June 26, 2025
11 min learn
Key takeaways:
- Interventional procedures with eye drops as an adjunct are slowly turning into the foundational remedy for glaucoma.
- Right this moment’s safer procedures enable surgical procedure to be thought-about earlier in these sufferers.
With extra choices accessible than ever to deal with sufferers with glaucoma, it has develop into clearer that therapy must happen as early as attainable to keep away from the worst outcomes of the illness.
Traditionally, eye drops have been the primary line of glaucoma remedy. Sufferers wanted to stick to a strict routine to keep away from illness development and potential blindness. However lately, this paradigm has shifted, in keeping with Healio | OSN Glaucoma Part Editor Thomas W. Samuelson, MD.
Interventional procedures with eye drops as an adjunct are slowly turning into the foundational remedy for glaucoma, in keeping with Thomas W. Samuelson, MD.
Picture: Courtesy of Minnesota Eye Consultants
“There may be now definitive, evidence-based knowledge confirming that laser trabeculoplasty is the very best preliminary therapy for many sufferers with major open-angle glaucoma,” he mentioned. “There appears to be widespread consensus inside the world glaucoma neighborhood supporting this paradigm shift. This, coupled with an array of much less invasive procedures, carried out with or with out cataract surgical procedure, and extra widespread adoption of sustained drug supply, has modified the panorama considerably.”
Though eye drops are nonetheless a part of glaucoma administration, Samuelson mentioned they’re shifting from preliminary and foundational therapy to an adjunctive remedy.
“We nonetheless use eye drops so much, however we’re slowly altering the foundational remedy from eye drops to safer interventional procedures and utilizing eye drops because the adjunct as a substitute of the procedures because the adjunct,” he mentioned. “Up to now, eye drops have been the inspiration, and we did adjunctive remedy. Now we’re sort of reversing that.”
However the technique of interventional glaucoma is greater than only a change in therapy choice.
“Interventional glaucoma is having somewhat bit extra of a proactive strategy to the administration of glaucoma,” Manjool M. Shah, MD, mentioned. “It appears to be like like utilization of diagnostics to attempt to determine sufferers who’re at best danger and to focus sources accordingly. It appears to be like like proactively utilizing procedures to regulate and stabilize strain. It means sufferers don’t need to depend on doing drops themselves and managing the illness themselves. It begins to suit the dialog away from simply being all concerning the strain. It’s about defending and preserving the affected person’s high quality of life.”
Healio | OSN Affiliate Medical Editor Leon W. Herndon Jr., MD, mentioned the choices for early therapy have made an enormous distinction for sufferers. When he began his profession 30 years in the past, the alternatives weren’t as clear lower.
“We might do watchful ready for a very long time as a result of the one choices I had 30 years in the past have been trabeculectomy or cycloablation surgical procedure,” he mentioned. “The potential issues related to these therapies weren’t nice choices for sufferers. Now, with safer choices launched during the last 10 years, physicians and surgeons are extra open to recommending earlier intervention surgically.”
The necessity for early intervention has been evident to glaucoma specialists who see the difficulties sufferers face with a day by day drop routine. In a research printed in Ophthalmology in 2006, researchers examined the issues sufferers had adhering to their glaucoma medicine. They despatched a survey to 324 sufferers who have been taking a couple of glaucoma medicine to find out their medicine adherence within the earlier week.
Leon W. Herndon Jr.
They discovered that 60% of sufferers reported at the very least one downside with taking their medicine and that 14% of sufferers reported being lower than 100% adherent, in keeping with the research. Sufferers reported quite a few points with taking drops, together with unwanted effects, issue getting the drops of their eye, inconvenient dosing instances and issue remembering to make use of their drops.
Samuelson mentioned the interventional glaucoma strategy takes compliance with eye drop remedy out of the equation for a lot of sufferers, though he added that compliance with follow-up appointments stays vital.
“We should emphasize that ongoing surveillance is vital, even when a affected person is now not on eye drop remedy,” he mentioned.
