Compliance with treatment of patients with chronic open-angle glaucoma

Facilitators and Barriers to Using Selective Laser Trabeculoplasty (SLT) as First-Line Treatment for Glaucoma: Physician and Patient Views Gathered during an Exploratory Descriptive Qualitative Study

PURPOSE

To explore the perception of selective laser trabeculoplasty (SLT) among physicians and patients and the acceptance of using SLT as first-line treatment for glaucoma.

METHODS

Exploratory descriptive qualitative study based on semi-structured interviews with glaucoma specialists and patients in two eye hospital of Zhejiang and Guangdong Provinces, China. Data were analyzed using the thematic analysis framework approach.

RESULTS

11 glaucoma specialists and 12 glaucoma patients were interviewed. Four themes were identified in the data: Physicians' preferences for treatment types, patient views on treatment types, decision-making during the physician-patient encounter and feasibility of SLT as a first-line therapy. Advantages of SLT include safety and repeatability with limited side effects. However, concerns about the durability of the effect of the treatment were often mentioned by both physicians and patients. Some factors such as practice preference, personal motivation and patient characteristics may influence treatment choice. Most patients lack knowledge about SLT and hold high expectations of their treatments. Physicians report insufficient evidence supporting the use of SLT as first line therapy. Physicians report the need for locally relevant, evidence-based guidelines regarding the use of SLT in the treatment of glaucoma.

CONCLUSIONS

SLT was suggested as the first-line treatment of glaucoma due to its reliable efficacy and potential advantage. Results from our study offer important insight into barriers of increasing the uptake of SLT, which also provides some guidance for the use of SLT in the future.

Validation of a More Reliable Method of Eye Drop Self-Administration

SIGNIFICANCE

We propose an alternative method for eye drop self-administration. Similar IOP reductions were found with this method compared with clinician instillation. The alternative method of self-administration potentially benefits patients who have trouble successfully instilling drops.

PURPOSE

The purpose of this study was to validate the efficacy of an alternative method of drop instillation.

METHODS

This study is a randomized controlled crossover clinical trial. Thirty participants were recruited. A drop of 0.5% timolol maleate was instilled into subject's eye on two separate visits. On one visit, eye drop instillation was by a trained clinician, and on the other, self-instillation using an alternative method was used. The order was randomly chosen. Intraocular pressure was measured before drop instillation and 2 hours after drop instillation. The investigator was masked during measurement, and an observer recorded the IOP measurements.

RESULTS

Mean ± SD IOP measurement before 0.5% timolol maleate instillation measured 13.89 ± 2.29 mmHg. An average reduction 3.75 ± 2.36 mmHg was found with clinician administration, and an average reduction of 3.32 ± 2.31 mmHg was recorded with the new method. No significance was found in IOP reduction between two groups P < .45. Percent reduction was 25.17 ± 16.21% and 24.38 ± 16.31% in clinician instillation and alternative instillation method group, respectively. No significant difference was found. This percentage reduction was similar to previously reported studies. No reported cases of eye infection or irritation were found in any case, within a 3-month follow-up period.

CONCLUSIONS

We have proposed a more reliable method for instillation that provides a larger area for instillation and lessen the risk of contamination and patient's fear for eye drops. Similar efficacy was found compared with that of having a clinician directly administer the drop. This alternative method could potentially benefit patients who require topical eye drop therapy and result in increased compliance.

Glaucoma - Next Generation Therapeutics: Impossible to Possible

The future of next generation therapeutics for glaucoma is strong. The recent approval of two novel intraocular pressure (IOP)-lowering drugs with distinct mechanisms of action is the first in over 20 years. However, these are still being administered as topical drops. Efforts are underway to increase patient compliance and greater therapeutic benefits with the development of sustained delivery technologies. Furthermore, innovations from biologics- and gene therapy-based therapeutics are being developed in the context of disease modification, which are expected to lead to more permanent therapies for patients. Neuroprotection, including the preservation of retinal ganglion cells (RGCs) and optic nerve is another area that is actively being explored for therapeutic options. With improvements in imaging technologies and determination of new surrogate clinical endpoints, the therapeutic potential for translation of neuroprotectants is coming close to clinical realization. This review summarizes the aforementioned topics and other related aspects.

