• The patient may have been prescribed the medicine in the past but stopped taking it, perhaps because of side-effects or not understanding the long-term nature of management strategies – so this question enables concerns to be aired and answered
• It also provides an opportunity to check that a contraindication or caution with the medication has not been overlooked at the prescribing stage (check individual SPCs).

• Prescribers are not always consistent. Check SPCs to ensure dosing falls within the product licence and question anything that seems unusual. A note should be made in the PMR if this is the case and may prove valuable in the future (e.g. if an incorrect prescription is selected for a repeat)
• Glaucoma treatment is usually (but not always) lifelong, which can prove challenging as it is about preventing problems rather than resolving symptoms. Getting into a good routine of regular dosing can help, so suggest putting eye drops near the kettle or bathroom sink to act as a visual prompt tied in with a daily activity, or propose the use of alarms or reminders; for example on a mobile phone calendar or via a smart speaker.

• Draw attention to the patient information leaflet to highlight common side-effects, ensuring the definition of “common” is explained in this context
• The more frequently experienced side-effects are listed in Table 1 below
• Local side-effects are relatively common but may settle down over time. Suggest the patient contacts you if they are finding any side-effects particularly troublesome.

• There is a significant interaction between topical sympathomimetics and some antidepressants (notably MAOIs and tricyclics), and also CNS depressants including alcohol, opiates and benzodiazepines
• This question provides an opportunity to emphasise the point that topical medicines, despite not being taken orally, are still medicines – something that is often not well understood by patients!
• Applicable to all medicines including topical preparations, this question also opens up an opportunity to highlight drug interactions, and how these are still possible with OTC preparations including supplements and alternative remedies. These may be overlooked as possible sources of interaction, including even certain food or drink items.

Lifetime monitoring is routine once treatment for glaucoma has started. And as glaucoma can only be diagnosed by a consultant ophthalmologist, or a healthcare professional working under their supervision, this is the individual who will dictate the frequency with which checks are required and the setting within which they can be provided, guided by parameters such as IOP and a patient’s risk of progression to blindness.

•  Someone with glaucoma is only allowed to drive if their vision fulfils the requirements set by the Driver and Vehicle Licensing Agency (DVLA):
  • If glaucoma affects just one eye and the other has normal visual acuity and field of vision, most car drivers do not need to notify the DVLA
  • Drivers of passenger-carrying and transportation vehicles are subject to different rules and they, plus individuals who have glaucoma in both eyes, should seek advice from DVLA. It doesn’t mean they definitely cannot drive, but they may need to undergo testing in order to retain their driver’s licence.
• Losing a driving licence can be a significant blow, particularly if other people rely on the individual for transport, so it is important to show compassion and provide information such as the leaflet published by Moorfields Eye Hospital NHS Foundation Trust
• Someone who has been diagnosed as visually impaired may be eligible for certain benefits. Information is available from Sense and RNIB.

• Instilling eye drops correctly is a technique that eludes many people, but getting it right can make a significant difference in terms of good glaucoma management, so run through the process (see panel), modifying it according to the specific product(s) prescribed
• If more than one eye drop is being used, wait at least five minutes between instilling the preparations
• At least 15 minutes should elapse between instilling drops and inserting any contact lenses
• Local adverse effects on periocular skin can be reduced by blotting any overflow immediately after instillation with a clean dry tissue
• Lacrimal/punctal occlusion after instilling eye drops not only prolongs the time the eye is in contact with the medication, but also reduces the risk of systemic side-effects. Simply closing the eyes for three minutes can halve systemic absorption and is further enhanced by pressing a finger on the lacrimal sac at the same time
• Eye drop dispensing aids can help if physical problems hinder instillation, although only some are prescribable (at the time of writing, various models of Opticare plus eyGuide and ComplEye were listed in the Drug Tariff). They are not universal and Glaucoma UK has a list of which aid fits which product, as well as a description of each.

• Manufacturer instructions should be followed when it comes to storage, but note that the requirements may differ according to whether or not the product is opened and in current use
• Expiry dates matter, both those on the bottle, and the time elapsed since opening – for most products the latter is 28 days. Writing the date of opening on the bottle is a sensible measure, and encourage the patient to return old, used or expired products to the pharmacy
• As well as washing hands before using eye drops, products should be stored with lids on to prevent contamination.

• Lifestyle changes can make a difference, but also make a patient feel like they are doing something tangible to manage their condition. Measures to suggest include:
  • Reducing caffeine intake; too much can raise IOP
  • Avoiding excessive alcohol consumption as this can damage the optic nerve as well as have other detrimental effects on health
  • Omega oils from fish and seeds have been shown to be good for general eye health and some patients may want to try ginkgo biloba, which has been linked to improved blood flow including to the optic nerve. Check interactions with other medications
  • Daily exercise has many benefits but activities that can cause IOP to increase – yoga positions where the head is lower than the heart, for example, and weight lifting – may be best avoided until the patient has sought advice from their specialist. Larger goggles should be worn when swimming as smaller ones can press on the eye, causing an increase in IOP
  • Smoking is associated with higher IOP and dry eye conditions, so should be avoided
  • A balanced diet and maintaining a healthy weight are good for general health, so are good for patients with glaucoma as well.