Patients may struggle to adhere to their glaucoma treatments for a number of reasons. Barriers to adherence range from the cost and side effects of medications to disease chronicity and lack of symptoms early in the treatment course. Further, obstacles that can be identified with frequency in the peer-reviewed literature include forgetfulness or memory deficits1,2 and poor communication between patient and provider.3 Although not as well studied or well documented, psychosocial factors may also pose challenges for patients throughout their glaucoma care.
In a study of 80 glaucoma patients who were using prostaglandin therapy, my colleagues and I found a significant association between medication adherence and specific personality types as measured by the Minnesota Multiphasic Personality Inventory-2.4 Depression was related to lower adherence and lower therapeutic coverage. We also found a relationship between hypochondriasis and poor adherence—it is possible that a barrier to taking medication may result from a personality type in which one is fearful of one’s disease.
As ophthalmologists know from clinical practice, psychological conditions such as anxiety and depression can manifest in various ways. Patients may sometimes fail to show up for follow-up appointments, or they may express anxious thoughts during an office visit. (I once had a patient tell me he would rather undergo a root canal than see me for an eye examination.) In part, patients’ anxiety surrounding their eye care may be influenced by the value they place on their sight; anxiety seems to be exacerbated in those who have experienced visual damage. Fear centering on the potential loss of sight can in turn cause patients to feel more anxiety surrounding the diagnostic evaluations we perform during an examination. It may also explain why patients tend to fixate intently on their IOP as a measure of “success.”
Glaucoma treatments can place stress on patients as well. In a study of 56 patients with open-angle glaucoma (OAG) and 52 control patients, my colleagues and I found that patients with OAG had significantly higher hypochondriasis, hysteria, and health concern scores than control patients and that these scores were related to the number of medications used.5 It is possible that the use of systemic medications serves as a constant reminder to patients of their illness. This reminder becomes especially problematic when drops are required to be instilled multiple times per day.
ADDRESSING THE OBSTACLES
There is no one-size-fits-all solution to addressing the many obstacles that impede optimal glaucoma care. However, physicians can implement certain practices into their patient encounters that may help to improve communication and understanding.
Switch perspectives. Glaucoma specialists encounter all aspects of the disease so regularly that we may forget how significantly glaucoma can affect the individual patient. I always ask myself, “How would I feel if I were this person and were anxious about my eyes?” For example, patients almost always complain about taking visual field tests because for many it is a stress-inducing experience. The periods without light stimuli seem to make patients assume the worst about their visual health. I encourage all glaucoma specialists to take a visual field examination from time to time to get a sense of what our patients experience.
Listen well. If, during an examination, a patient says something untrue, hear him or her out. The patient may be telling us something that could ultimately affect his or her treatment adherence and/or outcomes. Also, practice reflective listening—repeat what the patient has said back to him or her, and provide the necessary facts to help the patient reach a more accurate understanding (even when faced with questions like, “How do you know this is really glaucoma?).
Ask the right questions. Back in the days of paper charts, I was conducting a study for which I needed to recruit patients with severe visual field loss. After going through stacks of charts to identify cases, I realized that almost all of the charts I pulled were those of patients with some type of social issue that hindered their access to care. A practical lightbulb went off for me in that moment. Although all physicians are pressed for time, it is imperative that we ask patients questions about their social situation, such as: How did you travel to your visit today?, How long did it take you to travel here? and Are you having any trouble getting or paying for your drops? These questions may unearth some important factors that could be influencing the patient’s treatment success.
Practice acceptance. I once had a patient who was showing signs of glaucomatous progression and experiencing vision loss, but, for religious reasons, he refused treatment. Although situations like these may be hard for physicians to understand and accept, we must remember that patients are entitled to make their own clinical decisions, whatever they may be.
Each patient deserves to be treated as an individual—in fact, treatment success sometimes hinges on it. Given that physicians’ time is of the essence and there is no one-size-fits-all solution, implementing some basic practices into clinical encounters is a good place to start. Listening well and asking the right questions can reveal some important hurdles that, without proper recognition, would otherwise be impossible for patients to clear.
1. Kholdebarin R, Campbell RJ, Jin YP, et al. Multicenter study of compliance and drop administration in glaucoma. Can J Ophthalmol. 2008;43:454-461.
2. Sleath B, Robin AL, Covert D, et al. Patient-reported behavior and problems in using glaucoma medications. Ophthalmology. 2006;113:431-436.
3. Taylor SA, Galbraith SM, Mills RP. Causes of non-compliance with drug regimens in glaucoma patients: a qualitative study. J Ocul Pharmacol Ther. 2002;18:401-409.
4. Lim MC, Wathik MR, Porter SM, Granier AM. Adherence to glaucoma medication: the effect of interventions and association with personality type. J Glaucoma. 2013;22(6):439-446.
5. Lim MC, Shiba DR, Clark IJ, et al. Personality type of the glaucoma patient. J Glaucoma. 2007;16(8):649-654.