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ARCHIVOS DE LA SOCIEDAD
ESPAÑOLA DE OFTALMOLOGÍA

www.elsevier.es/oftalmologia

Review

Adherence to topical treatment of glaucoma, risk

and protective factors: A review夽

M.C. Vélez-Gómez ∗ , E.M. Vásquez-Trespalacios

Grupo de investigación Observatorio de la Salud Pública, Universidad CES, Medellín, Colombia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Glaucoma is a chronic asymptomatic disease, progressing to loss of vision. Ele-
Received 11 May 2017 vated intraocular pressure is the only modifiable factor. Adherence to glaucoma treatment
Accepted 28 July 2017 varies from 2 to 80%.
Available online xxx Objective: To evaluate factors associated with adherence to topical glaucoma treatment
reported in the literature, and to identify protective factors and risk factors, as well as modifi-
Keywords: able and non-modifiable factors, in order to take them into account to perform interventions
Glaucoma in adherence.
Adherence Materials and methods: A bibliographic search of articles published in the last 8 years in
Glaucoma treatment adherence databases such as Clinical Key, Cochrane (OVID), EBSCO, Lilacs, PubMed and Science Direct,
Race and glaucoma treatment of different observational studies that performed a measurement of the treatment of glau-
adherence coma and to identify associated factors.
Management Results: A total of 7 studies were selected that directly and indirectly measured adherence to
Compliance glaucoma treatment. Different risk and protective factors for adherence to treatment were
found. These showed that African-American race, poor education, low personal income,
and high treatment costs, are strongly related to poor adherence to treatment. It was also
found that educational interventions and a good patient–physician relationship impacted
positively on adherence.
Conclusion: The results found are a guide for risk and protective factors for adherence to
treatment of glaucoma. It is cost effective to educate patients to positively impact adherence.
By identifying such factors, attention can be focused on poor adherence patients.
© 2017 Sociedad Española de Oftalmologı́a. Published by Elsevier España, S.L.U. All rights
reserved.

夽
Please cite this article as: Vélez-Gómez MC, Vásquez-Trespalacios EM. Adherencia al tratamiento tópico del glaucoma, factores
protectores y de riesgo; una revisión del tema. Arch Soc Esp Oftalmol. 2017. https://doi.org/10.1016/j.oftal.2017.07.012
∗
Corresponding author.
E-mail address: mavelezgo@gmail.com (M.C. Vélez-Gómez).
2173-5794/© 2017 Sociedad Española de Oftalmologı́a. Published by Elsevier España, S.L.U. All rights reserved.

OFTALE-1234; No. of Pages 6

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Adherencia al tratamiento tópico del glaucoma, factores protectores

y de riesgo; una revisión del tema

r e s u m e n

Palabras clave: Introducción: El glaucoma es una enfermedad crónica asintomática, que progresa a pérdida
Glaucoma de la visión. Entre los factores de riesgo el único modificable es la presión intraocular elevada.
Adherencia La adherencia al tratamiento del glaucoma varía en un 2-80%.
Adherencia al tratamiento del Objetivo: Evaluar los factores asociados a la adherencia al tratamiento tópico del glaucoma
glaucoma reportados en la literatura, identificando factores protectores y factores de riesgo, además de
Raza y adherencia al tratamiento modificables y no modificables para tenerlos en cuenta a la hora de realizar intervenciones
del glaucoma sobre la adherencia.
Manejo Materiales y métodos: Se realizó una búsqueda bibliográfica de artículos publicados en los
Compromiso últimos 8 años, en bases de datos como Clinical Key, Cochrane (OVID), EBSCO, Lilacs, PubMed
y Science Direct, de diferentes estudios observacionales que midieran la adherencia al
tratamiento del glaucoma e identificaran factores asociados.
Resultados: En total se seleccionaron 7 estudios que midieron directa e indirectamente la
adherencia al tratamiento del glaucoma. Se encontraron diferentes factores de riesgo y
protectores para la adherencia al tratamiento. Se halló que la raza afroamericana, tener
pobre educación, pocos ingresos personales, y costos elevados de tratamiento, están fuerte-
mente relacionados con la pobre adherencia al tratamiento. Además se encontró que
intervenciones de educación y buena relación médico-paciente impactan positivamente
en la adherencia.
Conclusión: Los resultados obtenidos guían hacia los factores de riesgo y protectores para la
adherencia al tratamiento del glaucoma. Es costo-efectivo realizar educación a los pacientes
para impactar de forma positiva en la adherencia. Al identificar dichos factores se puede
enfocar la atención en pacientes poco adherentes.
© 2017 Sociedad Española de Oftalmologı́a. Publicado por Elsevier España, S.L.U. Todos
los derechos reservados.

