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Patient Acceptance and Attitude Toward an Alternative Method of Subconjunctival Injection for the Medical Treatment of Glaucoma

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Patient Acceptance and Attitude Toward an Alternative Method of Subconjunctival Injection for the Medical Treatment of Glaucoma ORIGINAL STUDY Patient Acceptance and Attitude Toward an Alternative Method of Subconjunctival Injection for the Medical Treatment of Glaucoma Rachel S. Chong, MBBS,* Daniel H.W. Su, FRCSEd,* Andrew Tsai, MBBS,w Yuzhen Jiang, MD, PhD,wz Hla Myint Htoon, PhD,w Ecosse L. Lamoureux, PhD,wy Tin Aung, FRCSEd, PhD,*w8 and Tina T. Wong, FRCSEd, PhD*w8z and patients. This is compounded when dealing with Purpose: Nonadherence to glaucoma medications may be a major asymptomatic illnesses such as glaucoma, the second most cause of treatment failure. We examined the acceptance of important cause of irreversible blindness in the world. glaucoma patients toward a possible new route of administering Elevated intraocular pressure (IOP) is the only modifiable glaucoma medication by subconjunctival injection. risk factor and IOP-lowering eye drops is the first line Patients and Methods: Patients were recruited from specialist treatment for glaucoma. It has been estimated that the glaucoma clinics on a voluntary basis. Trained interviewers proportion of nonadherers to antiglaucoma medication administered a 30-item questionnaire and an information sheet may be as high as 59%,1 and that deviations from the with details of an alternative subconjunctival injection route prescribed medication regime result in dose omission, or involving injections at 3-month intervals. Outcome measures inappropriate time intervals between doses.2–4 Further- regarding acceptance of the new procedure, social situational more, it has been reported that the proportion of doses factors, disease factors, and treatment factors were assessed. taken in the 24 hours before a scheduled clinic visit was Results: A total of 151 patients participated in this study. Of the significantly higher than over the entire observation 151 patients 112 (74.2%) were willing to have their glaucoma period,5 which implies that IOP measurements taken in medication given by the new method of subconjunctival injection, clinic may not accurately represent a patient’s usual IOP. 101 of 112 (90.2%) were willing to accept it at the same cost as their Efforts have been made to identify potential non- present medication, and 87 of 101 (86.1%) were willing to accept it adherers although a literature review examining 29 separate even at a higher cost. These patients tended to be on a greater number of medications (P = 0.006), and medicating more fre- studies has suggested equivocal relationships between quently in a day (P = 0.003). Nine of 10 (90%) patients who were nonadherence to glaucoma medication with patients’ age, admitted to nonadherence were willing to accept subconjunctival sex, ethnic background, education, knowledge of glaucoma, injections at 3-month intervals in place of their topical medication. or the frequency of side effects.6 However, a few studies have observed an association between a dose frequency Conclusions: Our study found that 74% of glaucoma patients were higher than twice a day with nonadherence to glaucoma willing to accept an alternative form of glaucoma treatment through 7–10 3-monthly subconjunctival injections. A large proportion of patients therapy. Electronic event medication monitoring devi- who were admitted to nonadherence to topical medication were ces have also demonstrated poorer adherence with more 11 willing to consider this alternative method of medication. Our complex regimens. findings are helpful when developing patient-acceptable drug- Interventions to enhance adherence that have been delivery regimes, which may alleviate the need for daily medication. tested include memory aids which display dosage informa- tion,12 audible medication alarm devices,13 and tailored Key Words: glaucoma medication, acceptance, subconjunctival education programs14 where patients were assisted in injection identifying suitable times for eye-drop application in their (J Glaucoma 2013;22:190–194) daily routines. Adverse side effects such as burning, stinging, and ocular hyperemia that are associated with glaucoma medications may be a deterrent to adherence, although a study suggests that subjects who acknowledge onadherence to treatment in chronic conditions these events are more likely to be taking their medication.15 remains a challenging problem for both clinicians N Poor administration of an eye drop resulting from visual impairment or physical disability has also been found to be Received for publication January 9, 2011; accepted September 12, 2011. a significant barrier to adherence in glaucoma patients, with From the *Singapore National Eye Centre; wSingapore Eye Research 16 Institute; 8Department of