The medical management of glaucoma relies primarily on the administration of topical ocular medications. Noncompliance with prescribed treatments has proven to be a significant obstacle to effective glaucoma management. Kass and associates^1,2 found that most patients overestimate their compliance and that physicians are unable to determine which patients adhere to prescribed therapy. Lack of compliance may be confused with a therapy’s lack of efficacy. This confusion could lead to a change in therapy or the application of more aggressive therapeutic measures, such as laser or incisional surgery.

A medication’s cost, the complexity of a medical regimen, and the side effects of medications are all factors that may contribute to noncompliance. One factor that is often overlooked is the method of each patient’s eye drop administration. Eye care providers often neglect the importance of instruction on how to handle, store, and administer eye drops. They do not ask patients how the medications are stored, whether patients rely on others for administration, and how patients actually place the medication on the eye. These issues may be related to the relative success or failure of new eye drop bottle designs as well as the success of currently prescribed therapies.

There have been few attempts to describe the practical aspects of patients’ eye drop administration and to identify potential problems that may adversely affect effective therapy. A better understanding of the settings, circumstances, and methods adopted by patients when they administer eye drops may be the first step toward improving patient education, compliance, and therapeutic efficacy. This study attempts to address this issue.

A 2-page questionnaire was distributed to 253 consecutive patients with various forms of glaucoma who had at least 6 months of experience with topical glaucoma medications. The questionnaire was given at the time of their regularly scheduled clinical visit with one of two geographically distinct glaucoma specialists. Before the regularly scheduled ophthalmic examinations, trained technicians asked both demographic information and a combination of 10 multiple-choice and open-ended questions about patients’ use of eye drops. Institutional review board approval was obtained, and all participants gave informed consent. This study followed the tenets of the Declaration of Helsinki. The study was performed and analyzed before HIPAA approval was required.

Demographic data for the surveyed patients are summarized in Table 1. The majority were older, white, and women.

TABLE 1 DEMOGRAPHIC DATA FOR 253 GLAUCOMA PATIENTS WHO COMPLETED QUESTIONNAIRE ON EYE DROP USE

Survey results for selected questions are summarized in Table 2. The majority (20, 82.6%) of the 253 participants reported administering their own eye drops. Forty-four (17.4%) admitted to being dependent on others for eye drop administration. The reasons for this dependency were inadequate vision (25%), problems with manual dexterity (25%), and trouble getting only 1 drop out of the bottle (25%).

TABLE 2 RESULTS OF QUESTIONNAIRE ON EYE DROP USE BY 253 GLAUCOMA PATIENTS

In those patients who self-administered drops, most took drops while either sitting (37.8%) or standing (36.4%). Of the 66 (31.6%) who lay down, most used the bed (57 of 66; 86.4%). Most patients administered their drops in either the bedroom or the bathroom and did not use a mirror.

Some patients may have a problem with eye drop bottle contamination. Only 36.4% of survey participants reported “always” washing their hands before administering eye drops, and 15.8% reported “rarely” or “never” doing so. Furthermore, almost 5% reported “always” or “usually” having the dropper tip touch the eye during administration.

Most patients used both hands to apply an eye drop. By far, the most common practice was to use the right hand to hold the dropper bottle and the left index finger to hold the eyelid open.

Most patients did not keep their medication in a refrigerated area. The most common storage locations for glaucoma medications were the bedroom (45.4%) and bathroom (23.9%). Twenty-five patients (12.2%) kept medications in the refrigerator, and half of these reported doing so at the instruction of a provider or the package.

In response to the open-ended question “What do you not like about administering your glaucoma medications?” many patients described no problems, but common responses also included frustration with difficult-to-handle bottles (14.1%), problems getting the proper dosage into the eye (12.9%), and general dislike of putting eye drops in their eyes (11.2%).

