Eye drop administration in patients attending and not attending a glaucoma education center.

BACKGROUND: To assess the technique of glaucoma eye drop instillation in patients who have and have not attended glaucoma education sessions. To compare this with their subjective perception of eye drop use and identify factors associated with improved performance. PATIENTS AND METHODS: An observational study of 55 participants who instill their topical glaucoma medication for more than 1 year. Twenty-five patients attended (A) glaucoma teaching sessions >1 year before the study and were compared to thirty patients who never attended (NA). Patients completed a self-reporting questionnaire. They instilled their eye drop, and the technique was video-recorded digitally and later graded by two masked investigators. The results were analyzed using Fisher's exact test and Chi-square test. Predictors were assessed using logistic regression models.
RESULTS: There was no significant difference in overall performance scores between the two groups. Good technique was observed in 16% of (A) group versus 23% (NA) group, (P = 0.498). There was a mismatch between patient's subjective and actual performance. Female gender and higher educational level were found to be predictors of good performance of drop instillation on univariable logistic regression analysis.
CONCLUSION: Glaucoma patients are challenged with eye drop instillation despite receiving education on drop administration. There is a discrepancy between patient's perceptions and observed technique of drop administration.

Introduction

Patient compliance to ocular hypotensive medications is a crucial element in the long-term success of glaucoma management.[123] Compliance is impacted by the technique of administering eye drops and the therapeutic benefits from medications are maximized when administered correctly. Numerous observational studies in the past have shown that the manner in which hypotensive eye drops are self-administered by glaucoma patients is suboptimal.[4567891011] Compliance was found to be strongly associated with patient education. It was, therefore, suggested that providing patient education could be one of the ways to increase compliance.[121314]

The McGill Glaucoma Patient Education Centre was established in 2006 and, since then, has provided monthly interactive glaucoma information sessions. Patients are educated in small groups about the pathophysiology and consequences of glaucoma, the importance of and tips of enhancing compliance to the regimen and they also have an opportunity of hands-on practice of instilling eye drops. The center also provides various resources and materials in the form of handouts and educational DVDs, designed to raise the public awareness and enhance patient knowledge on glaucoma and its treatment.

The primary aim of this cross-sectional observational study was to assess our educational program's effectiveness with respect to how patients instill their eye drops. Subjects who attended our teaching program greater than a year before this study and who continue to instill their eye drops were compared to patients who never attended our sessions but have been instilling their eye drops for at least 1 year. The secondary outcome was to compare their objective performance with their subjective perception of performance and identify any factors associated with improved performance.

Patients and Methods

This was a cross-sectional observation study of glaucoma patients attending the clinic of a single glaucoma specialist (Dr. O.K.) in the Department of Ophthalmology at the Jewish General Hospital, Montreal, Quebec, Canada. The study was approved by the Research Ethics Committee of the Jewish General Hospital, McGill University. All patients provided written informed consent in English or French.

Study population

All eligible subjects older than 18 years of age, diagnosed with glaucoma, and who were self-administering their glaucoma drops for at least a year in one or both eyes were included. Exclusion criteria included those who were unwilling to participate or to be filmed, those with a significant language barrier, dementia, poor manual dexterity, and an allergy to artificial tears.

Design/procedures

Patients completed an English or French questionnaire pertaining to demographic information and their perception of their drop instillation technique. An examination room with access to a reclining chair, sink, hand soap, paper towels, and mirror was provided and patients were told to use these facilities and instill their drops as they would typically use them at home. This eye drop instillation technique was video-recorded using a 720p rear-facing camera of an iPad2 tablet computer (Apple Inc., Cupertino). Patients used their own eye drops if available and if it was an appropriate time for their drop to be instilled or an unopened bottle of over-the-counter artificial tears (1.5 ml Systane bottle; Alcon Laboratories, Inc., Fort Worth, USA) was used instead. Patients were permitted up to two attempts at instilling an eye drop.

The digital video recordings were graded by two investigators (A.B.) and (K.S.). They were both masked to the patient questionnaire results and whether or not the subject attended the educational sessions. The following criteria were evaluated: (1) Hand washing, (2) eye drop applied to the eye, and (3) contamination of eye drop bottle tip. One point was granted for successfully accomplishing each criterion and the total sum (ranging from 0 to 3) represents each subject's total performance score. The patient was deemed to have a good technique if the video score was 3 out of 3 and to have a poor technique if scored anything <3. We arbitrarily chose to grade the performance of drop instillation only in the left eye since all our subjects used medications on the left eye but not the right eye.

Statistical analysis

Patient performance and knowledge of eye drop instillation were compared according to attendance at glaucoma education sessions using Fisher's exact test and the Chi-square test. Simple and multiple logistic regressions were used to further examine if eye drop instillation technique was associated with various demographic predictors (e.g., age, gender, race, education, and number of years since glaucoma diagnosis) and information session attendance. Statistical significance was accepted if P < 0.05. All analyses were performed using SPSS software version 22.0 for Windows.

Results

We enrolled a total of 55 consecutive subjects (25 attended [A], 30 not attended [NA] education sessions) between August 2013 and December 2013. Table 1 depicts the subjects’ demographic data. There was no significant difference in the characteristics between the two groups. The majority was in their eighth decade of life (60% in [A], 56.7% in [NA] groups), was Caucasian, and had glaucoma for a long period (more than 2 years). Table 2 summarizes the patients’ responses concerning their education experience and their subjective impression on their performance in instilling drops. The majority of subjects (96% in [A] and 86.7% in [NA] groups) reported that they experienced no trouble with self-administering eye drops.

