six articles). From electronic monitoring, most therapy-experienced patients took medication consistently, but ≥20% met criteria for poor compliance. From prescription records, only 56% (range 37%-92%) of the days in the first therapy year could be dosed with the medication supply dispensed over this period. At 12 months from therapy start, only 31% (range 10%-68%) of new therapy users had not discontinued, and 40% (range 14%-67%) had not discontinued or changed the initial therapy. From medical chart review, only 67% (range 62%-78%) of patients remained persistent 12 months after starting therapy.

CONCLUSIONS

Evidence provided by this review suggests that poor compliance and persistence has been and remains a common problem for many glaucoma patients, and is especially problematic for patients new to therapy. The direction of empirical research should shift toward a greater emphasis on understanding of root causes and identification and testing of solutions for this problem.

Noncompliance with drug therapy of glaucoma: a review about intervening factors

Glaucoma is defined as an optic neuropathy, characterized for loss of visual field and injury of the optic nerve, being considered as the second cause of blindness in the world, which could be prevented by the use of antiglaucoma eyedrops. The lack of adhesion of the patient to the drug treatment can culminate with loss of the vision. The objective was to revise possible literature data regarding intervening factors for noncompliance and explain estimated rates of noncompliance. A systematic review about the subject was carried out in the period of January to June of 2006. Articles had been searched in two data bases, in the National Library of Medicine (PUBMED) and in the Literature Latin American and Caribbean Health Sciences (LILACS) using the following keywords: glaucoma, compliance of the patient, noncompliance of the patient, treatment and eyedrops. In PUBMED, 199 articles were collected, written in English and French languages. No article was found in LILACS. Considering the inclusion and exclusion criteria, 27 articles were selected, with 25 originals and two reviews. Twelve possible intervening factors for noncompliance were raised, as well as estimates for rates of noncompliance. The noncompliance rates varied from 4.6% up to 59%. Two factors, forgetfulness and inadequate between-doses interval, had been associated to noncompliance of the drug therapy. The factors race, adverse effects, treatment cost, number of instilled doses, coexisting illnesses and number of eyedrops used, had resulted contradictory, being impossible to affirm that they have contributed for noncompliance. Age, sex, educational level and loss of visual field, had not been associated with noncompliance. The glaucoma patients tended to disregard the drug treatment. The wide variation in noncompliance rates could be an influence from the authors' difficulty to define the noncompliance and the variety of methodologies used to estimate it. More studies are necessary for a better evaluation of these 12 raised factors.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information and ongoing support according to patient need, may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, ZETOC and OpenSIGLE. In addition, we searched research registers of ongoing studies. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 15 January 2009.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We calculated the mean difference for continuous data and relative risks for dichotomous data. Where appropriate, we pooled data using a fixed-effect model.

MAIN RESULTS

Eight trials met the inclusion criteria. There was considerable heterogeneity of interventions and reported outcome measures and therefore, meta-analysis was limited to two studies. Overall, studies were not of high quality due to small sample sizes, missing data and short term follow-up. Three of five drug comparison studies provided evidence that reducing the frequency of drops can improve adherence. However, the study that compared the least frequent regime with one of the most complicated, showed no difference in reported adherence. A small study of thirteen patients found a reminder device beneficial to adherence levels yet only one of two studies involving education and individualised care planning was found to be successful.

AUTHORS' CONCLUSIONS

Interventions involving simplified dosing regimes, reminder devices, education and individualised care planning, did show improvements in adherence rates. However, due to inadequate methodological quality and heterogeneity of study design we are unable to advocate any particular interventions at this time.

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

PURPOSE

To identify specific items on knowledge and need for information that could be used to improve compliance with glaucoma medication.

METHODS

Forty-four randomly selected ophthalmologists assigned 166 consecutive glaucoma patients to complete a questionnaire. The questionnaire was developed systematically based on focus group interviews, consultation of experts and a pilot test. Items included knowledge about glaucoma and its treatment, need for information and compliance with therapy.

RESULTS

No statistically significant correlation was found between the total level of knowledge and compliance. Concerning knowledge of glaucoma, one out of 19 items had a statistically significant negative correlation with compliance. Concerning knowledge of glaucoma treatment, one out of 18 items had a statistically significant positive correlation with compliance. Regarding total need for information, no statistically significant correlation with compliance was found. Three out of 22 items had a statistically significant positive correlation with compliance.

CONCLUSION

Given the number of related items, their direction and limited strength of correlation and the difficulty of hypothesizing a causal relation for some items, it is unlikely that further improving knowledge will greatly improve compliance with glaucoma medication. Interventions focused on attitude and discipline may be of more benefit in improving compliance with therapy.

