Jessica Mendall
Royal Free London NHS Foundation Trust, London, UK
Background
Glaucoma is one of the leading causes of global blindness, responsible for approximately 8.4% of all blindness cases worldwide in 2020 (1). Medical treatment of glaucoma, ocular hypertension and glaucoma suspect involves use of long-term topical medications to lower intraocular pressure and thereby minimise optic nerve damage and sight loss. However, adherence to topical glaucoma medication is often poor, with reported rates of non-adherence varying from 30% to 80% (2, 3). Poor adherence can be attributed to a range of factors, including patient beliefs, potential or perceived side effects of medications, forgetfulness, difficulty with eye drop administration and insufficient patient education (4).
It is important to educate patients about the importance of medication adherence and attending glaucoma clinic appointments for monitoring of the disease, given that glaucoma is irreversible, and the more chronic forms are usually asymptomatic until the later stages. Whilst glaucoma is typically diagnosed and monitored in secondary care settings, GPs and other primary care professionals can play an important role in providing patients with long-term support, coordinating care, and promoting compliance with medication.
What Are Structured Medication Reviews?
Structured medication reviews in primary care provide a valuable opportunity to educate patients, address barriers to medication adherence, and provide tailored support to enhance patient engagement and medication compliance. The National Institute for Health and Care Excellence (NICE) guidelines on ‘Medicines optimisation’ state that “Service providers (such as GP practices, acute and mental health services) [should] ensure that systems are in place to identify people taking medicines who would benefit from a structured medication review. Such patients may include people taking medicines for long-term conditions and people taking multiple medicines” (5).
As glaucoma is a chronic condition, these guidelines suggest that patients with glaucoma are likely to gain benefit from structured medication reviews. Secondly, the NICE 2023 guidelines for ‘Primary open angle glaucoma and ocular hypertension’ advise that “Primary care practitioners may have a role in management to promote the correct use of eye drops and adherence to treatment… [and] monitor for allergy and other adverse effects of eye drops” (6).
Content to Cover in a Glaucoma Medication Review
A suggested five-step approach to conducting a structured glaucoma medication review in primary care is provided below, which aims to address medication adherence, minimise side effects of medication, and ensure effective disease monitoring and management.
Medication Adherence
To ensure patients are adhering to their prescribed glaucoma medication, it’s important to confirm the correct dose and frequency, including the number of drops and administration times. Discuss any missed doses to identify patterns of non-adherence and explore strategies to improve consistency, such as using phone alarms, written schedules, or linking drop administration to daily routines like brushing teeth. For patients struggling with compliance, combination drops may be a suitable option. Additionally, it’s crucial to identify and address potential barriers to adherence, such as difficulty remembering, challenges with administration, concerns about side effects, or financial constraints.
Side Effects and Tolerability
Patients should be asked about any local side effects they may be experiencing, such as irritation, redness, or blurred vision (common with prostaglandin analogues) or itching, burning, or a bitter taste (common with carbonic anhydrase inhibitors). Systemic side effects, particularly with beta-blockers, should also be monitored, including headaches, dizziness, low blood pressure, slow heart rate, fatigue, or respiratory issues. If side effects are problematic, consider adjusting the treatment, switching medications, or providing symptomatic relief, such as preservative-free formulations for irritation.
Eye Drop Technique
A face-to-face review is recommended to assess the patient’s eye drop technique and provide a demonstration if needed. Patients should be reminded to wash their hands before and after each application and to remove contact lenses before instilling drops, waiting at least 15 minutes before re-inserting them. After applying the drops, they should close their eyes gently without blinking or squeezing tightly. For patients with physical challenges, such as arthritis or tremors, dispensing aids like ‘Opticare’ or ‘Autosqueeze’ (available from Glaucoma UK) or assistance from family members can be helpful. It’s also important to advise patients to wait 5 minutes between different glaucoma medications and at least 30 minutes between glaucoma drops and dry eye drops.
Practical Considerations
Patients should be informed about storage requirements for their eye drops, as some, like certain prostaglandin analogues, may need refrigeration before opening. Additionally, they should be advised to discard most multidose drops one month after opening to prevent contamination.
Patient Education
Educating patients about their condition is vital. Ensure they understand the importance of glaucoma drops in reducing the risk of irreversible vision loss. Regular monitoring and follow-up in secondary care are critical to assess disease progression. According to NICE guidelines, the frequency of monitoring should be individualised based on the type and severity of glaucoma. For stable early-stage glaucoma, follow-up is typically recommended every 12 to 18 months, while more unstable or advanced cases may require monitoring every 1 to 4 months. This is also an opportunity to identify patients who may have been lost to follow-up and re-refer them to secondary care. Finally, patients can be directed to support resources such as Glaucoma UK and the Royal National Institute of Blind People (RNIB), which offer free resources, helplines, dispensing aids, and support groups.
