Interventional glaucoma (IG) is not a departure from evidence-based medicine. It is the natural evolution of it.

For decades, glaucoma management followed a familiar pattern: diagnose the disease, prescribe drops, monitor progression, and escalate treatment only when medications fail. That approach was understandable when our therapeutic options were limited, but today, the landscape has changed.

We now have compelling evidence that a proactive approach to glaucoma management, wherein selective laser trabeculoplasty (SLT), sustained-release drug delivery devices, or MIGS are used early in the treatment course, can reduce medication dependence, and provide more consistent disease control. Yet, despite these advances, many physicians continue to rely on a medication-first paradigm.

The reason is not a lack of technology, reimbursement, or clinical evidence. The greatest obstacle to the widespread adoption of IG is something far more fundamental: physician mindset. Until we fully embrace the idea that proactive intervention serves patients better than chronic drop therapy, the promise of modern glaucoma care will remain unfulfilled.

EVOLVING THE STANDARD OF CARE

For years, I have maintained that glaucoma is a surgical disease. That is not to say I believe every patient needs surgery. What I mean is that glaucoma is a progressive disease that ultimately requires intervention. Historically, we have relied heavily on medications to manage that disease. The problem is that medications only work if patients take them consistently—and it is well established that many do not.1

Fortunately, glaucoma care is no longer limited to drop therapy. We can now intervene earlier, reduce the medication burden, and create treatment plans that are less dependent on patient behavior. To me, that represents better medicine. Although many physicians may be inclined to continue practicing the way they were trained years or even decades ago, glaucoma care is evolving rapidly, and our responsibility is to evolve with it.

To those who may be unsure of how to start evolving toward an IG mindset, I would suggest walking into every glaucoma encounter asking a simple question: “What intervention am I going to recommend to this patient?” That intervention may be SLT, a procedural pharmaceutical, or a MIGS procedure, or it may be a future technology that has not yet been invented. Regardless, the important thing is that intervention becomes the starting point of the conversation rather than the last resort.

EMBRACING THE IG MINDSET

A significant opportunity for intervention is cataract patients with glaucoma. In such cases, the surgeon is already entering the eye, and adding an intervention to lower the IOP requires minimal extra effort. It doesn’t matter if the patient’s disease is well-controlled on drops; not considering combining MIGS and phaco is indefensible, especially in an era where the evidence supports the efficacy and safety of performing trabecular microbypass,2-4 ab interno viscocanaloplasty,5 and goniotomy6 at the time of cataract surgery.

More recently, data have emerged to support the use of procedural pharmaceuticals at the time of cataract surgery, demonstrating robust IOP reduction with most patients off of topical medications at 3 months of follow-up.7 Thus, if a surgeon was uncomfortable performing a trabecular bypass procedure at the time of cataract surgery, at a minimum, a travoprost intracameral implant (iDose, Glaukos) could be placed at the iridocorneal angle. With this approach, the trabecular meshwork is preserved, the medication burden is alleviated, and the patient can be referred to a glaucoma specialist for evaluation for a standalone procedure if warranted.

“Until we fully embrace the idea that proactive intervention serves patients better than chronic drop therapy, the promise of modern glaucoma care will remain unfulfilled.”

For surgeons willing to consider performing standalone MIGS (and, for the record, I think every ophthalmic surgeon managing patients with glaucoma should consider adding these procedures to their armamentarium), options abound for reducing IOP and medications, including procedural pharmaceuticals,8 trabecular microbypass,9 canaloplasty,10 goniotomy,11 endoscopic cyclophotocoagulation,12 or a combination of these methods.13 In my practice, my most frequently performed operation is likely a combination iStent Infinite (Glaukos) with iDose in a pseudophakic patient who desires drop independence or has an intolerance of drops due to dry eye.

Indeed, the evidence supporting IG is expansive and growing, so much so that those unwilling to accept the changing treatment paradigm may find themselves deselected by patients doing their own research. The truth is that patients want alternatives to drops, and IG offers a way to achieve that and offer better disease control. Once a physician truly believes that IG is the right approach for patients, every other impediment becomes manageable: Clinics can redesign workflows, staff can be trained, coding and reimbursement challenges can be solved, and new procedures can be learned.