The importance of eyelid closure and nasolacrimal occlusion following the ocular instillation of topical glaucoma medications, and the need for the universal inclusion of one of these techniques in all patient treatments and clinical studies

PURPOSE

To review the effects of nasolacrimal occlusion (NLO) and eyelid closure (ELC) on the ocular and systemic absorption of topically applied glaucoma medications and emphasize the need for the universal application of these techniques during patient treatment and in clinical studies of topically applied glaucoma medications.

METHODS

Following a review of data suggesting great clinical benefit from NLO and ELC, the absence of inclusion of these simple techniques in published studies of topical glaucoma medications is identified. The effect of this oversight on these studies is noted with reference to each of the 5 major groups of glaucoma medications.

RESULTS

A review of the literature suggests that NLO and ELC improve intraocular penetration of topically applied glaucoma medications and discourage systemic absorption. The US Food and Drug Administration and the National Institutes of Health discourage the inclusion of these techniques in studies of the efficacy and toxicity of topically applied glaucoma medications. Consequently, all glaucoma studies reported in the literature lack the inclusion of these techniques for 5 minutes. This omission has major implications for patient informed consent, study protocol consistency, and the value of clinical studies, and directly affects the therapeutic index of glaucoma medications in unpredictable and undesirable ways. The undesirable influence on the therapeutic index of each drug influences the safety and efficacy and has implications for the cost of medical treatments, the reproducibility of clinical study results, and dosing regimens, including those of combination therapy, as reflected in the peer-reviewed literature.

CONCLUSIONS

Patients should use NLO or ELC for 5 minutes following eye drop treatment with topically applied glaucoma medications. Furthermore, it is essential that these techniques be included in all clinical studies of topically applied glaucoma medications to ensure the most favorable therapeutic index and its accurate determination. This will also help provide the most consistent, reliable, and reproducible study results.

Twenty-four-hour efficacy of the brimonidine/timolol fixed combination versus therapy with the unfixed components

PURPOSE

To evaluate the 24-h intraocular pressure (IOP) control of brimonidine/timolol fixed combination (BTFC) versusthe unfixed combination of its individual components, each dosed twice daily, in patients with primary open-angle glaucoma or ocular hypertension.

METHODS

An observer-masked, randomized, crossover, active-controlled, two-centre comparison. Following a 6-week medicine-free period, patients were randomized to BTFC or to the unfixed combination of brimonidine and timolol for 3 months. Patients then were crossed over to the opposite treatment for another 3 months. At the end of the medicine-free period, and each treatment period, patients underwent 24-h IOP measurements at 0600, 1000, 1400, 1800, 2200, and 0200 hours.

RESULTS

Twenty-eight patients completed this study. Both BTFC and the unfixed components showed a significant IOP reduction from untreated baseline (P<0.0001), and were statistically equal when compared directly, for each individual time point and for the 24-h IOP curve (P>0.05). The mean 24-h IOP was 24.6+/-1.9 for baseline, 19.2+/-1.9 for BTFC, and 19.2+/-1.6 mmHg for the unfixed components (P=1.0). Four patients were discontinued due to side effects. The most common ocular adverse event was ocular hyperaemia (n=3 with BTFC and n=5 with the unfixed components, P=0.7) and systemic adverse events were rare.

CONCLUSION

This study suggests that both BTFC and the unfixed components of brimonidine and timolol provide a significant 24-h IOP reduction from untreated baseline, and statistically equal control when compared directly, at each time point and for the 24-h pressure curve.

An evaluation of how glaucoma patients use topical medications: a pilot study

PURPOSE

Multiple factors can influence patients' adherence to topical ophthalmic intraocular pressure-lowering medications. An important factor that is often overlooked is the method of eye drop administration, including the handling, storing, and actual administering of eye drops. These aspects of patients' eye drop administration, which may be strongly related to the success of prescribed therapies, are evaluated.

METHODS

A 2-page questionnaire was distributed to 253 sequential glaucoma patients at the time of their regular clinical visit with one of two geographically distinct glaucoma specialists. In addition to providing demographic data, the patients were asked to complete a 2-page questionnaire about their current use of eye drops.

RESULTS

The study participants had a mean age of 71.5 years (SD, 15.1 years) and were predominantly female (59.8%) and white (72.6%). Approximately 17% of them relied on others for the administration of drops and most commonly cited inadequate vision and trouble with manual dexterity leading to this dependency. Of those who self-administered drops, only 16.3% used a mirror. The most common location for administration was the bedroom (46.8%), followed by the bathroom (23.4%) and kitchen (16.1%). Almost 16% reported "rarely" or "never" washing their hands.

