When patients present for an evaluation or initial consultation after a glaucoma diagnosis, the question they ask me most frequently is, “Will I go blind?” The fear of vision loss for most people is greater than the fear of other medical conditions or disabilities.
As we know, most patients who are medication compliant will not go blind from glaucoma during their lifetime. Ultimately though, their prognosis depends on many factors, including where they lie on the glaucoma continuum and the timeliness of the initial therapeutic intervention. A patient’s treatment regimen and medical outlook are likely to be more challenging with advanced glaucoma compared to preperimetric disease without the presence of visual field defects.
As a glaucoma specialist for the last 2 decades, I’ve learned to stay focused on the variables we can control and to think holistically about how to set patients and their loved ones along on a journey to better health. Because the patient’s disease state at the time of our first appointment is not a factor I can control, it is important to focus on educating and empowering patients and caregivers to effectively participate in their own treatment, because knowledgeable, conscientious patients can better preserve their vision.
At the initial consult, turn patients’ anxiety into an opportunity to have an honest yet hopeful conversation about ways glaucoma can progress and how collaboration may slow disease progression and effectively manage symptoms in ways that improve or preserve their quality of life. Getting off on the right foot and helping patients form good habits can help mitigate disease fatigue in the years to come.
We all know the only modifiable risk factor scientifically proven to be efficacious against glaucoma is a reduction in intraocular pressure (IOP). To achieve and maintain reductions over the course of years or decades requires vigilance, medication adherence, and a commitment to ongoing follow-up care. My practice deploys several effective empowerment strategies to strengthen the patient–provider relationship, improve adherence, slow disease progression, and prevent or delay possible vision loss.
Arm Patients With At-home Reading
From the patient’s perspective, visits to the eye doctor can be overwhelming. One helpful book I often share with patients from the Glaucoma Research Foundation is called Understanding and Living with Glaucoma. My patients not only find it useful but also say it reduces their level of stress. As demands on physicians’ time continue to grow, providing tailored take-home information is critical to help patients and their caregivers manage their disease and stay adherent. Most medical record systems can now produce a medication sheet that tells patients how much medicine to use in each eye and at what time of the day. Our sheets are color-coded to match each medicine’s bottle cap.
Help Patients Maximize Their Time With You
Memory loss is a common byproduct of aging, but missed appointments and gaps in care can be dangerous for people with glaucoma. Technology can provide a safety net. Even for the technology averse, the solution can be as simple as setting a cell phone alarm to ring twice a day with a reminder to take their medications at the correct intervals. I also encourage my patients to take note of the difference between appointment types; for example, a quick pressure check vs a visit where they’ll be dilated. They should know that longer visits are a golden opportunity to ask questions and have a deeper dialogue. I encourage both patients and caregivers to write down questions in advance of these visits so I can address all their concerns, allowing them to leave feeling informed and empowered.
Encourage Patient Journaling
I ask my patients to keep a glaucoma journal and write down any symptoms or medication reactions they experience between office visits. I ask them also to keep an updated list of medications being prescribed by other doctors. Even a steroid injection to the knee or the brief use of an inhaler in the springtime can impact glaucoma. Deputizing your patients to track their medicines, side effects, and symptomology in real time can yield treatment insights and better outcomes. In my experience, a journal is far more reliable than human memory to track these linear medical details.
Empower the Caregiver
It is incumbent upon glaucoma specialists to remember that successful treatment of glaucoma often takes a village, given that much of the patient population is elderly. This is particularly important during diagnostic and early visits when patients often have limited knowledge of their condition. It’s also important when an aging patient begins experiencing cognitive decline or memory issues. No matter the patient’s disease state, there is value in finding that special someone who can offer a ride, an extra set of ears, and a helping hand with at-home care and medication adherence challenges.
Create a Safe Space for Honesty
It’s important for physicians to know when patients have been missing doses, whether it’s because they forgot to call in a refill or couldn’t afford the monthly copay. Sometimes, the delivery of messages to patients can be as important as the messages themselves. I always stress the importance of adherence, but I try to do so in a sensitive way that engenders honesty about any medication lapses. Treatment decisions are only as good as the facts that inform underlying assumptions.
One of the biggest treatment challenges with glaucoma is achieving adherence in an aging population. Although current eye drop therapies can be effective to lower IOP, a troubling percentage of patients struggle to administer drops properly and consistently. In fact, a study of 71 patients showed only 28% were able to correctly instill the eye drops.1 These challenges in medication administration have the potential to cost patients their vision, because glaucoma has become one of the leading causes of vision loss.
Most treatment paradigms today remain dependent on patients obtaining their medications and self-administering the correct number of eye drops at the correct intervals each day. Those taking 3 different drops may need to correctly sequence and self-administer 7 or 8 drops a day at the correct intervals. This can be a challenge even when the patient is doing everything right. But sometimes patients get busy with life or forget; we’re all human and memory can diminish with age.
For patients who are experiencing adherence challenges, one of the most exciting recent breakthroughs involves sustained drug-delivery mechanisms that gradually release medication into the anterior chamber of the eye over time. These innovations in drug delivery can help prevent IOP fluctuations while taking the adherence burden away from patients and caregivers. In this way, advancements in pharmacology are helping glaucoma specialists avoid the need for difficult conversations about adherence issues.
I’ve had positive initial experiences with Durysta bimatoprost intracameral implant (Allergan), the first FDA-approved sustained drug delivery for people with open-angle glaucoma or high eye pressure (ocular hypertension). The reality of cognitive and memory decline is one reason some families opt for intracameral implants. It removes “I forgot my eye drops today” as a cause of clinical deterioration. I had one patient who had been self-administering drops for many years, but eventually she was moved to memory care and started having adherence issues. Even when she remembered her drops, her unsteady hands often caused them to miss their mark. Her daughter started coming by the house twice a day to administer them. But she lived 20 minutes away, so that meant waking up early every morning and then driving back every evening.
I ultimately decided that using intracameral Durysta for a defined period could be an efficacious way to get her IOP down. It was also a way to reduce the caregiver burden as her wonderful family transitioned her to assisted living. It was a great bridge for this family until they could arrange a living situation where trained professionals could take over the administration of her medicines.
Technology and Patient Empowerment Combined
I cannot remember a more exciting and hopeful time to be a glaucoma specialist. I received my training at a time when traditional glaucoma surgery was the only option that was not an eye drop, and now new laser technologies and MIGS procedures are advancing through clinical trials and even earning FDA approvals. Other sustained drug-delivery technologies such as Idose TR (Glaukos), Travoprost XR (Envisia Therapeutics), and the Latanoprost FA SR Ocular Implant (Polyactiva), if approved, may further reduce the incidence of difficult conversations in my office. Ultimately, if a patient’s IOP is properly controlled, we gain better control of their disease state.
I feel both a privilege and an obligation to convey a sense of hope to patients and to assist those who want to explore new options, treatment modalities, and clinical trial opportunities that can improve their health, vision, and quality of life throughout their glaucoma treatment journey. GP
Reference
- Gomes BF, Paredes AF, Madeira N, Moraes HV Jr, Santhiago MR. Assessment of eye drop instillation technique in glaucoma patients. Arq Bras Oftalmol. 2017;80(4):238-241. doi:10.5935/0004-2749.20170058
