For decades, topical pharmaceutical therapy has been the default first-line treatment for glaucoma. Eye drops remain the most widely prescribed intervention for lowering intraocular pressure (IOP) and have historically been the most familiar starting point for managing a chronic, progressive disease. However, an alternative paradigm – interventional glaucoma – has gained increasing attention. This approach centers on procedure-based interventions, with topical therapies repositioned as a bridge or supplemental treatment rather than the primary long-term strategy.
In real-world practice, drop-based treatment relies on a critical assumption: that patients will use medications correctly and consistently over time. Evidence increasingly suggests that assumption may be optimistic at best.
Adherence to glaucoma medications is widely documented to be poor, with many patients discontinuing therapy within the first 6 months. As newer options such as selective laser trabeculoplasty (SLT), procedural pharmaceuticals, and a growing range of minimally invasive glaucoma surgeries emerge (MIGS), clinicians are questioning whether the traditional drop-first paradigm still represents the best approach to care.
But the implications are not purely clinical. From a practice operations perspective, reliance on drops introduces a significant and often under-recognized administrative burden. “As we look at what it takes us to manage glaucoma patients, the number of drops they are on is the biggest indication of how much staff resource it's going to take,” says Ben Seals, Chief Executive Officer of Thomas Eye Group, which spans 19 locations and 58 providers, serving around 18,000 to 23,000 unique glaucoma patients annually across the Metro Atlanta area in Georgia. “As regimens escalate, so too do refill requests, pharmacy issues and prior authorizations – placing additional strain on staff and systems.”
The hidden damage of topical therapy
Glaucoma specialist Dr. Christine Funke of Barnet Dulaney Perkins Eye Center (Scottsdale, AZ) argues that the traditional model often fails to address both the biological drivers of glaucoma and the realities of patient behavior. “The big issue is that topical therapy isn’t addressing the root cause of glaucoma.” Instead, she says, eye drops are a temporary solution rather than a disease-modifying one. “I think of them as Band-Aids. Most of the time we’re not actually doing anything to modify or alter the disease.”
By contrast, newer procedural approaches – often grouped under the concept of interventional glaucoma – aim to directly alter the eye’s drainage system. “Interventional procedures change the way the drainage structure physically works. We’re altering it in some way.” And that difference matters, particularly early in the disease. “If we miss that early in the disease process, where we still know we can modify the internal architecture of the eye, then we’re missing a very large opportunity.
Beyond failing to address the underlying pathology, topical therapy may introduce its own complications. Preservatives commonly used in eye drops can damage ocular tissues over time – ironically affecting the same structures clinicians are trying to protect. “We know that the preservatives, which are very commonly used, have negative impacts on the exact architecture we’re trying to preserve,” Dr. Funke explains. Meanwhile, “we’re not just allowing time to pass not working on that drain, but we may also be causing damage.”
Yet the system continues largely unchanged, often relying on an assumption that patients will follow their treatment plans. “That’s another problem,” she explains. “We’re assuming adherence.”
The reality of adherence
In practice, adherence to topical glaucoma medications is notoriously poor – and the reasons extend well beyond ophthalmology. “We know people just don’t take medications very well,” says Dr. Funke. “This isn’t just with glaucoma. People with cardiac disease don’t take their medications. People with blood pressure issues don’t take them. Diabetes – the list goes on.”
She adds, “This is down to the human factor. And that never goes away.”
Research reflects that reality. Within six months of starting treatment, about half of patients stop using at least one prescribed drop. “So, I assume at least half of my patients won’t be using whatever topical therapy I give them within a year.” For a chronic, lifelong disease, that presents a major challenge. “If therapy depends on perfect compliance,” she adds, “we have a problem.”
The operational consequences of that reality are immediate. “We’re constantly getting calls back from patients,” says Seals. “Ongoing education, making sure they understand how to take their drops, how to stack them, how long to wait in between.” As patients move onto multiple therapies, the complexity increases. “Two, three, four, even five drops depending on disease progression,” he notes. Each interaction may be brief – or it may escalate. “A single issue might be a five- to ten-minute phone call, or it can turn into hours of staff time with callbacks and phone tag,” he says. “We ballpark that for every thousand glaucoma patients, it’s about half an FTE of administrative burden tied to drop management.”
Financial barriers also play a role. Many glaucoma medications are expensive, and patients may feel uncomfortable discussing cost pressures with their physicians. “A lot of patients can’t afford what we’re asking them to do,” Dr. Funke says. “And that can be embarrassing sometimes, so it’s something we don’t hear about.” The result is a gap of silence between what clinicians believe is happening and what patients are doing. “We assume they’re taking their medications. But they may not tell us the truth.” Meanwhile, the disease is advancing “right under our noses, without us even knowing it’s happening.”