“Most of us have believed for a very long time that one of many main limitations of a day by day drop administration routine is that sufferers simply discover it onerous to adjust to,” he mentioned. “Whereas there could also be some physiological explanation why a affected person could not reply to a sure medicine, a lot of the time a scarcity of therapy impact is as a result of the drops are simply not administered correctly.”
Herndon mentioned one of many research that illustrates the risks of medicine nonadherence is the Collaborative Preliminary Glaucoma Remedy Research, which started in 1999.
“They discovered an actual, virtually dose response curve,” he mentioned. “They checked out sufferers’ compliance points, and those that adjust to their remedy have been in comparison with those that didn’t. They discovered that poorly compliant sufferers have far more development of their visible discipline loss. Once more, it was virtually a dose response curve the place you might see those that miss extra drops did extra poorly. I exploit that research on a regular basis in my conversations with sufferers concerning the significance of compliance. In the event that they’re not in a position to adjust to remedy, then I feel we have to take a look at interventional choices.”
There may be one more reason an early interventional therapy could be helpful for sufferers, Samuelson mentioned.
“One other issue affecting compliance is the opposed impact glaucoma drugs could have on the ocular floor. Particularly, surface-related unwanted effects could cut back high quality of life for glaucoma sufferers,” he mentioned. “With our interventional mindset, we cut back limitations associated to compliance, and we’re bettering the ocular floor well being by not subjecting sufferers to repeated dosing of ocular floor poisonous drugs.”
LiGHT
The shift in apply took maintain on the heels of the LiGHT trial, printed in The Lancet in 2019. Within the Laser in Glaucoma and Ocular Hypertension Trial, researchers in contrast conventional glaucoma eye drops with preliminary selective laser trabeculoplasty by randomly assigning 362 sufferers and 356 sufferers, respectively, to endure every therapy plan. The first final result of the research was health-related high quality of life at 3 years assessed by EQ-5D scores. Researchers additionally explored value, medical effectiveness and security of every therapy.
Out of 652 sufferers who returned their questionnaires at 36 months, there was no important distinction in EQ-5D scores between the 2 teams. Nonetheless, 74.2% of sufferers within the SLT group required no drops to take care of goal IOP. Eyes within the SLT group have been inside goal IOP at extra visits than within the drops group (93% vs. 91.3%), and no eyes within the SLT group wanted surgical procedure to decrease IOP in contrast with 11 within the drops group.
Moreover, there was a 97% chance that SLT as a primary therapy could be less expensive than eye drops as a primary therapy, in keeping with the research. The authors wrote that their findings supported a change in medical apply with a shift in the direction of providing SLT as a first-line therapy possibility for open-angle glaucoma and ocular hypertension. Subsequent analysis discovered comparable outcomes as much as 6 years after preliminary therapy.
“Not solely was laser not inferior to eye drop remedy, it was superior in lots of respects,” Samuelson mentioned. “Sufferers have been much less more likely to progress within the laser group. They required fewer secondary surgical interventions for glaucoma. They required cataract surgical procedure much less steadily, and nearly all of them remained off drugs as much as 6 years of follow-up. This was actually vital knowledge that we didn’t have earlier than. Most of us had a bias that laser was efficient, however we didn’t count on that it could be as efficient because the LiGHT trial proved it to be. That basically gave ophthalmologists confidence that laser first is certainly the very best preliminary therapy.”
As laser turns into extra widespread as a first-line therapy, Samuelson mentioned it’s altering affected person expectations.
“As soon as sufferers expertise that drug-free therapy possibility, then they have a tendency emigrate towards that for future choices,” he mentioned. “So, if preliminary laser remedy is waning, or supplemental IOP decreasing is critical, both the laser will be repeated or perhaps you may transfer to a sustained drug supply possibility or maybe cataract surgical procedure with a MIGS process. As nicely, some sufferers do proceed to progress regardless of these measures, and we nonetheless have the choice to go on to extra aggressive therapies akin to trabeculectomy or tube shunts, however we’re doing far fewer of these procedures than we used to nationwide and certainly worldwide. That’s as a result of the therapies which might be extra proximal within the therapy scheme are working. They don’t work in everyone, however they work in sufficient sufferers that the majority of them will be managed with much less invasive measures.”
