Within contemporary medicine, glaucoma is defined as an optic neuropathy, partially affected by intraocular pressure, that will eventually lead to vision loss. However, there is so much that we still do not know about the disease, including why some patients continue to progress despite having ostensibly normal pressures. The good news is that most patients in the US present with mild-to-moderate primary open-angle glaucoma (POAG), and so face a good chance of holding steady with the proper treatment.
As intraocular pressure (IOP) is the only modifiable risk factor for POAG, previous treatment options have included laser, drops, more drops, as well as trabeculectomy and tube shunts. But over the last decade there has been a dramatic shift in how we think about glaucoma care. The renewed focus is on patients’ quality of life and compliance, on reducing topical drops, and a belief in earlier interventions performed in a safe and effective manner.
In 2011 I joined my dad in practice as a third-generation comprehensive ophthalmologist. The following year, I started my journey into the world of minimally invasive glaucoma surgery (MIGS) with the first-generation iStent. Out of curiosity and a true need for alternatives, I began investigating how glaucoma care might be redefined. I started by looking at the angle in every cataract patient, as this set-up in surgery was all new to me. My iStent cases were in combination with cataract surgery, and there was a learning curve to perfecting this view of the angle, while also really trying to comprehend the angle, the position, and the force required to apply this tiny device.
This step started a journey that now evolved into caring for glaucoma patients in a very different way than before. And I’m grateful to say on the way I’ve had many opportunities to meet individuals who share my passion for redefining what glaucoma care should look like. Just as the term MIGS has been defined over the past dozen years, this new mindset has brought together a special group to discuss interventional glaucoma, and how we might establish a new protocol for those patients who present with mild, moderate, and severe POAG.
In the summer of 2024, some of us sat in a conference room and attempted to define what the treatment algorithm for the various stages of POAG might look like. Yes, it was a risk – this was a group united by the passion and enthusiasm for the new paradigm, but it was also diverse, coming from small rural towns and major cities from all over the US. The meeting could have ended much differently, with too many opinions and too many digressions disrupting proceedings. But it was a success! Our collaborative and solution-based discussions led to the establishment of a new Interventional Glaucoma Treatment protocol that could help to reset and revitalize the stage for glaucoma care.
Since its inception, interventional glaucoma has been defined as a mindset with some key messaging attached: 24/7 IOP lowering, early intervention with safe and effective options, a lessening of drop dependence, halting visual field (VF) progression, and – most importantly – improving patients’ quality of life. Now, after the publication of several papers describing the benefits of early intervention in optimizing the natural outflow pathway, as well as the decreasing need for more invasive procedures over time, this mindset has gradually evolved.
Selective laser trabeculoplasty (SLT) as a first-line therapy has allowed us to offer a viable alternative to topical drops. Procedural pharmaceuticals – such as Durysta and iDose TR – have shown the benefits of sustained-release of medication in the eye, even lasting beyond the proposed duration, without any observed side-effects. Furthermore, MIGS can be performed in a sequential order, depending on whether it is in combination with cataract surgery or standalone. We also have tissue-sparing devices and techniques available, such as stenting and canaloplasty, and tissue removal of the trabecular meshwork (TM) in the form of goniotomy; we have a full spectrum of how to treat the outflow pathway, depending on the stage of glaucoma and the need for meeting a certain IOP goal. All this is in addition to other options for bypassing the angle completely, such as minimally invasive bleb surgery or micro pulse laser.
With all of these options available to surgeons,we can start to really think about glaucoma as a long-term game, factoring in severity, age, and IOP goal, amongst other things. Ophthalmologists’ curiosity about the disease has now honed in on the cellular level – understanding inflow and outflow. And we now see that long-term topical medication could have a negative impact on the trabecular meshwork, whereas intracameral medication can potentially have a positive impact on outflow. We also see how some new Mechanism of Action (MOA) medications, such as ROCK inhibitors, work more effectively after a MIGS procedure, as well as being one of the only medications to also lower episcleral venous pressure.
In the world of interventional glaucoma, this collective curiosity about the disease has become creative, intuitive, and strategic. But it’s not simply investigational – rather, we understand glaucoma differently and are learning to become proactive rather than reactive to the disease. Interventional glaucoma offers an incredible opportunity both to our glaucoma patients and the broader profession. Using these new techniques, we are able to treat patients better than ever before, offering them tailored treatments in a safe and effective way. Personally speaking, I cannot wait to see what else interventional glaucoma has in store.