[Perception of ocular blinding manifestations of sickle cell disease by practitioners in Dakar university hospital]

INTRODUCTION

In Senegal, 10% of the population are said to be carriers of hemoglobin S, the most widespread hemoglobinopathy in the world. It is responsible for potentially blinding ophthalmological manifestations. Few practitioners refer patients for ophthalmologic screening. The goal of our study was to assess the level of knowledge of practitioners of the blinding ocular lesions of sickle cell disease.

MATERIALS AND METHODS

A cross-sectional prospective study was carried out over five months. It included Dakar university hospital practitioners aside from ophthalmologists. On the survey form, each practitioner specified his or her specialty and responded to eight questions regarding sickle cell patients seen in consultation, knowledge of the blinding lesions related to the disease, and ocular monitoring for blinding systemic diseases. The practitioners were divided into three groups: department of medicine and medical specialties (group I), surgery and surgical specialties (group II), and biology and functional testing (group III). The descriptive analysis was done with the EPI-INFO software version 6.04.

RESULTS

The participation rate was 45.88%. Group I represented 45.29% of the sample, Group II 35.85% and Group III 18.86%. In all, 87.73% of practitioners saw sickle cell patients in consultation, 75.47% were aware of ocular involvement related to sickle cell disease, and 58.49% were aware of blinding lesions. 94.62% of practitioners saw sickle cell disease patients without systematically recommending ophthalmological consultation.

CONCLUSION

Practitioners' level of knowledge of the blinding ocular lesions of sickle cell disease is considered to be low.

Is Patient Knowledge of Glaucoma Improved by Using a Glaucoma Logbook?

AIMS

Patient-held records are becoming more commonly used in health care, particularly in chronic diseases like glaucoma. There is a lack of evidence to support their use, however. This study examines the change in knowledge scores within a group following the introduction of a newly designed glaucoma logbook.

METHODS

This analysis uses a test and retest method where patients undergoing treatment for glaucoma or ocular hypertension were assessed using a validated knowledge questionnaire. They were then given a personalized glaucoma logbook and their knowledge scores retested after 4 to 8 weeks. The change in knowledge score was examined using a Wilcoxon signed-rank test.

RESULTS

A total of 56 patients were recruited and 35 completed both questionnaires equating to a 62.5% retention rate. The analysis showed a significant increase in the knowledge score attained following introduction of the questionnaire (Z=-4.176, P<0.001).

CONCLUSIONS

In this format, the glaucoma logbook has a positive impact on patient knowledge. Further research will be necessary to show if this result is maintained in a larger sample group and to investigate whether this improvement in knowledge is associated with any improvement in long-term structural and functional outcomes.

Eye drop administration in patients attending and not attending a glaucoma education center

Background:

To assess the technique of glaucoma eye drop instillation in patients who have and have not attended glaucoma education sessions. To compare this with their subjective perception of eye drop use and identify factors associated with improved performance.

Patients and Methods:

An observational study of 55 participants who instill their topical glaucoma medication for more than 1 year. Twenty-five patients attended (A) glaucoma teaching sessions >1 year before the study and were compared to thirty patients who never attended (NA). Patients completed a self-reporting questionnaire. They instilled their eye drop, and the technique was video-recorded digitally and later graded by two masked investigators. The results were analyzed using Fisher's exact test and Chi-square test. Predictors were assessed using logistic regression models.

Results:

There was no significant difference in overall performance scores between the two groups. Good technique was observed in 16% of (A) group versus 23% (NA) group, (P = 0.498). There was a mismatch between patient's subjective and actual performance. Female gender and higher educational level were found to be predictors of good performance of drop instillation on univariable logistic regression analysis.