CONCLUSIONS

Although most individuals may have little difficulty with the use, storage, and handling of eye drops, this study demonstrates that broad variation in reported practices exists. This finding suggests a need for better instruction in eye drop administration and illuminates some of the methodological problems that could be overcome to reduce patients' frustration, improve compliance, and increase efficacy.

The clinical validity of the treatment satisfaction survey for intraocular pressure in ocular hypertensive and glaucoma patients

PURPOSE

To provide initial validation of the Treatment Satisfaction Survey-Intraocular Pressure (TSS-IOP) quality-of-life survey that analyses specific issues related to side effects, patient satisfaction, and compliance.

METHODS

A prospective, observational cohort of 250 consecutive patients with primary open-angle glaucoma or ocular hypertension was administered the TSS-IOP survey.

RESULTS

Factors that correlated with patient satisfaction included perceived effectiveness of the medicine (F=7.47, P<0.001), ocular irritation (F=6.06, P<0.001), conjunctival hyperaemia (F=4.40, P<0.001), ease of use (F=8.52, P<0.001), and convenience of use (F=6.90, P<0.001). Patient compliance, acceptance of their illness, and knowledge of glaucoma were also related to perceived effectiveness of the medicine (P<0.001), ease of use (P<0.05) and convenience (P<0.001). Physician ratings of patient pressure control, side effects, and instillation problems also were significantly correlated to patient satisfaction (R=0.13-0.26, P=0.05-0.001). The physician ratings of patient compliance, however, were not significantly related to any dimension of patient satisfaction (P>0.05). Among monotherapy prostaglandin treatments, latanoprost demonstrated statistically greater satisfaction than bimatoprost or travoprost regarding conjunctival hyperaemia (P<0.05) and eye irritation (P<0.01).

CONCLUSIONS

This study provides initial evidence that patient satisfaction may be related to compliance, perceived effectiveness of treatment, adverse side effects, ease and convenience of use, acceptance of illness, and knowledge of glaucoma.

Prévalence et description du traitement par hypotonisants pour glaucome et hypertonie oculaire en France

PURPOSE

The first objective of the present study was to estimate the prevalence of patients treated for glaucoma or ocular hypertension (OHT) with an IOP (intraocular pressure) -lowering topical medication. Subjects were 40 years old and living in continental France. The second objective was to describe the type of therapy, compliance, and the quality of life of the subjects treated.

METHODS

This study was a telephone survey conducted in a general population on a representative sample of 5726 subjects in 2004. Subjects treated for glaucoma or OHT were defined as those declaring use of eye drops for more than 1 month and mentioning one of the 52 registered IOP-lowering topical medications and/or stating that they were taking eye drops for glaucoma or OHT. Quality of life was measured using the GlauQOL-17 questionnaire.

RESULTS

237 subjects (4.1%) corresponded to this definition. The prevalence increased with age, from 0.7% in subjects aged 40-44 years to 10.6% in those aged 80 years or more. The age-standardized prevalence was higher in the Paris area (5.3%), the Mediterranean (4.5%), and the Southwest (4.7%), and lower in rural areas (3.2%), and in subjects with less than high school education (2.9%). Beta-blockers (49.5%) and prostaglandins (37.4%) were the most frequent treatments, followed by carbonic anhydrase inhibitors (15.3%), sympathomimetics (5.7%), and myotics (1.3%). Compliance was not total in 39% of the patients (22% of those treated with once-a-day dosage).

DISCUSSION

The results of the present study are in line with French health authority data and with the results of the French "Glaucoma and intraocular high pressure, one day" study results. Moreover, the lower prevalence in regions with low medical density, low socioeconomic level, and rural areas, suggest that glaucoma or OHT might be underdiagnosed.

CONCLUSION

On the basis of this first nationwide study, it can be estimated that the prevalence of subjects treated with IOP-lowering topical medications is about 1.2 million in France. The number of daily doses appears to influence compliance.

Patient and ophthalmologist attitudes concerning compliance and dosing in glaucoma treatment

AIM

The aim of this study was to identify research avenues that might improve patient compliance with glaucoma therapy.

METHODS

500 patients and physicians were interviewed by telephone in 5 European countries, and the results were compiled and evaluated by 2 independent physicians.

RESULTS

Most physicians believed that pressure reduction is useful (UK (96%), France (94%), Spain (80%), Italy (72%), and Germany (70%), p < 0.0001). The majority of physicians believed that noncompliance exists in 0%-25% of patients, whereas 34% of patients admitted to noncompliance. Physicians believed patients would prefer once-daily dosing (92%) and that it would help compliance, whereas 60% of patients preferred once-daily dosing, and 20% of patients believed it would help compliance. Physicians (94%) believed that noncompliance could lead to visual loss and, while this information concerned most physicians, this was less likely in Germany (52%) (p < 0.0001). Most patients received information concerning dosing of their medicines (79%), and, accordingly, waited an average of 10 minutes between doses; but only half of the patients had been told to wait at least 5 minutes between instilling preparations. Approximately 2 of 3 patients knew that missing medicines could cause visual loss.

