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Treatment

Glaucoma can be treated with eye drops, pills, laser surgery, eye operations, or a combination of methods. The whole purpose of treatment is to prevent further loss of vision. LOSS OF VISION IN GLAUCOMA IS IRREVERSIBLE. Bringing the pressure under control will not restore lost vision, but only prevent further vision from being lost. Keeping the IOP under control is the key to preventing loss of vision from glaucoma. New approaches are being developed for the treatment of low-tension glaucoma [section under development].

In order to prevent further visual loss from glaucoma, the IOP must be constantly controlled. This requires taking medications chronically. If a drop is given four times a day, it is because the effect of the drop only lasts about 6 hours. Drops given twice a day have a "duration of action" of about 12 hours. Proper taking of drops and use of punctal occlusion will result in more of the drop getting into the eye and less into the blood stream, resulting in more effective treatment. Punctal occlusion and proper drop instillation are very important.

One of the most difficult problems faced by glaucoma patients is that of having to take medications which may have both ocular and systemic side effects to control a disease which is usually painless and has no symptoms. Understanding the necessity for the medication often helps to reduce the severity of a side effect, since it is often magnified by anxiety.

A side effect is any action produced by a drug beyond the intended one of lowering IOP. Some patients have no side effects whatsoever, while others find them too severe to tolerate. Why a drug causes side effects in some persons and not others or why the same side effect of the same drug is severe in one person and mild in another are poorly understood.

Quality of life is important. We sometimes have to make the decision to perform laser or surgery, even if the pressure can be controlled, if the side effects of the medications necessary for control are intolerable. It is up to the patient to participate in and ultimately make the decision in such a situation. What one should not do is skip taking the medications and lose vision because of side effects. One should also not be afraid to mention any side effects one might have or attribute to the drugs, since it is not one's fault that the drugs cause them.

All drops may cause some burning or stinging when instilled. Often, this effect is due not to the drug but to the antibacterial preservatives in the solution. It is rarely intolerable and can be used to advantage, since it lets the patient know that the drop got into the eye. Many patients don't think a drop is really medicine if it doesn't cause a little irritation.

I. MEDICAL TREATMENT

Eyedrops

Miotics (cholinergic agents) are drops which help to open the spaces in the trabecular meshwork and increase the rate of fluid flow out of the eye. The most common is pilocarpine. Carbachol is somewhat stronger and echothiophate (Phospholine®) is stronger still but has a tendency to cause cataracts and is only used in patients who have already had cataracts removed.

Epinephrine also lowers intraocular pressure by increasing the rate of fluid flow out of the eye. Dipivefrin (Propine®) is converted to epinephrine once inside the eye.

Beta-adrenergic blocking agents, or beta-blockers, decrease the rate at which fluid flows into the eye. Timolol (Timoptic®) and levobunolol (Betagan®) appear to have a slightly greater pressure-lowering effect than betaxolol (Betoptic®), but the latter is safer in patients with pulmonary disease, such as asthma or emphysema, and may have less of an effect on blood pressure. Oral beta-blockers are commonly used for hypertension and angina and in these situations, also lower IOP.

Carbonic anhydrase inhibitors (CAI) reduce fluid flow into the eye by inhibiting the enzyme which interconverts water and carbon dioxide to hydrogen and bicarbonate ions. For over 40 years, only pills were available. These consisted of acetazolamide (Diamox®), methazolamide (Neptazane®) and chlorpropamide (Daranide®). Although well tolerated by many patients, they were also associated with many serious side effects (see below), including fatalities. In 1995, the first CAI eye drop, dorzolamide (Trusopt®) became available. Brinzolamide (Azopt) was released in 1998. Although side effects may still occur in some patients, they have been greatly reduced overall.