This lack of adherence also introduces unpredictability into care delivery. “The biggest variability comes from our most noncompliant patients,” Seals explains. “They’re not predictable – when they’ll run out of drops, when they’ll come back in.” That unpredictability can disrupt not only clinic schedules but also the diagnostic pathway. “We’re trying to ensure the right testing at the right time, and every time that changes, it affects our ability to gather consistent clinical information over time.”
The illusion of control
Even clinical measurements can reinforce that false sense of security. Dr. Funke argues, for example, that intraocular pressure (IOP) checks – long central to glaucoma monitoring – can be misleading.
“The longer I’ve been involved in glaucoma care,” she says, “the more I’ve realized that an IOP check is probably the least important portion of my exam.” Pressure readings represent only a moment in time. “It’s giving me a snapshot in a very small piece of time.” Of course, patients may take their drops more diligently just before an appointment, but a pressure reading that looks good during the visit is still masking poor adherence. “If every time someone comes in their pressure is low,” she says, “you might assume they’re doing great, but the reality may be very different.”
Even when patients are perfectly compliant, topical therapy has limitations. “Diurnal control is still not happening,” she explains. “We know that from decades of data.”
Moving toward intervention
For many clinicians, these limitations are prompting a reconsideration of treatment strategies. Over the past decade, the landscape of glaucoma care has expanded dramatically. Historically, ophthalmologists relied on medications partly because the surgical alternatives were far more invasive. “When we only had topical therapy and surgeries like trabeculectomy and tube shunts,” says Dr. Funke, “it was obvious most patients went for topical therapy. But we now have an entire swath of different options, and the risks and burden around therapies like SLT and MIGS are very small compared with traditional surgery.” The balance is shifting, and “as physicians, we must prioritize procedural intervention over the default position of prescribing drops as primary therapy.”
From an operational perspective, this shift also offers greater consistency. “Interventional glaucoma allows us to standardize the treatment pathway,” says Seals. “It puts compliance on the surgeon, not on the patient.” That shift creates predictability in both outcomes and resource planning. “We’re managing a more predictable patient population because we understand the treatment paradigm,” he explains.
The potential impact is significant. “If we had more patients in outcomes similar to the SLT arm of the LiGHT trial,” he adds, “the number of patients on multiple or stacked drops would be significantly lower, and the administrative burden would be significantly less.”
Changing the conversation with patients
The transition toward a more interventional approach begins with clinicians themselves. “First you have to adopt it internally,” says Dr. Funke. “You really have to believe that interventional glaucoma is a preferred method of practice. If you don’t believe that, your patients will not gain a sense of confidence from you in the procedure recommendation.”
Once clinicians are comfortable with the tools and techniques available, the next step is to change how they discuss treatment options. “I usually tell patients two things,” she continues.
“First, no one is perfect with their drops, and I don’t assume they will be. Second, even if they are perfect with their medication, we may still be able to provide better control of their disease with other options.” When framed in that way, she adds, the conversation becomes much easier. “If you truly believe you’re recommending better care, it no longer feels like you’re trying to sell something.”
However, patient perception remains a barrier. “From a consumer perspective, putting an eye drop in your eye – if it’s tolerable – is easier to accept than the idea of a procedure,” Seals says. “If a doctor says, ‘we’re going to do a laser,’ that creates concern.” He argues that this reflects a communication gap. “I don’t think, as an industry, we’re doing enough to communicate the upside of procedural treatment compared to the risks of pharmacological therapy.” Without that context, patients may underestimate long-term risk. “This is a disease that silently kills sight, and we need to better communicate that early intervention is about keeping patients off that trajectory.”
Rebalancing risk
Ultimately, the question facing clinicians may be less about whether topical therapy works – and more about whether it works reliably enough in real–world settings. Glaucoma management has historically prioritized conservative treatment escalation, with medications used first and procedures reserved for later stages of disease. But the growing recognition of adherence challenges, combined with the emergence of lower – risk interventional options, is prompting clinicians to recognize that proactive procedural intervention is both appropriate and effective.
For Dr. Funke, the issue comes down to reframing risk. Her goal is to intervene earlier and more effectively whenever possible. “We should strive to avoid vision loss, and we know patients are often ineffective at self-treating medication therefore by deploying procedural intervention, I feel confident in minimizing potential vision loss.”
The central challenge for glaucoma care may lie not in developing new therapies – but in deciding when to deploy them. But the issue that keeps resurfacing throughout glaucoma care is strikingly simple: if adherence is widely recognized as one of the weakest links in treatment, why do so many care pathways still depend on it? As clinicians reassess the role of drops, procedures, and sustained therapies, the deeper question remains: are we designing treatment plans around how glaucoma behaves – or around how we hope patients behave?
Ben Seals and Dr. Christine Funke were compensated by Glaukos for their involvement this article.
Article 1 PM-GL-0130