Conclusion:

Glaucoma patients are challenged with eye drop instillation despite receiving education on drop administration. There is a discrepancy between patient's perceptions and observed technique of drop administration.

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.

Adherence and Persistence: The Challenges for Glaucoma Medical Therapy

Suboptimal adherence and persistence to therapy are major challenges for patients treated with ocular hypotensive medications. The problem affects 5% to 80% of glaucoma patients from all nations, ethnicities, socioeconomic backgrounds, and education levels. Although health care providers are generally poor at detecting suboptimal or poor adherence in the clinical setting, several strategies to systematically assess adherence and persistence rates are available. One strategy involves electronic monitoring of patient dosing, which provides useful insights into specific patterns of adherence behavior among glaucoma patients. Adherence behavior is complex with multiple interrelated determinants; these can be broadly grouped into provider factors, environmental factors, medication factors, and patient factors. Targeted patient education strategies, counseling, electronic monitors, alarms, and reminders have all been used in efforts to improve adherence. These interventions probably work best in combination. Identifying tangible barriers to adherence and simple strategies to overcome these through an open, discursive relationship between clinician and patient is key to optimizing adherence.

Noncompliance with Ocular Hypertensive Treatment in Patients with Primary Open Angle Glaucoma among the Arab Population in Israel: A Cross-Sectional Descriptive Study

Objective. To evaluate the noncompliance treatment rates among primary open angle glaucoma (POAG) Arab patients in Israel and to verify the associated factors for noncompliance. Patients and Methods. A cross-sectional study took place using a questionnaire. Patients were initially interviewed and requested to answer a questionnaire. The questionnaire was developed based on a pilot test. Items included information about age, gender, number of prescribed drugs, and multiple reasons for noncompliance with drug therapy. Setting. Ophthalmologic HMO clinics, located in 3 Arab cities in the center of Israel. Participants. 400 Arab participants (197 men, 203 women) undergoing routine clinical care were recruited. Results. General rate of noncompliance, for both genders, was found to be 50%. Factors associated with nonadherence included inadequate knowledge (32%), underestimation of the disease severity (25.5%), and denial 15.5%. Compliance rates were unaffected by gender or number of prescribed drugs. Compliance was significantly higher in younger patients (age < 50) and in older patients (age > 80), 63% and 77%, respectively, (P < 0.05). Conclusion(s). Noncompliance was found to be common among an Arab population in Israel, particularly between the ages of 50 and 80. Educational programs, improving patient-physician relationship, and personalizing treatment could provide means for improved adherence.

Patient acceptance and attitude toward an alternative method of subconjunctival injection for the medical treatment of glaucoma

PURPOSE

Nonadherence to glaucoma medications may be a major cause of treatment failure. We examined the acceptance of glaucoma patients toward a possible new route of administering glaucoma medication by subconjunctival injection.

PATIENTS AND METHODS

Patients were recruited from specialist glaucoma clinics on a voluntary basis. Trained interviewers administered a 30-item questionnaire and an information sheet with details of an alternative subconjunctival injection route involving injections at 3-month intervals. Outcome measures regarding acceptance of the new procedure, social situational factors, disease factors, and treatment factors were assessed.

RESULTS

A total of 151 patients participated in this study. Of the 151 patients 112 (74.2%) were willing to have their glaucoma medication given by the new method of subconjunctival injection, 101 of 112 (90.2%) were willing to accept it at the same cost as their present medication, and 87 of 101 (86.1%) were willing to accept it even at a higher cost. These patients tended to be on a greater number of medications (P=0.006), and medicating more frequently in a day (P=0.003). Nine of 10 (90%) patients who were admitted to nonadherence were willing to accept subconjunctival injections at 3-month intervals in place of their topical medication.

CONCLUSIONS

Our study found that 74% of glaucoma patients were willing to accept an alternative form of glaucoma treatment through 3-monthly subconjunctival injections. A large proportion of patients who were admitted to nonadherence to topical medication were willing to consider this alternative method of medication. Our findings are helpful when developing patient-acceptable drug-delivery regimes, which may alleviate the need for daily medication.