Alpha agonists reduce aqueous humor production and increase aqueous outflow. Uveoscleral outflow normally accounts for about 10% of the outflow from the eye. The rest is handled by the trabecular meshwork. However, when the meshwork is damaged by glaucoma, uveoscleral outflow becomes more important. Apraclonidine (Iopidine®) and brimonidine (Alphagan®) are presently marketed. Brimonidine has a significantly higher relative selectivity for the alpha-2 receptors, while apraclonidine has mixed alpha-1 and alpha-2 stimulatory activity.

Prostaglandins act to increase the rate of outflow of aqueous humor not through the trabecular meshwork, but by another pathway called uveoscleral outflow. Latanoprost (Xalatan®), the agent most recently brought to market in the U.S., represents a new class of compounds which should prove additive with all other antiglaucoma drugs.

Common Side Effects of Antiglaucoma Drugs

One should not become neurotic when reading a list of possible side effects of a drug, such as the package insert. You may not get any side effects at all. If you do, it may only be a minor bother. Serious side effects are rare. If they weren't, we wouldn't be using the drugs in the first place. Sometimes, the only way to prove a side effect, particularly subjective ones such as anxiety, depression, or vivid dreams, is due to the medication is to stop using it, wait for the reaction to go away, and try it again. This is known as retesting. If you think you have an unusual reaction to a drug, mention it to your physician or post it on the Internet. A good place for this is alt.support.glaucoma. If you retest yourself twice and prove the side effect related to the drug and it is an unusual one, contact us by e-mail. We can then forward it to the National Registry of Ocular Drug-Induced Side Effects. Remember that all drops may cause burning and stinging and that any drug may produce a rash. If you have a definite allergic reaction to a drug, you should stop using it.

Miotics may cause periorbital pain, browache, and pain inside the eye. This often disappears after a few days of taking the drop. Blurred vision and extreme nearsightedness are most common in younger patients, who often cannot tolerate these drops. Because miotics reduce the size of the pupil and prevent it from dilating normally in the dark, many patients complain of dim vision, particularly at night or when going into a dark room. Systemic side effects are rare with pilocarpine, more common with carbachol, and not unusual with echothiophate. These include stuffy nose, sweating, increased salivation, and occasional gastrointestinal problems. Rare side effects include retinal detachment, mostly on circumstantial evidence. Patients with high myopia and pigment dispersion are more prone to both retinal detachment and glaucoma. PILOCARPINE GEL is applied at bedtime and may be substituted for drops in many patients. In addition to the convenience of not having to use drops four times a day, the effect on the pupil is often less. Ocuserts are pilocarpine membranes worn under the lids and changed every 5 days. These cause less blurring of vision and are especially useful in younger patients.

PILOCARPINE GEL is applied at bedtime and may be substituted for drops in many patients. In addition to the convenience of not having to use drops four times a day, the effect on the pupil is often less. OCUSERTS are pilocarpine membranes worn under the lids and changed every 5 days. These cause less blurring of vision and are especially useful in younger patients.

Epinephrine and dipivefrin frequently cause burning on instillation. A red eye is common and is an effect not of the drop initially, which whitens the eye by constricting blood vessels, but of the rebound effect when it wears off. The most common problem is development of an allergic reaction, which may occur after years of use. Epinephrine may cause palpitations, elevated blood pressure, tremor, headache, and anxiety. Dipivefrin has a much lower rate of systemic side effects.

Beta-blockers cause few ocular side effects. A few patients have complained of blurring of vision. This is more common when beta-blockers and epinephrine are used together, because this combination dilates the pupil. The most common systemic side effects include exacerbation of pulmonary disease, difficulty breathing, slowing of the pulse, and decreased blood pressure. More recently, central nervous system side effects have been reported. These include memory loss, dizziness, fatigue, weakness, decreased exercise tolerance, anxiety, hallucinations, insomnia, and impotence.