CONCLUSIONS

Once-daily dosing to increase patient satisfaction and/or dosing convenience and providing patient education are potential clinical techniques that could be further evaluated as a means to increase compliance.

Microprocessor controlled compliance monitor for eye drop medication

BACKGROUND/AIMS

The effectiveness of a self administered eye drop medication can only be assessed if the compliance is known. The authors studied the specificity and sensitivity of a new microprocessor controlled monitoring device.

METHODS

The monitoring system was conducted by an 8 bit microcontroller for data acquisition and storage with sensors measuring applied pressure to the bottle, temperature, and vertical position. 10 devices were mounted under commercial 10 ml eye drops. Test subjects had to note down each application manually. A total of 15 applications each within 3 days was intended.

RESULTS

Manual reports confirmed 15 applications for each of the 10 bottles. The monitoring devices detected a total of 149 events; one was missed; comprising a sensitivity of 99%. Two devices registered three applications, which did not appear in the manual protocols, indicating a specificity of about 98%. Refrigerated bottles were correctly identified. The battery lifetime exceeded 60 days.

CONCLUSION

The new monitoring device demonstrated a high reliability of the collected compliance data. The important, yet often unknown, influence of compliance in patient care and clinical trials shall be illuminated by the new device. This may lead to a better adapted patient care. Studies will profit from a higher credibility and results will be less influenced by non-compliance.

Accuracy of an Electronic Monitoring and Reminder Device for Use With Travoprost Eye Drops

PURPOSE

To evaluate the accuracy of a prototype electronic device for recording eye drop usage.

PARTICIPANTS AND METHODS

Ten volunteers were randomly assigned to one of five usage patterns designed to mimic common patterns of use in glaucoma patients from 100% compliant to 50% compliant. All participants agreed to adhere to a pre-determined "dosing" schedule for 15 days using the monitoring/reminder device to instill artificial tears. Participants also recorded drop usage in a diary. The main outcome measures were device accuracy and reproducibility. Device accuracy was defined as the magnitude of the difference between the diary and device output for three variables: date, number of drops, and instillation time.

RESULTS

Date stamping by the device was 100% accurate. The mean +/- SD time difference between the device and the diary was -2.0 +/- 19.7 minutes when data from all participants was pooled. In seven of the ten participants, the device did not record at least one drop. The mean +/- SD difference in the number of drops recorded by the device minus the diary was 0.16 +/- 0.97 when data from all participants was pooled.

CONCLUSIONS

The prototype compliance reminder/monitoring device may underestimate compliance in some patients. The date and time stamping mechanisms were generally accurate and reproducible.

Compliance et persistance

PURPOSE

1) To summarize the literature on compliance (the extent to which the patient's behaviors correspond with the provider's recommendations) and persistence (total time on therapy) in patients with open-angle glaucoma or ocular hypertension. 2) To suggest guidelines to improve these two parameters, which are both essential and integral elements of optimizing patient care.

METHODS

Compliance-related research published between 1980 and March 2005.

RESULTS

Medication compliance has mostly been investigated and measured using patient self-reports, electronic monitoring, and medication possession ratio. Noncompliance-related problems are underestimated, complex, unpredictable and frequent. Noncompliance rates of at least 25% have been reported. The main obstacles to medication compliance are situational/environmental or related to the side effects or complexity of the medication regimen. Persistence with glaucoma medications has also been proven to be poor. Based on retrospective studies using survival analyses, fewer than 25% of patients may be persistent over 12 months. Persistence rates differ from one treatment to another and may fluctuate with time in the same patient.

CONCLUSIONS

Improving the quality of information, the patient-physician relationship, and educating patients are all crucial. Simplification of the treatment regimen and selection of medications with the fewest systemic and ocular side effects must be a priority. Accurately assessing patient compliance and persistence are indispensable to reducing mistakes from either medication noncompliance or lack of persistence with poor efficacy and to avoid unnecessary changes in a patient's therapeutic regimen or surgery.

Chronic open angle glaucoma: patient awareness of the nature of the disease, topical medication, compliance and the prevalence of systemic symptoms

PURPOSE

To study the awareness of the nature of the disease, compliance with treatment, and prevalence of systemic symptoms in a group of patients with chronic open angle glaucoma (COAG).

