Sarah ThomasFiona Chiu, and Cathy Kitney explain how a campaign was launched at Moorfields for good eye-drop technique and compliance, and why it has been successful

Photo of contributors Cathy Kitney, Sarah Thomas, Fiona Chiu

From left to right: Cathy Kitney, Sarah Thomas, Fiona Chiu

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Read this article to learn more about:

  • why correct eye-drop technique and compliance is important
  • barriers to good eye-drop compliance and why the campaign was needed
  • benefits for patients, carers, social care, and the NHS from improved eye-drop compliance.

Q: When and why was the #KnowYourDrops campaign launched?

A: The #KnowYourDrops campaign was launched in August 2016 by Moorfields Eye Hospital NHS Foundation Trust after a patient needed some extra support with putting in their eye drops. We reflected afterwards whether we could improve our service with respect to helping patients/carers with eye drop techniques and compliance, to ensure that we deliver the best possible help and support.

Through discussing the available support with our patients/carers, learning more about their needs, and discussing with other stakeholders including our consultants, optometrists, and nursing staff, we soon realised that a patient-focused day on eye-drop support would be beneficial.

We also wanted to ensure that we were following the national recommendations from NICE Clinical Guideline (CG) 85 on Glaucoma: diagnosis and management1 and NICE Guideline (NG) 67 on Managing medicines for adults receiving social care in the community.2

We therefore launched a pilot day in one of our Moorfields satellite sites, St Ann’s in the East of London, supporting all patients/carers in the glaucoma clinic that day who used eye drops, and working with our clinical colleagues.

Following very positive feedback from patients/carers and staff, we engaged all stakeholders and spread the campaign across our other East sites, and then to the North and South sites and main hospital. The campaign is now fully embedded into our whole hospital.

Q: Why is correct eye-drop technique and compliance important?

A: If someone using eye drops does not use them according to the clinician’s instructions, or manufacturer’s instructions if over-the-counter, the drops will not be as effective so the eye may not get better from whatever the treatment is for. For example:

  • if the technique is ‘incorrect’, with eye drops running down the face and not staying in the eye, then the drop may not be absorbed and so the eye may not be treated, which can lead to poor clinical outcomes
  • if the technique results in scratching the eye with the nozzle, this is another risk as the eye is then prone to infection and corneal damage
  • if a patient is meant to use the drops every day and misses using them a few times in the week, then this means that there is not enough eye drop in the eye to work effectively and again the eye may not get better from whatever the treatment is for.

The bigger picture is that eye-drop compliance in glaucoma is said to be around 50%, i.e. only about 50% of people using eye drops are doing so correctly, and the cost of preventable sight loss in the UK is estimated to be more than £28 billion.3–5 This is a really important issue as, for example, with the right level of compliance support, patients with glaucoma could be spared sight loss, and the burden this has on that individual, society, and the economy could all be reduced.

Q: What are the main barriers to eye-drop compliance and how can these be addressed?

A: There are several barriers to eye-drop compliance, including educational barriers such as poor technique when using them at home, or misunderstanding of the instructions; there are also non-educational barriers such as poor dexterity (e.g. being unable to open the bottle or squeeze the drops), or relying on a carer for administration who is not always available.5

From our experience, having seen hundreds of patients in a variety of settings, and through open discussions with patients where it is acknowledged that eye drops are not the easiest of treatments to administer, barriers can be often broken down and addressed using a patient-centred approach. For dexterity issues regarding opening the bottle, for example, a simple eye-drop opener may help, or if the patient relies on a carer and feels that this is a burden, then a compliance aid may be suitable.

Q: What are the benefits from improved patient compliance with eye-drop treatment?

A: Patients certainly benefit from improved clinical outcomes, but also from an improved quality of life. From our experience, we found that many patients who need to use eye drops describe a low quality of life, for example they feel:

  • that they are a burden to people who are helping them
  • uncomfortable talking to their doctor/nurse/pharmacist about their difficulties, as no one ever asks about them
  • that they will be in trouble or made to feel ‘stupid’
  • frustrated that they take an hour to put in one drop
  • sad that they have to miss out on lifestyle/social occasions as they have to stay in to put in their drops.

