The Why and the How of Adopting Interventional Glaucoma

Welcome to the inaugural installment of Interventional Glaucoma Business Matters, a series dedicated to exploring the economics of procedural interventions, practice development and management issues, and coding and billing topics related to interventional glaucoma (IG).

The IG concept was arguably first introduced in the published literature in 2023,1 although the idea that “glaucoma is a disease best treated surgically” has circulated for far longer. However, in the past, when ophthalmologists considered surgical interventions for managing glaucoma, they were thinking about when to intervene with a trabeculectomy or glaucoma drainage device (tube shunt). More often than not, because of the risk of failure or complications, trabs and tubes were deemed appropriate for end-stage disease, a last-ditch effort to thwart the threat of vision loss. Thus, the mindset to manage glaucoma procedurally may have existed in some shape or form, but the tools to realize that ideal were too limited to make it feasible.

What a decidedly different worldview we have today now that a wide variety of minimally invasive (read: safer) lasers, devices, and surgical procedures have become available for clinical use over the past decade-plus. This revolution in glaucoma procedural offerings has, in turn, fostered an evolution in how the insidious “silent thief of sight” is managed in everyday practice. We are, quite literally, witnessing a shift in mindset in real time when it comes to glaucoma treatment, as the field moves from a reactive stance (waiting for disease to progress before intervening) to a proactive approach in which procedures (lasers, devices, and surgeries) are favored early in the treatment paradigm.

A primary driver of the IG evolution is the fact that we’ve known for years that traditional pharmaceutical management, while effective, is not an ideal long-term solution for patients. In short, patients’ compliance with topical drop therapy is inadequate to sustainably maintain the target pressure, preserve the health of the optic nerve, and, ultimately, save vision.2 Moreover, poor adherence to medical therapy may be a harbinger of lapses in clinical follow-up. In a recent analysis of 27 practices encompassing 253 providers and 193,711 patient visits, patients whose glaucoma was managed with topical drops were 2.1 times more likely to miss follow-up appointments than those whose disease was managed surgically.3 In the analysis, 62% of patients were lost to follow-up for 3 years or longer. Importantly, other studies have shown that the risk of developing blindness in at least one eye is 2.17 times higher among patients lost to follow-up for a minimum of 3 years.4

While we have been able to identify the problem with traditional pharmaceutical management, historically, we have not had an adequate solution for taking control of the disease out of patients’ hands. But this is ultimately what makes IG such an exciting concept: It is a patient-centered glaucoma management paradigm in which patients are afforded a better chance of preserving their vision, and one in which providers can strive to modify the disease trajectory such that trabs and tubes may never be necessary. Removing the onerous task of instilling drops according to a complicated schedule is one obvious benefit; less appreciated, but equally as important, is the fact that procedural management appears to be superior to drops in providing long-term disease control, in reducing the need for incisional surgical intervention, and in preserving the visual field.5,6

Several authors have addressed the question of “why adopt IG?”7-9 Perhaps more daunting is the issue of how to start moving toward an IG mindset. Admittedly, it is overwhelming to view the entirety of the procedural glaucoma treatment landscape all at once when deciding where to start. We hope IG Business Matters can start to fill this implementation gap. To our great fortune, and to the benefit of patients, our industry partners have brought forth a plethora of lasers, surgeries, devices, and sustained-release drug delivery options; yet, if there is a shortcoming of having so many options, it is the potential for analysis paralysis in deciding which one is the most appropriate for the patient in front of us.

Perhaps, though, adopting IG can be simpler, because it all starts with a shift in mindset. As the authors in this publication highlight, the belief that interventions modify the architecture of the angle and alter the pathophysiology of glaucoma is fundamental to success in this evolving treatment paradigm. Because, in truth, we may not appreciate the effects of an intervention until years later. Unlike most forms of surgery, there is no immediate feedback after, say, a standalone MIGS procedure. The postoperative pressure may be equivalent to preoperative pressure readings, and yet, the surgeon must be confident that intervening has limited the potential for progression.

Many surgeons resist getting outside their comfort zone, and understandably so. After all, we are creatures of habit. We strive to perfect our techniques and routines in the OR so as to control the multiple variables that dictate success or failure. But if the data point us to a new direction—and certainly the emerging data on IG suggest it is an evidence-based approach that helps patients avoid confronting a reality in which they lose their vision—then we must be willing to unlearn old habits. First and foremost, IG represents a better way to mitigate the potential for glaucomatous progression. Its benefits for practice efficiency and revenue further support the rationale for changing ingrained practice patterns.

1. Radcliffe NM, Shah M, Samuelson TW. Challenging the "topical medications-first" approach to glaucoma: a treatment paradigm in evolution. Ophthalmol Ther. 2023;12(6):2823-2839.

2. Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606.

3. Data on file, Glaukos Corporation.

4. Williams AM, Wasser LM, Cassidy J, Lin HS. Loss to follow up among glaucoma patients: an IRIS® Registry (Intelligent Research in Sight) retrospective cohort analysis. Semin Ophthalmol. 2025;40(3):188-195.

5. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151.

6. Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual field outcomes of the HORIZON Trial. Am J Ophthalmol. 2023;251:143-155.

7. Bedrood S, Berdahl J, Sheybani A, Singh IP. Alternatives to topical glaucoma medication for glaucoma management. Clin Ophthalmol. 2023;17:3899-3913.

8. Gallardo M, Smith O, Trubnik V, Reiss G. Interventional glaucoma and the patient perspective. Exp Rev Ophthalmol. 2024;19(5):311-318.

9. Micheletti JM, Shultz M, Singh IP, Samuelson TW. An emerging multi-mechanism and multi-modal approach in interventional glaucoma therapy. Ophthalmol Ther. 2025;14(1):13-22.