Ophthalmology, National University of potential economic and therapeutic implications. Singapore; zSchool of Materials Science and Engineering, Nanyang Given the many challenges faced by patients and Technological University, Singapore, Republic of Singapore; zState clinicians in ensuring patient adherence in the treatment of Key Laboratory of Ophthalmology, Zhongshan Ophthalmic glaucoma and the growing interest in alternative treatment y Centre, Sun Yat-sen University, Guangzhou, China; and Centre methods to minimize patient’s nonadherence, including for Eye Research Australia, University of Melbourne, Royal 17,18 Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia. juxtascleral depot injections, we report on a study that Disclosure: The authors declare no conflict of interest. examined patients’ acceptance and attitudes toward a Reprints: Tina T. Wong, FRCSEd, PhD, Singapore National Eye proposed injectable slow-release drug-delivery system as Centre, 11 Third Hospital Avenue, Singapore 168751, Republic of Singapore (e-mail: [email protected]). an alternative method for delivering glaucoma medication. Copyright r 2013 by Lippincott Williams & Wilkins A better understanding of the beliefs and attitudes profile of DOI:10.1097/IJG.0b013e318237c6c4 these patients may enable the development of a simplified 190 | www.glaucomajournal.com J Glaucoma Volume 22, Number 3, March 2013 J Glaucoma Volume 22, Number 3, March 2013 Patient Acceptance to Alternative Glaucoma Treatment drug regime, which is less reliant on the self-administration CA). Questions asked about patients’ glaucoma medication of topical medication. regime at the time of the study comprised of the following: duration of medication, number of different types of METHODS medication, daily dosage frequency (based on the total number of drops instilled into the eye each day), and the Study Design occurrence of any side effects including burning sensation, This was a hospital-based, cross-sectional study of itch, foreign-body sensation, redness, bitter taste, or blurring patients in the glaucoma department at a public tertiary of vision. The sum total of all side effects was also added up hospital in Singapore. Consecutive patients were recruited for each patient. Patient charts were also reviewed for from specialist glaucoma clinics, and on providing in- previous documentation of medication regimens or side formed consent, volunteered to participate in an inter- effects if patients were unsure of the details. viewer-administered survey. Ethical approval was obtained from the Institutional Review Board of Singapore Eye Research Institute. Data Analysis The association between patients’ responses to ques- Participant Inclusion and Exclusion Criteria tionnaire items and each outcome measure was assessed. Recruitment was based on the following eligibility After testing for normal assumptions of continuous criteria: (1) diagnosed glaucoma on either 1 or more topical dependent variables, an independent t test and Mann- eye drop(s) with no prior history of intraocular or Whitney U tests were applied appropriately. Categorical 2 glaucoma surgery; (2) ability to converse in English or variables were evaluated using w and Fisher exact tests Mandarin; and (3) willingness to complete the question- appropriately for associations with the dependent catego- naire. Glaucoma patients who did not fulfill all of the above rical variables. SPSS version 17 was used for the analyses. were excluded from the study. Measures RESULTS Patients’ general and ocular health and socio-demo- A total of 151 patients comprising 90 (59.6%) men and graphic details were obtained by self-report. Details of the 61 (40.4%) women participated in the study (Table 1). The patients’ ophthalmic conditions were collected from medical patients’ mean ± SD age was 65.25 ± 11.33 years. There records. Patients were administered a 30-item questionnaire were 130 (86.1%) Chinese, 11 (7.28%) Indians, 7 (4.64%) and an information sheet containing details of a subcon- Malays, and 3 (1.99%) Eurasians. Of these 110 (73.9%) had junctival injection as a possible alternative method to receive primary open-angle glaucoma and 39 (26.2%) had primary the antiglaucoma medication by a trained assistant. angle-closure glaucoma. Data for the type of glaucoma were Three outcome measures identifying specific areas of missing for 2 patients. The mean ± SD duration of glaucoma acceptance of this new procedure were assessed: was 46.3 ± 49.8 months. The mean ± SD duration of 1. Willingness to have glaucoma medication administered glaucoma medication usage was 38 ± 44.2 months and a by subconjunctival injection at 3-month intervals mean ± SD value of 1.6 ± 0.8 types of medications was 2. Willingness to accept a novel drug-delivery route if it prescribed. Seven of 151 (4.6%) patients reported need for costs the same as present medication assistance in eye-drop administration. Five (71.4%) patients
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