The knock-on effects from improved clinical outcomes are that:

  • the patient is less likely to need to come back for more GP or hospital appointments—
    • GP or hospital waiting times may then be reduced and more appointments made available for more patients
  • the patient is less likely to need to use so many eye drops—
    • through repeat prescriptions, e.g. where the patient’s technique means that half the bottle is wasted and further supplies are obtained from the GP/chemist when only one bottle is needed
    • through polypharmacy, since if the eye is getting better with one drop there is less likelihood that another type of drop will be added into the treatment regimen.

These outcomes also help the patient by reducing the amount of time they need to spend administering eye drops, and if the patient pays for prescriptions, it may also save them money.

Finally, we have seen patients who have had such an improvement to their glaucoma intraocular pressures that they have not needed to have surgery, due to improved eye-drop compliance following a pharmacy-led support clinic.

There are also financial advantages to the NHS through:

  • reduced volume of patients with worsening/uncontrolled eye conditions seeing clinicians as a result of poor eye-drop compliance
  • reduced costs of repeat prescribing/polypharmacy/surgery when eye drops are being used correctly.

There are also potential resource and financial savings with state-funded carers not being needed to administer eye drops multiple times a day, as a patient may be able to do this themselves with the help of a plastic compliance aid.

Q: What forms does the #KnowYourDrops campaign take?

A: The pharmacy-led eye-drop compliance clinic is run all day alongside the clinical session, usually a glaucoma or dry-eye general ophthalmology outpatient clinic in the hospital. We see every patient using eye drops, including those who have never used drops and are being prescribed them first time, and those who have used them for years and rely on a carer to put them in. We assess the patient technique and timings regimen, and provide support, education, and advice on anything to do with their treatment regimen. We assess whether they or their carers would benefit from a compliance aid and give these to them. We also give out leaflets and brochures and watch instruction videos with the patient, as necessary.

We write up the consultation on a designated form and directly involve the clinicians/nurses as needed, as we are fully integrated into the team. We also record our recommendations in the patient medical notes so they can be referred to at the next appointment to see how the patient is improving.

The #KnowYourDrops resources are also available on the Moorfields website (see: www.moorfields.nhs.uk/knowyourdrops) and Twitter and Facebook. Patients and carers can tweet/message/email us any questions, as they regularly do.

We have also been on a roadshow event in the West Country to help support and raise awareness in a community charity setting.

In addition, when we run a patient clinic, we provide a lunchtime teaching workshop for all staff including doctors, optometrists, nurses, Eye Clinic Liaison Officers, and reception staff about how they can all help support and improve patient compliance with eye drops.

Q: What support did you receive from other organisations?

A: The Moorfields Eye Charity (see: www.moorfieldseyecharity.org.uk) has been hugely supportive and generous by raising awareness of the campaign and inviting us to speak to patients at their events. They have also provided us with a grant to further our work in this important area and awarded us with the Moorfields Eye Charity Award for Innovation, Research or Education.

The International Glaucoma Association was naturally very interested in our initiative as we were seeing a lot of patients with glaucoma, and they kindly came to support our clinic days while the new scheme was being fully embedded. The Royal National Institute of Blind People and other charities have also been very supportive in spreading the word to help improve eye-drop compliance and have also invited us to talk at team meetings and do roadshows.

Pharmaceutical companies have also been very helpful in supporting lunchtime staff workshop sessions.

Q: How did you raise awareness of the campaign?

A: We ran an intensive communications campaign with our communication team in the hospital, which included posters, leaflets, Facebook, Twitter, and a website.

Engagement with local clinical commissioning groups, GPs, community partners, and local eye networks through our clinic liaison officers helped to raise awareness and invite people to participate.

Q: What feedback did you receive from people who attended the campaign?

A: We ran a patient/carer feedback questionnaire about the support (n=95) and 100% said they felt more confident about putting in their drops and 100% more able to put them in.

Some comments from patients are shown in Box 1.

Box 1: #KnowYourDrops campaign—patient feedback comments

‘Thank you so much, this has been so helpful. My sons come four times a day to put in my drops as I find it hard and now I can use the aid and do it myself.’