Glaucoma severity and medication adherence in a county hospital population

OBJECTIVE

To assess the association between disease severity and adherence with glaucoma medications in a county hospital population.

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 126 patients diagnosed with glaucoma receiving intraocular pressure (IOP)-lowering medication were recruited from the San Francisco General Hospital Ophthalmology Clinic.

METHODS

Subjects completed an oral questionnaire to assess demographic information, knowledge of glaucoma, and perceptions of glaucoma medication adherence. Glaucoma disease severity was classified according to the American Academy of Ophthalmology's Preferred Practice Pattern guidelines. Medication adherence was measured for each patient by obtaining pharmacy refill data and calculating medication possession ratio (MPR), that is, the ratio of total days' supply of medication during a 365-day period. Adherence was measured retrospectively over the 18-month period before study entry. Subjects with an MPR >80% were considered adherent.

MAIN OUTCOME MEASURE

Medication adherence.

RESULTS

Subjects with mild or moderate glaucoma were more likely to be nonadherent to their prescribed glaucoma medications than those with severe disease (adjusted odds ratio [OR], 1.54; 95% confidence interval [CI], 1.03-2.31; P = 0.04). Age, gender, race, education level, years of glaucoma, number of medications, and glaucoma diagnosis were not found to be statistically significantly associated with adherence.

CONCLUSION

Patients with severe glaucoma were more likely to adhere to their topical IOP-lowering medication regimen than those with milder glaucomatous disease.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Extended release of timolol from nanoparticle-loaded fornix insert for glaucoma therapy

We have developed a cylindrical insert that can be inserted in the fornix for extended release of glaucoma drug timolol. The insert is prepared by incorporating timolol-loaded nanoparticles into a poly hydroxyl ethyl methacrylate (p-HEMA) matrix. A 1-mm diameter, 7.5-mm long insert with 25% (w/w) particles can release timolol for about 10 days at an average rate of about 15 μg/day, which may be therapeutically effective. The increase in particle fraction increases drug loading, but also increases the release duration. The net effect of increasing the particle fraction is a significant increase in release duration, but a decrease in daily drug release rates, in the first few weeks. The release duration increases to about 1 and 3 months on increasing the particle fraction to 50% and 75%, respectively. The average daily release rates in the first 3 weeks are 15, 9, and 3 μg/day for the inserts with 50%, 75%, and 100% (w/w) particles, respectively. The mechanism of release is hydrolysis of the ester bond that links timolol to the propoxylated glyceryl triacrylate matrix, and thus the release profiles fit a first order reaction model. The water content of the inserts decreases from 31% to almost zero on increasing the particle loading from 25% to 100%. The rate constant for the hydrolysis decreases with an increase in particle loading in the insert most likely due to the reduction in the water content. The inserts can be packaged in wet conditions and stored in a refrigerator, but the inserts will exhibit a burst release caused by release of the drug from the particles into the p-HEMA matrix during the shelf life. Also, the magnitude of drug release after the initial burst is reduced due to the storage. The burst effect could potentially be avoided by packaging the inserts in a dry state, with hydration before insertion.

Noncompliance with glaucoma medication in Korean patients: a multicenter qualitative study

PURPOSE

To investigate the common side effects of topical antiglaucoma medication, factors affecting compliance, and the utilization of herbal medicine for glaucoma treatment in South Korea.

PATIENTS AND METHODS

A cross-sectional multicenter hospital-based study. In-depth interviews using a structured questionnaire were conducted with 581 individuals diagnosed with glaucoma. Additional eligibility requirements were: all participants were diagnosed with glaucoma in one or both eyes and prescribed eye drops at least one month before the start of the study, and were in a suitable condition for an interview. The frequency of response for each category in the interview questionnaire was analyzed.