METHOD

A structured questionnaire was designed and given to 260 consecutive COAG patients attending a general ophthalmology clinic. Questions related to the increased risk of COAG amongst family members, screening of family members, nature of field defects, variation in IOP, topical treatment and availability of a free eye test for a COAG patient in the UK were asked. Compliance and systemic symptoms were also assessed.

RESULTS

Forty-one per cent (107 of 260) of patients in the study group were aware of the increased risk of COAG in family members and 45.5% (118 of 260) of patient's family members had undergone screening for COAG. Seventy-three per cent (191 of 260) of the patients were aware of their own and their family members' entitlement to a free eye test. Seventy-seven per cent of patients claimed full compliance. Thirty per cent of patients were noted to have systemic symptoms.

CONCLUSIONS

The awareness of the nature of COAG in this population was low and incidence of perceived drug related systemic symptoms very high. Both of these may contribute to poor compliance.

The Finnish evidence-based guideline for open-angle glaucoma

In most patients, chronic open-angle glaucoma is a slowly progressive disease. Eyes with very high intraocular pressure (IOP > 30 mmHg) represent an exception to this and should be treated and followed extremely intensively. As lowering IOP is, so far, the only means of treating glaucoma, the majority of research reports deal with the IOP-lowering effect of the treatment. The primary goal of treatment, however, is to prevent glaucomatous damage to the structures and function of the eye. The effectiveness of treatment is monitored with optic disc and retinal nerve fibre layer imaging and with visual field examinations. If the glaucomatous changes are progressing, more effective treatment should be given. In the course of follow-up, it should be noted that the changes in the optic nerve structure and function appear and progress at different time-points with delays of up to several years. The assessment of abnormalities is dependent on the examination method and requires a great deal of experience on the part of the examiner. The important risk factors in glaucoma are elevated IOP (even if IOP is within normal range in half of patients ), age, positive family history, exfoliation, race and myopia.

Causes of non-compliance with drug regimens in glaucoma patients: a qualitative study

The purpose of this study was to gain insights into why patients are not compliant with their glaucoma medications. Patients were recruited from lists provided by two ophthalmologists. Each patient had seen a minimum of two ophthalmologists for their glaucoma, and was taking at least two topical medications for glaucoma. Qualitative methodology was utilized, including two focus groups and eleven in-depth interviews in patients' homes. The results showed that forgetfulness was the number one reported reason for non-compliance. Patients did not claim to be non-compliant specifically because of side effects, but they did complain about them. Communication between physicians and patients is a key factor in compliance for glaucoma patients. Specifically, patients would like their physicians to teach them how to instill their eye drops, tell them about new/alternate medications and procedures as they become available, and offer new ways to make their regimen easier. Patients often do not tell their physician if they experience a side effect unless it is intolerable to them, yet they do realize the seriousness of glaucoma, and the consequences of not following their doctor's orders. Finally, while cost was not a reported deterrence to compliance, some patients would prefer less expensive alternatives.

Compliance and viewpoint of glaucoma patients in Greece

PURPOSE

To document the prevalence of non-compliance and to investigate patients' perceptions concerning glaucoma in a Greek cohort.

METHODS

We investigated 100 consecutive patients referred to our glaucoma clinic and already treated for chronic glaucoma. Compliance and patients' insight were ascertained by two independent observers by means of a predetermined questionnaire. All patients were subsequently assessed for their ability to instil their eyedrops accurately.

RESULTS

Fifty one per cent of our patients were not aware of the nature of glaucoma, but 80% were afraid it might lead to blindness. Clinically significant non-compliance (more than two doses missed per week) was established in 44% of our patients. Men and those using eyedrops more than 4 times a day were more likely to default. Non-compliant patients exhibited higher mean intraocular pressure (22.9 vs 18.5 mmHg; p > 0.001) and worse visual field loss (10.8 vs 7.0 dB; p = 0.008) compared with compliant patients. Involuntary non-compliance was also common in our group, with only 53% instilling their eye drops accurately.

CONCLUSION

Non-compliance is a significant limiting factor in glaucoma therapy in Greece.

A critical evaluation of the methodology of the literature on medication compliance

OBJECTIVE

To develop a simple evaluation tool to assess methodologic rigor of the literature on patient compliance with medications, and to apply the tool to a sample of the literature.

METHODS

A computerized search of the MEDLINE database (January 1980-December 1996) was performed. All English-language articles on compliance with medications were identified, using the MeSH terms patient-compliance and drug-therapy. A 10% sample was then randomly selected for review. Methodologic rigor was assessed on eight standards: study design, specification of patient sample, power analysis, specification of disease, specification of therapeutic regimen, duration of follow-up, definition of compliance, and compliance measurement. The raw scores of the eight standards were then combined in three summary scores, standardized from 0 to 100: study design, disease-related features, and compliance issues.

