Ask when the drop goes in, not whether it goes in

'Are you using your drops?' gets a yes from nearly everyone, including the patients who are not. It is a question about compliance, which people answer defensively, rather than a question about a routine, which people answer accurately.

Ask instead: what time of day do you put it in, where do you keep the bottle, and when was the last time you missed one? A patient with a real routine answers all three immediately. A patient without one hesitates on the first, and the hesitation is the finding. Then ask them to show you — hand them the bottle and watch. Head not tilted, bottle touching the lashes, a drop landing on the cheek, both eyes squeezed shut afterwards and the excess wiped away: each of these is common, each is correctable in thirty seconds, and none of them shows up in an adherence questionnaire.

Finish by teaching punctal occlusion — one finger at the inner canthus for a minute after the drop. It reduces systemic absorption, which matters most for exactly the beta-blocker-containing drops a progressing patient is likely to be on.

• Ask about time of day, bottle location and last missed dose rather than about compliance.
• Watch the patient instil a drop at least once, ideally at the visit where you escalate treatment.
• Check for the bottle touching the lashes — it contaminates the tip and wastes the drop.
• Teach punctal occlusion for a full minute, particularly with any beta-blocker.
• Count bottles and dosing times; a three-bottle regimen is a different proposition from a one-bottle one.

Why it matters

Treatment failure in glaucoma is usually a delivery problem, and the question we ask is the one least likely to detect it.

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