Understanding Barriers to Glaucoma Treatment Adherence among Participants in South India

Factors affecting adherence to glaucoma medication: Patient perspective from North India

PURPOSE

Adherence to glaucoma medical therapy is a key factor in achieving target intraocular pressure to prevent glaucoma progression. To determine factors affecting medication adherence in glaucoma patients in an urban population belonging to poor socioeconomic status.

METHODS

A cross-sectional study was conducted on 200 patients attending glaucoma services in a tertiary referral hospital of North India. Adherence to medication was determined subjectively by questionnaire and objectively by counting the number of used bottles at the end of a month or during refill, whichever was earlier. Patient-related parameters in adherence toward glaucoma medication were studied based on demography, knowledge, attitudes, and practices (KAP). The statistical techniques of bivariate and multivariate logistic regression were adopted to test the objective.

RESULTS

The population was statistically homogeneous based on gender and income in both groups. A large proportion of patients had bilateral disease (87%) and were on two or more medications (62.5%). Adherence to glaucoma medical therapy was seen in 68% of patients, with knowledge about glaucoma present in 58% of patients. Deterrents to drug adherence were identified as forgetfulness (71%), unavailability of drugs (19%) or funds to purchase the same (26%), polypharmacy (21%), and side effects (5%). Dependence on an escort by 44% and dependence on hospital supply of medications by 60% emerged as the contextual factors requiring scrutiny while prescribing lifelong glaucoma medications. Disease misconceptions (53%) were prevalent and drug instillation practices were unsatisfactory (57%).

CONCLUSION

The study offers insight into patients' perspectives regarding the lifetime use of antiglaucoma medications and focuses on key issues linked to drug nonadherence.

Barriers and enablers to medication adherence in glaucoma: A systematic review of modifiable factors using the Theoretical Domains Framework

PURPOSE

Nonadherence to medication reduces treatment effectiveness, and in chronic conditions it can significantly reduce health outcomes. In glaucoma, suboptimal adherence can lead to sight loss, which places a greater financial burden on society and reduces patients' quality of life. Interventions to improve adherence have so far had limited success and lack robust theoretical underpinnings. A better understanding of the determinants of medication adherence behaviour is needed in order to develop interventions that can target these factors more effectively. This systematic review aims to identify modifiable barriers and enablers to glaucoma medication adherence and identify factors most likely to influence adherence behaviour.

RECENT FINDINGS

We searched CINAHL, MEDLINE, PsycINFO, EMBASE, the Cochrane Library and sources of grey literature up to August 2022 for studies reporting determinants of glaucoma medication adherence. Data describing modifiable barriers/enablers to adherence were extracted and analysed using the Theoretical Domains Framework (TDF), a behavioural framework consisting of 14 domains representing theoretical factors that most likely influence behaviour. Data were deductively coded into one of the TDF domains and inductively analysed to generate themes. Key behavioural domains influencing medication adherence were identified by frequency of study coding, level of elaboration and expressed importance. Eighty-three studies were included in the final synthesis. Four key domains influencing glaucoma medication adherence were identified: 'Environmental Context and Resources', 'Knowledge', 'Skills' and 'Memory, Attention and decision processes'. Frequently reported barriers included complex eyedrop regimens, lack of patient understanding of their condition, forgetfulness and difficulties administering eyedrops. Whereas simplified treatments, knowledgeable educated patients and good patient-practitioner relationships were enablers to adherence.

SUMMARY

We identified multiple barriers and enablers affecting glaucoma medication adherence. Four theoretical domains were found to be key in influencing adherence behaviour. These findings can be used to underpin the development of behaviour change interventions that aim to improve medication adherence.

A Drug Utilization Study of Anti-glaucoma Drugs in a Tertiary Care Hospital

BACKGROUND AND OBJECTIVES

Today, branded medications and polytherapy are frequently prescribed for glaucoma, even without giving the patient the proper instructions. Hence, the safety, effectiveness, cost, and patient compliance of glaucoma medication must be weighed, and the anti-glaucoma medicine usage must be studied. Analysis of glaucoma patients' prescription usage was the objective of this study.

MATERIAL AND METHODS

Between January 2021 and February 2022, this prospective and observational study was carried out at Andhra Medical College in Vishakhapatnam. One hundred prescriptions of those with primary open-angle and angle closure glaucoma were assessed. Age and gender-based subgroup analyses were conducted. R software (version 4.2.1) (The R Foundation for Statistical Computing, Vienna, Austria) was leveraged for data analysis.

