Potential Limitations of E-mail and Text Messaging in Improving Adherence in Glaucoma and Ocular Hypertension

Osamah J. Saeedi, MD; Christine Luzuriaga, OD, MSc; Nancy Ellish, DrPh, MSPH; Alan Robin, MD


J Glaucoma. 2015;24(5):e95-e102. 

In This Article

Abstract and Introduction


Purpose: To determine how receptive patients are to the use of e-mail and text message reminders for appointments and medications.

Methods: We conducted a consecutive cross-sectional survey of eligible patients with glaucoma or ocular hypertension at a private glaucoma subspecialty practice with 3 locations from February 2011 to January 2012. Main outcome measures were answers to survey questions regarding how receptive patients are to e-mail and text messaging reminders for appointments and medications.

Results: Of 989 patients, 404 (40.8%) patients reported that e-mail reminders would help remember appointments and 185 (18.7%) reported that they would help for medications. Among those with access to text messaging, 280 (68.9%) reported text messaging would help them remember appointments and 193 (47.5%) reported it would help with medications. Patients who reported e-mail would help them remember medications were more likely to live in an urban location [P=0.05, odds ratio (OR)=1.84], check the internet at least daily (P≤0.001, OR=1.04), check e-mail when not at home or the office (P=0.02, OR=1.62), and know how to open attachments (P=0.03, OR=1.87). Patients who reported that text messaging would help them remember their medications were more likely to be 40 or less (P≤0.001, OR=8.54) and African American (P<0.001, OR=2.59).

Conclusions: E-mail and text messaging reminders currently may have a limited utility in improving adherence in the general glaucoma population but may be useful in younger patients with glaucoma.


Although there are many potential choices, intraocular pressure lowering medications are currently the mainstay of glaucoma therapy.[1] Long-term adherence has been estimated to be 50% to 60% by studies using electronic monitoring devices.[2–5] Automated reminders such as telephone calls and audible and visual alarms have been successfully used to improve adherence to glaucoma medications in some populations.[5–8] Because of the relative pervasiveness of cell phones and e-mail access, electronic reminders via text messaging and e-mail could represent a relatively low-cost, effective method of increasing adherence and improving outcomes. Text messaging and e-mail have been used successfully to improve adherence to medications in other fields in generally younger, urban populations.[9–16] We aimed to determine the utility of such reminders in patients with glaucoma, hypothesizing that this generally older population, that includes both urban and rural patients, may be less receptive to the use of e-mail and text messaging to improve adherence.

Cell phone and Internet use has significantly increased in recent years. 88% of all US adults now own a cell phone, 73% of cell phone users send and receive text messages, and 55% use their phone to go online.[17] With the increase in cell phone usage, the usage of text messaging has also increased. In 2005, approximately 57.2 billion text messages were sent in the United States, whereas 2.27 trillion were sent in 2012.[18] Similarly, >80% of adults in the United States use the internet. Whereas younger individuals have a greater internet presence, the majority of Americans over 65 years have internet access and the over 75 age group is one of the fastest growing segments online.[19]

Whereas few studies in ophthalmology have evaluated the effect of text messaging and e-mail reminders on adherence,[20,21] text messaging has been effectively utilized in other medical disciplines to improve medication adherence and ultimately, health care outcomes. Daily text messaging has been shown in multiple studies to improve adherence and significantly decrease viral load among HIV patients.[9] In a study of pediatric liver transplant recipients, daily text messages improved adherence and reduced acute rejection episodes 6-fold.[10] Text messaging has been studied as a means to improve adherence among patients using oral contraceptives,[11,12] smoking cessation,[13] and sunscreen use,[14] as well as those with lupus[15] and diabetes.[16] E-mail has also been used to remind patients about appointments in major health systems with promising results.[22,23] Such studies in other disciplines generally targeted younger patients in urban areas. Given that glaucoma patients are generally older and may have barriers to adoption of technology, we aimed to determine if our population would be receptive to the use of e-mail and text message reminders. To our knowledge, this is the first assessment of text messaging and e-mail use in patients with glaucoma. These results may allow us to better evaluate the potential role of these electronic messaging modalities to improve glaucoma care by improving adherence to appointments and medications.