CONCLUSION

At this point in time, the pertinent question is not, “Why should ophthalmologists embrace IG?” Instead, those not practicing with an IG mindset may wish to ask, “Why am I not yet on board with the evolving standard of care, and what is stopping me from adopting a model of glaucoma management that serves patients’ interests better than drop therapy?”

Answering the first part of that question is highly personal; however, I can address the second part by saying that implementing IG into everyday practice is a lot simpler than you may imagine. There are certainly hurdles. But in my experience, successful IG adoption begins with a philosophical commitment to intervention. Or, said another way, the primary cause of IG failure to launch is that the doctor has not owned it in their heart that IG is important. Once you embrace the mindset, no obstacle is insurmountable.

1. Newman-Casey PA, Weizer JS, Heisler M, et al. Systematic review of educational interventions to improve glaucoma medication adherence. Semin Ophthalmol. 2013;28(3):191-201.

2. Samuelson TW, Sarkisian SR Jr, Lubeck DM, et al; iStent inject Study Group. Prospective, randomized, controlled pivotal trial of an ab interno implanted trabecular micro-bypass in primary open-angle glaucoma and cataract: two-year results. Ophthalmology. 2019;126(6):811-821.

3. Singh IP, Sarkisian S, Hornbeak D, et al; iStent inject Study Group. Treatment success across different levels of preoperative disease burden: stratified two-year outcomes from the pivotal trial of iStent inject® trabecular micro-bypass in primary open-angle glaucoma and cataract. Clin Ophthalmol. 2021;15:3231-3240.

4. Richter GM, Takusagawa HL, Sit AJ, et al. Trabecular procedures combined with cataract surgery for open-angle glaucoma: a report by the American Academy of Ophthalmology. Ophthalmology. 2024;131(3):370-382.

5. Gallardo MJ. 36-Month effectiveness of ab-interno canaloplasty standalone versus combined with cataract surgery for the treatment of open-angle glaucoma. Ophthalmol Glaucoma. 2022;5(5):476-482.

6. Kuerten D, Walter P, Baumgarten S, et al. 12-month outcomes of ab interno excisional goniotomy combined with cataract surgery in primary open-angle glaucoma and normal tension glaucoma. Int Ophthalmol. 2023;43(8):2605-2612.

7. Singh IP, Voskanyan LA, Barber KM, et al. Safety and efficacy of travoprost intracameral implant administered in combination with cataract surgery. Ther Adv Ophthalmol. 2025;17:25158414241310275.

8. Teymoorian S, Kaur J, Hornbeak DM, Barr E. Twelve-month outcomes of standalone travoprost intracameral implant in glaucoma or ocular hypertension. Life (Basel). 2026;16(4):614.

9. Sarkisian Jr SR, Grover DS, Gallardo MJ, et al; iStent infinite Study Group. Effectiveness and safety of iStent infinite trabecular micro-bypass for uncontrolled glaucoma. J Glaucoma. 2023;32(1):9-18.

10. Gallardo MJ. 36-month effectiveness of ab-interno canaloplasty standalone versus combined with cataract surgery for the treatment of open-angle glaucoma. Ophthalmol Glaucoma. 2022;5(5):476-482.

11. ElMallah MK, Berdahl JP, Williamson BK, et al. Twelve-month outcomes of stand-alone excisional goniotomy in mild to severe glaucoma. Clin Ophthalmol. 2020;14:1891-1897.

12. Amaral DC, Louzada RN, Moreira PHS, et al. Combined endoscopic cyclophotocoagulation and phacoemulsification versus phacoemulsification alone in the glaucoma treatment: a systematic review and meta-analysis. Cureus. 2024;16(3):e55853.

13. Deitz GA, Patnaik JL, Young CEC, et al. Comparison of outcomes of phacoemulsification combined with endoscopic cyclophotocoagulation, iStent, or both in the management of open-angle glaucoma. Adv Ther. 2023;40(4):1444-1455.