adherence can be divided into 4 categories: those related to

Introduction
Glaucoma is one of the main causes of vision loss,1–3 the
second cause of blindness worldwide4 because it is a silent
disease with progressive loss of vision without patients
exhibiting symptoms.5–7 Glaucoma is defined as an optic nerve
neuropathy, its main risk factors being increased intraocular
pressure (IOP) and old age.4,8 Primary open angle glaucoma
(POAG) is the most common form of glaucoma and requires
long-term treatment.9–11
Even though not all of glaucomas course with high IOP,
treatment endeavors to diminish it because it is the only
modifiable risk factor that has demonstrated to diminish the
progression of the disease.4,10,12,13 The first line of treatment
is topical2,13 comprising prostaglandin analogs, betablock-
ers, carbonic anhydrase inhibitors, sympathomimetics and
myotics.7 The Afro-American population is highly vulnerable
to chronic diseases, including glaucoma.14,15 It has been found
that this population has between 6 and 8 times more optic
nerve damages than Caucasian patients.15
Adherence to glaucoma treatment is a very important
factor to prevent progression of the disease,1,2,13 because
patients with poor adherence exhibit poorer results with
greater vision impairment and even blindness.4,5 Noncompli-
ance has been described between 2 and 80%.3,15–17 In addition
to being multifactorial,18 it has been found that barriers for
the physicians, environmental/social factors, others related
to medicaments and to the patient.11,19,20 This broad range
is due to the lack of studies with adequate samples to mea-
sure the actual difference between variables associated to poor
adherence. Available studies assess adherence in different
forms and are not conclusive in the quantitative measurement
thereof.
Population groups with poor adherence include Afro-
American patients.5,11 It was found that Caucasian patients
adhered to treatment 71.2% of treatment days, whereas Afro-
American adhered to 53.4% of days.15
The objective of this review is to analyze the factors
that influence adherence with pharmacological treatment
for glaucoma, comprising barriers as well as protective fac-
tors and including the above mentioned 4 categories. In
addition, the review analyzes the factors inherent to the
Afro-American population, the influential factors will include
strategies implemented to improve adherence with treatment,
the results thereof and their applicability to the population.
Materials and methods
This review collected information from scientific articles pub-
lished as of 2008. A systematic search was conducted in
specialized databases such as Clinical Key, Cochrane (OVID),
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In accordance with said variables, data of the 7 selected

Table 1 – Search.
articles were extracted and included in Table 2, i.e., type of
Search engines Results Keywords
study, method for measuring adherence and results, specify-
Academic Search 8 Glaucoma ing factors associated to adequate or poor adherence.
Complete (EBSCO) The analysis of the selected studies focused on risk and
Cochrane (Ovid) 8 Treatment adherence protective factors for poor and adequate adherence with topi-
PubMed 16 Adherence AND
cal glaucoma treatment, respectively. Three of the 7 studies
glaucoma AND
assessed factors related to adherence directly, while 4 of
treatment
Clinical Key 11 Race AND glaucoma the 7 studies that evaluated the influence of medical inter-
AND adherence ventions such as positive affirmation during the visits, the
quality of the physician–patient relationship and the efficacy
of education sessions on patient adherence. Additional results
included factors related to adherence. None of the studies
Identification

Records identified through Additional records identified

database search through other resources specified the medicament used for topical treatment. Data
( n= 43) (n = 0)
were collected from medical interviews and clinic records,
consultation videos and demographic surveys with prior con-
sent. In 3 studies, adherence was measured through the
medication possession ratio (MPR) as data obtained from the
Records after eliminating studies
that did not evaluate adherence pharmacies where the patients acquired their medicaments.
directly or indirectly
(n = 16) In 2 studies, adherence was measured through the medication
Screening

event monitoring system (MEMS) in medicament packages

Excluded records
that recorded the times the patient opened the package and
Screened records
(n = 16) (n = 9) applied the medication. In 2 studies, adherence was registered
subjectively according to patient adherence estimates, and in
one through an analog visual scale and in another on the basis
Articles with full of patient descriptions.
Eligibility

