Glaucoma rarely presents the same way twice. A patient may arrive in the glaucoma clinic with established disease and elevated intraocular pressure (IOP), or glaucoma may first become part of the conversation during a routine cataract evaluation. Disease severity, medication burden, ocular surface health, visual goals, anatomy, and the possibility of future intervention can all influence the surgical approach taken.
To explore how those considerations translate into everyday decision-making, three surgeons from Omni Eye Services in Atlanta, Georgia, brought perspectives from different areas of anterior segment care:
Arkadiy Yadgarov – Glaucoma Specialist and Cataract Surgeon
Lawrence Woodard – Corneal Specialist and Cataract Surgeon
Priya Patel – Corneal Specialist and Cataract Surgeon
Their conversation revealed an increasingly individualized approach to glaucoma intervention, one that began with a fundamental question: What does this particular eye need today, and what options should remain available tomorrow?
Different Patients, Different Starting Points
For glaucoma specialist Dr. Yadgarov, the disease is often the reason a patient is in his chair, whereas for Drs. Woodard and Patel, it may be discovered or reconsidered during a cataract evaluation.
“In my practice as a cornea and cataract specialist, glaucoma patients aren’t necessarily funneled directly to me for disease management,” Dr. Patel explained. “However, they frequently land in my chair for cataract evaluations.” When ocular hypertension or mild-to-moderate glaucoma accompanies a cataract, she considers not only the patient’s visual needs, but also medication burden and ocular surface health.
Dr. Woodard has seen this patient population evolve as a sub-specialization within his own practice. With a dedicated glaucoma specialist now managing many moderate-to-severe cases, the glaucoma patients he encounters during cataract evaluation often have milder disease or are newly diagnosed. For these patients, less invasive, angle-based approaches may become part of the cataract surgery conversation.
The broader point, Dr. Yadgarov noted, is that glaucoma intervention is no longer confined to the glaucoma specialist. Cataract, cornea, and comprehensive ophthalmologists increasingly encounter patients for whom IOP management is part of the surgical decision-making process.
Moving from “Which Procedure?” to “What Does This Eye Need?”
With goniotomy, trabeculotomy, canaloplasty, micro-stenting, and combinations of these approaches available, the decision is no longer simply whether to intervene; it is also where and how much to intervene.
Dr. Patel’s early surgical experience centered largely on goniotomy. More recently, she has incorporated canaloplasty into her approach.
Similarly, Dr. Woodard begins by considering the patient’s starting point. “For me, pressure control on medications and baseline pressures without medications dictate the selection,” he explained. “If someone is well-controlled on a single drop and just needs a modest boost, I might consider a stent. But when I need more substantial IOP reduction, such as in newly diagnosed patients with higher baseline pressures, I reach for canaloplasty and goniotomy.”
For Dr. Yadgarov, no single angle-based approach is appropriate for every eye. Disease severity, anatomy, surgeon experience, safety considerations, treatment goals, and the amount of tissue being treated all factor into the decision.
These considerations have led the surgeons to think increasingly about titrating intervention rather than applying the same procedure to every patient.
How Much Treatment is Enough?
Treatment extent is one of the variables surgeons can adjust. For mild-to-moderate disease, Dr. Woodard noted that he typically treats approximately 180 degrees when combining canaloplasty and goniotomy, while more extensive treatment may be considered in more advanced cases. Disease severity, however, is not his only consideration. Patients receiving premium intraocular lenses (IOLs) may have particularly high expectations for early postoperative vision, making the possibility of hyphema and transient visual obscuration part of procedural selection.
Dr. Patel shares that concern: “A hyphema in a patient who paid for premium presbyopia correction can compromise their early recovery experience,” she said. “I’ve looked at doing more canaloplasty alone in those eyes to minimize bleeding risks while still lowering pressure.”
This raises another important consideration: Does every intervention need to alter the trabecular meshwork?
Preserving Anatomy and Future Options
The conventional outflow pathway involves more than a single point of resistance. The trabecular meshwork, Schlemm’s canal, collector channels, and distal outflow system all play roles in aqueous humor drainage and create opportunities for intervention.
In Dr. Yadgarov’s practice, one approach may involve circumferential canaloplasty with a more targeted trabeculotomy. Alternatively, in other eyes, particularly those milder cases, he may consider canaloplasty without cutting or removing trabecular meshwork. He explained: “If a surgeon performs pure canaloplasty without disrupting the trabecular meshwork, the anatomical architecture remains intact.”
For Dr. Yadgarov, that preservation has strategic value for the surgeon. Glaucoma is a chronic disease, and today’s procedure may not necessarily be the patient’s last. Therefore, preserving anatomy can become part of a longer-term treatment strategy for the patient.
This collective attitude represents a shift in thinking: How much intervention does this eye need now, and how much anatomy can be preserved?
The Evolution of Canal Access
Canal-based treatment has also evolved to offer different ways of delivering viscoelastic into Schlemm’s canal. One contemporary approach uses a flexible microcatheter advanced circumferentially through the canal. Another uses a direct, point-and-click approach to deliver controlled amounts of viscoelastic through an angle-based entry point.
The objective is related, but the surgical experience can differ. Dr. Patel has primarily incorporated the point-and-click approach into her own practice. “Because it requires minimal manipulation inside the angle, it makes providing meaningful IOP lowering simpler,” she explained, adding that in her opinion, the approach was “extremely efficient.”
Dr. Woodard previously used catheter-based approaches more frequently, but noted that workflow has become an increasingly important consideration in his high-volume cataract practice. “We are constantly under pressure to minimize unnecessary intraocular time,” he explained. As such, reducing the number and complexity of intraocular maneuvers can be particularly valuable when a patient moves or has difficulty cooperating during surgery.
Dr. Yadgarov saw this particular development as part of a broader evolution in ophthalmic device design aimed at simplifying procedural steps, reducing technique sensitivity, and creating greater consistency in delivery.
Looking Ahead: More Options, More Individualization
For all three surgeons, the evolution of canal-based intervention is creating more flexibility in how they approach the conventional outflow pathway. Rather than treating every eye the same way, surgeons can now consider the extent of treatment, whether to combine canaloplasty with trabecular intervention, or whether viscodilation alone may fit the needs of a particular patient. Just as importantly, advances in delivery are making it possible to approach Schlemm’s canal in different ways – from targeted, point-and-click viscoelastic delivery to circumferential catheter-based treatment.
Looking ahead, the surgeons see opportunities for even greater visualization and feedback during canaloplasty. Dr. Woodard would like the ability to better visualize where viscoelastic travels through the canal, while Dr. Yadgarov sees potential for technologies that provide greater insight into the outflow pathway during surgery.
Ultimately, the evolution of canal-based glaucoma care is giving surgeons something increasingly valuable: choice. Choice in how they access the canal. Choice in how much they treat. Choice in whether to preserve or modify the trabecular meshwork. And choice in how they tailor an intervention to the patient in front of them.
As the field continues to evolve, canal-based approaches are expanding the possibilities for surgeons to treat with intention, preserve options, and individualize the approach, one eye at a time.
