Standard of care is elusive given the preponderdance of new options.

After what seemed like an eternity of stagnation in the world of glaucoma, 2018 promises to unveil tremendous new options. We finally have MIGS procedures that target the 3 main outflow pathways, and we have 2 new molecules, each of which boasts a new mechanism of action. While our heads spin as we try to take in all of the possible treatments for glaucoma, we must also ask: What is the new glaucoma treatment algorithm?

To definitively answer this question would require a clinical trial with 1,000 or so arms. We simply can’t know how each option stacks up against the next with scientific certainty now. To me, even more questions immediately arise. Will the MIGS algorithm be tailored to each patient? We know that patients’ biology (age or race) can influence wound healing, or that disease stage can affect which procedure might be best. Will the physician’s particular skill set determine which procedure should be preferentially performed? Surely there is some truth to the oft-heard phrase, “This works best in my hands.” Will new outflow medications augment or facilitate MIGS, and how will that influence our choices? And finally, in an algorithm with so many options, how do you weigh safety vs efficacy? We may now have 50 different surgical options for our patients, but no patient will let us perform 50 separate procedures, in just the right sequence from safest to most efficacious. In glaucoma, you only have a few shots at goal, and we need to make the most of each surgical opportunity.

I think these questions are important and that we will have plenty of time to ponder them as we gather comparative data for each new procedure. Until then, the “Wild West” of glaucoma surgical decision-making is here. These are indeed good problems to have for glaucoma physicians and patients alike.

Change is afoot in glaucoma therapy, and therapies are being studied and tweaked daily. In this issue of Glaucoma Physician, we hear from leading experts about techniques being used now to lower IOP. We hope these articles advance your treatment of glaucoma patients, and we look forward to sharing information on advances in glaucoma care in future issues. GP

Dr. Radcliffe is Clinical Assistant Professor in the Department of Ophthalmology at the NYU Langone Medical Center and a surgeon at the New York Eye Surgery Center.