RESULTS

Conjunctival injection, a stinging sensation, and blurred vision were the most frequently reported side effects, among which blurred vision was the most unbearable. Patient knowledge of glaucoma was the only factor associated with the patient's self-evaluation of compliance. Forgetfulness was the most common reason for nonadherence. Only 2.9 % of patients were taking herbal medicine.

CONCLUSIONS

Physicians should address a patient's complaint of blurred vision resulting from medication. Complete initial explanation of the consequences of nonadherence and of the potential vision loss from glaucoma are critical elements in improving patient adherence in Asian populations.

The influence of health literacy level on an educational intervention to improve glaucoma medication adherence

OBJECTIVE

To test an educational intervention targeted to health literacy level with the goal of improving glaucoma medication adherence.

METHODS

One hundred and twenty-seven veterans with glaucoma were randomized to glaucoma education or standard care. The intervention included a video scripted at a 4th, 7th, or 10th grade level, depending on the subject's literacy level. After six months, the number of days without glaucoma medicine (DWM) according to pharmacy records for the intervention and control groups was compared.

RESULTS

The number of DWM in the six months following enrollment was similar for control and intervention groups (intervention, n=67, DWM=63 ± 198; standard care, n=60, DWM=65 ± 198; p=0.708). For each subgroup of literacy (adequate, marginal, inadequate), subjects in the intervention group experienced less mean DWM than subjects in the control group and the effect size (ES) increased as literacy decreased: adequate literacy, ES 0.069; marginal, ES 0.183, inadequate, ES 0.363. Decreasing health literacy skills were associated with decreasing self-reported satisfaction with care (slope=0.017, SE=0.005, p=0.002).

CONCLUSIONS

Patients with decreased health literacy skills may benefit from educational efforts tailored to address their health literacy level and learning style.

PRACTICE IMPLICATIONS

Providers should consider health literacy skills when engaging in glaucoma education.

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.

Prevalence and correlates of self-reported nonadherence with eye drop treatment: the Belgian Compliance Study in Ophthalmology (BCSO)

PURPOSE

This study aimed to investigate (1) the prevalence of nonadherence with eye drop treatment; (2) selected correlates of nonadherence at the patient and health-care organization level; and (3) the diagnostic value of the ophthalmologists' ratings, using patients' self-reports as standard.

METHODS

This cross-sectional multicenter survey used questionnaires for ophthalmologists and their patients to assess self-reported nonadherence and its correlates. One item, using a 4-point scale [never (ie, adherent) to daily], asked the patients whether they had forgotten to administer eye drops during the past 2 weeks. Ophthalmologists rated their patients as adherent or nonadherent. Nonadherence was also determined by combined methods, whereby either could indicate nonadherence. Given the nested structure of the data, multilevel modeling was used to investigate self-reported nonadherence-correlates. Diagnostic values of ophthalmologists' report were calculated.

RESULTS

Of 663 patients (48% female, 44% >69 years), nonadherence was indicated in 39.2% (n=260) through self-reporting, 2.1% (n=14) through ophthalmologists' ratings, and 40% (n=266) through combined measures. The multivariable, multilevel model showed following significant nonadherence-correlates: Male sex (P=0.01), younger age (P=0.027), and higher-dose frequency (P=0.001). No significant correlation with treating ophthalmologist (P=0.21) could be seen. Yet, the patients visiting their ophthalmologists at least every 3 months were less nonadherent than patients with fewer consultations (P=0.01). The ophthalmologists' report showed a sensitivity and specificity of 3% and 98.5%, respectively.

CONCLUSIONS

The prevalence of self-reported nonadherence was congruent with literature. The patients visiting their ophthalmologists at least every 3 months have a lower risk of nonadherence. Ophthalmologist report is an insensitive method for detecting nonadherence.

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.

An exploratory study of factors influencing glaucoma treatment adherence

PURPOSE

To understand the factors that influence glaucoma treatment adherence with medication taking, prescription refills, and appointment keeping to develop an intervention for a specific population.