RESULTS

Out of 146 examined prescriptions, 100 (69%) were deemed suitable for analysis. Participants' mean age was 54.2 ± 10.8 years. Sixty-two were over 50 years old, and 36 were men. The mean intraocular pressure was 25.4 ± 1.7 mm of Hg. Per prescription, there were about 1.75 anti-glaucoma drugs. Fixed-dose combinations (FDC) were found in 43 prescriptions. Generic medications and patient instructions prevailed in most prescriptions (78%) and (84%). Timolol was used in each FDC with brimonidine, dorzolamide, or bimatoprost.

CONCLUSION

The most often prescribed anti-glaucoma drug, timolol, was also identified as an essential component of the FDC. Doctors must prescribe generic medications with detailed directions for the patients.

Perspectives on Adherence to Glaucoma Medical Therapy in Brazilian Patients

BACKGROUND

Poor adherence to glaucoma medication regimens may be associated with subsequent optic nerve damage and irreversible visual loss. Specific barriers to effective patient adherence in low-middle income countries are not fully recognized and new disease-specific instruments to assess adherence have been developed.

OBJECTIVE

The purpose of this cross-sectional study was to evaluate adherence of primary open-angle glaucoma (POAG) patients to treatment in a middle-income country.

METHODS

POAG patients were recruited from the Glaucoma Service - Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil. Clinical and demographic data were retrieved from participants' electronic records. All patients answered the Glaucoma Treatment Compliance Assessment Tool (GTCAT). This 27-item questionnaire was designed to evaluate multiple behavioral factors associated with glaucoma medication adherence.

RESULTS

The sample comprised 96 patients with POAG. The mean age was 63.2 ± 8.9 years; 48 were male and 48 female; 55 (57.3%) were White, 36 (37.5%) African-Brazilian, and five (5.2 %) were of mixed color. Most patients (97.9%) had less than a high school degree and all had a family income < US$10,000. The GTCAT identified 69 (71.8%) patients who "sometimes forget to use drops," 68 (70.8%) patients who "sometimes fall asleep before dosing time," and 60 (62.5%) patients "whose drops aren't with them at the time to take them"; 82 (85.4%) patients admitted to using "reminders to take medications." Eighty-two (85.4%) patients agreed that "doctor answers my questions," and 77 (80.5%) said "they are happy with their eye doctor."

CONCLUSIONS

The GTCAT identified a number of mostly unintentional factors associated with adherence in this cohort of Brazilian patients. The data may impact on how to understand and improve adherence to ocular hypotensive treatment in the Brazilian population.

Medication Adherence and Common Barriers for Caregivers of Preschool Children with Pediatric Glaucoma

Purpose. To investigate the medication adherence among caregivers of preschool children with pediatric glaucoma and to elucidate common barriers leading to poor adherence. Methods. A cross-sectional study. Caregivers of preschool children with pediatric glaucoma completed a questionnaire on demographic information of caregivers, demographic and disease characteristics of children, caregivers-reported medication adherence (by an adapted Morisky Adherence Scale), and possible 13 barriers. Results. Overall 132 questionnaires were considered valid. Thirty-six percent of all reported poor medication adherence. Caregivers’ age and self-evaluated knowledge about pediatric glaucoma showed a significant difference between the adherent and nonadherent groups ( $P<0.05$ ). Nineteen percent of all reported only one barrier as important, 65% cited multiple barriers, and 16% cited no barriers. Anxiety and depression were cited as important by most caregivers in both groups. Univariate logistic regression analysis demonstrated that difficulty with the acquisition of medications (OR, 2.5; 95% CI, 1.1–5.7; $P=0.025$ ), difficulty with medication schedule (OR, 2.3; 95% CI, 1.0–5.0; $P=0.043$ ), and high expenses for medications (OR, 4.8; 95% CI, 1.4–15.9; $P=0.011$ ) were significantly associated with higher odds of poor adherence. Conclusions. Over one-third of caregivers of preschool children with pediatric glaucoma were in poor medication adherence. Nearly two-thirds of caregivers cited multiple barriers simultaneously as important hindrances to medication usage. Anxiety and depression, difficulty with the acquisition of medications, difficulty with the medication schedule, and high expenses for medications were prominent barriers. Individualized solutions should be provided according to reported barriers by each caregiver and the other most common barriers.