Full text of articles text excluded

(n = 7) with reason
(n = 1)

Studies included in Discussion

qualitative summary
Included

(n = 6)
Figure 1 – Prism diagram: search strategy.
EBSCO, Lilacs, PubMed and Science Direct, in order to find
different types of studies analyzing adherence with phar-
macological treatment of glaucoma. The English language
search terms were: glaucoma, treatment, adherence, management,
adherence, using the “AND” and “OR” Boolean connectors. The
search also included filters for observational study results,
articles in Spanish or English, only on humans, carried out
in the past 8 years and search terms in titles or abstracts.
Results
Overall, 43 articles were obtained with the above search crite-
ria. Complete texts were found, selecting those that included
patients with glaucoma or ocular hypertension diagnostic,
patients of all ages, those with topical treatment for glau-
coma, articles that assessed treatment adherence in different
ways including factors inherent to patients, factors related to
medicaments and physicians. After applying the above crite-
ria, 7 articles were selected for analysis.
Table 1 summarizes the results per search engine, key-
words and records. Fig. 1 illustrates the selection process.
The World Health Organization defines poor adherence as “a
large worldwide problem”.21 There is a range of factors related
to adherence with treatment in patients with chronic dis-
eases, including glaucoma. After this review, said factors could
be grouped as those inherent to the patients, to the disease,
socioeconomic, medicaments, medical follow-up and medic-
patient relationship. On the other hand said factors could be
grouped as modifiable and unmodifiable in order to calculate
the impact toward improved adherence in patients with glau-
coma. It is important to mention adherence when initiating
treatment for any disease because it has a direct influence on
morbidity and mortality.21
In what concerns factors related to the patient, i.e., non-
modifiable factors, it has been found that age and the
socio-cultural environment have a direct effect on patient
adherence to treatment.21 This review found that in the major-
ity of studies elderly and Caucasian patients tend to be more
compliant. Interestingly, it was found that patients with other
chronic diseases in addition to glaucoma also tend to be more
compliant. In addition, patient beliefs have influenced adher-
ence to treatment and all types of diseases, i.e., if the patient
believes that the treatment will not be effective, that the
health professionals are not treating the disease adequately
and not understanding the indications given by the doctor
have an important influence on adherence.21
The objective of glaucoma treatments is to diminish the
progression of the disease and not to cure it.22 Being entirely
asymptomatic, patients tend to believe they do not need the
medication because they have no symptoms or discomfort.23
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Table 2 – Charateristics and results of analyzed articles.

Author Year Type of study Adherence n Adherence Factors Factors
(%) measure- associated associated
ment with good with poor
adherence adherence

Tamrat et al. 2010 Transversal 65 (32.5%) Noncompliance Low-frequency between visits (p = 0.00)
with dosages, Advanced stage of the disease (p < 0.05)
noncompli- Age > 55 years (p = 0.04)
ance with Report of patient with financial problems
visits (p = 0.00)
Sleath et al. 2015 Longitudinal Not reported MEMS Positive Afro-American ethnicity (OR = 0.29;
reinforcement to IC95%: 0.16–0.52)
patient (OR = 3.37 Multiple medications (OR = 0.62)
[1.69–6.71]) Establishment of collaborative objectives
(OR = 0.54; IC95%: 0.29–0.98)
Cohen et al. 2014 Transversal 523 (71%) MPR Frequent Poor education level (p = 0.002)
ophthalmological Low income (p = 0.004)
visits (p = 0.04) Multiple medications (p = 0.02)
Topical medication Higher number of drops per day
(p = 0.002) (p < 0.0001)
Discussion on
importance of
treatment (p = 0.005)
Relatives or friends
with glaucoma
(p = 0.014)
Slota et al. 2015 Transversal 193 (89%) Analog visual Poor education level (OR = 0.4)
scale Number of medicaments for glaucoma
(0–10 cm) (OR = 0.52 [0.29–0.92])
8 cm = 80% Multiple medications (OR = 0.87; IC95%:
adherence 0.81–0.94)
Sleath et al. 2012 Transversal 145 (89%) MEMS Caucasian (OR = 3.53
[1.16–10.76])
Newman 2015 Longitudinal 840 (68.9%) MPR Medications sent Non-Caucasian (OR = 0.0003)
et al. through mail Low income (OR = 0.02)

MEMS: medication event monitoring system; MPR: medication possession ratio.

