The second major reason people continue to lose vision from glaucoma is non-compliance with therapy. This is a long-recognized problem and, in day-to-day clinical practice, it is often the single greatest obstacle to successful long-term disease control.
Non-compliance presents a unique and frustrating challenge for clinicians because it lies at the intersection of human behavior, health literacy, socioeconomic factors, and the natural history of the disease itself.
The Scope of the Problem
The magnitude of non-compliance in glaucoma care is striking. Approximately 50% of patients discontinue their prescribed topical therapy within six months of initiation, even when treatment is clearly indicated.¹ This level of attrition would be unacceptable in most chronic diseases—and yet it remains common in glaucoma.
There are many contributing factors, including:
• Medication cost and insurance limitations
• Adverse effects (stinging, burning, hyperemia)
• Complex dosing schedules
• Difficulty administering drops
• Disruptions during travel or changes in routine
However, one of the most important—and least appreciated—factors is the patient’s limited understanding of the disease itself.
Glaucoma is a progressive, potentially blinding optic neuropathy, but it is typically painless, slowly progressive, and often asymmetric. As a result, patients frequently struggle to reconcile the seriousness of the diagnosis with the absence of symptoms. When vision appears “normal,” adherence becomes psychologically difficult to sustain.
What the Evidence Shows
The Glaucoma Adherence and Persistency Study (GAPS) remains the most comprehensive investigation of adherence in glaucoma patients.² The study identified several factors independently associated with poor adherence, including:
• Believing that vision loss is not a consequence of poor adherence
• Financial difficulty paying for medications
• Problems maintaining treatment while traveling or away from home
• Failure to acknowledge medication side effects
• Lack of reminder systems
• Receiving medication samples rather than stable prescriptions
Notably, patient belief systems—particularly whether reduced vision was perceived as a real risk—were among the strongest predictors of adherence. Even taken together, these variables explained only about 21% of the variance, underscoring how complex and multifactorial the problem truly is.
What Can Be Addressed
While not all drivers of non-compliance are modifiable, several practical steps are within the clinician’s control.
1. Education
Education remains the most powerful intervention. A study by Hahn and colleagues demonstrated that a focused, three-hour educational program significantly improved physicians’ ability to recognize and address non-adherence in glaucoma patients.³
In my own practice, patient education begins at the initial visit and continues at every follow-up. These encounters are used not only to review medications and dosing, but to repeatedly reinforce why treatment matters—even when the patient feels well.
2. Making the Disease Visible
One of the most effective tools I’ve found is showing patients their visual field progression plots. Seeing change unfold over time—especially when correlated with lapses in therapy—often creates a powerful and lasting impression that verbal explanations alone cannot achieve.
Reducing Dependence on Compliance
Recognition of the limitations of patient adherence has driven increasing interest in therapies that do not rely primarily on daily patient behavior. This has led to broader adoption of:
• Laser trabeculoplasty, particularly as early or first-line therapy
• Minimally invasive glaucoma surgery (MIGS) in appropriate patients
These approaches reduce the burden of adherence and, in some cases, improve long-term outcomes by removing the weakest link in glaucoma care: perfect, lifelong compliance.
Looking Ahead
Non-compliance remains a formidable challenge, but it is not insurmountable. Through education, better communication, thoughtful use of technology, and strategic treatment choices, its impact can be reduced.
Still, this is only the second reason people continue to go blind from glaucoma.
Stay tuned for the next installment.
— J.J. O’Donnell, OD, FAAO (Dipl. Glaucoma)
Evergreen Eye Consultants
Selected Citations
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Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598.e1–598.e11.
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Susanna R Jr, De Moraes CG, Cioffi GA, Ritch R. Why Do People (Still) Go Blind from Glaucoma? Transl Vis Sci Technol. 2015;4(2):1. doi:10.1167/tvst.4.2.1
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Hahn SR, Friedman DS, Quigley HA, et al. Effect of patient-centered communication training on glaucoma medication adherence. Ophthalmology. 2010;117(7):1339–1347.