Some benefits of interventional glaucoma over traditional treatment of the disease are obvious: We can now eliminate poor patient compliance; reduce patients’ financial and lifestyle burdens; and decrease iatrogenic damage to the ocular surface and adnexa caused by drop toxicity. Less obvious are the secondary gains to physicians. Surgical solutions provide patients with long-term therapy, reducing or eliminating their need for drops—as well as the amount of time we must spend discussing them and trying different formulations. Plus, the process of getting the right drops to our patients can burden offices with excessive calls from insurance companies, pharmacies and patients, requiring additional payroll to handle the volume, and multiple follow-up appointments to confirm efficacy with drop changes.

Minimally invasive glaucoma surgery (MIGS), an umbrella term encompassing a range of surgical procedures that require less tissue manipulation than conventional glaucoma surgery, forms the foundation for interventional glaucoma therapy.

MIGS isn’t new. The first MIGS, Argon laser trabeculoplasty, was FDA- approved in 1979, and was relatively widely used until it was replaced by selective laser trabeculoplasty (SLT) in 2001. However, the use of traditional drop therapy remained the mainstay of glaucoma treatment until 2019, when the LiGHT trial¹ demonstrated the efficacy and safety of MIGS compared to traditional glaucoma drops.

Several studies have shown that large IOP fluctuations are a risk factor for the progression of glaucoma² and that SLT reduces IOP variations.³ However, despite the evidence, only 20-50% of ophthalmologists use SLT as first-line therapy.⁴ Fast-forward to 2025, and we now have a multitude of options to use with cataract surgery or as standalone procedures to effectively treat all stages of glaucoma while eliminating the issues of compliance; financial and lifestyle impact on the patient; damage to the ocular surface; and the time and payroll burden to doctors and their staff—saving countless hours and payroll dollars. In addition, most of these options are well reimbursed both to the surgery center and to the surgeon. The learning curve to manage most of the techniques is short, and the procedures themselves can be efficiently incorporated into a busy surgical schedule.

Why, then, is interventional glaucoma slow to gain traction? There are many reasons: most surgeons have a difficult time changing practice pattern; there is a learning curve for the physician and support staff; and some surgeons not trained in glaucoma surgery are uncomfortable operating in the angle. Shifting to an interventional mindset, with drops used as a bridge to surgery, is likely to be the new standard of care. My hope is that this transition will happen more quickly than history suggests, improving our ability to manage glaucoma early while easing the burden on patients and doctors. OM

REFERENCES

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al., Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393:1505-1516.

2. Asrani S, Zeimer R, Wilensky J, Gieser D, et al. Large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma.
J Glaucoma. 2000;9:134-142.

3. Mohammed EM, Walsh MM, Stinnett SS, Asrani SG. Selective laser trabeculoplasty reduces mean IOP and IOP variation in normal tension glaucoma patients. Clin Ophthalmol. 2010;4:889-893.

4. Bonafede L, Sanvicente C, et al., Beliefs and Attitudes of Ophthalmologists Regarding SLT as First Line Therapy for Glaucoma. J Glaucoma. 2020 Oct;29(10):851-856.

Lisa K. Feulner, MD, PhD is Ophthalmology Management’s chief medical editor. She is the founder and CEO of Advanced Eye Care & Aesthetics in Bel Air, Md., where she specializes in cataract surgery, medical and surgical glaucoma care and dry eye disease.