In our resident ophthalmology clinic, I repeatedly hear the same types of comments and questions from patients with glaucoma. These include:

  • “Sorry, doc, life got busy, and I haven’t used my eye drops since my last visit.”
  • “I have 20/20 vision. Do I really have glaucoma?” and
  • “I already have poor vision. Do I need to use eye drops?”

Glaucoma is one of the most challenging chronic diseases to manage as it is relatively asymptomatic until late in the disease course. The rate of patient nonadherence to glaucoma medication can be as high as 80%.1 Among the major barriers to adherence are limited knowledge of the disease and low health literacy among patients.


Published studies have reported that patients with lower literacy skills demonstrated more advanced visual field loss at the time of glaucoma diagnosis,2 were less likely to express difficulty with eye drop administration,3 refilled glaucoma medication prescriptions less frequently,4 were more likely to miss appointments,2 reported higher levels of dependency on others,4 had greater difficulty naming and describing their medications,5 and had health beliefs that hindered their adherence.6

A study conducted in Switzerland found that only 28% of patients could correctly define glaucoma, and patients with a greater understanding of the condition were more likely to be adherent to their medication.7 Patient education is a crucial component of glaucoma care, and ophthalmologists play an essential role as teachers. However, Sleath et al found that, when prescribing medication for the first time, providers educated patients on the importance of medication adherence in only 39% of visits and 14% of follow-up visits.8 These investigators found that providers were less likely to educate African American patients about glaucoma,8 despite this patient population having an estimated four times greater risk for developing the disease than white patients in the United States.9-11


Assessing patient knowledge and literacy during busy clinic hours can be difficult, but there are simple steps to take that can help broaden patients’ understanding of their disease. “Did you know that the nerve in your eye looks like a donut?” is a line that I adopted from my attendings, and it has become one of my favorite ways to start a conversation about glaucoma with my patients.

Online Resources for Patient Education

Resources such as outreach tools and tips from the National Eye Health Education Program, Glaucoma Research Foundation, and other support groups, particularly for young patients, can help increase awareness about glaucoma. I often refer patients to the National Eye Health Education Program and AAO websites for educational materials, which are written at fifth-to-eighth-grade reading levels. In patients with diabetes and poor health literacy skills, interventions tailored to patients’ characteristics have improved hemoglobin A1C.6 Directing glaucoma patients toward simple and clear educational materials can potentially similarly improve their treatment adherence and ultimately affect their visual outcomes.


Limited knowledge of glaucoma and low health literacy can be significant barriers to patient adherence. However, challenges with adherence can be overcome with effective physician-patient communication that assesses patients’ knowledge and provides them with the necessary education. Physicians can help bridge the gaps in patient knowledge by referring them to online outreach tools and social media groups that aim to increase patient awareness of glaucoma.

1. Resnikoff S, Pascolini D, Etya’ale D, et al. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004;82(11):844-851.

2. Juzych MS, Randhawa S, Shukairy A, Kaushal P, Gupta A, Shalauta N. Functional health literacy in patients with glaucoma in urban settings. Arch Ophthalmol. 2008;126(5):718-724.

3. Slota C, Sayner R, Vitko M, et al. Glaucoma patient expression of medication problems and nonadherence. Optom Vis Sci. 2015;92(5):537-543.

4. Muir KW, Santiago-Turla C, Stinnett SS, et al. Health literacy and adherence to glaucoma therapy. Am J Ophthalmol. 2006;142(2):223-226.

5. Williams MV, Parker RM, Baker DW, Coates W, Nurss J. The impact of inadequate functional health literacy on patients’ understanding of diagnosis, prescribed medications, and compliance [abstract]. Acad Emerg Med. 1995;2(5):386.

6. Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14(5):267-273.

7. Mansouri K, Iliev ME, Rohrer K, Shaarawy T. Compliance and knowledge about glaucoma in patients at tertiary glaucoma units. Int Ophthalmol. 2011;31(5):369-376.

8. Sleath B, Blalock SJ, Carpenter DM, et al. Provider education about glaucoma and glaucoma medications during videotaped medical visits. J Ophthalmol. 2014;2014:238939.

9. Quigley HA, Vitale S. Models of open-angle glaucoma prevalence and incidence in the United States. Invest Ophthalmol Vis Sci. 1997;38(1):83-91.

10. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med. 1991;325(20):1412-1417.

11. Varma R, Ying-Lai M, Francis BA, et al. Prevalence of open-angle glaucoma and ocular hypertension in Latinos: the Los Angeles Latino Eye Study. Ophthalmology. 2004;111(8):1439-1448.