PATIENTS AND METHODS

In-depth interviews were conducted with 80 individuals diagnosed with open-angle glaucoma, glaucoma suspect, or ocular hypertension. Additional eligibility requirements were that all participants were: between the ages of 18 to 80; white or African American; spoke and understood English; and were taking daily doses of topical glaucoma treatments for at least the past year. Cross-tabulations and chi2 tests were conducted to compare adherent and nonadherent individuals, classified as such based on self-report and medical chart/pharmacy data.

RESULTS

Compared with adherent participants, nonadherent participants were less likely to: believe their eye doctors spent sufficient time with them; ask their eye doctor if they had any questions; know of benefits to taking their glaucoma medication regularly; and have someone help them take their glaucoma medications or drive them to eye appointments. Conversely, compared with adherent individuals, nonadherent participants were more likely to have difficulty remembering to take their medications and to believe their glaucoma would affect their eye sight in the future.

CONCLUSIONS

Nonadherent glaucoma patients struggle with a variety of issues related to consistent use of glaucoma medicine and routine eye care. Interventions are needed to address these modifiable factors related to glaucoma treatment adherence.

Glaucoma patients' trust in the physician

Objectives. To describe glaucoma patients' trust in the physician and to test the hypothesis that increased interpersonal trust is associated with increased medication adherence. Methods. One hundred ninety-five subjects with open-angle glaucoma seen by multiple glaucoma subspecialists participated in a cross-sectional patient survey and concomitant chart review which included a test of health literacy and the Trust in Physician Scale (TPS), a scale from 1–100, with 100 indicating greatest trust. Charts were reviewed for visual acuity and visual field results. Subjects' pharmacies were contacted to ascertain medication refill rates over the preceding six months. Results. TPS scores ranged from 57.5 to 100, 78.7 ± 8.4 (mean ± SD,) median 75.0. When age, race, gender, baseline visual acuity and visual field status, education level, and literacy status were considered, only race was associated with TPS. Caucasians expressed slightly higher levels of trust (n = 108; TPS 80.1 ± 8.2) than non-Caucasians, (n = 87 (82 Africans Americans); TPS 77.1 ± 8.4; P = .012). TPS score was not associated with refill rates (P = .190). Conclusions. Trust in physician is generally high in this group of glaucoma patients but varies slightly by race. Trust in physician was not associated with glaucoma medication adherence in this tertiary care population.

Adherence and persistence with glaucoma therapy

Adherence and persistence with chronic therapies is crucial to prevent disease progression, such as in glaucoma. Patients report high rates of adherence, which are not supported by pharmacy claims analysis. This article reviews the literature regarding methods to assess adherence and persistence and the patient behaviors that pose challenges to proper treatment. Rates for persistence are generally below 50% at 1 year. Differentiating efficacy of eyedrops from lack of adherence presently confounds ophthalmic treatment. Additionally, as intraocular pressure (IOP) can appear controlled by short-term adherence, the physician can be fooled into believing the patient's glaucoma is well-controlled. Likewise, when progressive worsening is noted despite good IOP control, it can be problematic whether the patient's target pressure needs to be lowered or adherence needs to be improved. White-coat adherence is common, in which patient adherence rises sharply 1 week before the appointment with the physician, then declines rapidly following the appointment. White-coat adherence may make it difficult to assess IOP control over the longer term; cycling behavior with medication use is well-documented. Adherence and persistence rates differ by class of drug, with higher rates associated with prostaglandin use. We review findings from The Glaucoma Adherence and Persistency Study that identified behaviors associated with poor adherence. Greater physician awareness of adherence and persistence issues is necessary in order to help the patient become more adherent.

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.

Prevalence and determinants of non-adherence to topical hypotensive treatment in Dutch glaucoma patients

BACKGROUND

To assess the prevalence and determinants of non-adherence to topical hypotensive treatment in glaucoma patients in order to support interventions targeting enhancement of patient adherence.