Carbonic anhydrase inhibitors commonly cause side effects. The most common are urinary frequency and tingling in the fingers and toes. These are often transient and disappear after a few days. Kidney stones may occur, but are also common without their use. Most glaucoma specialists use them unless a patient has had or develops a kidney stone or only has one kidney. A rare but serious side effect is aplastic anemia. Rashes are not uncommon. Potassium loss may occur when these drugs are taken simultaneously with digitalis, steroids, or chlorothiazide diuretics.

Depression, fatigue, and lethargy are common side effects and are often not realized by the patient or by close family. These side effects may not appear immediately but develop gradually. Since many patients with glaucoma are elderly, these side effects are attributed to getting older. Patients and their families should be on the alert for these side effects and, when suspected, the drug can be stopped for a short time for verification. Other common side effects are gastrointestinal upset, metallic taste to carbonated beverages, impotence, and weight loss. Sequels cause less side effects than tablets.

The use of topical CAIs has markedly reduced the frequency and severity of these side effects. With chronic use, some 20% of patients develop a topical allergy, with conjunctival redness and itching, redness, and scaling of the lower eyelids.

Alpha-agonists are chemically related to systemic medications for the treatment of hypertension, and systemic side effects of these medications are unusual. Ocular allergy develops in a high percentage of patients using apraclonidine on a prolonged basis; allergic reactions appear to be less with brimonidine. Patients who develop an allergy to apraclonidine can be switched to brimonidine. The most common side effects are slight elevation of the upper lid, dry mouth, dry nose, and mild sedation. Some patients may develop dizziness.

Prostaglandin analogues stimulate the uveoscleral pathway for aqueous outflow, and can be potent pressure-reduction medications. Although ocular injection and irritation may occur, these drugs are extremely well-tolerated and require only once daily dosing. A darkening of iris color occurs in approximately 5% of eyes with use of latanoprost for several months or more due to an increase in the production of melanin in the melanocytes of the iris. Pure brown eyes and pure blue eyes are not effected. Hazel, green, and golden-brown eyes are. Increased eyelash growth is not uncommon (and a patent for hair growth has been granted). Since the drug is new, other side effects are only beginning to be reported and have not been proven yet. Conjunctival redness is common. Flareups of uveitis and macular edema, facial burning or rash, and uterine bleeding in postmenopausal women are possibilities.

II. LASER SURGERY

Laser surgery is been used as treatment for a wide variety of glaucomas. The ability of light to penetrate the transparent structures of the eye (cornea and lens) allows it to have its desired affect on the targeted tissue. This is different from most other sites in the body, where penetration of light is blocked by the skin or thick outer tissues. Numerous different types of lasers are used in eye surgery for various purposes. These include argon, krypton, neodymium-YAG, diode, and excimer lasers.

Open-angle glaucoma: Laser Trabeculoplasty

In eyes with open-angle glaucoma, the laser energy is applied directly to the damaged drain, or trabecular meshwork. Argon laser trabeculoplasty (ALT) was first used as an intermediate step between drugs and surgery, but is now being used earlier in the disease process. ALT is most successful in eyes which do not have active inflammation. Its success increases with the age of the patient (except in pigmentary glaucoma) and the amount of pigment on the trabecular meshwork. Of the three most common forms of open-angle glaucoma, primary or chronic open-angle glaucoma, pigmentary glaucoma, and exfoliative glaucoma, the effect of ALT is greatest in the latter. In general, ALT is more effective in older individuals, except in pigmentary glaucoma, where younger patients tend to have a better pressure-lowering response. ALT works less well in eyes with a history of prior surgery, such as cataract or angle-closure glaucoma following laser iridotomy (see below). It may be useful in normal-tension glaucoma. ALT produces borderline or poor results in most other open-angle glaucomas. Aside from pigmentary glaucoma or other glaucomas with pigmentation of the trabecular meshwork, we do not feel that it should be performed in patients under age 40, as it is usually ineffective and may worsen the condition. It should also not be performed in eyes with active uveitis, neovascular glaucoma, iridocorneal endothelial syndrome, aniridia, or other childhood glaucomas.

