Do programs with multiple behavioral components improve the regular usage of eye pressure-lowering medications in people with glaucoma?

Key messages

  • Multifaceted behavioral programs that are intended to improve regular usage of eye pressure-lowering eye drops in people with high eye pressure or diagnosed with glaucoma can include a combination of reminders, multimedia education, in-person education, dosing aids, mindfulness-based stress reduction, monetary incentives, simplification of drop regimen, and doctor education.

  • How well these programs work is unclear; some data show favorable effects compared with standard care, and other data did not.

  • We need research: 1) with uniform ways of measuring eye drop usage; 2) that includes other important things doctors use to check the status of the disease; and 3) that includes patient-related challenges or issues that may affect eye drop usage or other things, such as how stable the disease is.

What is glaucoma, and why is treatment adherence important?
Glaucoma is a condition that can lead to vision loss and blindness. It results from multiple factors that cause the optic nerve, a bundle of nerve fibers that carries visual information to the brain, to degenerate. High pressure inside the eye is the only known risk factor of glaucoma that can be treated. Regular usage of glaucoma eye drops can help, but often usage is low because people:

  • forget to take them;

  • have competing activities;

  • have difficulty keeping to the correct dose and timings;

  • have physical or mental (e.g. fear, anxiety) difficulties with inserting eye drops; or

  • have difficulty buying them because of the cost of eye drop medications.

What did we want to find out?

We wanted to find out if two or more behavioral components when used together improve regular usage of pressure-lowering eye drops among people with high eye pressure or glaucoma.

What did we do?

We searched for studies that compared combinations of at least two types of behavioral programs to usual care or with a single behavorial intervention. Behavioral programs could include reminders through phone calls, text messages, calendars, use of a dosing aid, devices that help with eye drop instillation, educational videos, written materials, and in-person education. Usual care involves a doctor explaining the disease, the purpose of treatment, and details about treatment or drops (e.g. how often to use them, time of day, which eye), which is frequently done at the in-person clinic visit.

We summarized the results of these studies, and rated our confidence in the evidence based on factors such as the study methods and size.

What did we find?

We found 17 studies that included 4536 people who had glaucoma or high eye pressures and were using pressure-lowering eye drops. The average age of participants in these studies ranged from 42 to 76 years. Most people in the studies were White (62%), but also included Black (26%), Hispanic (1%), Asian (7%), and others (3%). Most included studies were conducted in the USA (47%), but also in other countries in Europe and Asia.

The results of our analyses were mixed. Most studies used some type of educational component. Our analyses found that having multiple behavioral components may slightly help people with regular usage of medicated eye drops, but it may not increase eye drop usage. It is uncertain whether programs with multiple behavioral components have an effect on disease-related outcomes (e.g. disease progression or prevention of vision loss) relating to eye pressure measures.

What are the limitations of the evidence?

The quality of the included studies varied. A challenge with this type of behavorial research is that it is difficult to prevent people knowing which intervention they are using (i.e. their study group assignments). The way studies measured adherence and other outcomes varied, making it difficult to combine and compare the results. Many studies did not measure clinical factors that health practitioners would be interested in, such as eye pressure, side vision loss, or the stability of the disease, in addition to patient-related issues or barriers, such as the ability to understand one's own health status or personal finances. Future research that can include consistent reporting, standard ways of measuring outcomes, and patient-related challenges would help to advance scientific knowledge in the field.

How up to date is this evidence?

The evidence is current to 31 May 2024.

Authors' conclusions: 

Based on very low- and low-certainty evidence identified in this review, it is unclear if multifaceted behavioral interventions have a beneficial effect on patient adherence to topical IOP-lowering medications and IOP in people with ocular hypertension or glaucoma. In most cases, we were unable to conduct meta-analysis due to the diversity of interventions, varying outcome definitions, and inconsistent reporting across studies. Future research would benefit from the adoption of standardized measurements and reporting methods for adherence to medication and clinical outcomes on disease stability, while taking social determinants into account.

Read the full abstract...
Objectives: 

To assess the impact of two or more behavioral interventions (i.e. multifaceted interventions) on topical glaucoma therapy adherence in people utilizing IOP-lowering therapy for at least three months for treating ocular hypertension or glaucoma.

Search strategy: 

We searched four electronic databases (CENTRAL, MEDLINE, Embase, LILACS), two clinical trial registries, and checked references. The latest search date was 31 May 2024.

Funding: 

Cochrane Eyes and Vision US Project is supported by grant UG1EY020522, National Eye Institute, National Institutes of Health.

Registration: 

Protocol available via doi.org/10.1002/14651858.CD015788.

Health topics: