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Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 23-26

Evaluation of reasons of glaucoma treatment dropouts in a health-care center

Department of Ophthalmology, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India

Date of Submission31-May-2021
Date of Decision01-Oct-2021
Date of Acceptance15-Nov-2021
Date of Web Publication3-Feb-2022

Correspondence Address:
Khushi Shah
Department of Ophthalmology, GCS Medical College, Hospital and Research Centre, Naroda, Ahmedabad, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcor.jcor_81_21

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Aims: The aim of this study is to evaluate the reasons of dropout in glaucoma patients in a health-care center. Materials and Methods: A cross-sectional study was carried out among 135 glaucoma patients assessed from January 2013 to January 2016 and lost to follow-up for more than 1 year; who were inquired about their reason of dropout through telephonic talk. Statistical Analysis Used: Z-test (SPSS-Statistical Package for the Social Sciences; version 21). Results: Out of 135 patients, 11 were untraceable due to wrong numbers. Of the remaining 124 patients, 33.1% cited lack of communication as their reason of dropout, followed by 29.8% of patients citing distance from the hospital and 19.3% citing no immediate visual improvement/symptoms. Among the dropouts, 49.2% of patients were on medical treatment, 26.4% of patients underwent laser peripheral iridotomy (LPI) only, 12.1% were on medical treatment post-LPI, 9.7% of patients underwent trabeculectomy, and 1.6% of patients were on medical treatment postsurgery. Conclusions: The most common factors of glaucoma treatment dropout found in our study were lack of communication followed by far distance from hospitals and no immediate visual improvement on treatment. Strategies to improve follow-up may include provision of appropriate education, motivation, and adequate counseling as well as accessible health care to prevent blinding eye disease.

Keywords: Compliance, dropouts, glaucoma

How to cite this article:
Shah S, Shah K, Popat A, Desai H, Jariwala D, Chaturvedi N. Evaluation of reasons of glaucoma treatment dropouts in a health-care center. J Clin Ophthalmol Res 2022;10:23-6

How to cite this URL:
Shah S, Shah K, Popat A, Desai H, Jariwala D, Chaturvedi N. Evaluation of reasons of glaucoma treatment dropouts in a health-care center. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Jun 2];10:23-6. Available from: https://www.jcor.in/text.asp?2022/10/1/23/337198

Glaucoma is the leading cause of irreversible visual impairment globally. The number of affected individuals is expected to reach 111.8 million in 2040.[1],[2] In India, at least 12 million people are affected, and nearly 1.2 million people are blind from glaucoma.[3] More than 90% of cases of glaucoma remain undiagnosed in the community.[3] In spite of considerable efforts made for the prevention of glaucoma, no good evidence exists regarding its prevention. Early diagnosis and treatment to reduce intraocular pressure (IOP) remains the only proven method to prevent the progression of the disease. Regular follow-up is considered important in maximizing the likelihood of visual preservation in those with glaucoma and allows the clinician to adjust therapy. In addition, disease progression resulted from noncompliance incurs direct and indirect societal costs such as drug cost, need of advanced therapeutics, and productivity lost.[4],[5],[6] A greater understanding of the barriers to follow-up from the patient's perspective would allow eye care providers to develop targeted strategies to eliminate obstacles to clinic follow-up. This study was aimed at identifying the most significant barriers to follow-up in a population of patients with glaucoma attending a tertiary health-care hospital in India.

  Materials and Methods Top

A cross-sectional study was conducted at a tertiary health-care hospital among glaucoma patients aged 30 years and above who presented to the hospital between January 2013 and January 2016 and were put on some form of glaucoma treatment. The patients who had not been coming for follow-up for more than 1 year were identified from hospital records and were labeled as “dropouts.” The study used a questionnaire [Appendix] to assess patient-reported problems, which was filled through telephonic talk. The questions included information on patient's demographic profile, type of glaucoma (obtained from past records), number of medications used, duration of treatment, history of other systemic illnesses, and multiple checkboxes for their reasons of leaving glaucoma treatment. The study was preapproved by the Institutional Ethics Committee of the hospital, and verbal consent was taken from each of the patients participating in the survey. The collected data were edited and coded in Microsoft Excel and analyzed using the IBM SPSS Statistics for Windows, Version 21.0 (Armonk, NY: IBM Corp.). Descriptive statistics in the form of frequencies and percentages were then calculated. Statistical significance was considered when the P value stood at <0.05.

  Results Top

Out of 1521 patients who were diagnosed with glaucoma from January 2013 to January 2016, 135 were identified as dropouts; thus, the dropout rate was 8.9%. Among them, 11 patients could not be contacted due to wrong/nonexistent phone numbers leaving 124 patients/their guardians who were questioned. Sixty-six patients who dropped out of glaucoma treatment were males (53.2%), whereas 58 were female (46.8%). This difference was not significant (P = 0.31). The age distribution of patients did not suggest predominance of any specific age group. The majority of dropouts were more than 55 years old (P < 0.001; significant). Majority of the patients (28.2%) belonged to the age range 61–65 years, followed by 23.4% between 56 and 60 years old, and 16.1% within 66–70 years age group.

Out of the study sample, 60.6% of the patients were unemployed (majority), 3.03% were professionals, 18.2% had a clerical job, 9.1% were skilled workers, and 9.1% were unskilled workers. While 25% of the patients were illiterate, 18.5% had completed their education up to middle school, 25% had studied up to high school, 15.6% had completed intermediary education, and 15.6% were graduates (according to the Modified Kuppuswamy Socioeconomic Scale). The income was not disclosed by the majority.

Refractory error was present in 86 out of 124 patients (69.3%), which was significant (P < 001). Family history of glaucoma was present in 7 out of 124 dropouts, which was not significant. Primary open-angle glaucoma was the most predominant glaucoma type, seen in 48.4% patients followed by 26.6% having primary angle-closure (PAC) glaucoma, 12.1% having PAC, 8.9% who were PAC suspects, 2.4% having ocular hypertension, and 1.6% patients having secondary angle-closure glaucoma.

Out of the different treatment modalities dispensed to the patients, those taking topical antiglaucoma drops (medical treatment) constituted the majority of dropouts; 49.2% of the sample size. Out of these, currently, only 32 patients were receiving drops to control IOP, which they continued buying without hospital visits. Among the others, 26.4% of patients had undergone laser peripheral iridotomy (LPI) only, 12.1% had LPI followed by medical treatment, and 9.7% underwent surgery, whereas 1.6% of patients had surgery followed by medical treatment.

When asked for reasons of leaving treatment, lack of communication/motivation was reported as being a major factor of dropping out, seen in 33.1% of patients. The second most common reason found was the distance from the hospital (seen in 29.8% of the patients). Among them, 25% of patients lived within 10 km range of the hospital, 31.2% lived beyond 10 km from the hospital, but in the same city, 12.5% of patients resided in other cities from the same state, whereas 31.3% were living in a different state (majority) and hence could not come for regular visits. The third most common reason was no symptoms/no immediate visual improvement (seen in 19.3% of the patients). Ten of the patients (8.1%) could not come for follow-up as they were bedridden due to medical reasons, while 15 of the patients (12.1%) died due to other medical causes during their follow-up. The various reasons cited by patients for leaving treatment are shown in [Figure 1].
Figure 1: Different reasons of treatment dropout given by study participants

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  Discussion Top

Glaucoma is the second most common cause of irreversible blindness worldwide. The World Health Organization has estimated that 4.5 million people are blind due to glaucoma.[3] As the symptoms in early cases of glaucoma are not debilitating, patients tend to ignore the importance of adhering to the treatment protocol and frequent follow-ups required for the disease. Blindness due to glaucoma is preventable if diagnosed and treated in the early stages, then visual field loss can be halted, and vision can be maintained.

Numerous studies[7],[8],[9],[10],[11],[12] have demonstrated poor patient adherence to glaucoma medication regimens, but relatively little is known about the problem of poor follow-up among existing patients of glaucoma. Kosoko et al.[12] anecdotally reported several primary reasons for poor follow-up in an inner-city glaucoma clinic in Baltimore, Maryland. They included costs of glaucoma care, the perception that this disease was ''not serious enough,'' and dissatisfaction with waiting times. Lee et al.,[13] in a study at the Aravind Eye Care System in South India, found that the most prevalent patient-reported barriers to glaucoma follow-up were the patients' belief that they had no problem with their eyes, lack of an escort to assist patients in attending the clinic and inability to be absent from work responsibilities. Glaucoma medication noncompliance has been the subject of intensive investigation due to the assumed importance of administering prescribed therapy to slow disease progression and to identify new cases. However, there has not been much research regarding the problem of poor patient adherence to recommended glaucoma follow-up, an issue that is important in providing quality glaucoma care for individuals and populations. Without proper glaucoma follow-up, care providers cannot monitor treatment efficacy and adverse effects. It is thereby difficult to create individualized therapeutic regimens or offer continual counseling and education to patients about their disease.

