The customary prescription of topical antibiotics, steroids and non-steroidal anti-inflammatories (NSAIDs) for the prevention of infection and inflammation is an important management consideration for patients undergoing cataract surgery. Although these medications represent a convenient, noninvasive method of delivering drugs to the anterior segment of the eye,¹ patient nonadherence persists and can negatively impact clinical outcomes.² Research shows the average noncompliance rate for eyedrop treatment to be approximately 30%.³

Let’s take a closer look at the realities of compliance in our cataract surgery patients so that we can more effectively intervene.

FIRST, UNDERSTAND NONCOMPLIANCE

Compliance is a multifactorial issue, which makes it so difficult for physicians to combat. Illness and health beliefs, degree of self-efficacy, communication styles, cognitive factors, social support, trust in health-care providers, literacy, race, income and age can all play a role.⁴ Although noncompliance has been formally defined in a variety of ways, it is understood to be a failure to conform to recommendations made by the provider with respect to timing, dosage and frequency of medication use.^2,4

Behavioral scientists have identified two categories of noncompliance: unintentional and intentional.⁵ Intentionally noncompliant patients decide to disregard or amend recommendations for treatment.⁵ Conversely, unintentional noncompliance is passive and may manifest as forgetfulness, misunderstanding or lack of awareness.⁵

With respect to eyedrops, noncompliance is most often unintentional and includes diminished ability or inability to properly instill the medication into the eye. This is a significant concern, particularly given the inherent challenges of eyedrop absorption across the cornea and conjunctiva. Only 1-7% of the instilled drug makes it through the cornea to reach the aqueous humor due to the hurdles posed by the precorneal tear clearance mechanism, the corneal-epithelial barrier and drug loss through the conjunctival-scleral route.¹

THE INTRICACIES OF INSTILLATION

Instillation technique is not intuitive. It takes practice and requires manual dexterity, eye-hand coordination and good vision.⁶ Blurring of vision and burning from the medication itself can interfere with drop instillation by triggering excessive tearing.

Using too many drops can pose challenges as well. Patients may utilize too much product, especially if they miss their target and make repeated attempts to get the drops in their eyes. The results are wastage and additional costs, along with phone calls for refills and denials by insurance plans for additional bottles within the specified timelines.⁷

A final key consideration in drop instillation is the importance of getting the drops into the eye without contaminating the bottle tip by touching it to the eye or adnexa, which can lead to infection or corneal abrasions.^8,9 While devices to assist patients with drop administration are available, they are underused and have received mixed reviews.^9,10

AGE-ASSOCIATED CHALLENGES

Unsurprisingly, older patients are the most likely to have difficulties with eyedrop administration, including problems with manual dexterity, lack of tactile sensibility, tremor of the hands or head, difficulty in tilting the head back or various degrees of visual impairment.¹¹

This creates unique challenges for cataract surgeons because age is also the biggest risk factor associated with cataracts. By age 80, 70% of white Americans, 61% of Hispanic Americans and 53% of black Americans have cataracts.¹²

Even when they are free of other physical conditions hindering self-application, correct handling of eyedrop containers may present a manual problem for older patients.^11,13 Decreased finger strength can result from arthritis, osteoarthritis, carpal tunnel syndrome or stroke. Deficits in control and direction of force application — both of which are required to squeeze a bottle — can also be caused by neurologic disease.^12,13

Additional obstacles include the ability to lift a hand to the face and maintain aim as the bottle is directed to the eye.

Beyond the physical limitations, older patients may have cognitive or memory problems that make it hard to follow complex eyedrop regimens.²

FINANCE-ASSOCIATED CHALLENGES

The high cost of the medications remains a key reason for noncompliance. Out-of-pocket cost to the consumer may depend on age (Medicare eligible), income (Medicaid eligible) and type of commercial insurance, but consider the typical estimated pre- and post-surgery protocol pricing reported on Drugs.com :

• $191 for 3 mL of a branded antibiotic eyedrop
• $288 for 3 mL of a branded NSAID
• $209 for 5 g of a branded corticosteroid

Generics may be substituted, but even generic prices are increasing rapidly.¹⁴ Surveys show that the retail cost of the drug combination used for post-cataract therapy ranges from a low of $175 to a high of $431 per eye, with a weighted average of $323.30. For some patients, out-of-pocket co-payments can be as much as $650 per eye.¹⁵

When drops are wasted due to failed attempts at instillation, patients may have to pay even more, especially if insurance companies deny approval for additional bottles.^7,15 Many patients may have no choice but to delay second-eye surgeries due to such unanticipated costs.