This review found that patients with advanced diseases tend
to be more compliant.
In what concerns modifiable factors, the review evidenced
that patients with lower educational levels23 and high medica-
ment costs21 exhibit poor adherence. Consequently, the
review found that patients with lower education and less
personal income persistently exhibit less adherence, which
makes this population even more vulnerable to loss of vision.
In addition, it must be taken into account that the studies
included herein originate in the United States and there-
fore the population groups exhibiting lower adherence are
those with lower socioeconomic level and higher proportion of
Afro-Americans, which means that these conclusions do not
necessarily apply to European or other developed countries.
In addition to the above socio-economic factors, the anal-
ysis of medication-related factors did not include a specific
medicament. Multiple reviews consistently reported that
adverse effects and treatment complexity are the main causes
for discontinuing treatment for different diseases.21 Specif-
ically for glaucoma, it was found that complex treatments
including more than one topical or oral medicament, that
required topical application more than once a day and exhib-
ited adverse effect were closely related to poor adherence.
In this review, 4 studies focused their attention on the
impact of education sessions or medical advice on adher-
ence. It was found that in general doctors do not ask of
their patients about adherence and do not educate them
about the disease and the importance of treatment, which
clearly impacts adherence mainly because glaucoma is an
asymptomatic disease that does not prompt the patient to
apply the prescribed treatment. In previous reviews, this
finding was consistent, relating poor adherence with defi-
cient doctor–patient relationships.21 In addition, the present
review found that a good doctor–patient relationship, fre-
quent follow-up visits or educational intervention improve
adherence. Educating the patient on the reasons that pro-
duce glaucoma, the effect of the medication on the disease,
explaining that the objective is to slow down the progression
of the disease to prevent blindness, in addition to provid-
ing positive reaffirmation and emphasizing the importance
of treatment in the follow-up visits, have highly significant
effects on adherence. Several strategies have been studied to
improve adherence from this viewpoint, but until now none
has had clearly significant results in their application.21
Some of the limitations of the present review include the
fact that not all studies focused directly on factors related
to adherence and were additional findings. Attention was
focused on the studies that objectively measured adherence,
i.e., measurement with MPR (utilized in the majority of stud-
ies) which has the disadvantage of not measuring directly the
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application of the medicament, instead it interprets the extent
in which the patient is acquiring the medicament against the
prescribed treatment days, which could be a false adherence
indicator because the patient could acquire the medicament
without applying it.
Despite age and ethnicity being nonmodifiable factors, it
can be concluded that these factors could have an impact on
adherence to enable health professionals to improve adher-
ence with glaucoma treatments. Taking into account that
younger and Afro-American patients are less compliant, addi-
tional resources could be dedicated to patient education on
glaucoma and the importance of treatment.
Doctors should educate patients about the disease and
the importance of treatment by means of simple interven-
tions such as openly asking them about adherence, verbally
reaffirming the patient when demonstrating genuine commit-
ment with treatment and follow-up. It has been demonstrated
that good doctor–patient relationships are a protective factor
for adherence with treatments.21
Additional studies are necessary to quantitatively measure
adherence in a precise and objective manner. Currently avail-
able studies have utilized different methods, some of which
included multiple variables that could affect results. In addi-
tion, adequate samples are necessary in which the possible
variables are taken into account and the true percentage of
adherence is measured quantitatively.
More studies are needed to evaluate adherence with glau-
coma treatment which should include factors associated
to the health system of each country, the medicaments
included in the required health plans and the services
provided to patients to improve adherence, in addition
to the systemic limitations that could negatively impact
adherence.
Conflict of interest
The authors declare that they have no commercial interests
and have not received financial support.
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