In apply
Rather a lot has modified as interventional therapy has develop into extra standard, however Sarah H. Van Tassel, MD, mentioned it means greater than only a laser-first strategy. It’s a couple of change in mindset.
“Interventional glaucoma doesn’t essentially imply doing a process on each affected person, although I actually suppose the SLT-first paradigm for major open-angle glaucoma is essential,” she mentioned. “Interventional glaucoma is basically about having the arrogance in our knowledge and likewise in our abilities to contemplate interventions at every step of the glaucoma journey and, importantly, to get away from the prior thought course of, which was that drops are the risk-free possibility and that every little thing else has dangers as a result of, in truth, the largest danger of prescribing drops is that the sufferers don’t use them.”
Nonetheless, regardless of the drawbacks of drops, Van Tassel believes that they nonetheless have a task to play within the administration of glaucoma, even when it’s not their conventional use.
“I’ve some issues that the fervor for interventional glaucoma has come off as an anti-drop marketing campaign,” she mentioned. “I feel that’s misguided as a result of drops actually aren’t the enemy right here. Glaucomatous visible dysfunction is the enemy, and drops stay an vital software in our armamentarium for prevention of glaucomatous blindness. In a way, that is sort of the identical revolution that most cancers remedy had a decade in the past when individuals have been speaking about personalised drugs. To me, it’s extra about ensuring that each affected person hears concerning the interventional choices and that you simply current them not as a second selection however in lots of instances as an equal option to drops.”
Sarah H. Van Tassel
An individualized strategy means presenting choices to sufferers and explaining the journey, Shah mentioned.
“I joke with sufferers that I’m going to indicate them the menu,” he mentioned. “I sometimes current the choices so as from least to most invasive or least to most aggressive. You wish to tailor the journey for every particular person affected person based mostly on their illness severity, their age and their objectives. There could also be some customary finest practices. Clearly, we would like a cautious examination in addition to early and frequent diagnostics to characterize the illness.”
For typical glaucoma instances, Shah mentioned he depends closely on SLT early within the course of.
“That’s type of undeniably our major therapy modality, and that’s how we begin the dialog,” he mentioned. “We nonetheless use drops, however ideally, we use them as type of a bridge remedy between different interventional methods, whether or not that’s cataract surgical procedure/MIGS, stand-alone MIGS or drug supply if SLT shouldn’t be sufficient.”
When Van Tassel lays out choices for sufferers, she mentioned the dialog round SLT is the best to have as a result of the advantages are clear.
“I inform sufferers that their eyes would profit from pressure-lowering remedy and that there are two methods to get that carried out,” she mentioned. “I inform them, ‘The primary is with a laser remedy that’s carried out right here within the workplace. You don’t have to carry anybody with you. It stimulates the pure drain inside the attention to work higher. The opposite possibility is with a watch drop that you must use each night time, and in the event you miss even a single night time, it’s not working for you.’ Sufferers will typically ask me what I’d advocate. I inform them if it have been my eyes, I’d need the laser.”
She mentioned the outcomes final years, SLT will be repeated if mandatory, and sufferers can keep away from a day by day reminder of their continual illness for which they’re in any other case asymptomatic.
“Our different conversations are extra nuanced partly as a result of the info are murkier and since every affected person’s issues will be totally different,” Van Tassel mentioned. “Have they got a visually important cataract? Are they already pseudophakic? Do they need stand-alone or mixed remedy? It’s much more affected person and physician particular.”
What comes subsequent?
If preliminary SLT shouldn’t be sufficient, Samuelson mentioned the subsequent steps rely upon a number of elements, together with the standing of the native crystalline lens. If the affected person wants cataract surgical procedure, he mentioned it’s a good alternative to carry out mixed cataract and glaucoma surgical procedure. In some ways, the 2 procedures are nicely suited to be carried out in the identical surgical setting.
“In most situations, we do the very best we will in managing sufferers with minimally invasive measures together with laser and sustained supply or eye drop remedy till the affected person develops a visually important cataract. As soon as we all know they’re going to the working room for cataract surgical procedure, we mix phacoemulsification with an individualized glaucoma intervention,” Samuelson mentioned. “So, we’ll make use of laser, drug supply and even drops, however ultimately, nearly all sufferers, in the event that they reside lengthy sufficient, would require cataract surgical procedure.”
