What helps glaucoma patients better adhere to their treatment?

The Support, Educate, Empower (SEE) personalized health coaching intervention was associated with a more than doubled increased likelihood of patients achieving ≥80% adherence to their glaucoma medication than the standard treatment education methods.^1,2

SEE was developed by investigators from the University of Michigan to address the multifactorial barriers to glaucoma treatment adherence through a series of tailored multimedia assets, motivational interviewing-based coaching, medication reminders and treatment monitoring managed by a non-physician coach. In the randomized clinical trial data published to JAMA Ophthalmology last month, the investigators observed an approximate 20% improvement in self-reported treatment adherence from baseline through the intervention compared to a control group.

In a Q&A with Ophthalmology Times, Paula Anne Newman-Casey, MD, MS, of the Department of Ophthalmology and Visual Sciences at the University of Michigan, discussed the various factors that impact glaucoma treatment adherence, her history with developing what would eventually become the SEE program, and the “holy grail” of research relevant to glaucoma treatment adherence outcomes.

What is it specifically about glaucoma that we understand may drive a patient to non-adherence with their treatment? Is it a lack of outcome? Is it the method of care? Are there clear trends?

Newman-Casey: I think that the reasons glaucoma patients have trouble taking their medications perfectly all of the time are probably not so different from the reasons that AMD patients have trouble coming back for (intravitreal) injections — though, I think there may be some additional fears around pain, nfections the use of needles that maybe don't enter the paradigm for glaucoma patients yet (although those treatments are also on the horizon).

About 10 years ago, we surveyed 190 glaucoma patients trying to figure out if there was potentially one reason why glaucoma patients really struggled with taking their medications that we could address and look to see if maybe that would be the magic bullet. But, what we found was that there really wasn't one reason. We had 11 different reasons that we put out there that we identified from reviewing the literature and conducting focus groups.

It's a huge range, all the way from simply saying that people are forgetting to take their medicine to having concerns about the medication's side effects, skepticism that the medicine is actually helping or that glaucoma is actually causing vision loss. Patients reported having not a trusting relationship with their doctor, having issues with the cost of the medications, issues with the schedule, or having trouble getting the drops in their eyes. I mean, just tons of different reasons. And what was so interesting was about one-third of the people we surveyed said that each reason applied to them.

So, there was no reason that no one said was important. That's what led me to think that we really needed a very multi-faceted intervention if we were going to move the needle on adherence. Some people might say the SEE program is like throwing the kitchen sink at people. But, I would say that I think that's what's needed when everyone's got a different problem and people may have more than one issue. I think really personalizing the intervention is highly important.

In a recent meta-analysis (Anhul Ha, MD, and colleagues)³ conducted looking at interventions to improve glaucoma medication adherence, they found the same thing: that multi-faceted, multimedia, highly personalized interventions are what really moves the needle on medication adherence. People need attention that's directed towards them and their problems, their adherence needs, their doctor's recommendations, their test results, and their medications.

It's interesting how your team described it as essentially a response to a call for this approach: we need more personalized coaching intervention for something that could measure as a public health-scale issue. Can you explain a little bit more about the inception of the SEE Program itself, and what drove its final design?

Newman-Casey: I started working on trying to understand how to help people become motivated to improve their glaucoma medication adherence about 15 years ago, when I was a resident. I had come to understand how many of the people sitting in front of me in clinic had high pressures because they hadn't taken their drops. And so, I conducted a systematic literature review trying to understand what had already been done in the field, in 2013.⁴ And in 2015 I analyzed focus groups where patients were telling us why they think people still go blind from glaucoma. There was a lot of talk about the lack of support and understanding — how the health system doesn't support people's self-management.

We looked at secondary data analysis, looking at whether people's patterns of adherence change over time. And we found that, really, once people establish a pattern of behavior, it doesn't change that much over time. So, we need to intervene if we want people's pattern to improve. I read about how there's tons of different models trying to help people with diabetes or pre-diabetes improve their self-management. And I tried to learn from best practices in the diabetes space about what we could bring into glaucoma to help our health system deliver more patient-centered care, more more ways to support people's self-management.

And then I started creating things and and iteratively testing it, one-by-one, while interviewing patients to see what resonated with people. I made content changes as people gave me feedback. I did that a couple of times, with 30 participants each times, making iterative changes until I got something that I felt like people were giving me positive feedback about. We then pilot-tested it, and in a pre-post analysis with people who self-reported poor adherence, we gave them the coaching program. And we saw a robust response with that design, where people's adherence improved about 20 percentage points. And then we thought, 'To get this into practice, we need to generate level 1 evidence.'

We applied to the National Eye Institute for funding to conduct a randomized, controlled trial of the program compared to standard written education. And that was funded, and we carried out the work, and the same robust response that we saw in the pilot study was replicated in the controlled trial. So, I think this is a real response, and the devil is in the details. It's very important, the way the program was delivered, in order to get this kind of response.

Having all these various components that really spoke to people and was able to be personally tailored was very important in getting this response. And the reason I say that is because we interviewed each person after the trial who participated in the SEE program, and they named these things as really important. They said, "My relationship with a coach was really important, understanding getting my adherence score and talking about it with a coach was really important. Having an alarm system that I could opt into or opt out to was really important. Seeing what would happen to my vision over time in the personalized education session if I didn't take my drops was really important, and motivating me to change my behavior. Figuring out how to integrate my medication into my daily routine with a coachwas really important."

These were key pieces of the program that we thought might be important. And when we interviewed participants, they reall said so too. So, I think all of the pieces are important in actually helping people change their medication use behavior.

I understand there's now plans for a pragmatic trial to assess biological outcomes for patients in the SEE program, which of course is a key outcome complementary to improved treatment adherence. Is there anything else you're hoping to learn more about the program as you assess it?

Newman-Casey: The holy grail is always to see if we can really decrease visual field progression. And I think that would be the next pragmatic trial I would love to see our team undertake, is to see if we can, measure whether improving people's adherence with this self-management support approach can improve people's biological outcomes, mainly decreasing visual field progression.

References

Newman-Casey PA, Niziol LM, Lu M, et al. Effect of the Support, Educate, Empower Personalized Glaucoma Coaching Program on Medication Adherence: The SEE Program Randomized Clinical Trial. JAMA Ophthalmol. Published online February 26, 2026. doi:10.1001/jamaophthalmol.2026.0001

Kunzmann K. Personalized glaucoma coaching program improves treatment adherence. Ophthalmology Times. Published March 4, 2026. https://www.ophthalmologytimes.com/view/personalized-glaucoma-coaching-program-improves-treatment-adherence

Ha A, Jang M, Shim SR, Kim CY, Chang IB, Kim YK. Interventions for Glaucoma Medication Adherence Improvement: A Network Meta-analysis of Randomized Controlled Trials. Ophthalmology. 2022 Nov;129(11):1294-1304. doi: 10.1016/j.ophtha.2022.06.025. Epub 2022 Aug 23. PMID: 36028393.

Newman-Casey PA, Weizer JS, Heisler M, Lee PP, Stein JD. Systematic review of educational interventions to improve glaucoma medication adherence. Semin Ophthalmol. 2013 May;28(3):191-201. doi: 10.3109/08820538.2013.771198. PMID: 23697623; PMCID: PMC3992247.