Impact of COVID-19 on glaucoma management: A review

Glaucoma is the leading cause of irreversible vision loss and the second leading cause of blindness worldwide. The rapid transmission of SARS-CoV-2virus compelled governments to concentrate their efforts on emergency units to treat the large number of cases that arose due to the Covid-19 outbreak. As a result, many chronically ill patients were left without access to medical care. The progression of glaucoma in previously diagnosed cases has been accelerated; due to this, some have lost their vision. Evaluation of Covid-19's effect on glaucoma treatment was one goal of this study. We used search phrases like "COVID-19," "telemedicine," and "glaucoma" to find published papers on COVID-19 and glaucoma. Artificial Intelligence (AI) may be the answer to the unanswered questions that arose due to this pandemic crisis. The benefits and drawbacks of AI in the context of teliglaucoma have been thoroughly examined. These AI-related ideas have been floating around for some time. We hope that Covid-19's enormous revisions will provide them with the motivation to move forward and significantly improve services. Despite the devastation the pandemic has caused, we are hopeful that eye care services will be better prepared and better equipped to avoid the loss of sight due to glaucoma in future.

Impact of COVID-19 on follow-up and medication adherence in patients with glaucoma in a tertiary eye care centre in south India

Purpose:

COVID-19 pandemic has affected the healthcare system worldwide hindering the continuum of treatment of chronic disease patients. The objective of the study is to analyze the barriers encountered by the glaucoma patients for the follow-up visit and medication adherence during the pandemic.

Methods:

This cross-sectional study included glaucoma patients who did not attend the scheduled appointment from April 1, 2020 to July 31, 2020 in a tertiary eye care center (88.21%). Eligible patients of age >18 years and advised antiglaucoma medication in Madurai Zone were interviewed with validated questionnaire through telephonic call.

Results:

363 patients answered the questionnaire through telephonic interview. 57.3% of the patients were found to be non-adherent to medication. The main barriers for glaucoma follow-up visit during the pandemic were lockdown restriction, transport problem, and financial difficulties. The top barriers for medication adherence were non availability of medication (54.81%), financial difficulties (30.29%), did not feel much improvement with eye drops (20.19%). On multiple regression analysis, longer distance to hospital, low socioeconomic status, more than one antiglaucoma medication use, lack of awareness of glaucoma, non-complaint before COVID-19 and stress due to the pandemic were found to be significant factors for medication non adherence.

Conclusion:

COVID-19 pandemic has emphasized the need for reformation in health care system for accessibility of medical care to patients in rural areas. Decentralization of health system to primary care level and utilization of teleophthalmology should be considered by health care planners in future.

A Prospective Analysis of iStent Inject Microstent Implantation: Surgical Outcomes, Endothelial Cell Density, and Device Position at 12 Months

PRECIS

The surgical outcome of iStent inject devices is associated with device protrusion within the anterior chamber. Schlemm canal (SC) dilatation has a prognostic value. iStent inject devices do not move within the first year after implantation.

INTRODUCTION

The iStent inject is a device designed to be implanted ab-interno through the trabecular meshwork. The present study follows up on our preliminary report, using successive in vivo anterior segment optical coherence tomography (AS-OCT) imaging to analyze the associations between stent positioning, iridocorneal angle structures, and surgical outcomes.

METHODS

In total, 54 eyes of 42 patients (73.3±7.4 y) with cataract and mild-to-moderate open-angle glaucoma were examined in this prospective study. All patients underwent implantation of 2 iStent inject devices combined with phacoemulsification. Patients were followed up over a 12-month period. AS-OCT was performed after 3 and 12 months. Thirty unoperated fellow eyes served as control eyes.

RESULTS

Intraocular pressure (IOP) decreased from 16.5±4.2 mm Hg at baseline to 15.1±3.7 mm Hg at 12 months (-8.7%; P=0.004), while medications decreased from 1.8±1.0 to 0.5±0.9 (-72.2%; P<0.001). Unmedicated IOP≤18 mm Hg was achieved in 58.8% of operated eyes. No sight-threatening complications were reported. On AS-OCT, 44.9% of devices were buried within the trabeculum. Device position was unchanged between scans. Regression analysis elicited significant predictors: SC dilatation effect [risk ratio (RR)=0.230; P=0.003], greatest SC diameter (RR=0.991; P=0.049), extrusion of the most anterior device (RR=0.993; P=0.012), gonioscopically visible devices (RR=0.406; P=0.040), baseline treatments (RR=2.214; P=0.001), and baseline IOP (RR=0.184; P=0.006). Endothelial cell density decreased by 14.6% at 12 months (P<0.001).

CONCLUSIONS

This study demonstrates the IOP-lowering and medication-lowering potential of iStent inject surgery in primary open-angle and pseudoexfoliative glaucoma. It confirms that surgical outcomes are positively associated with device protrusion within the anterior chamber, and suggests SC dilatation effect as a favorable prognostic indicator. It shows that stents are stable in time, highlighting the importance of the initial implantation location.