Topical Therapies for Dry Eye and Glaucoma: They Only Work if Patients Use Them Properly
By Marguerite McDonald, MD, FACS
Thanks to research and clinical trials, we know a great deal about what topical treatments are effective against dry eye and glaucoma, and we have a number of treatments at our disposal. However, none of these treatments are effective if patients don’t use them, or don’t use them properly.
Little has been written about compliance with artificial tears among dry eye patients. One of the best studies is an older one: "Compliance with and Typical Usage of Artificial Tears in Dry Eye Conditions," by Mark Swanson, was published in November 1998 in the Journal of the American Optometric Association. By reviewing charts and conducting telephone surveys, Swanson and his team found that only 63 percent of patients reported using artificial tears after their doctor recommended them. Even fewer patients (53 percent) continued using ointments.
In addition, Swanson found high variability in the number of artificial tears used, as well as a great deal of day-to-day variability for each patient. Patients seemed to use drops according to the presence and severity of symptoms. Swanson noted that patient education regarding treatment goals, the specific agent, and recommended dosage might improve compliance rates.
An unpublished study by an ophthalmic pharmaceutical company found that the primary reason women don’t use artificial tears as often as prescribed is that they are afraid it will adversely affect their eye makeup. Even when patients try to comply with treatment, many of them simply don’t, or can’t, properly administer eyedrops.
In the February 2010 Review of Ophthalmology, Alan L. Robin, MD reported on his study of 139 patients diagnosed with ocular hypertension or glaucoma who had self–administered eyedrops for at least six months. The patients were videotaped instilling drops, and answered questions about medication use. Researchers found that 20 percent of "compliant" patients didn’t get even a single drop into their eye. Most of them didn’t realize that they had failed to instill the medication. Still others instilled too many drops. Most patients wasted drops – they used an average of seven drops in each treatment attempt, and successfully instilled an average of 1.8 drops per eye, almost twice the recommended dosage. What’s more, most of them thought they were correctly administering the medication. This is clearly the reason we hear patients complain that their drops don’t last as long as they are supposed to. Robin had several suggestions for addressing these issues:
Let patients know this is a common problem. Discussing it focuses their attention on technique and the importance of correctly instilling drops. Discussion also allows them to air their difficulties without fear of ridicule.
Ask patients to show you how they put in eyedrops. This is an easy way to determine whether a patient may have trouble getting the prescribed dose into the eye.
Have a staff member teach the patient ways to address specific delivery problems. Although this strategy will help in many cases, it's not foolproof. If a lack of fine motor skills is contributing to the problem, training may not solve it. In this case, it might be a good idea to ask that someone else help with eyedrop administration, if possible. If this is not a viable solution, it may be advisable to try another form of therapy; for glaucoma, this would be laser or surgery. For dry eye, this might include Microblepharoexfoliation, thermal pulsation therapy, or intense pulsed light treatments.
Suggest that patients follow basic strategies for successful drop administration, including:
Regular hand-washing (Robin’s study found one-third of patients rarely do so)
Using fingers to hold both lids open, look at the bottle and brace the hand holding the bottle against either your nose or the hand holding the lids open
Minimize the distance from the bottle to the eye (without touching the eye)
Position the bottle above the eye so gravity will put the drop onto the eye
If feasible, chill the drops so you can tell when it has landed on the eye
Become an advocate for your patients with pharmacy benefit managers and write for more bottles per month if at all possible. When talking to industry, campaign for a more realistic number of drops in the bottle. If your patients don't use drops correctly, both you and they will pay a price.
These suggestions will take a few extra minutes, though most can be delegated to staff members. But by helping assure compliance with dry eye and glaucoma treatment, they may save you time in the long run, and save your patients unnecessary discomfort and frustration.
Marguerite McDonald, MD, FACS, with OCLI on Long Island, NY, is clinical professor of Ophthalmology at NYU Langone Medical Center, NY, and clinical professor of Ophthalmology at Tulane University Health Sciences Center, New Orleans, Louisiana.