RESULTS

Seventy-two articles from 719 identified were reviewed. The majority of the research articles were descriptive (63.9%), and patients in these studies were selected mainly from a convenience sample (41.7%). Just nine studies were multicenter studies, and three employed power analysis. The compliance definition was replicable in 41.7% of the studies. In 22 articles neither the compliance measure nor the criteria were stated. One-quarter of the studies (18) used a nonvalidated measure of compliance. Only two studies reached a score of 6 in the compliance measure, and eight studies used two different measures of compliance simultaneously. The median values in the summary scores were: study design 8.3, disease 42.9, compliance issues 50.

CONCLUSIONS

The quality of the compliance research was generally poor. These low scores reflect very important shortcomings in the methodology. Such oversights make it difficult for the reader to critically assess the validity of the conclusions.

Prolonged, contemporaneous administration of pilocarpine and timolol increases the aqueous humor pilocarpine levels in rabbits

The purpose of this study was to gather information on the mechanism by which timolol/pilocarpine (TI/PI) combination eyedrops provide additive ocular hypotensive effects. An hypothesis, according to which the combination eyedrops prolong the intraocular permanence of PI as a consequence of decreased aqueous humor secretion induced by TI, was not supported by clear-cut literature evidence. It was thus sought to verify if repeated instillations in albino rabbits of combination TI/PI eyedrops do effectively prolong the turnover of PI. Commercial eyedrops containing 0.68% w/v TI maleate and 2.0% w/v PI hydrochloride, buffered at pH 6.8, and two reference solutions containing PI hydrochloride alone (2% w/v), buffered at pH 5.5 and 6.8, were instilled b.i.d. in albino rabbits for five days. Aqueous humor samples, analyzed after the last treatment, showed that the aqueous humor PI levels observed after administration of the combination eyedrops were significantly higher than those resulting from administration of the reference formulations. When compared with the pH 6.8 reference solution, the pH 5.5 one produced slightly higher and more sustained drug levels in the aqueous humor. The present results appear to confirm the assumption that an increased retention of PI in the aqueous humor is responsible for the additive effects on intraocular pressure reported by several authors for the combination TI/PI eyedrops.

The efficacy and safety of the dorzolamide-timolol combination versus the concomitant administration of its components. Dorzolamide-Timolol Study Group

OBJECTIVE

To evaluate whether a fixed combination of 2% dorzolamide and 0.5% timolol given twice daily showed equivalent efficacy to the concomitant administration of 2% dorzolamide given three times daily and 0.5% timolol given twice daily in patients whose intraocular pressure (IOP) remained elevated during monotherapy with 0.5% timolol twice daily.

DESIGN

Multicenter, parallel, randomized, double-masked clinical trial with an open-label extension.

PARTICIPANTS AND INTERVENTION

In the masked phase, 242 patients received either the dorzolamide-timolol combination twice daily and placebo three times daily or dorzolamide three times daily and timolol twice daily for up to 3 months. In the open-label extension, 220 patients received the dorzolamide-timolol combination twice daily for up to 9 months.

MAIN OUTCOME MEASURES

The criterion for establishing treatment equivalency was a 95% or greater confidence that the absolute difference in the mean change in IOP from baseline was less than 1.5 mmHg between treatments.

RESULTS

During 3 months of treatment, the dorzolamide-timolol combination reduced IOP relative to the 0.5% timolol baseline by approximately 14% at hour 0 (just before the morning dose), 20% at hour 2, and 15% at hour 8. The IOP-lowering effect of concomitant therapy with dorzolamide and timolol was approximately 16% at hour 0.20% at hour 2, and 17% at hour 8. At hours 0, 2, and 8, there was greater than 97% confidence that the treatments were equivalent. During the open-label extension, the mean IOP reduction ranged from 14% to 15% at hour 0 and from 20% to 21% at hour 2. The treatment groups were generally comparable in terms of adverse events, symptoms, ocular signs, visual acuity, visual fields, physical examination, and laboratory measures.

CONCLUSIONS

The IOP-lowering effect of the dorzolamide-timolol combination is comparable to that of dorzolamide three times daily plus timolol twice daily and is maintained for up to 1 year. The dorzolamide-timolol combination provides clinically important reduction in IOP relative to baseline treatment with timolol alone and is generally well-tolerated for up to 1 year.

Compliance with timolol treatment in glaucoma

PURPOSE

To assess levels of compliance in elderly patients on timolol eyedrops for glaucoma.