‘I’ve been using drops for 7 years and I never knew to close my eye and press. I always feel the drops going down into my mouth and taste, so thank you for helping me.’

‘I am very thankful for the video and the flyer and how the staff have shown me how to use the drops.’

‘Thank you for the helpful Aid. My drops now don’t run down my face. The team at Moorfields are wonderful. I never knew there was a help for my drops.’

‘GPs should know about this when they give our drops. The knowyourdrops should show demo also at GP surgeries.’

‘I usually stand up to use my eye drops but now whilst doing it sitting down as advised I find it much easier to use my eye drops. This session was very useful and I should be alright now putting in my drops.’

‘It was very useful training. I wish I had had this at the start of my treatment. It is a great idea. More support in this area is needed.’

Q: What support did you give to World Glaucoma Week 2017?

A: We ran a patient awareness week throughout the entire Glaucoma Week 2017, with a pharmacy-led stand in the hospital and patient consultations alongside all our clinics. We supported patients with any questions about glaucoma-associated treatments, advising them on various topics (e.g. correct storage of eye drops, whether the eye drops will cure their glaucoma so they do not have to use them, whether it is okay to miss drops on some days).

We also invited patients to a patient information afternoon where we spoke about eye drops, and two of our leading consultant ophthalmologists spoke about glaucoma and also driving with glaucoma. The afternoon was hugely popular, with 60 patients attending.

We have already started planning our activities for World Glaucoma Week 2018.

Q: What are the benefits of compliance aids and what types are available?

A: There are around a dozen compliance aids available and they each help in a different way and are for different types of formulations: some are for round bottles and some for single dose units, for example.

Compliance aids in general assist with technique by helping to make the eye-drop bottle more stable over the eye, enabling it to be held at a safe distance that will not result in the nozzle scratching the cornea, and also making the bottle easier to squeeze.

Depending on what the patient is using, and what their needs are, we will assess and try out a few options before recommending a compliance aid that is best for them as this is often down to personal preference.

Q: What are the future aims of the campaign?

A: We are currently extending our campaign and raising awareness to improve patient eye-drop compliance support at national and international levels, with the aim of eye-drop compliance support being incorporated into all ophthalmic pathways globally in future.

We aim to achieve:

  • defined national compliance support guidance
  • a standardised care model for all patients using ophthalmic medicines
  • pharmacy-led ophthalmic medicines usage review that is embedded into care in the same way as asthma and diabetes medicines
  • improvement in the availability of compliance aids and increased awareness of these
  • a culture shift so eye drops are no longer viewed as unimportant
  • evidence-based research into the benefits of eye-drop compliance support and benefits to quality of life
  • national standardisation of our patient-led safe administration technique (‘wrist and knuckle’ technique) via an information leaflet given to all patients using eye drops
  • roll out to all community pharmacies in the UK so that patients know where to access support and pharmacy teams know how to support patients—we are currently working with the National Pharmacy Association to achieve this.

Sarah Thomas

Lead Pharmacist, Moorfields Eye Hospital NHS Foundation Trust

Fiona Chiu

Associate Chief Pharmacist, Moorfields Eye Hospital NHS Foundation Trust

Cathy Kitney

Specialist Pharmacy Technician, Moorfields Eye Hospital

References

1. NICE. Glaucoma: diagnosis and management. Clinical Guideline 85. NICE, 2009. Available at: www.nice.org.uk/cg85

2. NICE. Managing medicines for adults receiving social care in the community. NICE Guideline 67. NICE, 2017. Available at: www.nice.org.uk/ng67

3. Johnson M, Cross V, Scase M et al, 2012. A review of evidence to evaluate effectiveness of intervention strategies to address inequalities in eye health care. RNIB and De Montfort University. RNIB report: RNIB/CEP/01, 2011. Available at: www.rnib.org.uk/knowledge-and-research-hub/research-reports/prevention-sight-loss/intervention-strategies

4. Royal National Institute of Blind People. The state of the nation eye health 2016. RNIB, 2016. Available at: www.rnib.org.uk/stateofthenation

5. Thomas S, Chiu F. #KnowYourDrops: breaking down barriers to poor compliance. Eye News 2017; vol 24, no 1.