The entire procedure takes less than ten minutes, is painless, and is performed on an outpatient basis. A single drop of anesthetic is administered beforehand. Most doctors also pretreat with a drop of apraclonidine (Iopidine), which decreases the likelihood of a postoperative rise in pressure. The laser beam is focused on the trabecular meshwork and 50 to 100 burns over 180 to 360 placed on the meshwork. Many surgeons divide the treatment into two sessions of 180 treatment each, in order to gauge its effectiveness and limit complications. If IOP comes under control after the first treatment, the second may be postponed until the effect of the first treatment wears off. One to three hours after the surgery the pressure in the eye is rechecked. Follow-up varies from 1 day to 1 week, and depends upon the type and status of the glaucoma. The final effect is often not attained for 4-6 weeks. Complications are infrequent and usually transient and include of pressure and mild inflammation.

Contrary to what some people think, the laser does not burn a hole through the eye. Instead, the heat causes some areas of the trabecular meshwork to shrink, theoretically resulting in adjacent areas stretching open and permitting aqueous humor to drain more easily. It is also possible that the laser stimulates DNA synthesis, promoting regrowth of trabecular cells.

The timing of laser trabeculoplasty remains controversial. In the 1980s, it was first used as an intermediate step between drugs and surgery, but is now being used earlier in the disease process. A long-term study performed by the National Eye Institute/National Institutes of Health (USA) has confirmed the clinical impression that, at the very least, laser trabeculoplasty is a safe and effective method of lowering IOP.

The effectiveness of laser trabeculoplasty varies from individual to individual and usually cannot be predicted. The average reduction in eye pressure is approximately 11 mmHg in exfoliative glaucoma and 7 mmHg in POAG and younger patients with pigmentary glaucoma. On the other hand, if the target pressure is 16 mm Hg, and the starting pressure is 35 mm Hg, the likelihood of achieving the target pressure with ALT is low. Unfortunately, virtually all patients who undergo ALT will either need to continue their eye drops or require them later on. The duration of the effect is also variable. Some individuals appear to respond only transiently, while others can maintain good control for years.

Angle-closure glaucoma

1. Laser Iridotomy

Blockage of aqueous flow between the posterior and anterior chambers in relative pupillary block (the most common cause of angle-closure glaucoma) can be relieved with a procedure called laser iridotomy. This surgery, which can be performed with the argon or Nd-YAG lasers, creates a hole in the iris to allow free passage of aqueous. In angle-closure glaucoma, the blockage of fluid flow may cause an acute attack of glaucoma and very high IOP, pain, and loss of vision. Laser iridotomy can successfully eliminate the chance of acute or chronic angle-closure glaucoma in most eyes. A series of high quality images of the living eye depicting the anatomy before and after laser iridotomy can be found at the Ocular Imaging Center, information for patients.

Laser iridotomy is also being evaluated as a possible therapy for reverse pupillary block in pigment dispersion syndrome and pigmentary glaucoma, although this remains under investigation. The procedure for laser iridotomy and potential for complications are described above. The procedure is ambulatory, generally pain-free, and takes approximately 10 minutes to perform.

2. Argon Laser Peripheral Iridoplasty (ALPI)

Under certain circumstances, laser iridotomy may fail to open a closed angle. If the angle is not permanently closed with scar tissue, ALPI may help to open the angle. This is particularly useful in less common forms of angle-closure, such as plateau iris syndrome or lens-related angle-closure. The procedure consist of applying the laser to contract and mechanically pull the iris out of the drain. Other uses include acute attacks of angle-closure in which laser iridotomy cannot be performed or is ineffective or continued angle-closure despite a patent laser iridotomy is present.