METHODS

A postal questionnaire was sent from the general practitioner to 86 patients over 55 years of age on repeat prescriptions for timolol eyedrops. The questionnaire asked details about the duration of treatment, family history, the level of understanding of the disease and the importance of treatment, other regular medication, side-effects attributed to the drops and how often patients omitted their drops. A search of practice and local hospital dispensing data was carried out to assess how frequently monthly repeat prescriptions for timolol eyedrops were dispensed over a 12 month period. This allowed a total volume to be calculated for each patient.

RESULTS

Twenty-four per cent of patients admitted to omitting eyedrops either occasionally or frequently. Fifty-one per cent were found to have had insufficient drops dispensed to comply with treatment as prescribed. In non-complaint patients the mean period without drops was 85 days of the year, with a maximum of 165 days.

CONCLUSION

Compliance with treatment is poor and patients underestimate their level of defaulting when questioned.

Short-term efficacy of apraclonidine hydrochloride added to maximum-tolerated medical therapy for glaucoma. Apraclonidine Maximum-Tolerated Medical Therapy Study Group

PURPOSE

We determined whether the addition of topical apraclonidine hydrochloride to eyes that are receiving maximal medical therapy but still have inadequate intraocular pressure control and that are scheduled to undergo surgery could adequately decrease intraocular pressure, postponing the need for further intervention.

METHODS

We performed a prospective, 90-day, multicentered, placebo-controlled, double-masked parallel study. We enrolled one eye each of 174 glaucoma patients with inadequate intraocular pressure control who were on maximally tolerated medical therapy. We continued to administer maximum medical therapy for glaucoma. Study medications were either apraclonidine hydrochloride 0.5% or placebo (apraclonidine's vehicle). Patients were instructed to take the study medication every eight hours. We measured intraocular pressure, change in intraocular pressure from baseline, and the number of eyes requiring surgery after the addition of study medication.

RESULTS

Fifty-two (60%) of 86 patients treated with apraclonidine maintained adequate intraocular pressure control throughout the study and avoided surgery, compared with 28 (32%) of 88 patients treated with placebo (P < .001). Apraclonidine treatment resulted in significantly more patients attaining an additional 20% reduction or more in intraocular pressure from baseline and an intraocular pressure less than or equal to 20 mm Hg (P < .05). The most common ocular complication was conjunctival hyperemia (11 of 86 patients, 12.8%). The most frequent nonocular problem was dry mouth (four patients, 4.7%).

CONCLUSION

Apraclonidine appeared to be safe in all eyes and efficacious in some eyes. It significantly lowered intraocular pressure when used in combination with maximally tolerated medical therapy, which delayed or prevented further glaucoma surgery for at least 90 days in 52 (60%) of 86 treated patients.

Topical apraclonidine hydrochloride in eyes with poorly controlled glaucoma. The Apraclonidine Maximum Tolerated Medical Therapy Study Group

OBJECT

We determined whether the addition of topical apraclonidine hydrochloride to eyes receiving maximal medical therapy, with inadequate intraocular pressure (IOP) control, and scheduled to undergo surgery, could adequately lower IOP, postponing the need for surgical intervention.

DESIGN

A prospective 90 day, multi-centered, placebo-controlled, doublemasked parallel study.

PATIENTS

We enrolled 174 glaucoma patients with inadequate IOP control on maximally tolerated medical therapy. All were candidates for either laser trabeculoplasty or invasive surgical intervention. We enrolled only one eye per patient.

INTERVENTIONS

We continued to administer maximum-tolerated medical therapy for glaucoma. Patients took the study medication every eight hours. Study medications were either apraclonidine hydrochloride 0.5% or placebo (apraclonidine's vehicle).

MAJOR OUTCOME MEASURES

We evaluated IOP, IOP change from baseline, and the number of eyes requiring surgery after the addition of study medication.

RESULTS

Sixty one percent of patients treated with apraclonidine maintained adequate IOP control throughout the study, avoiding additional surgery compared to 33.9% patients treated with placebo (P < .001). Apraclonidine treatment resulted in significantly more patients achieving either an additional > or = 20% reduction in IOP from baseline (resulting in an IOP < or = 20 mm Hg) (P < 0.05). The most common ocular complications were conjunctival hyperemia (12.6%), itching and foreign body sensation (6.8%), and tearing (4.5%). The most frequent non-ocular adverse events related to apraclonidine were dry mouth (4.5%) and unusual taste perception (2.2%).

CONCLUSIONS

Apraclonidine appears safe and efficacious. It significantly lowered IOP when used in combination with a patient's maximum tolerated medical therapy. This delayed or prevented further glaucoma surgery for at least 90 days in approximately 60% of treated patients.