METHODS

One-hundred and sixty-six glaucoma patients, recruited by nationwide multi-stage sampling, filled in an extensive and carefully developed questionnaire covering various theoretically relevant determinants of patient adherence which were categorized as psychosocial aspects, barriers and skills.

RESULTS

Prevalence of self-reported non-adherence was 27.3%. Younger patients (<55 years of age) had a higher risk of being non-adherent. Forgetfulness, unavailability of eye drops and difficulties with holding the bottle above the eye when applying the eye drops were the most cited reasons for non-adherence. Fifty percent of the patients indicated that they required more information on the correct administration of eye drops. There was no association between non-adherence and sex, level of education, type of insurance, duration of disease or family history of glaucoma.

CONCLUSIONS

Non-adherence to topical glaucoma medication is fairly common. Aids that minimize forgetfulness and delivery systems facilitating the delivery of medications to the eye could be considered to enhance patient adherence before advancing to other therapies with additional risks and costs.

Acute bacterial conjunctivitis

Acute bacterial conjunctivitis is the eye disease most commonly seen by general practitioners, and is estimated to represent approximately 1% of all consultations in primary care. This article gives a review of the epidemiology, aetiology, clinical picture, complications, differential diagnoses, in vitro examinations and therapy of acute bacterial conjunctivitis. Until now, topical antibacterial therapy has generally been preferred by both physicians and patients because this will usually shorten the course of the disease slightly and allow the early readmittance of children to their kindergarten or school. Recently, several reports from primary care have confirmed the well-known clinical experience that the disorder has an excellent prognosis with a high frequency of spontaneous remission. In accordance, an expectant attitude or delayed prescription policy are now frequently strongly recommended. However, these reports also emphasize the difficulty in making a correct clinical distinction between bacterial and viral conjunctivitis. The effect of a general non-prescription attitude on transmission rates of pathogens also remains to be clarified. This must be born in mind when deciding how these patients should be handled. The socioeconomic and medical pros and cons of different treatment policies are discussed, and a highly personal view on the optimal handling strategy for these patients is also presented.

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.

Psychiatric manifestations and personality traits associated with compliance with glaucoma treatment

OBJECTIVE

The aim of this study was to assess the impact of psychological distress and personality traits on self-rated compliance with glaucoma treatment.

METHODS

One hundred patients with primary open-angle glaucoma participated in the study. General Health Questionnaire, Symptom Distress Checklist, Center for Epidemiological Studies Depression Scale, Defense Style Questionnaire, and Hostility and Direction of Hostility Questionnaire were used.

RESULTS

Forty-two percent of patients with glaucoma classified as "noncompliers," those who omitted more than two doses per week. Noncompliers presented more severe symptoms of glaucoma. Depression was found to be associated with poor compliance, whereas adoption of immature defensive style further increased the risk for noncompliance with glaucoma treatment.

CONCLUSIONS

Depression is associated with self-reported noncompliance with glaucoma treatment, whereas certain personality traits are involved in the increased risk for noncompliance. Further assessment of the depressive feelings by an ophthalmologist and treatment of depression as well as proper psychotherapeutic approaches for maladaptive personality features could be an essential strategy to diminish compliance problems.

Health literacy and adherence to glaucoma therapy

PURPOSE

To describe the health literacy of subjects with open angle glaucoma and to investigate the hypothesis that low health literacy is associated with poor glaucoma medication adherence.

DESIGN

Cross-sectional patient survey and concomitant chart review.

METHODS

One hundred and ninety-seven subjects with open angle glaucoma participated in a survey which included basic demographic information such as age, gender, ethnicity, and level of education completed, and a test of heath literacy, the Rapid Assessment of Adult Literacy in Medicine. Information was collected regarding visual field tests and prescribed medication. The subjects' pharmacies were contacted to ascertain the number of refills requested over the previous six months.

RESULTS

Although 146 subjects (74%) reported completing high school, only 94 subjects (48.0%) read at or above a ninth grade level; 23 (11.7%) read at a level of third grade or below. The mean number of refills requested by a subject in the preceding six months was not predicted by race (P = .27,) gender (P = .31), age (P = .92), mean deviation of the visual field (P = .36), or level of education (P = .58). There was a positive relationship between health literacy and the number of refills obtained (P = .003).