III. OPERATIVE SURGERY

Filtering Surgery

Operative surgery for glaucoma falls into 2 general categories reflecting the mechanism by which the surgery lowers the pressure. Since the problem in most glaucomas is that the drain does not function properly, the most commonly performed type of surgery involves creation of a new drainage structure for aqueous to leave the eye. The most common operation of this type is called trabeculectomy. In trabeculectomy, the surgeon fashions a new drain in the region of the trabecular meshwork (the damaged drain) and the sclera (which is the white covering of the eye). Fluid production within the eye is allowed to continue normally, and pressure reduction is achieved by allowing the fluid to exit the eye through the new drain.

With the advent of microsurgery and the use of the antiscarring drugs 5-fluorouracil (also known as 5-FU) and mitomycin C, these procedure have become much more effective at lowering pressure, preserving vision, and preventing complications. Techniques such as releasable sutures and laser suture lysis allow for a more gradual reduction of IOP after surgery and often avoid periods of prolonged low pressure, which can be a major source of complications during the first few weeks after surgery. Long term complication of this type of surgery include the possibility that cataract formation might accelerate and failure of the filtering operation months or years later.

Since this procedure is performed in an operating room, it typically takes longer (about 30-45 minutes) and involves more frequent follow-up care by the surgeon. Most patients are seen frequently (once or twice per week) for the first 4-6 weeks following the surgery, during which time the pressure is monitored and the healing process monitored. Postoperative drops can often be eliminated during this time.

Glaucoma Implants

Upon occasion, because of abnormal eye anatomy or history of previous eye surgery, it is not possible for the surgeon to build a new drain from the tissue present within the eye. Under these circumstances, an artificial drainage tube, made of plastic, may be inserted into the eye to act as a new drain. Although the modern form of glaucoma drainage tube implant surgery was first developed in the 1960s, advances in implant design during the 1980s and 1990s have made this procedure safer.

Combined cataract and glaucoma surgery

Since glaucoma often occurs in older individuals, the presence of a hazy lens, or cataract, is common during the preoperative examination. Although the correction of vision loss due to cataract requires surgery, the good news is that cataract surgery can successfully reverse the vision loss associated with the cataract, although the glaucoma damage will still be present. In this situation, the presence of coexisting cataract and glaucoma can be addressed by combined cataract surgery and glaucoma filtering surgery, most often with good results for both. The success of the glaucoma surgery in this instance is aided by the use of the anti-scarring medication mitomycin C, which has been a huge advance for glaucoma surgeons and their patients requiring combined cataract and glaucoma surgery.

Cyclodestruction

As mentioned earlier, in the above forms of glaucoma surgery the surgeon creates or implants a new drain for fluid to exit the eye and fluid production is allowed to continue. In cyclodestruction, the gland that produces the fluid, the ciliary body, is partially destroyed to decrease the amount of fluid produced in the eye. This is analogous to turning down the faucet in an overflowing sink. Unfortunately, the functioning of the eye depends upon the production of fluid, and cyclodestruction can cause a change in the composition of the fluid. Fortunately, the development of new laser technologies have made his procedure safer and less uncomfortable than in the past. Most physicians, however, reserve this surgery for eyes which have failed filtering surgery or those which are so badly damaged that the prognosis for the retention of vision is grim.

IV. ALTERNATIVE MEDICINE

[section under development]

V. LIFESTYLE

Compliance: The Patient's End of the Bargain

Definition

Compliance is a measure of the patient's ability to adhere to a prescribed medication regimen. Compliance is particularly relevant to glaucoma, a chronic disease. Visual loss often begins peripherally, with central vision often preserved until late in the disease. Meanwhile, patients must commit to taking multiple medications several times daily at regular intervals. These medications may have side effects ranging from minor and inconvenient to serious and disabling. All for a disease which often has no symptoms.

Compliance encompasses the patient's active participation in his or her own health care: seeking medical advice, keeping appointments, following implicit and overt recommendations concerning life style, diagnostic investigations, and medical and surgical regimens.