There can be little doubt that noncompliance with prescribed medical management is a major factor in glaucoma treatment failure. Studies have repeatedly shown that missed doses are commonplace.^1–6 Kass and associates¹ demonstrated with an electronic medication monitor built into an eye drop bottle that 62% of patients surveyed omitted 10% of prescribed doses and 15% of patients omitted 50% of prescribed doses. A commonly overlooked component contributing to noncompliance with eye drop therapy is the method of patients’ eye drop administration. The current study begins to address the paucity of data in the literature regarding many of the practical aspects of eye drop administration. Although most participants in this study reported little difficulty with the use, storage, and handling of eye drops, the survey results demonstrate that broad variations in reported practices appear to exist.

Preferred techniques for applying eye drops have been described in the literature.^7,8 Fraunfelder⁷ has confirmed that variations in technique can have a significant impact on the ocular contact time of a topically applied medication. Contact time is related to a medication’s efficacy and potentially to its systemic absorption and adverse events.

Maximizing ocular contact time is easily achieved by directing patients to follow these simple instructions: First, grasp the lower eyelid near the margin with the thumb and index finger and pull outward to create a pouch in the lower cul-de-sac. Then, without touching the dropper tip to any ocular structures, position it above the eye by direct visualization. Just before releasing a drop, look upward. Allow the drop to settle by gravity into the lower cul-de-sac before releasing the eyelid. With the drop in place, close the eyelids and apply pressure to the nasolacrimal duct or forced eyelid closure for at least 2 minutes to minimize drainage and systemic absorption.⁸

The results of this survey study highlight multiple avenues eye care providers can use to improve patients’ eye drop administration. First, the variability in patient practices suggests that eye care providers need to first ask patients how they administer medications. In fact, it may be helpful to directly observe patients administering medications. Eye care providers should give better instructions about optimal eye drop administration techniques. For example, several questions in this survey indirectly addressed whether or not patients followed the recommended eye drop procedure. Most seemed to follow something similar to the recommended best practice by holding the lower lid with the index finger of the left hand. It is concerning, however, that 25.4% of participants reported contaminating the dropper tip by touching it to the eye at least sometimes. Similarly worrisome is the admission by 15.8% of participants that they rarely or never wash their hands prior to eye drop administration. The reported practices illustrate deficiencies in patients’ understanding of optimal methods of safe and effective eye drop administration. These results are consistent with those of other investigators who find a high rate of eye drop contamination.^9,10 Many nations address this problem by prohibiting eye drop bottles to contain more than approximately a 1-month supply.

The results of this survey may better inform both physicians and eye drop manufacturers about ways to better accommodate patient individuality, thereby making eye drop administration easier to remember and eyedroppers easier to use. The frequency of dropper contamination and infrequency of hand washing may argue that eyedroppers should be constructed to better protect the tip from contamination. Alternatively, it may be preferable for eye drops to be supplied in smaller, disposable bottles to prevent prolonged use of a contaminated bottle.

We found that many patients lack the manual dexterity to administer their own eye drops. Many reported “difficulty getting one drop out” as the reason they preferred having an assistant, a response supported by previously published observations that over 37% of patients instill 2 or more drops per eye treatment.¹¹ The volume of the conjunctival sac is smaller than a drop from most commercial droppers.¹² Therefore, the administration of multiple drops per treatment is, at best, an unnecessary waste and, at worst, a potentially harmful practice, because the risk of side effects increases when excess drug drains into the nasolacrimal system and is systemically absorbed. Some medications, such as prostaglandin analogues, may be less effective if given more than once daily.¹³ This problem might be addressed by better eyedropper technology.

