Nonadherence to Glaucoma Treatment: Relax, Relate, and Communicate!

Early in my career I had a patient encounter that remains vividly etched in my mind. He was a 75-year-old patient, whom I will refer to as Mr. Smith, who presented for a glaucoma follow-up visit. Mr. Smith was diagnosed with glaucoma 10 years prior to this visit and was followed in my office every six months. He was treated with Latanoprost, one drop in each eye at night, and Timolol, one drop in each eye twice per day. He stated that he “occasionally forgets to use the drops,” and reported that when he does use them, he experiences redness and stinging. His intraocular pressure (IOP) was well above my target of 14mmHg OU, with measurements of 22mmHg OU. OCT and visual field testing revealed that his glaucoma had progressed.

“Mr. Smith, when is the last time you used your drops?”, I asked.

“Well, I ran out of one of them about two months ago. And the other one I put in every morning like I’m supposed to”, he stated.

“Which one did you run out of, Mr. Smith?”

“I’m not sure. I don’t remember the name,” he answered quietly with a look of shame and embarrassment.

Sadly, this type of scenario is common in glaucoma care. Often the doctor is left with the nagging feeling – “I thought I explained the treatment regimen… I thought I explained the importance of using the drops as prescribed… how did he run out early?… why didn’t he call to inform us he had run out of medication?”

This patient encounter remains permanently etched in my memory because it was the day I learned an invaluable lesson that I carry with me to this day. I learned to relax, relate, and communicate. It is no accident that this sounds like a self-help mantra for navigating difficult times, or for maintaining healthy relationships. It turns out that successful glaucoma management involves navigating the difficulties associated with glaucoma treatment and understanding the core elements of a good doctor-patient relationship.

What are the difficulties of glaucoma treatment? Glaucoma is a complex group of chronic optic neuropathies that, when left untreated, can lead to irreversible blindness.¹ IOP lowering is the mainstay treatment, typically involving lifelong use of IOP lowering eyedrops, regular follow-up visits, frequent testing (including the universally dreaded visual field test), and in some cases surgical management. Failure to follow the treatment regimen as prescribed, or nonadherence, often leads to worsening of the disease and in some cases blindness. With that said, it boggles my mind that studies show there is poor adherence in up to 50% of glaucoma cases.²

Does this mind-boggling adherence problem indicate a failure on the part of the patient, the doctor, or both? Full understanding of the patient’s perspective and challenges is paramount in mitigating poor adherence. In addition, the doctor must have a clear understanding of their own behaviors and their role in empowering the patient to achieve maximal adherence to their treatment regimen. Therefore, I would argue that nonadherence represents failures by both the patient and the doctor.

Going back to my patient encounter, how could I have proactively collaborated with the patient to improve adherence?

Relax. Avoid rushed judgments or decisions. A warm, inviting atmosphere encourages patients to openly share concerns and questions. Allocate time during glaucoma appointments for discussion and education, allowing patients to express any anticipated challenges or existing issues.

Relate. Empathize with the patient’s situation. Recognize their potential fears upon receiving their diagnosis. Respect their possible reluctance to take medication due to cultural, religious, or personal beliefs. Understand that some patients may distrust the medical system or face socioeconomic challenges hindering their treatment. Consider any mental or physical obstacles they may encounter in adhering to their treatment plan. Show genuine interest in understanding the patient’s perspective and unique identity. Building rapport with the patient encourages them to openly discuss any barriers they may face, such as limited access to care, financial constraints, difficulties in obtaining or administering medication, or struggles with forgetfulness.

Communicate. Give clear verbal and written explanations of the condition, treatment, and follow-up. Confirm understanding by having the patient repeat it. Demonstrate how to use drops correctly. Discuss side effects. Ask if there are any anticipated or current barriers (physical, financial, lifestyle, or belief systems). Offer options like reminders, simpler regimens, alternative modalities, or generics. Encourage questions and assure openness. Make sure the patient feels heard. Clear and transparent communication fosters trust, thereby encouraging patients to adhere faithfully to their treatment plans and follow-up schedules.

Enhancing adherence requires the establishment of a robust partnership, the conscientious gathering and transparent relay of information, its continuous evaluation, and regular revisiting. None of these crucial steps can occur without the facilitation of effective doctor-patient communication and the nurturing of a personalized relationship.

The journey towards optimal adherence begins the moment the patient steps into your practice and persists through every subsequent visit (yes, even after a decade of care).

As I now embark on 20 years of patient care I still find that, with every patient interaction, a mantra echoes in my mind: "Relax, relate, and communicate".