Noncompliance

Many patients miss anywhere from an occasional dose to most of the prescribed regimen. Others do not know how to take drops properly, and still others misuse the medications. Noncompliance can be defined as the intentional or accidental failure to comply with a physician's expressed or implied directions with regard to taking medications. The most advanced diagnostic and therapeutic advances techniques are of little importance if the patient is noncompliant. Noncompliance often leads to blindness in patients with glaucoma.

Examples of Noncompliance

1. Failure to take medications. This includes missed doses, premature cessation of therapy, and ineffective methods of taking medications. This last problem is especially pertinent to instilling eye drops.

2. Taking too much medication. Some patients, hoping for additional benefit, increase the number of doses and/or the amount taken each time - incorrectly assuming that if some is good, more must be better.

3. Taking a drug for the wrong reason. This may arise from confusion about the purpose of using a drug, particularly if several drugs are being used.

4. Improper timing of drug administration is more likely to occur if the medical regimen is complex: the administration of numerous medications at frequent or unusual times during the day.

Some patients take medications only just after and before their appointments. Halfway between appointments is the time at which the least number of prescribed doses are taken. Not taking medications can lead to visual field loss in a patient whose intraocular pressures at the time of the visit are measured as being normal. If noncompliance is not suspected or detected, patients may be subjected to expensive and invasive procedures and/or have their already partly ignored medical therapy accelerated (requiring higher drug concentration, number of drugs, and frequency of use), thereby increasing the risk of side effects and even worse compliance. There are other ways in which patients are noncompliant. These include not filling prescriptions, not refilling prescriptions when the first bottle runs out, and not getting the drops in the eye. It has been found that 3% to 7% of prescriptions written are never filled. Patients may fill prescriptions but never use the drops. They may forget one or more doses, particularly when away from home. One way to get around this is to keep medications both at home and at the office. This dramatically reduces the chances of missing a dose.

In one study, when serum carbon dioxide levels were measured, 35% of patients for whom Diamox had been prescribed were not taking it at all, and an additional 22% were taking it less often than directed. This may not be surprising, because side effects include loss of appetite, tingling of the fingers, weight loss, malaise, depression and fatigue.

Dyscompliance

Dyscompliance refers to an improper technique of taking medications, even though the patient takes all the prescribed medications. The most important problem in glaucoma therapy is failure to properly space multiple medications and to use nasolacrimal occlusion.

Proper Techniques of Drop Administration

Nasolacrimal duct occlusion. The tear duct (nasolacrimal duct) runs from the punctum, a pinpoint opening in the eyelid, into the nose. When drops are put in the eye, some pass through the cornea and get to the inside of the eye, where they are medically effective. Most of the drop, however, runs into the nose, and thence into the bloodstream, delivering the drug to the rest of the body, where they can cause side effects. Side effects are defined as effects of drugs on either the eye or other parts of the body which are not the intended effects for which the medication was prescribed. When pressure is applied with the index finger to the punctum and tear duct for 1 to 2 minutes following drop instillation, about 50% more medication gets into the eye. This gives more effective pressure lowering, a longer duration of action of the drops, more consistent lowering of intraocular pressure, and a reduction in the swings of pressure, in addition to fewer side effects elsewhere.

Drop spacing. When multiple eyedrops are prescribed, these must be taken at a minimum of 10 to 15 minutes apart. Drops taken a minute apart will wash each other out of the eye and the full effect will not be obtained.

This is the most important point we can make about taking glaucoma medications. We have seen patients' pressures drop from 30 to 15 with proper spacing and occlusion. Many other patients who had progressive visual loss and were facing surgery, stabilized with this simple technique. Some even reduced the amount of medications they were taking.

