With so many interventional treatment options available in the glaucoma space today, how are ophthalmologists speaking to their patients about early intervention? GT asked glaucoma specialists to share what the conversation looks like for them.
Larissa Camejo, MD
When I meet a new patient or need to advance therapy in an established patient, I first listen, next educate, then propose a treatment plan, and finally, listen again. This structured, empathetic approach guides every interaction I have with patients with glaucoma.
My clinical goals are clear, and I communicate them as such: (1) lower IOP to a target at which progression is unlikely, and (2) reach that target with the fewest medications possible. Early in the conversation, I address patients’ common misconceptions. In my clinic, I find that patients often assume dry eye symptoms are caused by their glaucoma rather than by its treatment. Clarifying this detail improves their understanding of why it might be beneficial to decrease their number of glaucoma drops. Additionally, treating and improving dry eye symptoms builds trust. In fact, addressing dry eye early—often on day 1—is one of the most effective ways to establish rapport with patients in glaucoma care.
From this foundation, I introduce the evolving landscape of interventional glaucoma. I explain how the field has shifted toward earlier, proactive intervention and emphasize the time-sensitive nature of glaucoma treatment, given the irreversible vision loss caused by the disease. The wait-and-see approach is not a safe one. I compare our management approach to a marathon, not a sprint. I explain that current treatment options include selective laser trabeculoplasty (SLT), sustained-release drug delivery systems, angle-based MIGS, minimally invasive bleb surgery, suprachoroidal devices, and traditional surgery. Treatment selection is always individualized and shaped by clinical need, by prior discussion, and, regrettably, sometimes by insurance limitations.
It is important to inform patients that these interventions are not always sequential. Even patients with a history of tube shunt surgery or trabeculectomy may benefit from additional, less invasive strategies—especially if the goal is to further lower IOP or reduce medication.
Practicing interventional glaucoma means adopting a proactive, comprehensive mindset. It involves educating both patients and their families; understanding the nuances of the patient’s daily life (eg, caregiver status, ability to administer drops, need for occupational therapy); and stepping in early before more vision is lost.
Ultimately, we are not treating just IOP or optic nerves; we are treating people. Enhancing their quality of life through better vision, fewer drops, improved ocular comfort, and cataract and dry eye management is often the most meaningful outcome we can offer. The biggest reward is when a patient verbalizes how much better they feel, how their vision has improved, and how well they now understand their disease. Then, the patient-physician relationship becomes a partnership.
Lorraine M. Provencher, MD
Counseling patients with glaucoma is an art—always evolving, never perfected. As the field advances, so do our conversations. Right now, my approach to discussing interventional glaucoma revolves around three core principles:
1. Keep it personalized;
2. Make it evidence-based; and
3. Aim for simplicity.
These principles guide me when patients ask, “What would you do if it were your eye?”
Although shared decision-making is emphasized in modern medicine, I find that most patients still want an expert recommendation. Whether they are newly diagnosed or new to my care, I begin with a clear explanation of their diagnosis, disease stage, and mechanism. I often use images or test results to support the discussion. Since many newer treatments target the trabecular meshwork, I include a brief overview of the eye’s drainage anatomy.
I reassure patients that we have multiple effective options and emphasize our goal: to halt disease progression while maintaining quality of life. I discuss whether their IOP is acceptable or needs to be reduced, while also addressing their lifestyle and treatment tolerability. I clearly state a personalized goal, whether that is to lower IOP, reduce the medication burden, or reduce IOP fluctuation.
I explain that, although drops were once the first-line treatment, the landscape has shifted. I acknowledge that they may already be on drops or know others who are, and I assure them that this was once standard care. I then explain that noninvasive or minimally invasive procedures now offer better long-term control and help delay or avoid riskier surgeries. I emphasize that eye drops should be used only as a bridge or supplement, not as a lifetime crutch.
When explained clearly, patient buy-in for interventional glaucoma is rarely a challenge—because it is logical. I always offer a confident, singular recommendation, such as, “I recommend SLT, a simple laser treatment that rejuvenates your eye’s drainage system. It is quick, safe, and we can do it today. It is what I would choose for my own eyes.”
Finally, I remind patients that, although this is a strong starting point, additional treatments may be needed over time, and I may allude to a few “plan B” options. This sets realistic expectations and reinforces that glaucoma is a chronic but manageable disease. I want patients to leave knowing that glaucoma is serious and lifelong, but they are not alone; we are a team, and our goal is to keep them seeing well and living well.
Brian M. Shafer, MD
When presenting early intervention to a patient with glaucoma, the key is to speak confidently, succinctly, and calmly about the glaucoma journey ahead. Patients detect doubt when a physician wavers in their response, so having a talk track is paramount. The following is my talk track for speaking to patients about interventional glaucoma:
Glaucoma is a disease of high pressure in the eye. Our goal in treating glaucoma is to lower the pressure in your eye to a level that is safe for your optic nerve. We can do that with medicine, lasers, and surgery; over the lifetime of a glaucoma patient, we do all these things.
At the beginning of the journey, we start with a gentle laser procedure known as SLT, which helps rejuvenate the drain that gets clogged in the eye. If your pressure does not go down as much as we’d like, or when your pressure starts to rise again, we can then move on to placing medicine in the eye that can work for months to years, depending on which product we use. After this, we can place stents in the drain to help open it even more.
Being on a glaucoma journey with me is like going to a restaurant and ordering the chef’s tasting menu. I have a huge menu of options, and it is my job to choose when each new course comes out. Throughout the journey, we will likely utilize eye drops to cleanse the palate in between therapies, but our goal is to minimize their long-term use to keep your eyes happy and healthy. Glaucoma is like a game of tug-of-war—sometimes your glaucoma will fight us, but we will fight back harder.
