In this episode of Pressure Points Glaucoma, Justin Schweitzer, OD, FAAO, and Danica Marrelli, OD, FAAO, discuss the importance of patient education in enhancing compliance and increasing understanding of treatments.
Dr. Marrelli is a board-certified optometric physician who has been a member of the faculty at the University of Houston College of Optometry for 31 years, where she currently serves as Assistant Dean for Clinical Education and is a clinical professor.
Case report
A 61-year-old Caucasian male presented to the clinic. He had previously undergone cataract surgery and was seeing very well, with a best-corrected visual acuity (BCVA) of 20/20-1 OU.
His gonioscopy was normal—though he did have a little pigment in the trabecular meshwork, and thin corneas—and the slit lamp exam (SLE) showed that he had well-centered intraocular lenses (IOLs).
He had been prescribed a prostaglandin analog once daily OU, however, he disclosed that he’s a little “hit or miss” when it comes to taking them.
The clinical evaluation revealed:
- Tmax: 27mmHg OU
- IOP: 17mmHg OD, 16mmHg OS
- Cup-to-disk ratio (C/D): 0.60/0.60, OD 0.70/0.70 OS
- Pachymetry: 510 OD, 505 OS
Optic nerve head (ONH) photos
Figures 1 and 2: Fundus images of the patient’s optic nerve head OD and OS, respectively.
Figure 1: Courtesy of Justin Schweitzer, OD, FAAO.
Figure 2: Courtesy of Justin Schweitzer, OD, FAAO.
OCT imaging
Figure 3: The retinal nerve fiber layer (RNFL) appeared to be normal in OCT imaging—though Dr. Schweitzer did note potential slight thinning in the patient’s left eye on examination.
Figure 3: Courtesy of Justin Schweitzer, OD, FAAO.
Figure 3: The ganglion cell analysis (GCA) displayed asymmetry between the patient’s two eyes—there was a defect present in his left eye, and a potential early defect in his right eye—and, while concerning, both eyes had been stable for the past 2 years.
Figure 4: Courtesy of Justin Schweitzer, OD, FAAO.
Visual field testing (VFT)
Figure 5: The VFT OD was normal, but in the 24-2 VFT of the left eye, there was a worrying paracentral defect (red circle) with a possible early nasal step.
Figure 5: Courtesy of Justin Schweitzer, OD, FAAO.
Figure 6: A 10-2 VFT was also performed to assess the defect more closely for continual management. Similar to the OCT imaging, the patient’s visual field had been stable for 2 years.
Figure 6: Courtesy of Justin Schweitzer, OD, FAAO.
Initial reflections on the case
When evaluating cases, Dr. Marrelli tends to create two lists: one of factors that may warrant taking a more aggressive treatment approach, and another of those that indicate the opposite.
Here’s what she identified:
Points that increase concern:
- The patient’s young age is her main cause of concern—she aims to ensure that he can see well over the rest of his life.
- The patient’s thin corneas and the early central visual field loss in his left eye, pose potential future harms to his visual functioning should further expansion or deepening occur.
Points that lower concern:
- The patient’s stability for 2 years—even while not being great at taking his drops—indicates that he’s likely not a “rapid” progressor. This provides some comfort.
Treatment approaches for this patient
Given his stability, Dr. Marrelli’s management approach would be education-focused, with the aim of improving the patient’s adherence.
She notes it’s long been known that very few patients—less than half—are truly persistent with their glaucoma therapy.1 Additionally, practitioners aren’t usually good at predicting whether a patient will be compliant, which is why it’s so beneficial when patients eliminate any guesswork by disclosing this information.
During education, Dr. Marrelli first explores the factors resulting in non-adherence to better tailor her efforts. She says that the key to this education is reminding the patient about glaucoma as a disease, the consequences of not being well-managed, and helping him to make the connection between using his eye drops to lower his eye pressure, and stabilizing his glaucoma.
By doing this—and incorporating other measures, such as medication reminders—the patient may be able to address his non-adherence.
To read about current trends in glaucoma management, check out the 2025 Glaucoma Report!
When patients are resistant to education
Where Dr. Marrelli notes that patients are unlikely to be receptive to such education, or in whom it has proven to be unsuccessful, she will look to other treatment options that don’t require regular adherence.
A primary choice is selective laser trabeculoplasty (SLT), which is well-documented in providing patients with long-term IOP control.2 There are other treatment options to discuss with patients, such as implantable slow-release medications like the iDose TR and Durysta—the latter of which can be implanted in-clinic.
However, as what she calls a “no harm, no foul” procedure, SLT would be Dr. Marrelli’s primary recommendation for these patients for whom medication adherence is very poor.
Education on initial glaucoma treatments
Dr. Marrelli recalls hearing Harry Quigley, MD, speak and asking him if the results of the LiGHT study influenced his initial treatment of glaucoma.3 His response? No; he’d already been offering SLT as a first-line therapy—but given the choice between medication and SLT, 80% of his patients chose the former.
It’s her perception that patients typically make this choice because they feel that taking an eye drop every day is the simpler option. However, it’s only after they start that they realize adherence is more difficult than it initially seems.
Dr. Marrelli explains that establishing a new daily routine at any age is hard—and any changes can upset this balance, resulting in patients missing out on their daily dose of medication.
She uses her daughters as an example—two of whom took a daily Singulair growing up to manage asthma. Dr. Marrelli’s family incorporated taking this medication into their dinnertime routine. However, any changes—such as eating out—could result in her daughters accidentally missing out on taking their medication.
This is why she feels that it’s important for practitioners to properly educate patients on all of their treatment options, and what their actual experience of living with these options may look like in practice.
Conclusion
Dr. Schweitzer agreed with Dr. Marrelli that the patient’s stability over the prior 2 years indicated that a change of treatment or aggressive management approach wasn’t needed.
Likewise, he concurred that taking the time to effectively educate patients at all stages of management is an essential piece of the treatment puzzle.