Other valuable hints about taking drops

Another example of dyscompliance is failure to shake a bottle of steroid suspension prior to instillation, which markedly decreases the amount of drug delivered to the eye. A surprising number of patients are unable to get the drop into the conjunctival sac, even though they think they have. We have seen patients who put the drops on their eyebrows or cheeks and thought the drops were going in the eye. One way to help with this problem is to keep the drops in the refrigerator. When the drops are cold, it is easier to tell if they have gotten onto the eye. It is useful to have a friend or relative watch occasionally to make sure that the drops are going where they should.

The bottle tip should never physically contact the eye. Not only is there danger of contamination, but contact also stimulated blinking, lid squeezing and reflex tearing, all of which dilute the drug and pump it away from the eye.

Many patients rely on someone else to instill their drops. Many others take their own drops with difficulty. Problems include difficulty breaking the bottle top seal, raising the arms, tilting the head, holding and squeezing the bottle, directing the bottle, fear of hitting the eye (leading to the bottle being held too high), involuntary blinking and poor sighting of the bottle tip. Severe physical difficulties may be presented by arthritis or a tremor, as in Parkinson's disease. Squeezing too hard on the bottle to expel a drop can lead to an increased hand tremor or a spurt of drops.

Factors Associated with Noncompliance

There are many reasons behind poor compliance. Most of the factors can be grouped under the following headings: the patient, the disease, the regimen, and the doctor-patient relationship.

1. The patient: None of the common demographic factors such as age, marital status, living alone, sex, race, income, occupation, fear of blindness, number of dependents, visual acuity, reading ability, subjective assessment of visual ability, sense of self-esteem, intelligence, level of education and personality type has been shown consistently to be related to noncompliance. Factors which do appear to correlate include frequently missing appointments, an unstable home or family situation, dissatisfaction with the treatment, and a poor understanding of the disease and its treatment. Greater understanding of glaucoma by the patient, including how it is related to levels of intraocular pressure, knowing that glaucoma can cause blindness, and that regular drop instillation could prevent blindness, all lead to better compliance and a better result of treatment.

Lack of concern about one's health in general and, more specifically, thinking that glaucoma does not pose a threat to one's well-being or that the treatment is not going to help, contribute to defaulting. With glaucoma, the patient's viewpoint can significantly affect the results of treatment.

2. The Disease: Diseases that produce severe symptoms or disability are associated with improved compliance. Chronic glaucoma fosters noncompliance, since visual loss is often not noticed by the patient untill the disease is well-advanced. Patients with glaucoma may need life-long, costly treatment and supervision, with no subjective improvement.

Patients often do not understand and cannot remember what they have been told, particularly if detailed information is provided immediately after a diagnosis has been made. Such a situation may engender a shock-like state during which little if anything is mentally and emotionally absorbed and digested. Material presented may be conceptually too complex for the medically uninitiated, and may be couched in language which is too difficult.

3. The Medical Regimen: Poor compliance correlates with increased regimen complexity: a greater number of drugs, required to be taken more frequently, with further life-style disruption. More side effects, particularly those which are alarming or unexpected, provoke defaulting. Duration of treatment has also been emphasized. While patients may be willing to take drugs for a limited period, when therapy has to be extended indefinitely, defaulting becomes more common.

4. The Doctor-Patient Relationship: Perception of the physician as warm, caring, friendly, accessible, active and thorough encourages compliance. Poor communication between the patient and the physician's team or a doctor's apparent lack of concern, can lead to the opposite. Long waiting times to obtain an appointment and long waiting times to be served at the pharmacy may also contribute to subsequent noncompliance.

No matter how well doctors think they know a patient, their judgments about compliance are often inaccurate. Physicians often automatically assume that patients are compliant. When noncompliance is discovered, the patient is blamed, sometimes with anger and rejection. Rather, it should be recognized that the management situation is inadequate in meeting that patient's needs.

5. Special problems in the very elderly: Elderly patients face particular problems. They are more likely to be treated for multiple disorders, creating a greater chance of side effects and drug interactions. Older patients are less able to recognize these reactions and separate them from other diseases. Poor hearing and diminished cognitive abilities may compound communication difficulties and reduce understanding of what treatment is required, and why.

