Glaucoma care does not happen only in the exam lane. For many patients, it happens at the kitchen table, in the pharmacy queue, in the passenger seat on the way to an appointment, or in a long-term care facility where a nurse may be juggling dozens of medication orders at once.
This matters because drop-based therapy rarely depends on the patient alone. It often depends on spouses, adult children, neighbors, or facility nurses who quietly become care coordinators. They arrange transport, collect prescriptions, track appointments, interpret instructions, watch for side effects, and, in many cases, physically administer the drops.
“The patient may be the person sitting in the exam lane,” says Hayley G. Boling, Chief Executive Officer of Boling Vision Center in Indiana, “but the caregiver is often the person making sure the appointment happens, the transportation is arranged, the medications are picked up, the instructions are understood, and the drops are actually used.”
Across practices, she adds, glaucoma care often depends more heavily on that invisible support system than clinicians realize. “When the regimen becomes more complicated, the care becomes more caregiver dependent. And when the caregiver system breaks down, the clinic feels it too.”
That burden has become a central part of the case for interventional glaucoma. As surgeons reconsider the default role of topical therapy, the conversation is moving beyond adherence alone. The question is not only whether patients can use drops reliably, but whether the people and systems around them can sustain that responsibility for years.
For Whitney S. Boling, MD, a board-certified ophthalmologist at Boling Vision Center specializing in eye disease, cataract surgery, medical retina, aesthetic procedures, and LASIK, caregiver dependence is more common than patients acknowledge. Published rates suggest 17–20 percent of patients openly rely on someone else to administer drops, but she believes that figure understates the true burden.
"The gap between what patients believe and what actually happens is the real story," she says, noting that video-based studies show many glaucoma patients struggle to instill a single complete drop." “One study found 93% of patients said they had no trouble with their drops, while under 40% were actually getting a clean, single drop in the eye.”
The problem is not just remembering the medication. It is also technique: missing the eye, over-dosing, contaminating the bottle tip, or being physically unable to position the head, hand, bottle, and eyelid correctly. Older patients, and those with poor near vision, advanced visual field loss, arthritis, tremor, prior stroke, cognitive decline, or limited support at home, are especially vulnerable.
For patients in assisted living or nursing facilities, those risks can multiply. In theory, facility staff provide the support. In practice, eye drops can be quietly deprioritized.
“Staffing shortages are everywhere in healthcare right now, and nursing homes are no exception,” Dr. Boling says. “When nurses are stretched too thin to keep up with every order and medication, eye drops are often the first thing to get quietly skipped, because in a caregiver’s eyes they aren’t ‘life-saving’ the way an insulin dose or a blood pressure pill is.”
Many patients do not know whether they are actually receiving their drops. In those cases, the eye itself can reveal the gap between the chart and reality. “I tell them that their eyes tell me a story,” Dr. Boling says. “Depending on the drop regimen, I expect to see a certain local reaction – follicles, mild redness, or even orbitopathy-type changes – and if that expected reaction isn’t there, I know the drops aren’t being given as directed.”
In one case, a family had repeatedly raised concerns that a facility was not administering drops reliably. When Dr. Boling offered an alternative that eliminated the need for manual instillation, they were relieved.
“For her, a couple of carefully planned procedures took the daily instillation burden completely off the table for three to five years,” she says. “No more relying on a nurse who’s covering 40 other patients to remember, and no more guessing whether her eyes were actually protected.”
Beyond the drop-first default
This is where the caregiver-burden discussion quickly becomes an interventional glaucoma discussion. Drop therapy places multiple daily failure points between prescription and treatment effect. A procedure does not eliminate the need for monitoring, but it can reduce the number of steps that depend on memory, dexterity, access, transportation, caregiver availability, pharmacy coordination, and cost.
At Boling Vision Center, this thinking shapes a stepwise interventional glaucoma protocol that moves the conversation beyond an automatic drop-first default. The pathway begins with lasers and procedural pharmaceuticals, then moves through tissue-sparing and non-tissue-sparing MIGS, maximum tolerated drop therapy, and, when needed, filtering surgery. The selected intervention depends on disease severity, insurance coverage, and access to a surgery center, but the principle is consistent: treatment should match the patient’s real-world ability to sustain care, not assume daily drops will remain practical indefinitely.
“Drop therapy puts the treatment burden on the patient and caregiver every single day,” Hayley Boling says. “The clinic can prescribe the medication, educate the patient, document the plan, and send the refill, but the treatment only works if the patient can afford it, remember it, tolerate it, and physically get it into the eye consistently.”
