Yes, lowering intraocular pressure decreases the likelihood of glaucomatous disease progression, but the impact of such therapy varies considerably between patients. Some of those diagnosed with glaucoma who never miss a drop of their medications may still get worse and even go blind, while others who use their medications only sporadically, or not at all, may show no measurable disease progression.

Medication nonadherence is considered a serious problem and is thought to be responsible for disturbingly large numbers of patients losing vision from glaucoma. Among patients with glaucoma, approximately 50% do not take medications as prescribed. Yet, there is another form of compliance or noncompliance that is often overlooked, and that may overshadow in importance the significance of medication adherence. Specifically, we refer to adherence to recommended follow-up visits. Recent work has shown that 41% of patients fail to undergo subsequent eye examination after screening positive for glaucomatous disease. Further, approximately 50%–59% of patients with a glaucoma diagnosis are unwilling to use follow-up eye services. These follow-up visits are important in allowing practitioners to gauge the stability or progression of the disease, modify medical therapy, and consider surgical options as needed. Without such visits, patients can worsen markedly without recognizing that they are losing their vision from glaucoma.

The importance of adherence to follow-up visits is highlighted in several studies, which have found an association between worsening glaucoma disease severity and poor follow-up. Among patients who may be at highest risk for such worsening are those who wrongly believe that they do not require regular follow-up because, by virtue of taking their medications as prescribed, they are safe from their disease’s getting worse. Interestingly, 1 study found an association between medication adherence and worsening disease severity. These studies suggest that such individuals may actually be at greater risk of substantial disease worsening and severe vision loss than those patients who sometimes miss their medications but who see their ophthalmologist at appropriate intervals.

Why is it, then, that there is a paucity of presentations and published papers regarding the importance of regular surveillance and the perils of noncompliance with follow-up visits? Among other reasons, a contributor to the absence of data on glaucoma follow-up may be lack of special interest groups that benefit from results of such studies. Glaucoma is a lifelong disease, often requiring visits every 3–6 months for decades. Practitioners can be inundated with glaucoma follow-up visits, preventing them from having openings for other types of patients. The anticipated staffing shortages for providing glaucoma care in coming generations will likely make matters worse, unless models using additional personnel, and perhaps telemedicine, are developed for efficient glaucoma surveillance.

While conscientious practitioners spend time and effort educating glaucoma patients regarding the benefits of medication adherence and regular follow-up, emphasis should also be placed on educating patients about the dangers of insufficient follow-up. Factors contributing to poor follow-up adherence are myriad and include lack of visual symptoms, physicians not communicating the importance of disease surveillance, and lack of patient education. Patient education, in particular, has been found in several studies to improve adherence. A recent study showed that eye care providers do not always educate patients about glaucoma or glaucoma medications. This is an indicator that we may not be adequately communicating with our patients about important tasks such as follow-up visits. A positive correlation was also found between educating a patient about how to administer glaucoma drops and patient glaucoma medication adherence. In an era of the electronic medical record, we may be better able not only to monitor follow-up visits, but to also increase adherence and follow-up utilization through revamping of medical and resident education.

Academic meetings, journals, and even the World Wide Web contain articles and videos of patients incorrectly instilling their glaucoma medications, yet there is rare mention of patients blind from glaucoma primarily as a result of insufficient disease surveillance, sometimes due to the false sense of security that taking their glaucoma medications or having previously undergone a laser or surgical procedure arrests their disease, making such follow-up less important.

Primary open-angle glaucoma is a common disease that can result in severe visual disability. Given the unpredictable course of glaucomatous disease, the only reliable way to distinguish those who are destined for poor outcomes from the many who are not is to make sure that all those with the disease are seen at prescribed intervals. Woody Allen is credited with a quote that has led to the now famous mantra: “80% of life is just showing up.” Perhaps the same can be said for glaucoma care.