Very elderly patients also have profound physical changes, including decreased lean body mass, decreased cardiac output, and decreased blood flow to the liver and kidney, which metabolize and excrete drugs. Drug concentrations are more likely to build up, leading to cumulative overdosage. Many elderly patients may alter their drug intake intentionally, partly at least to reduce side effects.

Falls are a major threat to the elderly and visual deficits aggravate this. Hip fracture risk is 50% greater with moderately impaired visual acuity, and 120% greater with very poor vision. In one study, nearly 10% of patients over age 65 had suffered a major fall in the previous 12 months.

Strategies to Enhance Compliance

Patients who understand the therapeutically relevant concepts of a disease are more compliant and have realistic expectations of the clinician and the management strategies.

Minimize the Treatment Regimen: Use the least number of drugs, at the lowest concentrations, the fewest number of times necessary. Because intraocular pressures can fluctuate widely throughout the day, new drugs should be started one at a time and to only one eye if possible. After the drug has been started, pressures should be measured in both eyes so that the physician can compare the effect of the drug on the treated eye with the untreated eye to assess effectiveness and side effects. If one drug is ineffective, substitute another drug for it before adding drugs and forcing the patient to take multiple medications. Record the time the pressure was taken and the time of the last medication, so that when treatment is being changed, the pressures can be taken on the new medication at the same time of day as it was taken on the old medication.

Minimize Inconvenience: Introduce the concept of 24-hour control. Try to fit the regimen into the patient's life-style. Determine the patient's daily routine, such as times for waking, morning break, lunch, return from work, evening meal, bedtime) and link this to the desired instillation schedule. If pilocarpine precludes driving, it may be acceptable to instill the drops after getting to work, and once back at home. In one study, these approaches reduced the frequency of missed and mistimed pilocarpine drops by 50%.

Predict Likely Side Effects: Nothing reinforces patient confidence as much as accurate prediction of effects and side effects. Patients are usually grateful to be made aware in advance of what to expect. Allergies to topical medications are often reactions to the preservatives. If patients understand this, they will be more willing to try alternatives.

Who Has The Time? All these suggestions require time. Many physicians do not have the resources to cover and regularly reiterate all these factors with all their glaucoma patients, especially under managed care. Trained staff can assist, especially if the patient perceives the effort as one that is co-ordinated by a concerned and involved clinician. Illustrated, informative pamphlets and booklets, audio tape and/or video tape presentations can be used by patients with relatives and friends in a relaxed setting, and should be re-exhibited intermittently or regularly as the patient may require. Expect to repeat much of this information on many occasions as the years of treatment unfold.

Community support groups play an important role. A number of organizations produce regular newsletters, run support group meetings, provide educational booklets and specific information sheets for glaucoma patients and their families, as well as enhancing public knowledge of the need for regular ophthalmic examinations as well as raising funds for glaucoma research. A booklet has been suggested for each patient containing the medication schedule, a record of the doses and the times they are needed, and listing all the treatments (systemic as well as topical) and all involved doctors. Patients are invited to document their problems, including inconveniences and side effects.

Use Compliance Aids: To encourage open communication with patients, try to reduce their anxiety about difficulties with the treatment program. Make them aware of compliance aids such as instillation frames and some eye drop brands with compliance caps.

Several styles of instillation frames are now available to assist in positioning the dropper bottle over the eye without tissue contact. The compliance cap contains a side window which displays a number. The patient turns the cap after each instillation to reveal the next drop number for that day's schedule.

For patients with memory difficulties, write the schedule out in large clear letters, identifying the bottles by description as well as name, e.g., "the bottle with the green or lilac top." For others with poor sight, use colored squares representing the bottle top color to reduce confusion. Large print labels around each bottle indicating the number of times to be taken daily can help the patient remember and also serve as a handle to facilitate drop instillation

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of New York


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