Sponsored by Glaukos
Interventional glaucoma has been described as a mindset, one in which the use of procedural pharmaceuticals, MIGS, and other therapies early in the disease course is emphasized. It is a notable shift away from the historical preference of starting every patient on drops, and if they do not work as desired, to add more drops before moving to lasers and, finally, surgery as a last resort. But perhaps because the interventional approach is a new way of managing glaucoma, informing patients about its benefits may seem daunting; after all, it may seem easier to simply prescribe a topical drop and see the patient back at the next visit for follow-up.
In this exclusive, Savak Teymoorian, MD, MBA, and J. Morgan Micheletti, MD, offer perspective on why educating patients about early glaucoma intervention is important, how they describe the benefits to patients, and what key messages they communicate during clinical encounters to ensure patients understand that simply prescribing a topical medication may not be so easy or effective.
What does the term “interventional glaucoma” mean to you, and how are you using this mindset in practice?
Savak Teymoorian, MD, MBA: In essence, interventional glaucoma describes being more proactive in managing glaucoma. It's a philosophical change in the way we practice. Instead of playing not to lose—which is the older way of thinking about treatment—we’re playing to win. So, instead of waiting for there to be active optic nerve damage, or changes in the visual field, or decreases in the patient’s quality of life, we use interventional procedures with the goal of bringing down IOP before the negative impacts of the disease are experienced.
The LiGHT study was foundational in advancing the notion of using interventional procedures earlier in the treatment paradigm. It showed us that using selective laser trabeculoplasty (SLT) in newly diagnosed patients was comparable, if not better than using drops to control IOP, and that procedural interventions could potentially be disease modifying.1 And so, the LiGHT study really changed the paradigm, to the point where we want to begin treatment with SLT or procedural pharmaceuticals and use medications as a bridge between interventions. Ideally, we start the treatment-naïve patient with SLT or procedural pharmaceuticals, and if the pressure is still elevated, we can add a drop while we assess the next best option. Secondary treatments might be a combination of MIGS and cataract surgery depending on the lens status, or it might mean offering a drug delivery device like Durysta (bimatoprost intracameral implant, Allergan/AbbVie) or iDose TR (travoprost intracameral implant) 75 mcg, (Glaukos) if they were not already utilized as the first-line treatment. After we take that next step with the patient, we discontinue the drop in the interest of taking patients’ compliance out of the equation.
J. Morgan Micheletti, MD: Although eye drops can help control pressure, they require regular use, and about 80% of patients stop using their drops within 6 months because of issues like inconvenience, side effects, and/or cost.2-4 We also know that adding more drops to a regimen lowers compliance, and that medication stacking is not necessarily effective in controlling pressure.5 As well, regular use of topical therapy can lead to ocular surface toxicity.6 For these reasons, drops are often a temporary solution until a more lasting approach can be used.
Are you educating patients about interventional glaucoma (or early procedural intervention) versus specific products and procedures?
Dr. Micheletti: I do educate about early intervention. The key message I want patients to understand is that glaucoma is a serious, progressive disease that needs early and effective management to prevent vision loss. It’s important for patients to know that we have options, and they don’t need to wait until their glaucoma progresses or becomes harder to manage. By intervening early with MIGS, SLT, or procedural pharmaceuticals, we can often stabilize IOP, reduce or eliminate the need for daily drops, and ultimately preserve their vision for longer. I emphasize that these treatments are safe, effective, and can be tailored to fit their lifestyle and needs to offer a better quality of life than relying on medications.
Dr. Teymoorian: Because topical therapy has been our standard of care for so long, patients already on glaucoma medications require some re-educating. But with a treatment-naïve patient, it’s more of a cleaner slate. I still provide patients all the viable options, but I also offer my recommendation when I feel it’s best to intervene with something other than drops. Fortunately, interventional glaucoma has a plethora of options with which to individualize the approach to management, which tacitly acknowledges that every patient’s journey is going to be different. In the end, we want to empower patients to make the best decision for their own care and lifestyle. That may mean taking a little more time in the beginning to inform patients about the historical challenges with using drop therapy, but in the end, it’s worth the effort. If we tell patients ahead of time what they can expect to experience, we’re warning them, but if we tell them afterwards, we’re playing defense.
Do patients generally understand and accept this new way of managing glaucoma?
Dr. Teymoorian: Again, it’s a little bit easier with patients who are just starting their treatment journey. Many individuals have already heard about people having difficulty with drops, or maybe they’ve had prior LASIK, so they’re more open-minded about a procedural intervention. We should also remember that patients who have been on medication for 5, 10, or even 20 years may not even know there is an alternative with MIGS, SLT, and procedural pharmaceuticals.
Still, it’s natural for patients to have some fear and anxiety at the prospect of undergoing surgery. Often, people believe that topical therapy is more benign. That belief gives us clinicians an opening to discuss the costs and side effects associated with topical medical therapy and to talk about the safety profile of MIGS and other procedural options.
Dr. Micheletti: Overcoming this anxiety involves providing a clear, simple explanation of how minimally invasive these procedures are and the benefits they impart. I emphasize that treatments like MIGS or SLT are different from traditional filtering surgeries, with less risk and shorter recovery times. These options help with consistent IOP control and may not require daily topical medication, which can often lead to better outcomes and a lower likelihood of progression.
An effective way to start this conversation is by asking patients to reflect on how well they currently use or believe they will use their eye drops. This encourages honesty, and many patients become more open about their challenges with compliance when they learn that alternatives exist. Framing these procedures as a way to protect their vision long-term and maintain a high quality of life can be reassuring. Showing patients pictures or videos of the procedures helps demystify them and reduce fear, such as demonstrating how the laser for SLT resembles the equipment used in their eye exam. Ultimately, it’s about helping them understand that these procedures are not just safe, but also an important step toward preserving their vision.
1. 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.
2. Quaranta L, Novella A, Tettamanti M, et al. Adherence and persistence to medical therapy in glaucoma: an overview. Ophthalmol Ther. 2023;12(5):2227-2240.
3. Nordmann JP, Baudouin C, Renard JP, et al. Measurement of treatment compliance using a medical device for glaucoma patients associated with intraocular pressure control: a survey. Clin Ophthalmol. 2010:4:731-739.
4. Feehan M, Munger MA, Cooper DK. Adherence to glaucoma medications over 12 months in two US community pharmacy chains. J Clin Med. 2016;5(9):79.
5. Neelakantan A, Vaishnav HD, Iyer SA, Sherwood MB. Is addition of a third or fourth antiglaucoma medication effective? J Glaucoma. 2004;13(2):130-136.
6. Baudouin C, Renard J-P, Nordmann J-P, et al. Prevalence and risk factors for ocular surface disease among patients treated over the long term for glaucoma or ocular hypertension. Eur J Ophthalmol. 2012;23(1):47-54.
