Embracing the proactive approach of interventional glaucoma

This treatment approach involves proactive rather than reactive glaucoma intervention earlier in the disease.

One of the most impactful recent developments in the glaucoma community is the concept and paradigm shift toward interventional glaucoma (IG), according to J. Morgan Micheletti, MD, FACS, a board-certified ophthalmologist, partner, director of research, and fellowship director at Berkeley Eye Center, and coauthor of a recent paper on the topic published in The Journal of Cataract and Refractive Surgery.¹

“The shift is toward a more proactive approach in glaucoma care. Historically, the paradigm has been reactive, adding treatments as disease progression is noted,” he said. “Now, we are moving toward earlier intervention with minimally invasive procedures and procedural pharmaceuticals to better control intraocular pressure (IOP), improve patient adherence, and reduce the risks associated with disease progression. By doing so, we can lessen or eliminate the burden of daily drops and ultimately provide a safer, more comprehensive approach to glaucoma management.”

Benefits of Early Procedural Intervention

Using procedures as first-line treatments—such as microinvasive glaucoma surgery (MIGS), selective laser trabeculoplasty (SLT), or procedural pharmaceuticals—can offer multiple benefits over topical medication alone. “Most notably, it addresses issues like patient adherence, side effects, and fluctuations in IOP often seen with drop therapy,” Dr. Micheletti said.

Medication drops are commonly used as a bridge, but it is estimated that about 50% of patients discontinue their use within 6 months.² Additional research has demonstrated that compliance declines significantly when more than 1 medication is prescribed, and this is problematic because 40% to 75% of patients with glaucoma are prescribed 2 or more medications.^3,4

Dr. Micheletti noted, “By intervening earlier with these procedures, we can likely maintain consistent pressure control and potentially prevent irreversible vision loss, which is critical since glaucoma damage cannot be restored. This proactive approach not only strives to well control disease progression but also simplifies treatment, improves the patient’s quality of life, and mitigates long-term medication costs.”

Standalone MIGS Use

This approach also allows for standalone procedural interventions rather than letting cataract surgery dictate the glaucoma treatment plan. The first US Food and Drug Administration (FDA)-approved trabecular micro-bypass device (iStent, Glaukos) was developed for use in conjunction with cataract surgery. Other MIGS devices followed the same path. In 2022, standalone trabecular bypass became available when the FDA cleared the iStent infinite® for patients who failed prior surgical and medical therapy.¹

In the past, MIGS has often been performed in conjunction with cataract surgery, but it is equally effective as a standalone intervention for glaucoma control as a growing body of research has shown, according to Dr. Micheletti.

“It’s crucial for MIGS to be accepted as a standalone surgery because it allows for more flexible treatment options. Having MIGS as a standalone option means patients with glaucoma who don’t have cataracts or have already undergone cataract surgery can still benefit from minimally invasive treatment. This widens the treatment window for patients and provides an opportunity to intervene early in the disease course, leading to better IOP management and potentially preventing progression,” he said.

The increasing diversity and availability of effective minimally invasive treatment options have made this interventional mindset possible. With these options as a springboard, it is time to reevaluate and advance the traditional glaucoma treatment paradigm, he added. 

Dr. Micheletti and his coauthors¹ emphasize that glaucoma treatment is a continuum, with no single therapy being the answer for all patients. “SLT is an excellent option as a first-line therapy, and there is certainly a role for different approaches depending on the patient’s case. SLT is non-invasive, quick, and effective, often described as ‘reopening the eye’s drainage system’ to improve fluid flow,” Dr. Micheletti explained. “It’s also repeatable, which makes it a versatile option for early intervention. While some patients may benefit more from a surgical procedure like MIGS or a procedural pharmaceutical, others may prefer or respond better to laser therapy like SLT. The key is individualizing treatment based on patient preferences, disease stage, and the goal of maintaining IOP control with minimal side effects or medication burden.”

