How Cornea Surgeons Can Expand Access to Interventional Glaucoma Treatment

Glaucoma eye drops present a significant challenge for patient compliance. They often irritate the ocular surface, and they are prescribed to patients who may have limited dexterity and face the burden of a lifelong daily regimen. Compounding the issue, glaucoma is asymptomatic until vision loss occurs, providing no immediate incentive for patients to remain consistent with their treatment. Unsurprisingly, only about 40 percent of patients adhere to their prescribed therapy, leaving the remaining 60 percent at increased risk of vision loss (1).

Interventional glaucoma offers a far more practical solution for these patients. It enables surgeons to manage glaucoma proactively by addressing the disease directly and earlier rather than relying on patients to adhere to a burdensome at-home therapy regimen.

As a cataract and refractive surgeon who also manages ocular surface disease (OSD), I have expanded my interventional treatment options for glaucoma to ensure my patients receive the highest standard of care. Additionally, I am addressing an unmet need in my community by accepting referrals for mild to moderate glaucoma – an easy integration into my practice using three reliable modalities. As I continue to encounter patients with eye drop-induced OSD and poorly controlled intraocular pressure, I hope more of my colleagues will adopt this approach, making interventional glaucoma therapy more widely accessible.

A patient-driven approach to glaucoma
 

For cataract surgeons, minimally-invasive glaucoma surgery (MIGS) is indispensable – when we are already in the eye, it’s a unique opportunity to address both cataracts and glaucoma in a single surgery with one recovery period. It is our responsibility to help patients achieve better glaucoma control while restoring clear vision. In my practice around half of my cataract/glaucoma patients are referred for both procedures, while the other half come in for cataract surgery alone. I make it a priority to educate referring practitioners about interventional options that can help their patients – whether or not they have cataracts – to reduce or eliminate their reliance on eye drops.

As a cornea surgeon, I also encounter a significant amount of preoperative OSD. Over time, our practice has developed specialized expertise in managing OSD. This has become a major entry point for glaucoma patients, many of whom have been on one or two glaucoma drops for years and now suffer from severe OSD. These patients often have no symptoms of glaucoma itself, but the side effects of their medications wreak havoc on their ocular surface and test their commitment to treatment. In such cases, we take a step back, introducing interventional treatments to reduce or eliminate their dependency on drops, and giving their ocular surface a much-needed break.

For anterior segment surgeons already skilled in angle-based surgery, MIGS are relatively straightforward. To better serve OSD patients with glaucoma, I expanded my treatment options to include more standalone MIGS procedures – performed independently of cataract surgery and suitable for both phakic and pseudophakic patients. This decision was reinforced when I attended an interventional glaucoma course and heard six distinguished glaucoma surgeons present six different (yet equally effective) approaches highlighting the versatility of interventional care. It showed that we can confidently select effective, patient-centered options tailored to our skills and preferences – just as we do when personalizing refractive cataract surgery.

Patient education is also crucial. Cataract and OSD patients often don’t anticipate a recommendation for a glaucoma procedure and so they naturally have questions. I take the time to explain that glaucoma is a progressive condition, and early intervention significantly reduces the risk of vision loss. Unlike eye drops, these interventional options don’t contribute to OSD, nor do they rely on patient adherence. I also reassure them that if their glaucoma progresses in the future, additional treatment options are available. In nearly all cases, patients quickly understand the benefits and agree to proceed with the recommended treatment.

My three reliable modalities
 

Since embracing an interventional approach to glaucoma treatment, I now rarely prescribe glaucoma drops – using them only to manage occasional pressure spikes or as a temporary measure before surgery. Interventional therapies allow me to manage glaucoma without burdening the patient, and integrating them into our practice has been a very smooth process. My three preferred modalities aren’t first, second, and third steps, but rather a toolbox of options available to meet patients’ varying needs and situations.

1. Selective laser trabeculoplasty (SLT). For a long time, eye drop medications were the only first-line glaucoma therapy. However, SLT has emerged as a proven alternative, demonstrated in multiple studies to be more effective than drop therapy while causing fewer side effects. This shift has positioned SLT more frequently as a first-line therapy option. My preference for SLT stems from wanting to improve the ocular surface and remove adherence as a barrier to managing this disease.
    
2. Extended-release medication implants. Extended-release medication implants are an innovative solution for managing glaucoma, offering reliable intraocular pressure (IOP) reduction while eliminating the burden of daily self-administered treatments and the associated risks of poor adherence and OSD. Bimatoprost SR (Durysta, Allergan) is a biodegradable implant designed to provide sustained IOP reduction for several months. It’s injected directly into the anterior chamber during a simple in-office procedure at the slit lamp. Travoprost (iDose TR, Glaukos) is a tiny titanium implant preloaded with medication. Anchored to the scleral tissue, it provides consistent drug delivery for well over a year. Unlike Durysta, the iDose TR requires placement in the operating room, making it a longer-lasting option for sustained glaucoma management. Both options exemplify the potential of extended-release therapies to improve outcomes and simplify care for patients with glaucoma.
    
3. MIGS surgery. With the wide variety of MIGS devices available, it’s important to focus on options that work seamlessly in practice. For me, the ideal MIGS is one that feels intuitive, delivers consistent clinical outcomes, and is versatile enough to be used alongside cataract surgery or as a standalone procedure. I frequently perform the OMNI procedure (Sight Sciences), which combines canaloplasty followed by trabeculotomy. This procedure stands out because it leaves no implant behind, while addressing three areas of resistance: Schlemm’s canal, collector channels, and the trabecular meshwork. This makes it an effective option for managing primary open-angle glaucoma across its entire spectrum, from mild to advanced stages. Additionally, the OMNI procedure has demonstrated excellent outcomes in lowering IOP and reducing the need for medications (2).

The flexibility of these treatment options is invaluable. For patients with well-controlled pressure on a single medication but with significant ocular surface damage, I often opt for SLT or an implant, either of which can typically replace one drop. I also frequently perform standalone MIGS, particularly with OMNI, which is highly effective for OSD patients taking two or more medications. This is also my go-to for post-cataract glaucoma patients with OSD, as it alleviates the burden of eye drops and provides much-needed relief for the ocular surface.

Many patients with both cataracts and glaucoma suffer from severe OSD; it is essential to reset the treatment algorithm to address both conditions simultaneously. Beyond standard bilateral cataract surgery, MIGS offers the flexibility to individualize care based on diagnostic findings. For instance, if one eye demonstrates visual field defects or optic nerve changes while the other does not, I can perform OMNI on the affected eye, treat the other with SLT, and continue monitoring its progress. This tailored approach ensures both problems are managed effectively, improving outcomes and quality of life for my patients.

Helping to expand access
 

Expanding access to interventional glaucoma therapies is a critical step in transforming how we care for patients with glaucoma. By integrating advanced modalities like SLT, extended-release medication implants, and a MIGS procedure with OMNI into our routine practice, we can reduce the reliance on patient adherence to medications and improve both ocular health and quality of life. These approaches empower anterior segment surgeons to address glaucoma effectively while minimizing the burden of long-term therapy, especially for patients with OSD.

For practitioners, embracing these options also broadens the scope of care, meeting a growing need in the community for comprehensive glaucoma management. As we shift towards patient-driven, interventional care, we have the opportunity to make a profound impact on the lives of those affected by this sight-threatening disease.