We found variations in eye drop storage. While most patients stored eye drops in the bedroom (45.4%), significant numbers also stored them in the bathroom or kitchen, where there may be inadequate temperature control. Commercial eye drop preparations currently come with a broad range of storage requirements.¹⁴ Most specify an upper range for temperature exposure during storage, not uncommonly 25ºC (77ºF)—a temperature that could easily be exceeded in locations such as the kitchen or bathroom. Even the bedroom can exceed these temperatures in warm climates without constantly maintained air conditioning. Some medications have express warnings against freezing, whereas others do not recommend storage temperatures in the near-freezing or refrigerator range. This may be especially problematic for the 12.2% who store medications in the refrigerator, if instructions are not well understood or if the temperature in the refrigerator is not held constant. Certainly, these results welcome the development of eye drops that are stable in a broader range of conditions to better accommodate the actual storage conditions adopted by patients.

Caution is needed when interpreting these results. First, this is a pilot study and as such relies upon patients’ self-report. Patients are known to overestimate their ability to comply with therapy.^1,2 Second, enrollment in the study was limited to patients in glaucoma practices in either Baltimore, Maryland (A.L.R.), or Fort Worth, Texas (J.P.S.). Greater geographic diversity may yield different results. Furthermore, results may not be applicable to all forms of prescription or nonprescription eye drop therapy or to practices not specializing in glaucoma. Patients were asked about their use of topical glaucoma therapy only.

Nevertheless, the results of this survey add to a growing body of literature that addresses many of the problems contributing to noncompliance with topical glaucoma therapy.¹⁵ This survey study confirms that eye drop practices can vary considerably from one patient to the next. Some patients even report practicing behaviors, such as contamination of the dropper tip and administering more than 1 drop per treatment, that are potentially harmful. These results agree with other studies in the literature that suggest a need for better instruction in the use of topical eye medications.

In order to meet the challenge of improving adherence by our patients, we must first understand the factors that lead to suboptimal patient use of medications. Studies attempting to address this subject specifically in glaucoma have shown that patient forgetfulness, unavailability of the medication, and the timing or frequency of drop administration are identified by patients as barriers.² However, the actual instillation of a drop is a barrier as well.³ The authors should be congratulated for their attempt to begin to decipher this important question with this pilot study exploring the method of topical ophthalmic medication instillation as it may impact adherence.

Given all the factors that stand in the way of our patients actually using their medications appropriately, it is particularly frustrating if the final hurdle of actually putting the drop in is the fatal flaw that prevents success. However, given the paucity of information on this subject, this study represents a very reasonable first step. The use of a questionnaire presents many challenges, including the method of administration and the validation of the instrument. As this is a pilot project, the plan for validation should be addressed. Additionally, technicians administering the questionnaire in the clinic setting could influence patient responses, the validity of which is already questionable.

An unfortunate reality is the current unavailability of a method to determine the actual successful use of eye drops. Even with the best information to date, the measure was removing the cap and inverting the bottle, not an actual drop in the eye.⁴ As the authors point out, if we cannot believe patient reporting of compliance, is the information going to be better concerning the method of administration? Additionally, it would be interesting to know if the use of multiple bottles of medication or the duration of use of eye drops has an effect on patients’ behaviors in instilling medications.

However, the results are informative. The relatively high frequencies of needing assistance with instillation and contamination of the bottle are factors that can be identified and addressed. The concern with the temperature of storage needs more clarification. Is this a real concern? Are FDA guidelines for temperature stability inadequate?

Given the results of this study, the authors’ conclusions are important messages to the practitioner: Increased education as to how to instill a drop into the eye with follow-up to evaluate technique is a valuable step in addressing this important, although often underestimated, factor in all forms of topical ophthalmic therapy.

Financial Disclosures: Dr Gross is a consultant to Alcon Laboratories, Allergan, and Ista Pharmaceuticals. He has performed clinical research for and received honoraria from Alcon Laboratories, Allergan, Pfizer, and Merck and Co.

Funding/Support: None.

Financial Disclosures: None.

Author Contributions: Design and conduct of the study (A.L.R., J.P.S.); Analysis and interpretation of data (A.L.R., T.T.); Preparation of the manuscript (A.L.R., T.T.); Review and approval of the manuscript (A.L.R., J.P.S., T.T.).