“You take the blue pill — the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill — you stay in Wonderland, and I show you how deep the rabbit hole goes.”

This decision was offered to Neo in the movie, “The Matrix.” Fifteen years ago, as a fresh minded, eager third-year resident, I had to make a difficult decision myself.

I was quite intrigued with cornea and felt it was the most technologically advanced field of ophthalmology, incredibly innovative and provided patients unlimited potential for clear vision — or at least that is what I “believed.” I was also engrossed with glaucoma because the disease had visually impaired my grandmother.

However, at the time, glaucoma offered a much darker road with limited therapeutic options and the potential for many sleepless nights due to overfiltering blebs, hypotony, permanent nerve damage and vision loss. Do I take the red pill or the blue pill?

JOINING THE DARK SIDE

When I made the decision to go down the rabbit hole, glaucoma was the dark side. While our objective was to preserve vision, we didn’t improve vision or quality of life. Our medical therapy often induced ocular surface disease, allergy and irritation and was perceived by patients as being more caustic than helpful. Even our “new” medications were simply a combination of two older medications.

Our surgical procedures, though critical, were not much better. Unlike cataract surgery and LASIK, glaucoma procedures did not improve vision; rather, they had the risk of further impairing vision.

INNOVATION OFFERS LIGHT

Fortunately, we have seen an explosion of innovation and a significant paradigm shift in glaucoma management.

We are now enhancing the natural outflow system instead of bypassing it both medically and surgically. For decades, we have reduced IOP by suppressing aqueous humor production, but now we are targeting the pathologic changes to the trabecular meshwork with drugs like netarsudil or latanoprostene bunod. These medications relax the abnormally contracted cytoskeleton of the trabecular meshwork and reduce outflow resistance. Micro-invasive glaucoma surgery (MIGS) transformed glaucoma from that “dark rabbit hole” of tubes, trabs, hypotony, bleb dysesthesia etc., into a blissful reality — we can improve a patient’s quality of life!

Instead of limiting glaucoma surgery to those with uncontrolled or end-stage disease, we are now offering angle-based procedures to reduce medication burden. I would never have fathomed performing a trabeculectomy in a patient with controlled mild to moderate glaucoma to simply reduce or remove medication burden. But, with the excellent safety profile of MIGS procedures, we are operating much sooner in the disease course, especially if managing a concomitant cataract. We have myriad options when approaching our glaucoma patients with all stages of severity. We use MIGS to control the uncontrolled, minimize medications, alleviate adverse reactions, improve compliance (if meds are still needed) and reduce the monthly expenditures on medications.

THIS ISSUE

In this issue, we review the pathologic changes of the conventional outflow system seen in glaucoma patients and review the physiologic process of aqueous outflow. Also, we review medications both commercially available and in clinical trials and various MIGS procedures. These innovations are some of the reasons I’m glad I took the red pill. OM

Mark J. Gallardo, MD, is a glaucoma specialist at El Paso Eye Surgeons in El Paso, Texas.

Dr. Gallardo is a consultant, speaker and clinical investigator for Allergan, Glaukos, Ivantis, Nova Eye (Formerly Ellex) and Sight Sciences, a clinical investigator for Alcon, Equinox and New World Medical and a speaker for Aerie and Bausch and Lomb. Email him at gallardomark@hotmail.com