CATARACT-SPECIFIC CHALLENGES

Complex regimens cause confusion and often result in noncompliance. Patients undergoing cataract surgery are generally prescribed an antibiotic, a steroid and NSAID drops postoperatively. Each of these medications has a unique dosing schedule requiring administration multiple times per day.

If the patient has a second-eye cataract surgery, the routine becomes even more complex. Steroid drop schedules pose the greatest challenges because they require tapering.

Waiting at least 5 minutes before instilling different drops into the same eye creates additional burdens. Imagine how much time and wherewithal it takes for patients undergoing cataract surgery who are on concomitant eyedrops for glaucoma, dry eye disease or other ophthalmic conditions. These patients may be managing up to 14 drops per day from four or more different bottles, each with its own dosing schedule. Even if you provide pictures as instructional aids, generic substitutions can make the creation of these visual aids an effort in futility.

TESTED SOLUTIONS

Now that I’ve detailed the many formidable compliance obstacles we cataract surgeons face in our quest to optimize patients’ outcomes, what can practices do to counter them? At my practice, we have discovered some approaches that minimize confusion and aid compliance with the preoperative drop regimen.

An easy-to-follow medication instruction sheet with colored pictures of the prescribed bottles makes an excellent visual aid. The eye and frequency of the drops can be specified and clearly numbered in large font to help patients adhere to the instructions.

Practices can share coupons with patients depending on medication class and insurance type. Prior authorization is often mandated for branded prescriptions. A senior technician who is knowledgeable with medications can make a big difference to advocate on behalf of patients. Even though this gesture may result in added payroll costs, it goes a long way to generating practice goodwill.

A bi-directional software platform such as MDbackline’s cloud-based web service can provide more detailed instructions to patients, underscore compliance and serve as a conduit to clarify medication instillation questions. This not only streamlines communication between technicians and patients, but it also saves time from playing telephone tag with patients.

Consider the services of an online prescription management service. I use LeGrandeRx, which acts as an extension of the practice by tailoring prescription management to each doctor’s unique preferences and local market needs, while providing price transparency and home delivery to patients. This service also reduces the administrative workload for the technicians.

Simple steps such as the ones outlined above enhance compliance while building patient loyalty and trust.

TAKE A NARROW LOOK AT A BROAD ISSUE

Noncompliance has several causes and serious ramifications in the context of cataract surgery. The first step in overcoming these barriers involves awareness of why, when and how these struggles occur for patients. Without this insight, surgeons can’t possibly intervene effectively. Individual patient challenges should be considered during the preoperative assessment with a customized a drug delivery process crafted to address existing obstacles. OM

In my next installment, I will address new innovations to reduce noncompliance.

REFERENCES

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4. Dreer LE, Girkin C, Mansberger SL. Determinants of medication adherence to topical glaucoma therapy. J Glaucoma. 2012;21:234-240.
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11. Dietlein TS, Jordan JF, Lüke C, et al. Self-application of single-use eyedrop containers in an elderly population: comparisons with standard eyedrop bottle and younger patients. Acta Ophthalmol. 2008;86:856-859.
12. Olson RJ, Braga-Mele R, Chen SH, et al. Cataract in the adult eye preferred practice pattern. Ophthalmology. 2017;124:P1-119.
13. Connor AJ, Severn PS. Force requirements in topical medicine use — the squeezability factor. Eye. 2011;25:466-469.
14. Loden JC. Dropless cataract surgery. Ophthalmol Mgmt. Oct. 2014. 20-22.
15. Analysis of the Economic Impacts of Dropless Cataract Therapy on Medicare, Medicaid, State Governments, and Patient Costs. Andrew Chang & Co, LLC. Sacramento, CA. 2015. https://tinyurl.com/yy6mhqrl .
16. An JA, Kasner O, Samek DA, Levesque V. Evaluation of eyedrop administration by inexperienced patients after cataract surgery. J Cataract Refract Surg. 2014;40:1857-1861.
17. Liu Y, Murdoch A, Bassett K, Dharamsi S. Proficiency of eye drop instillation in postoperative cataract patients in Ghana. Clin Ophthalmol. 2013;7:2099-2105.

About the Author

Cynthia Matossian, MD, FACS, is the founder and medical director of Matossian Eye Associates, an affiliate of Prism Vision Group, with multiple offices in Pennsylvania and New Jersey. She specializes in refractive cataract surgery and dry eye disease.

Disclosures: Dr. Matossian is a consultant to MDbackline and LeGrandeRx.