An attempt has been made to elaborate on various causes of noncompliance among patients in this study. Although we have a routine to counsel each patient, especially glaucoma patients, regarding the disease process, its treatment and need for follow-up and lack of communication has been identified as a major barrier. This necessitates the need of proper recounseling and guidance, especially to old patients who tend to be forgetful. As the patient's understanding may be a limiting factor to counseling, taking his/her background into consideration and using pictures may be useful. Making the patient speak whatever they have understood after proper counseling may direct our recounseling and make sure that the most common factor of dropout (i.e., lack of communication or motivation) is taken care of. Frequent eye checkup camps by the government in small neighborhoods and peripheries may also increase the awareness among the people along with making health-care facilities more accessible to the general public, which will take care of the second most common factor (distance from the hospital). Glaucoma awareness leaflets/advertisements on television and radio may help make the general population understand the disease process. For the sake of patients and the public system, clinicians should pay more attention to assess and explore drug compliance of their patients, and most importantly, look for ways of improvement. By identifying the important causes of treatment dropouts, we can predict the chances of the patient not coming for follow-up based on his/her background.

One limitation of this study was that the study population was drawn from a very specific practice environment (an urban teaching hospital). Thus, our findings may not be generalizable to other glaucoma populations. While the sample size was adequate to assess our primary study goal of determining the barriers to follow-up, it was limited, and caution must be used in attempting to generalize our findings to other populations.

  Conclusions Top

Understanding patient-reported barriers to glaucoma follow-up may give providers insight as to why patients do not adhere to follow-up recommendations. The most common factors of glaucoma treatment dropout found in our study were lack of communication followed by far distance from hospitals and no immediate visual improvement on treatment. Strategies to improve follow-up may include the provision of appropriate education, motivation, and adequate counseling as well as accessible health care to prevent this blinding eye disease.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Appendix Top

Pro forma used

  References Top

Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis. Ophthalmology 2014;121:2081-90.  Back to cited text no. 1
World Health Organization. Blindness and Vision Impairment Prevention; c2020. Available from: http://www.who.int/blindness/causes/priority/en/index6.html. [Last accessed on 2020 Dec 07].  Back to cited text no. 2
World Glaucoma Week. National Health Portal of India; c2019. Available from: http://www.nhp.gov.in/world-glaucoma-week_pg. [Last accessed on 2019 Apr 01].  Back to cited text no. 3
Rein DB, Zhang P, Wirth KE, Lee PP, Hoerger TJ, McCall N, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol 2006;124:1754-60.  Back to cited text no. 4
Nelson P, Aspinall P, Papasouliotis O, Worton B, O'Brien C. Quality of life in glaucoma and its relationship with visual function. J Glaucoma 2003;12:139-50.  Back to cited text no. 5
Friedman DS, Quigley HA, Gelb L, Tan J, Margolis J, Shah SN, et al. Using pharmacy claims data to study adherence to glaucoma medications: Methodology and findings of the Glaucoma Adherence and Persistency Study (GAPS). Invest Ophthalmol Vis Sci 2007;48:5052-7.  Back to cited text no. 6
Tsai T, Robin AL, Smith JP 3rd. An evaluation of how glaucoma patients use topical medications: A pilot study. Trans Am Ophthalmol Soc 2007;105:29-33.  Back to cited text no. 7
Robin AL, Novack GD, Covert DW, Crockett RS, Marcic TS. Adherence in glaucoma: Objective measurements of once-daily and adjunctive medication use. Am J Ophthalmol 2007;144:533-40.  Back to cited text no. 8
Sleath B, Robin AL, Covert D, Byrd JE, Tudor G, Svarstad B. Patient-reported behavior and problems in using glaucoma medications. Ophthalmology 2006;113:431-6.  Back to cited text no. 9
Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol 2005;140:598-606.  Back to cited text no. 10
Ngan R, Lam DL, Mudumbai RC, Chen PP. Risk factors for noncompliance with follow-up among normal-tension glaucoma suspects. Am J Ophthalmol 2007;144:310-1.  Back to cited text no. 11
Kosoko O, Quigley HA, Vitale S, Enger C, Kerrigan L, Tielsch JM. Risk factors for noncompliance with glaucoma follow-up visits in a residents' eye clinic. Ophthalmology 1998;105:2105-11.  Back to cited text no. 12
Lee BW, Sathyan P, John RK, Singh K, Robin AL. Predictors of and barriers associated with poor follow-up in patients with glaucoma in South India. Arch Ophthalmol 2008;126:1448-54.  Back to cited text no. 13


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