Table 1

Baseline characteristics of glaucoma patients included in the evaluation

Table 2

Subjects responses to questionnaire concerning eye drop usage and technique

The inter-rater reliability between (A.B.) and (K.S.) in terms of rating performances was very high with an 86% agreement rate. Therefore, only ratings of investigator (A.B.) were considered for analysis. Figure 1 shows the performance of drop instillation assessed objectively for each group. There was no significant difference in overall performance between those who did and did not attend our education sessions (16% of [A] group showed good technique versus 23% [NA] group, P = 0.498).

Figure 1

Results of videotaped evaluation of eye drop instillation in glaucoma patients who have and have not attended glaucoma educative sessions

Table 3 shows the individual objective performance scores for each category evaluated. Although a higher percentage of attended subjects got the drop to land in the eye compared to the not attended group (52% vs. 23% respectively), the difference was not statistically significant (P = 0.134). The only significant difference was in tip touching scores where 52% of attended subjects exhibited tip touching versus 23% of subjects who did not attend (P = 0.028).

Table 3

Categories used to evaluate performance

Table 4 shows the patients’ demographics as a predictor of performance. Only gender and educational level were found to be predictors of good performance of drop instillation when using the univariable logistic regression analysis. Females overall performed better than males (72.2% vs. 27.2%, respectively showed good technique, P = 0.019). Those with higher educational levels (university or college) overall performed better than those with a high school educational background (72.7% vs. 27.3%, respectively, P = 0.043). However, these variables were found not significant when further analyzed using the multiple regression models.

Table 4

The results of univariable logistic regression for predicting good drop instillation technique overall

There was no correlation between the subjects’ self-perceived performance and their actual performance in any of the categories assessed. Figures 2-4 show results in details.

Figure 2

Comparison of patient's subjective perception of performance and actual performance in terms of hand washing

Figure 4

Comparison of patient's subjective perception of performance and actual performance in terms of contaminating the bottle tip

Comparison of patient's subjective perception of performance and actual performance in terms of getting the drop to land on the eye

Discussion

Although the effects of educational interventions on eye drop administration technique have been studied, this has not occurred within the context of an ongoing glaucoma education center.[121415] Despite the evidence that education and reminders may be effective in improving patient adherence with intraocular pressure-lowering drops, our study did not reveal a significant difference in overall performance of drop instillation between the group of subjects who attended compared to those who did not attend our glaucoma education center. Although the group that attended our sessions tended to administer the drop on to the eye with better success compared to the group of nonattendees, they were significantly worse in terms of contaminating the bottle tip. This is in agreement with numerous observational studies that also found high rates of poor drop technique.

There are several reasons why despite educating some subjects on correct instillation technique we did not see a significant improvement in their technique compared to other subjects who did not attend our education sessions. In our current investigation, subjects from both groups were “experienced” in self-administering eye drops for at least 1 year. It is possible that after one or more years of chronic drop use, both groups have acquired similar skills with or without having attended an education session through repetition. Previous studies have suggested that self-instillation of eye drops is a skill that is trainable, but ultimately there are several limitations to its practical application such as fear, poor hand-eye coordination, or other physical or psychological factors that may impact the patients’ overall performance.[16] There is also variability in performance, and so a single in-office visit might not be the ideal way to accurately assess technique. In addition, a good proportion (33.3%) of those in the group that did not attend our teaching sessions received some form of teaching elsewhere with majority of these subjects being taught by pharmacists. This may also explain the lack of difference observed between the two groups. The majority of attendees (56.0%) attended the session 3-5 years ago before our study. These patients may have also forgotten some elements from their teaching that occurred several years before being tested.

Patient subjective perceptions about their performance did not seem to concur with objectively observed technique of drop instillation. These discrepancies have also been consistently found in previous studies and suggest that caution is needed when accepting patients’ reports in assessment of performance.[46] Patients tend to overestimate their ability to properly comply with therapy, continue to demonstrate lack of awareness, or simply are in denial of their errors in safe and effective eye drop administration. If the latter is true, this could hinder them from seeking additional help in optimizing their technique if they do not perceive a problem with it in the first place.

Factors associated with poor technique were found to be poor manual dexterity, older age,[78] limited school education,[817] and poor vision.[41718] In contrast to these previous studies, we did not find age to be a predictor of performance. Higher educational level and female gender were the only factors in this study shown to affect performance. The mean of educational level and age of our study population was high and, therefore, it is possible that the difference in overall performance between the groups could have been masked.

Patient education requires both time and financial resources and so implementing modifications to our educative strategies is an important aspect to tackle so as to increase its effectiveness and efficiency. It may be helpful to directly observe patients administering medications and offer on the spot feedback and reinforcement preferably on a one-to-one and a continuous basis. There is a need for better instruction methods and reminders since therapy is a lifelong commitment.

Limitations of this study were that this was a single in-office visit with a small sample size in each subgroup. Only the left eye was arbitrarily chosen to be analyzed; results might have been different if the right eye was chosen since self-administration of drops might be easier on the side with eye and hand dominance. We did not look at vision, mean visual field defect study populations as contributors to the differences between the groups. These have been found to affect drop instillation error rates in previous studies.[457171819] In addition, a portion of the data was collected using a questionnaire unique to this study and, therefore, not previously validated. Finally, the design of this study with an element of recall bias is not the most effective method of assessing the effect of an intervention such as education on performance but rather a randomized controlled clinical trial is ideal to be conducted in the future to provide sound evidence of cause and effect.

Conclusion

This study has demonstrated that glaucoma patients despite receiving education on proper drop administration techniques continue to have difficulties with eye drop administration. We need to look for ways to modify our teaching strategies to best deal with this problem in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.