When the affected person is available in for cataract surgical procedure, Shah mentioned he’ll select his subsequent step based mostly on severity and mechanism.
“For instance, if we have now somebody who has pseudoexfoliation, which is a trabecular meshwork illness, we is perhaps extra inclined to do one thing procedural to the trabecular meshwork versus doing sustained drug supply or one thing like that,” he mentioned. “That’s a method how we’d individualize issues once more after SLT, sometimes.”
Herndon urged surgeons to have a great sense of the literature and to attract on their very own expertise and outcomes when recommending a change in therapy choices.
“Once I’m discussing change and therapy choices to my sufferers, it’s nothing that I draw back from as a result of one factor you see in a 30-year apply is sufferers going blind,” he mentioned. “I can share with sufferers that based mostly on my background, my coaching and my 30 years of expertise, I do know that glaucoma is nothing to play with. Blindness even in 2025 continues to be a possible for each glaucoma affected person.”
In the case of glaucoma administration, Shah mentioned there are nonetheless a number of unmet wants. Drug supply has proven potential, however selections are restricted to a couple molecules. He believes there may be room for progress with much more potential targets for medicine, however he mentioned that diagnostics, regardless of their significance, go away a bit to be desired.
“We don’t have actually predictive diagnostics that may look upstream of harm. The one issues we have now are methods to determine injury after it’s already occurred, and that injury is everlasting,” Shah mentioned. “We actually have an enormous deficit there by way of attempting to be that rather more proactive and danger stratify. There are positively actions in that route, whether or not it’s polygenic gene scores or useful imaging or issues like that. There’s some promise, but it surely’s not fairly mainstream but and accessible to all sufferers.”
Wanting again on the final 10-plus years of innovation, Shah is inspired to see what’s to come back.
“It is a course of that’s simply going to maintain getting higher and higher,” he mentioned. “I’ve little question that we have now room to develop on our stents and our surgical methods in addition to understanding how our surgical procedures succeed, how they fail and the way we will modulate our surgical procedures and take into consideration mechanisms to do higher. We’re getting there, and the truth that we’re having these conversations and there’s an identification of have to do higher with glaucoma administration is the gas that permits this to occur.”
For extra data:
Leon W. Herndon Jr., MD, of Duke Eye Middle in North Carolina, will be reached at leon.herndon@duke.edu.
Thomas W. Samuelson, MD, of Minnesota Eye Consultants, will be reached at twsamuelson@mneye.com.
Manjool M. Shah, MD, of Kellogg Eye Middle on the College of Michigan, will be reached at manjool@med.umich.edu.
Sarah H. Van Tassel, MD, of Weill Cornell Drugs, will be reached at sjh2006@med.cornell.edu.
References:
- Gazzard G, et al. Lancet. 2019;doi:10.1016/S0140-6736(18)32213-X.
- Gazzard G, et al. Ophthalmology. 2023;doi:10.1016/j.ophtha.2022.09.009.
- Musch DC, et al. Ophthalmology. 1999;doi:10.1016/s0161-6420(99)90147-1.
- Sleath B, et al. Ophthalmology. 2006;doi:10.1016/j.ophtha.2005.10.034.
Sources/Disclosures
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Healio Interviews
Disclosures:
Herndon reviews consulting for AbbVie, Stability Ophthalmics, Iantrek, Implandata, Myra Imaginative and prescient, New World Medical and Sight Sciences, conducting analysis for Bausch + Lomb, and consulting/conducting analysis for Alcon, Glaukos and Ocular Therapeutix. Samuelson reviews having monetary disclosures for AbbVie, Alcon, Glaukos, New World Medical and Sight Sciences. Shah reviews consulting for AbbVie, Alcon, Bausch + Lomb, Corza, Glaukos, MicroSurgical Expertise and Nova Eye Medical. Van Tassel reviews having monetary disclosures for AbbVie, Alcon, Bausch + Lomb, Glaukos and New World Medical.
