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MANAGING OPEN ANGLE GLAUCOMA

d. Adherence
“Drugs don’t work in patients who don’t take them”, once said C. Everett Koop, former U.S. Surgeon General.

“More than half of the progression in treated OAG may be attributable to poor adherence with treatment” (World Glau-
coma Congress, Vancouver, 2013).

It is hard to argue with these statements, just as it is hard to argue with the fact that non-adherence to medical
therapy is essentially preventable.
That being said, studies on adherence to glaucoma treatment are many, and have consistently concluded that be-
tween 5% and 80% of patients are non-adherent to their treatment regimen for glaucoma. 307 Unfortunately, a far
lower percentage of the clinicians that treat glaucoma feel that their patients are non-adherent, compounding the
problem. There is no question that eye drop instillation is a challenge, and for many a burden, and eliminating that
element of glaucoma management would invariably support the protection of visual function in our patients.
The four categories of issues related to adherence include: situational or environmental (e.g. cost); patient-related
(e.g. lack of understanding of the treatments, outcomes and need for follow-up, and others such as self-reported
symptoms of depression); treatment-related (complexity of regimen, adverse effects); and provider-related factors
(communication, engagement). 383,384
Adherence to the treatment regimen for any disease condition is challenging, and sustaining this adherence in the
presence of a chronic disease is an even more formidable obstacle. Glaucoma treatment poses the ultimate chal-
lenge because its successful management requires not only sustained adherence to a treatment regimen for a chron-
ic disease, but adherence in the face of a disease that is essentially asymptomatic until its very late stages.
Follow-up Considerations
Considerations for appropriate follow-up have been discussed through this guideline. Some key considerations re-
garding frequency of follow-up and recommended testing can be categorized under:

• current IOP and relationship to target;
• structural assessment and relationship to baseline;
• assessment of visual function through timely and appropriate visual field strategies;
• repeat gonioscopy to ensure nothing has changed in the original diagnosis or prognosis.

It is helpful to consider how to follow those patients who are high risk for developing glaucoma and those who have
been recently diagnosed.

Summary: Recommendations for follow-up

IOP Structure Function Gonioscopy
Applanation tonometry Objective imaging every AVF depending upon reliability Approximately
at every visit (consider 6 months and risk of progression annually
re-measuring pachymetry (assuming baseline 6 VF
once every 1-2 years) established in first 18-24
months)
• Baseline At least every 6 months; more • 24-2 SS every 6 months Consider sooner
• Set target often if progression suspected if stable/mild but more if history changes,
• Post-treatment (sooner or severe disease frequently (3-4 months anterior segment
for faster acting therapies, • Dilated assessment if unstable and/or findings warrant,
4-6 weeks for prostaglandin • Fundus photographs moderate/severe unusual findings noted
analogs) • OCT • 10-2 SS once per year, once
baseline established

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