Clinical experience with a fixed dose combination therapy of timolol and pilocarpine used twice daily in the management of chronic open angle glaucoma

Twenty-five eyes of 25 patients with primary chronic open angle glaucoma deemed controlled for 12 months were converted from timolol 0.25% or 0.5% b.d. and pilocarpine 2% q.i.d. to a combination drop (TP2) of combined timolol 0.5% and pilocarpine 2% given b.d. Mean intraocular pressures (IOP) were 18.68 +/- 2.84 mmHg at 1 month, 18.81 +/- 2.56 mmHg at 3 months and 18.56 +/- 2.01 mmHg at 6 months. These values were significantly higher than the initial IOP of 17.48 +/- 2.2 mmHg (p values 0.0006, 0.0001 and 0.0004 respectively). However, 1 month following reconversion to initial therapy the IOP was 17.68 +/- 2.67 mmHg, which was not significantly higher than the initial IOP (p = 0.46). In addition, of 8 eyes uncontrolled during the course of the study, 6 became controlled following reconversion to initial treatment. Combination therapy of TP2 b.d. cannot be recommended to control IOP satisfactorily in patients maintained on timolol 0.25% or 0.5% b.d. and pilocarpine 2% q.i.d.

Timolol-pilocarpine combined vs timolol and pilocarpine given separately

In a controlled, double-observer, multicenter study, we compared the effect of a fixed combination of timolol 0.5%-pilocarpine 4% twice a day with that of timolol 0.5% twice a day plus pilocarpine 4% three times a day in 80 patients with open-angle glaucoma whose intraocular pressure was greater than 21 mm Hg on timolol 0.5% twice a day alone. Administered twice daily, the combination drug lowered intraocular pressure as effectively as concomitant treatment with timolol twice a day and pilocarpine three times a day. No statistically significant differences in reduction of intraocular pressure were found between the two groups nor were any unexpected side effects observed.

Early trabeculectomy versus conventional management in primary open angle glaucoma

The results of a randomised, prospective, multicentre trial of the management of primary open angle glaucoma are presented at up to five years' follow up. Previously undiagnosed cases were selected with intraocular pressure of 26 mmHg or more on two occasions together with field loss characteristic of glaucoma. Analysis was performed on one eye selected at random from each of 99 patients. Conventional medical treatment followed in unsuccessful cases by trabeculectomy (group A) was compared with trabeculectomy at diagnosis followed when necessary by supplementary medical therapy (group B). The life expectancy of these glaucoma patients was found to be similar to that for the local population matched for age and sex. In group A after four years trabeculectomy had been performed in 53% of eyes because medical management had failed to control the disease. The rate of operation was lower in those patients with intraocular pressure less than 31 mmHg and mild relative field loss (17% at three years) than in those with intraocular pressure greater than 30 mmHg and dense scotomas (75% at three years). Early surgery provided much more stable control with fewer changes in treatment than in group A. The group mean intraocular pressure after trabeculectomy was 15.0 mmHg irrespective of the time of operation, and this was significantly lower than the intraocular pressure in those cases thought to be controlled on medical therapy alone at the end of the first year (20.8 mmHg). Early operation provided significantly better protection of visual field, and the extra loss of visual field with delayed operation occurred in the preoperative period. Changes in visual fields were not related to the use of miotics. There was no significant difference in the final visual acuity in the two groups, but six cases in group A lost central fixation because of progressive loss of visual field, and there were no such cases in group B. Cataract occurred in approximately 10% of cases in both groups, but in group A this happened with only half the number of operations and at a shorter postoperative follow-up than in group B. It appears that in cases of primary open angle glaucoma of this severity the risk of delaying operation are significantly greater than those of performing trabeculectomy as the primary treatment.

A double-masked study of timolol and pilocarpine combined

In a double-masked, randomized, multicenter study, 25 patients received timolol 0.5%-pilocarpine 2% twice a day, 25 received timolol 0.5%-pilocarpine 4% twice a day, and 25 received pilocarpine 4% four times a day. The combination drugs showed an immediate, significant reduction in intraocular pressure of 7.2 mm Hg (25%) and 10.7 mm Hg (37%), respectively. The lowered intraocular pressure level was maintained throughout the three-week test period. With pilocarpine alone, intraocular pressure was reduced 5.3 mm Hg (19%). The mean intraocular pressure 12 hours after the last dose compared to two hours after the last dose was significantly higher both in patients receiving pilocarpine four times a day and in patients receiving timolol 0.5%-pilocarpine 4% twice a day (5.1 and 3.6 mm Hg, respectively), but not in patients receiving timolol 0.5%-pilocarpine 2% twice a day (2.6 mm Hg).