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Why noncompliance will ruin your perfect treatment plan


You diagnosed a patient and developed a treatment plan to improve the ocular surface. This is only the first (and often the easiest) step. The more challenging aspect is assuring that the patient follows through with the plan.

You diagnosed a patient and developed a treatment plan to improve the ocular surface. This is only the first (and often the easiest) step. The more challenging aspect is assuring that the patient follows through with the plan.

We know adherence is poor for treatments for chronic conditions, such as glaucoma.1-5 If patients are not adhering to treatments, and the end result is blindness, how can we assure adherence with ocular surface disease? One advantage just might be the nagging symptoms that remind patients of their problem.


Know the barriers to adherence

The most common barriers to adherence include:

• Ease of dosing schedule

• Cost of treatment

• Ability to properly instill eye drops

• Proper education

• Ease of finding over-the-counter (OTC) products

Next: Patient education


Patient education

Let’s take a closer look at these barriers and find way to improve patient adherence. The first starts in the office: proper education. Talking to your patient about his condition and need for treatment will improve his understanding that dry eye is not only an uncomfortable ocular condition but also a true disease state that, if not adequately treated, will progress.

Your diagnostic and clinical findings during your exam are your best educational tools. External photos work great and really can reduce the time it takes to educate the patient. Seeing really is believing for these patients. If you show them keratitis and at a follow-up exam show them how this is improving, it will motivate them to continue treatments. 

Related: Why the tear film matters

Drop instillation

Teach proper drop instillation any time you are recommending an eye drop, OTC to prescription. Do not assume patients know how this is done. Alan Robin, MD, et al have clearly demonstrated that glaucoma patients struggle with drop instillation through his work with video taping his patients instilling their medications.6

There are a number of resources available, including simple how-to instruction sheets and videos you can show while the patient is in the office. Technicians can also teach and observe drop instillation before the patient leaves.

Other studies in glaucoma research have shown that ease of dosing schedule will greatly improve adherence to medications.7

Most dry eye treatments do not allow the luxury of once-daily dosing, but we can be conservative about how many combined treatments we start. In my practice, I use a building-block treatment approach starting one treatment at a time and re-evaluating to determine the effectiveness of each step.

Next: Be aware of cost


Be aware of cost

Another consideration is cost of goods. Be aware of the cost of medications by calling your local network of pharmacies. There can be price differences from one pharmacy to the next, so directing patients to the one with the best price can help. Explain to patients that some medications are expensive but are far superior to other alternatives, especially generics.

Be understanding of her financial situation to make the best choice for that patient. The cost for OTC products and tear supplements can be a big monthly and yearly expense for our patients. Simplifying treatment whenever possible will help with cost of treatment.

Related: Why dry eye means poor vision

Following recommendations

Lastly, how easy is it for patients to find our specific recommendations for OTC tear supplements, omega 3 fish oil, or hot compresses? If you have a dedicated dry eye center in your practice, why not take the next step to create a dry eye boutique, a one-stop shopping experience for your patients that will assure they are getting the exact treatment you are recommending?

There’s nothing worse than your patient coming back for follow up, stating he is using a generic tear supplement because his pharmacist told him it was the same as the drop you recommended at half the cost. 

Some patients could be considered a treatment failure, leading to changes in treatment plans and medications that are unwarranted. They simply failed treatments as a result of poor adherence.

Next: Make everyday connections


Making everyday connections

Relating to the patient is a crucial part of successful treatment. Analogies for each patient based on their activities and lifestyle are a great start.

Equating the use of OTC products to that of sunscreen helps patients gain a better understanding of why they are using it before they have symptoms. You wouldn’t apply sunscreen when your skin was already pink, or you will feel the burn. If you wait to use artificial tears until the eye is uncomfortable, symptoms will be harder to control.

More blogs: Optometry on fleek

Another analogy is equating tears to a lotion for the eye. Explain how the tears moisten the surface of the eye, and when there is a deficiency in that tear, the eye’s surface will dry out, much like our skin in the winter. Eye drops are like the lotion we apply to our dry skin.

These patients are using supplemental tears because they are deficient in something-aqueous or oil. Proper education can improve adherence.

Keep in mind that a textbook treatment plan may look good on paper but needs to be achievable by the patient. Keep patient compliance in mind when creating a treatment plan, and be sure to educate your patients each step of the way.

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1. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertensive Treatment Study: a randomized trail determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002 Jun;120(6):701-13.

2. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004 Mar;42(3):200-9.

3. Kass MA, Meltzer DW, Gordon M, et al. Compliance with topical pilocarpine treatment. Am J Ophthalmol. 1986 May 15;101(5):515-23.

4. Kass MA, Gordon M, Meltzer DW. Can ophthalmologists correctly identify patients defaulting from pilocarpine therapy? 1986 May;101(5):524-30.

5. Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthalmic Surg. 1995 May;26(3):233-36.

6. Hennessy AL, Katz J, Covert D, et al.  A video study of drop instillation in both glaucoma and retina patients with visual impairment. Am J Ophthalmol. 2011 Dec;152(6):982-8.

7. Osterberg L, Blaschke T. Adherence to Medication. N Engl J Med. 2005 Aug 4;353(5):487-97


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