Implantable Medication Devices

Procedural pharmaceuticals, such as bimatoprost intracameral implant (DURYSTA®, Allergan/Abbvie) and the sustained release travoprost implant (iDose® TR [travoprost intracameral implant] 75 mcg, Glaukos) are essential components of this paradigm shift. Dr. Micheletti points out that these implantable devices deliver medication consistently over time, overcoming one of the major barriers to effective glaucoma treatment—patient adherence.

“By providing continuous drug delivery directly within the eye, they maintain stable IOP and remove the challenges associated with daily eye drop use. This sustained approach fits well into the IG model and provides long-term control with minimal patient burden,” he explained.

A recent review article by Kamat et al⁵ in the Journal of Clinical and Experimental Ophthalmology concluded that procedural pharmaceuticals, which have been developed to overcome the physical barrier of the ocular surface by bypassing the cornea and conjunctival tissues for intraocular delivery, have demonstrated durable IOP-lowering effects with favorable safety and varying key distinguishing characteristics.

These drug delivery systems are designed to continuously provide therapeutic concentrations of medication to the target tissues, and they have

the potential to occupy an important position in the ophthalmologists’ armamentarium for treating glaucoma and ocular hypertension, including at earlier stages in the treatment journey, the researchers reported.

Additionally, they noted that although topical ocular medications have been considered first-line therapies for glaucoma and ocular hypertension, long-term therapy with topical medications can adversely impact the ocular surface and be difficult for patients to tolerate. Other noted disadvantages include significant cost and patient compliance issues due to multiple drop therapy, resulting in adversely affecting patient quality of life.^6-8

Conclusion

Dr. Micheletti is developing a novel microgoniotomy device to enhance minimally invasive options for IOP control, particularly one suited for surgeons new to MIGS or just becoming comfortable with angle-based procedures.

“It’s truly an exciting time in the glaucoma world, as these innovations bring renewed possibilities for safer, more effective, and personalized treatment options, greatly expanding our ability to provide tailored care to our patients,” Dr. Micheletti concluded.

References

1. Micheletti JM, Brink M, Brubaker JW, Ristvedt D, Sarkisian SR. Standalone interventional glaucoma: an evolution from the combination-cataract paradigm. J Cataract Refract Surg. 2024. doi:10.1097/j.jcrs.0000000000001537
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. doi:10.1016/j.ajo.2005.04.051
3. Robin AL, Covert D. Does adjunctive glaucoma therapy affect adherence to the initial primary therapy? Ophthalmology. 2005;112(5):863-868. doi:10.1016/j.ophtha.2004.12.026
4. Saini SD, Schoenfeld P, Kaulback K, Dubinsky MC. Effect of medication dosing frequency on adherence in chronic diseases. Am J Manag Care. 2009;15(6):e22-e33.
5. Kamat S, Baudouin C, Shah M, Radcliffe N. Long-term chronic drop therapy vs. intracameral procedural pharmaceuticals for glaucoma: what does the evidence support? J Clin Exp Ophthal. 2024;15(5):986.
6. Nordmann JP, Auzanneau N, Ricard S, Berdeaux G. Vision related quality of life and topical glaucoma treatment side effects. Health Qual Life Outcomes. 2003;1:75. doi:10.1186/1477-7525-1-75
7. Stalmans I, Lemij H, Clarke J, Baudouin C; GOAL study group. Signs and symptoms of ocular surface disease: the reasons for patient dissatisfaction with glaucoma treatments. Clin Ophthalmol. 2020;14:3675-3680. doi:10.2147/OPTH.S269586
8. Samuelson TW, Singh IP, Williamson BK, et al. Quality of life in primary open-angle glaucoma and cataract: an analysis of VFQ-25 and OSDI from the iStent inject® pivotal trial. Am J Ophthalmol. 2021;229:220-229. doi:10.1016/j.ajo.2021.03.007