Early last month, on an uneventful clinic day full of glaucoma patients, a 67-year-old white male presented for a follow up related to his glaucoma. He was scheduled for threshold visual field testing, HRT 3 optic nerve imaging and stereo disc photography. The problem was, he was scheduled for these tests 20 months earlier. 

On the same day, a 64-year-old black female presented for a cataract evaluation. She was scheduled for a refraction, dilation and evaluation of her cataracts. The problem this time? She is also a glaucoma patient who was last seen in the office approximately two years earlier.

When looking at each of the patients more closely, we observed the following pertinent information. 

Case One’s Diagnostic Data
The 67-year-old white male was initially diagnosed with open angle glaucoma four years earlier due to elevated intraocular pressure (IOP) and characteristic optic nerve damage. Specifically, his pretreatment IOP was in the upper 20s in both eyes, central corneal thickness measured 522µm OD and 511µm OS. His cup-to-disc ratio at the initial evaluation was 0.55 x 0.65 OD and 0.6 x 0.7 OS. Thinning of the neuroretinal rims was observed superiorly and inferiorly in both eyes, with corresponding field defects in the arcuate regions, not involving fixation. Gonioscopy demonstrated open angles in both eyes. 

After an initial trial period, the patient was stabilized on Lumigan (Allergan) HS in both eyes. In the subsequent two years of therapy, the fields, neuroretinal rims and structural indices all remained stable, with post medicated pressures averaging 16mm Hg OU. He was then lost to follow up and presented to the office last month because he “felt it was time to come back.”

Compliance Do’s and Don’ts DO (while maintaining standard of care): Simplify the medication regimen Try to make the testing as simple and as infrequent as possible Try to have the patient understand the nature of the disease Encourage patients to “buy in” to care Communicate in a way that makes patients comfortable Express your expectations firmly Be confident in your care and plan Understand the patient expectations Document, document, document DON’T: Dismiss a patient’s concerns Forget to communicate with the patient Make them feel insignificant in the patient care encounter Become complacent in your care Frighten a patient to foster compliance NOT care about the patient

At this most recent visit, his IOP was 24mm Hg OD and 25mm Hg OS at 10:15am. When queried about his use of glaucoma therapy, he admitted that he ran out of medications about a year earlier. He was maintaining close liaison with his primary care physician and continued his hypertensive and GERD medications regularly. By the time I saw him, the patient already had his visual field and HRT 3 testing. Both the visual fields and the HRT 3 results revealed progression of his disease in both eyes. Neuroretinal rim loss had progressed, and the fields had worsened accordingly. No disc hemorrhages were noted. Other than early nuclear sclerotic cataracts, the remainder of his ophthalmic evaluation was unremarkable.

Case Two’s Diagnostic Data
The 64-year-old black female had a lengthy and complex medical record. She was initially diagnosed with bilateral uveitic glaucoma seven years earlier. This time around, I reviewed her records from the past, both electronic and paper. Three visits were recorded in EMR and 12 visits in the paper record. In reviewing the paper records, it became evident that she had been seeing no less than four different eye care providers, one of whom was my partner. She was pseudophakic in the right eye, and there was information from a cataract surgeon regarding referral to a glaucoma surgeon for elevated IOP following cataract surgery. 

Sometime after the cataract surgery (approximately eight years earlier), my partner and I both became involved in her care. The patient also continued to see a glaucoma surgeon, and one other provider in town. 

Her chart and care had become so confusing and complicated by so many people providing care that, when I saw her earlier in July, I was uncertain about her stability. Interestingly, and not surprisingly, while reviewing the paper charts, I noticed a post-it note that I had attached to one of my partners’ office notes from five years ago, addressed to him, simply asking: “who is driving this bus?” Not remembering the exact nuances of her case, seeing this note reaffirmed that, even years ago, I was concerned that there were too many cooks in the kitchen.

To complicate it further, she was an unreliable historian. She did affirm that she was taking Travatan Z (Alcon) HS for both eyes and Alphagan-P (Allergan) BID for her right eye and TID for her left eye. Otherwise, she was not clear on when she had seen any other eye doctor in the past six to nine months, but mentioned that she saw the glaucoma surgeon “several months ago.” 

To complicate an already muddy case, the surgeon’s notes clearly mentioned that she was being treated for uveitic glaucoma bilaterally, yet she had two laser peripheral iridotomies in her left eye, one at 10 o’clock and one at 2 o’clock, both of which were patent. In this phakic left eye, angles were wide open, the chamber was quiet and the natural lens was characterized by moderate nuclear sclerosis. The anterior segment of the right eye was essentially unremarkable, with a well-centered posterior chamber IOL, a clear posterior capsule and a clear anterior chamber. Both discs were characterized by 0.5 x 0.55 cup-to-disc ratios, and relatively healthy neuroretinal rims, with no frank evidence of focal loss.

Discussion
Two patients with varying degrees of noncompliance are presented here. At the end of the day, our responsibility is to make an accurate diagnosis and offer an acceptable and sound medical plan, but it is ultimately up to the patient to comply. Unfortunately for us, we may face blame even for noncompliant patients. And unfortunately for the patient, if they’re noncompliant, they may lose vision.

So how do we deal with noncompliance? Individualize your approach based on the case specifics and the likelihood of the patient truly understanding the necessity for compliance. There are some caveats on what not to do, but how you approach a noncompliant patient will differ in the same number of ways that patients manifest their noncompliance. 

This topographical change analysis shows progressive loss of neuroretinal rim and perioptic nerve fiber layer in a 67-year-old white male glaucoma patient who skipped out on his scheduled testing and didn’t return for nearly a year.

Some ways to proceed are more subtle, such as getting patients to “buy in” to their own care. Other ways are more dramatic, such as covering patients’ eyes and telling them this is what they will see if they don’t comply—nothing.

For the 67-year-old white male, I chose to lay it all out on the line, in frank terms, that he has worsened in the past 20 months and will continue to do so if we don’t make a change in his compliance. Yes, I did tell him he will lose vision as time progresses. But unfortunately for him, I had evidence that he already lost vision. I assumed that because he “thought it was time” to return, that meant he actually does have an interest in his care. This was my opportunity to say, in essence, “OK, you worsened, you get a pass this time, you will get worse if we don’t change anything, so I need your help to prevent that from happening.” 

For the 64-year old-black female, I took an entirely different approach. I looked her squarely in the eyes and said that we have been down this path before and that too many people are involved in her eye care—and that she needs to pick one. It didn’t matter to me who she chose; it was in her best interest that one person was driving her care, not several people. Things weren’t adding up (multiple providers, LPIs with open angles and deep chambers, etc.). I told her, if she wanted me to be that provider, then she was to return in one to two months for specific testing and that if she didn’t return, which was certainly her prerogative, we would no longer be able to see her. And I documented it clearly in her chart.

Different scenarios and patients require different approaches. At the end of the day, if you care more about your patient’s health than they do, there is little you can do for the patient. 

You can’t protect them from themselves, but you must protect yourself.