CONCLUSIONS

Many patients with open angle glaucoma may have poor health literacy. The subjects in our study with low literacy were less adherent with their glaucoma medications than those with a higher level of literacy. Interventions specifically targeting patients with low literacy may improve medication adherence.

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.

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.

The Impact of a Nationwide Introduction of New Drugs and a Treatment Protocol for Glaucoma on the Number of Glaucoma Surgeries

PURPOSE

To study the trend in number of glaucoma surgeries, and the influence hereon of the introduction of new glaucoma medication, reimbursement of its costs, and the introduction of a treatment protocol.

METHODS

Out of the Dutch Health Care Registration, all open angle glaucoma and ocular hypertension patients aged 20 years and older, who underwent glaucoma surgery were selected. Over the period 1995 until 2003 the trend in the number of monthly performed glaucoma surgeries was described by LOESS spline procedure.

RESULTS

From 1995 until 2003, 15,888 surgeries were included. Overall mean age was 67.5 years (SD 13.0). Mean age declined by 0.29 year per year (95% CI, 0.21-0.37). In 1995 and 1996 the number of yearly performed glaucoma surgeries was approximately 2400. From 1997 onwards this number started to decrease, resulting in a 45% decrease in the year 2000. From 2000 on the number of surgeries stabilized at approximately 1350 per year. In 1999 the total number of prescriptions rose by 20% compared with 1998, and then stabilized. In 2002, 48% of the prescriptions were prescriptions for new medication.

CONCLUSION

The number of glaucoma surgeries in the Netherlands almost halved over a 3.5-year period, most likely due to the introduction of new medications. In the remaining study period the number leveled off. From the present data a substitution effect and not merely a postponement of glaucoma surgeries may be suggested, providing additional evidence that a sustained reduction in the number of glaucoma surgeries was reached in the studied period.

Compliance and persistency in glaucoma follow-up treatment

PURPOSE OF REVIEW

To summarize research published between 1980 and October 2004 regarding compliance (the extent to which patients' behaviors correspond with providers' recommendations) and persistency (total time on therapy) in patients diagnosed with open-angle glaucoma or ocular hypertension; to suggest approaches ophthalmologists might consider to improve compliance and persistency; and to identify areas warranting future research.

RECENT FINDINGS

Medication compliance, the focus of most compliance-related research, has been measured using a variety of methods including patient self-reports, the medication possession ratio, and electronic monitoring. Noncompliance rates of at least 25% commonly have been reported. The primary obstacles to medication compliance appear to be situational/environmental (e.g., being away from home or a change in routine) or related to the medication regimen (e.g., side effects or complexity). Persistency with ocular hypotensive therapies has been found to be poor. Retrospective cohort studies using survival analyses have reported that fewer than 25% of patients are persistent over 12 months.

SUMMARY

Accurately assessing patient compliance and persistency is important to optimizing patient care. Physicians may mistake either medication noncompliance or lack of persistency with poor efficacy. Such errors would likely increase health care costs if they result in unnecessary changes to a patient's therapeutic regimen or in surgery.

Achieving low target pressures with today's glaucoma medications

In the 21st century there are more highly effective medical management options for glaucoma than there were in the 1980s and 1990s. In deciding among them, the clinician's challenge is to select what is clinically relevant from the large amounts of available data. In evaluating different drugs the clinician must consider not only the mean intraocular pressure (IOP) of a trial population, but also the percentage of patients achieving clinically relevant low IOPs. The consistency of IOP control throughout the day and night is also critical. Other factors such as safety, tolerability, and cost-effectiveness must also be kept in mind, with an awareness (both in human and monetary terms) of the cost of treatment failure. This overview concludes that newer medical regimens for IOP lowering address efficacy and safety issues more successfully than older ones.

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.