By addressing these areas comprehensively, healthcare providers can help patients manage their glaucoma more effectively and improve their overall quality of life.
Assessing uptake of medication reviews in primary care
To put this theory into practice, we conducted a closed-loop audit in a London GP practice with 23121 registered patients, of whom 139 patients (0.60%) were taking glaucoma medication. Whilst 74/139 patients (53.24%) took more than one glaucoma drop, only 53/139 patients (38.13%) used a combination eye drop. 16/139 patients (11.51%) taking glaucoma drugs had neither received a medication review nor been seen in a glaucoma clinic in the past year. These 16 patients were invited via text message to attend for a face-to-face structured medication review with the practice pharmacists, and four weeks after the initial text messages were sent, a re-audit was performed. Interestingly, only 3 out of 16 patients (18.75%) had attended a face-to-face medication review at the GP practice after 4 weeks.
This real-world audit highlights some important considerations and challenges in addressing medication compliance in glaucoma in a primary care setting. Firstly, it has identified that there is scope to increase the uptake of combination drops; whilst a majority of this cohort were taking more than one glaucoma medication, only 38.13% used a combination drop. Secondly, whilst the majority of patients taking glaucoma medication had been seen in a glaucoma clinic or had their medication reviewed in the GP setting in the past year, 11.51% of patients had not.
This highlights a wider problem; that a significant number of patients with glaucoma are either not attending their appointments at glaucoma services, or they have been lost to follow-up. This reflects the literature, with a recent study reporting non-attendance rates of up to 10.5% at ophthalmic clinics (10). Furthermore, only 3 out of 16 patients (18.75%) attended the GP practice for a face-to-face medication review within 4 weeks of receiving a text invite.
It would be important to explore on a wider scale whether this trend applies more broadly, and whether there are underlying healthcare inequalities (e.g. language barriers, difficulties in attending the practice for a face-to-face consultation, or lack of digital skills to book the appointment) contributing to the lack of engagement that can be addressed (10).
Conclusions
In summary, face-to-face structured medication reviews are a useful tool to educate and support patients in adhering to their glaucoma treatment and engaging with glaucoma monitoring services. There is however a subpopulation of patients taking glaucoma medication who do not attend secondary care appointments or have been lost to follow-up. Future study should attempt to characterise this cohort, and whether healthcare inequalities can be addressed to improve engagement with glaucoma services and medication reviews in primary care.
References
- Vision Loss Expert Group of the Global Burden of Disease Study & the GBD 2019 Blindness and Vision Impairment Collaborators. Global estimates on the number of people blind or visually impaired by glaucoma: A meta-analysis from 2000 to 2020. Eye. 2024;38(11):2036-2046.
- Olthoff CM, Schouten JS, van de Borne BW, Webers CA. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension an evidence-based review. Ophthalmology. 2005;112(6):953-61.
- Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol. 2008;53(Suppl1):S57-68.
- Newman-Casey PA, Robin AL, Blachley T, et al. The Most Common Barriers to Glaucoma Medication Adherence: A Cross-Sectional Survey. Ophthalmology. 2015;122(7):1308-1316.
- National Institute for Health and Care Excellence. Medicines optimisation, Quality standard [QS120], Quality Statement 6: Structured Medication Review.[online] 2016 [Accessed 26 January 2025]. Available from: https://www.nice.org.uk/guidance/qs120/chapter/quality-statement-6-structured-medication-review
- National Institute for Health and Care Excellence. Glaucoma, Scenario: Primary open angle glaucoma and ocular hypertension. [online] 2023 [Accessed 26 January 2025]. Available from: https://cks.nice.org.uk/topics/glaucoma/management/primary-open-angle-glaucoma-intraocular-hypertension/
- Glaucoma UK. Easy read: Putting in your eye drops. [online] [date unknown] [Accessed 2nd February 2025]. Available from: https://glaucoma.uk/wp-content/uploads/2022/02/2021-Booklets-Easy-read-Putting-in-your-eye-drops-Digital-Version.pdf
- Glaucoma UK. Eye drops and dispensing aids: A Guide. [online] 2020 [Accessed 3rd February 2025]. Available from: https://glaucoma.uk/wp-content/uploads/2020/07/3000_GlaucomaUK_PatientLeaflet_A5_EyeDropsandDispensingAids_Web.pdf
- National Institute for Health and Care Excellence. Glaucoma: diagnosis and management, NICE guideline [NG81]. [online] 2022 [Accessed 26 January 2025]. Available from: https://www.nice.org.uk/guidance/ng81
- Wagner SK, Raja L, Cortina-Borja M, et al. Determinants of non-attendance at face-to-face and telemedicine ophthalmic consultations. Br J Ophthalmol. 2024;108(4):625-632.