An interventional approach to glaucoma management emphasizes early, targeted procedural solutions over traditional medication escalation. This strategy aims to enhance long-term IOP control, reduce treatment burdens, and potentially slow disease progression. Procedures such as selective laser trabeculoplasty (SLT), procedural pharmaceuticals systems, and MIGS devices, when integrated into early management, may help delay or avoid reliance on multiple medications, thereby enhancing patients’ quality of life. Certain procedural interventions may achieve more stable 24-hour IOP control than extended pharmacotherapy, particularly when topical medication regimens expand to three or more agents.1-3
THE FIVE PILLARS OF INTERVENTIONAL GLAUCOMA
Interventional glaucoma (IG) is founded on five core principles that emphasize the importance of proactive management to prevent glaucoma progression:
No. 1: Proactive versus reactive care. Adopting a proactive mindset to stabilize IOP and address compliance and adherence, often by employing earlier procedural intervention before visual field progression and higher disease burden.
No. 2: Early predictive diagnostics. Risk stratification and early identification of high-risk patients allow for timely procedural interventions, targeting those who would benefit most from early treatment.
No. 3: Active monitoring. Continuous assessment of disease progression and patient adherence to medical therapy helps ensure timely adjustments to treatment plans.
No. 4: Early procedural intervention. Prioritizing interventions like procedural pharmaceuticals, SLT, and MIGS early in the treatment course is preferred over escalating medication regimens, which can be associated with compliance issues.
No. 5: Adherence and risk management. By minimizing barriers to treatment adherence—such as complex medication regimens and side effects—clinicians may improve patient quality of life and reduce the risk of disease progression.
RETHINKING THE CONVENTIONAL TREATMENT PATHWAY
The conventional glaucoma management pathway, which typically begins with a single or multiple topical agents before escalating to laser and procedural interventions, faces significant challenges due to poor medication adherence4 and disease progression despite therapy.5 Studies demonstrate that early intervention can slow disease progression more effectively than a medication-first approach.6,7 Although topical medications remain the most common treatment modality, representing around 80% of glaucoma management,8 adherence rates are concerningly low. According to a retrospective cohort study, approximately 50% of patients actively discontinue all topical glaucoma medications within 6 months, and only 37% refill their original prescription 3 years after initiation.4
EVOLVING PRACTICE TRENDS
The 2024 Interventional Glaucoma Survey by Market Scope revealed a slight shift in preferences, with more clinicians favoring SLT as a first-line treatment (20.6% in 2024 vs. 18.7% in 2023).9 Over half of clinicians (53.3%) remain cautious, opting to monitor and increase medications before considering surgery. The survey also indicates that visual field progression (46.3%) and lack of IOP control (34.1%) are the primary triggers for moving beyond medical management to procedural solutions. These findings may make us consider where the role of IG fits in the glaucoma paradigm.
Topical drops are associated with significant compliance barriers. The survey showed that efficacy ranked low among the perceived benefits (8.4%), reflecting dissatisfaction with their long-term impact. Side effects such as hyperemia, ocular surface disease, and periorbital changes further diminish quality of life, highlighting the need to minimize medication use.
THE ROLE OF CLINICIANS
To successfully implement the IG model, clinicians must take the following multifaceted approach:
- Master IG principles and procedural options. A deep understanding of early interventions like SLT and MIGS is crucial for incorporating these procedures into practice.
- Adapt practice patterns for early intervention. Transitioning from a medication-first model to an interventional model requires rethinking approaches to glaucoma management and restructuring workflow and practices, including comanagement.
- Educate peers, hospital staff, and patients. Increasing awareness of the benefits of early procedural intervention among both patients and colleagues can be helpful for broader adoption of the IG model.
By embracing these principles, clinicians can lead the shift toward a more proactive approach to glaucoma care, improving patient outcomes and reducing the burden of disease progression. Finally, although IG has an evolving role in glaucoma management, it is important that no single solution applies to all. We must develop a clearer understanding of how to choose wisely—determining who, when, and how to intervene—by selecting the best therapy for each patient at the appropriate stage of their glaucoma journey.
1. Konstas AGP, Quaranta L, Bozkurt B, et al. 24-h efficacy of glaucoma treatment options. Adv Ther. 2016;33(4):481-517.
2. 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.
3. Bedrood S, Berdahl J, Sheybani A, Singh IP. Alternatives to topical glaucoma medication for glaucoma management. Clin Ophthalmol. 2023;17:3899-3913.
4. 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.
5. Malihi M, Moura Filho ER, Hodge DO, Sit AJ. Long-term trends in glaucoma-related blindness in Olmsted County, Minnesota. Ophthalmology. 2014;121(1):134-141.
6. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. 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.
7. Musch DC, Gillespie BW, Lichter PR, Niziol LM, Janz NK; CIGTS Study Investigators. Visual field progression in the Collaborative Initial Glaucoma Treatment Study: the impact of treatment and other baseline factors. Ophthalmology. 2009;116(2):200-207.
8. 2024 Glaucoma Surgical Device Market Report: Global Analysis for 2023 to 2029. Market Scope. August 2024. Accessed November 5, 2024. https://www.market-scope.com/pages/reports/456/2024-glaucoma-surgical-device-market-report-global-analysis-for-2023-to-2029-august-2024
9. Interventional Glaucoma Survey. Market Scope. Q1 2024. Licensed to Glaukos Corporation.
INDICATIONS FOR USE: The iStent® Trabecular Micro-Bypass System is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent® Trabecular Micro-Bypass Stent is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: For prescription use only. This device has not been studied in patients with uveitic glaucoma. Do not use the devices if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. iStent is MR-Conditional. Physician training by Glaukos personnel is required prior to use of this device. Do not re-use the stent(s) or inserter, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events. There are no known compatibility issues with the iStent and other intraoperative devices (e.g., viscoelastics) or glaucoma medications. Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and infected products must be disposed of as medical waste.
INDICATIONS FOR USE: The iStent inject® is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject® can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent inject® System is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: • For prescription use only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the devices if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent inject® is MR-Conditional; see MRI Information below. • Physician training is required prior to use of the iStent inject® System. • Do not re-use the stent(s) or inserter, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events as shown below under “Potential Complications.” • There are no known compatibility issues with the iStent inject® and other intraoperative devices (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminated products must be disposed of as medical waste. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure.
INDICATION FOR USE: The iStent inject® W, is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject® W, can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent inject® W System is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations. • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: • For prescription use only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the device if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e. the insertion sleeve
and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent inject® W is MR-Conditional; see MRI Information below. • Physician training is required prior to use of the iStent inject® W System. • Do not re-use the stent(s) or injector, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events as shown below under “Potential Complications.” • There are no known compatibility issues with the iStent inject® W and other intraoperative devices. (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminated products must be disposed of as medical waste. • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure. • Patients should be informed that placement of the stents, without concomitant cataract surgery in phakic patients, can enhance the formation or progression of cataract. ADVERSE EVENTS: Please refer to Directions For Use for additional adverse event information. CAUTION: Please reference the Directions For Use labelling for a complete list of contraindications, warnings and adverse events.
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