A procedure-first approach, she adds, “does not mean patients never need drops, and it does not mean they do not need follow-up. But it can reduce the number of daily failure points.”
Dr. Boling sees the same advantage clinically. “Procedural options like these don’t just reduce a drop count – they remove the human-error step entirely,” she says. “A laser or a stent doesn’t depend on whether someone’s hands are steady enough that week, or whether a caregiver is available on a Tuesday morning.”
For patients without reliable support at home, that difference may be more than a convenience. It may determine whether the disease is controlled.
Defeating the “Drop Bandit”
Caregiver burden rarely appears in the chart as caregiver burden. “The chart may say the patient missed an appointment or is not taking drops as prescribed,” Hayley Boling says, “but the real issue may be transportation, cost, dexterity, cognition, caregiver availability, or lack of understanding.”
She calls the cumulative effect the “Drop Bandit.”
"It steals patient, caregiver, and HCP resources through extra phone calls, prior authorizations, medication questions, refill problems, pharmacy confusion, missed appointments, and pressure checks that reveal what we already suspected: the drops are not happening the way we hoped they were happening."
“Caregivers end up managing the pharmacy refill cycle, building and enforcing a schedule across multiple bottles with different dosing frequencies, driving to and from appointments, sitting in on visits to relay instructions the patient may not fully retain, watching for side effects, and simply remembering that this disease exists day to day when the patient feels no symptoms at all.”
For patients on multiple medications, that schedule can become overwhelming. Attempts to simplify it may introduce new complications if fixed-combination drugs are not covered or carry high copays, forcing caregivers and practices to pursue assistance programs or substitutions.
This is why Dr. Boling believes caregiver capacity should be part of the treatment decision from the start.
“A prescription only works if it can actually be executed correctly, consistently, for years,” she says. “If I hand a patient a bottle knowing they can’t see the cap, can’t squeeze the bottle reliably, and have no one reliably helping them, I haven’t really treated their glaucoma – I’ve just written a prescription.”
The same issue applies when support is present but fragile. Caregiver availability can change without warning. A spouse may become ill. An adult child may move away. A family member may burn out. When care rotates among multiple people, timing and technique can become inconsistent.
Dr. Boling recalls a long-standing patient with end-stage, no-light-perception vision in one eye and severely limited vision in the other. For years, his wife had attended every appointment with a notebook, asking questions and ensuring his medications were administered correctly. At a recent follow-up, Dr. Boling learned she had died suddenly.
“Now his family is scrambling to find someone who can provide the level of constant care he needs, especially now that he can barely see,” she says. “It’s one of the saddest kinds of cases I encounter, because mentally he is completely there – he just can’t see, and his physical stewardship depended entirely on her.”
The case left her thinking about whether earlier intervention might have reduced his long-term dependence on drops before his circumstances changed.
Earlier procedural treatment is not simply about reducing inconvenience. It can allow treatment plans to be built around the patient’s real life. Dr. Boling points to a nursing home patient who was not reliably receiving two scheduled drops. Cataract surgery combined with glaucoma procedural intervention eliminated drops in both eyes, with pressures settling around 10.
“The family’s relief was palpable,” she says, “and these interventions may very well last her the rest of her life.”
Extending the options
Dr. Boling continues: “We now have enough options on the table to stop treating glaucoma as one-size-fits-all. I can genuinely build a plan around who the patient is – their age, their support system, their dexterity, their living situation – rather than handing everyone the same bottle and hoping it works out.”
This is the core promise of interventional glaucoma in the context of caregiver burden. It does not remove clinical complexity, and it does not make follow-up optional. But it can reduce the reliance on a daily ritual that may be difficult for the patient, dependent on another person, and vulnerable to disruption.
Drops, of course, have helped millions of patients and will continue to have a role in glaucoma care. The question is whether they should remain the automatic first-line burden for every patient and caregiver when adherence is known to be imperfect and procedural options can reduce that burden.
“Sometimes it is arthritis. Sometimes it is dementia. Sometimes it is cost. Sometimes it is transportation. Sometimes it is a spouse who is exhausted,” says Hayley Boling. “Sometimes it is a patient who is doing their very best, but simply cannot be perfect every day, for the rest of their life.”
For interventional glaucoma, caregiver burden may be one of the strongest arguments for earlier action. It reframes treatment success not as a prescription written, but as therapy that can realistically be delivered over time. “Glaucoma steals sight silently,” Hayley concludes. “A procedure-first mindset gives us a chance to fight both the disease and the caregiver burden.”
Hayley G. Boling and Dr. Whitney S. Boling were compensated by Glaukos for their involvement in this article.
PM-GL-0138
