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Rethinking the glaucoma visit: why the psychology of care matters as much as IOP

By Savak Teymoorian, MD, MBA

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Ophthalmology 360.

When I share with a patient that they have glaucoma, they usually experience a moment of disbelief. The patient may nod in understanding, but the information I share with them at that time doesn’t fully land. They are wondering what the diagnosis means for driving and their independence, worrying about possible blindness, or simply trying not to show the fear they feel.

One reality of glaucoma care we don’t talk about enough is its psychological burden. Studies show approximately 40% of patients diagnosed with glaucoma experience clinically significant anxiety, and nearly 35% screen positive for depression.¹ These rates far exceed those in the general population.

Glaucoma’s psychological burden appears from the moment of diagnosis and is independent of disease severity,² suggesting the uncertain prognosis, chronicity of disease, and fear of vision loss drives distress more than the extent of visual field loss. Understanding how the patient feels at the moment of their diagnosis is not merely an empathy exercise. It has direct implications for treatment success.

Two out of 3 patients who are prescribed topical intraocular pressure (IOP)-lowering drops will be lost to follow-up. About 90% don’t adhere to their drop schedule, and even those who do are at a 50% risk of completely stopping their drops within 6 months of first use.^3-5 Side effects, difficulty of drop instillation, regimen complexity, forgetfulness, lack of motivation, quality-of-life issues like ocular surface disease, and cost are frequently to blame.^6-12

These numbers are clinically consequential. Glaucoma is a disease that progresses silently and irreversibly, and uncontrolled IOP is its most modifiable risk factor. When drops fail in practice, the window for preserving functional vision narrows. The loss-to-follow-up data compound this further: Patients who disengage from care are at the highest risk for incident blindness.¹² We don’t view the failure of topical therapy as an administrative inconvenience but as a pathway to preventable vision loss. If we continue to default to a delivery system that most patients cannot or will not maintain long-term, we are accepting those outcomes as inevitable when they are not.

Framing the Conversation

If you ask a patient if they are doing okay with their drops, chances are they will answer yes. Even the most noncompliant patient wants to please their doctor. A better approach is to ask: “What difficulty are you having with your drops?” The fundamental difference in framing acknowledges that barriers exist, and it invites a patient to name them without shame.

Failing to maintain a drop regimen is not a character flaw. It is a predictable human response to a chronic, invisible, asymptomatic disease that requires daily and indefinite behavioral commitment. IOP-lowering medication works, but the delivery system is often where we lose the battle. In the long run, helping our patients feel less guilty about their lack of adherence and presenting them with options that take the treatment burden out of their hands ultimately leads to better patient care and long-term outcomes.

Starting an Interventional Practice

I finished fellowship in 2012 with essentially no training in interventional glaucoma (IG). The technology existed, but it wasn’t used widely and therefore rarely discussed. My experience lends to understanding firsthand the hesitation that many ophthalmologists feel about IG, particularly those who have been in practice for decades under a drops-first paradigm.

My conversion to an interventional approach was practical rather than ideological. I had a patient whose branded prostaglandin analog was denied by prior authorization. Instead of fighting the insurer, I asked myself: Why not just treat the patient with selective laser trabeculoplasty (SLT)? The landmark LiGHT trial demonstrated that SLT as first-line therapy achieved target IOP at more visits than drops and kept nearly 75% of patients medication-free at 3 years.¹³ A subsequent 6-year follow-up showed that almost 70% remained at target without additional medication or surgery.¹⁴ It also showed SLT slowed visual field progression by 29% compared with drops.

For colleagues who may be skeptical of IG, my advice is simple: Start with a procedural intervention such as SLT. The long-term evidence is compelling,^13,14 the procedure is accessible, and the patient response is immediate. When a patient comes back after SLT and their IOP is controlled without drops, their eyes are not red, and they look at you without the quiet anxiety of a chronic disease patient, you begin to understand what an interventional approach can do. From there, adding 1 tool at a time becomes a natural progression.

Building Momentum

One of the most meaningful additions to my treatment algorithm has been procedural pharmaceuticals. Treatments like travoprost intracameral implant (iDose TR, Glaukos) and bimatoprost intracameral implant 10 mcg (Durysta, AbbVie) deliver continuous therapy from inside the eye without asking the patient to do anything.

The pivotal phase 3 trials (GC-010 and GC-012) demonstrated that a single iDose TR administration achieved noninferiority to twice-daily topical timolol through 3 months.¹⁵ The treatment maintained favorable safety and tolerability profiles through 12 months. Phase 2b data showed sustained mean IOP reductions of 7.3 to 8.0 mmHg through 36 months following a single implantation, and the medication burden was substantially reduced.¹⁶

Phase 3 data further validated the findings. In the pivotal GC-010 trial, iDose TR achieved its primary noninferiority endpoint versus timolol through 3 months and demonstrated statistically superior IOP-lowering of 1.3 mmHg compared with patients’ pretrial prostaglandin analog therapy.¹⁵ Twelve-month phase 3 data confirmed a durable and well-tolerated IOP-lowering profile with no new safety signals emerging over the full year of follow-up.

Real-world data have been similarly encouraging. In our early outcomes study, mean IOP decreased by 33.2%, from 19.6±3.8 mmHg preoperatively to 13.1±2.5 mmHg at 3 months postoperatively (P=0.001). Most eyes (83.3%) achieved an IOP of 15 mmHg or better compared with 11.1% at baseline, and 100% reduced their use of adjunctive medication (P=0.006).¹⁷

Procedural pharmaceuticals are particularly valuable for pseudophakic patients with ocular hypertension or mild-to-moderate glaucoma. These patients have experienced intraocular surgery in the past, are familiar with procedural care, and often have Medicare with supplemental coverage that addresses the cost differential. We recently expanded to both commercial insurance and Medicare Advantage. Especially if they have struggled with drops for years, a procedural pharmaceutical like iDose TR removes the compliance variable entirely.

When I introduce this therapy to a patient, I say something like, “Mrs. Smith, I heard you’ve been having some irritation with your eye drops. I have a different way to deliver the same medication that I think you’d do well with.” Planting the seed before the exam gives them time to think about what a life without drops may be like. By the time I sit down to explain what an intracameral implant is, the patient is already receptive because I’ve connected a solution to their specific problem.

Completing the Toolbox and Personalizing the Journey

My standard approach begins with SLT for newly diagnosed patients. If the response is sustained, I monitor. If it wanes, I consider repeating SLT or using a procedural pharmaceutical such as iDose TR or Durysta. When cataract surgery becomes indicated, I routinely discuss a concurrent minimally invasive glaucoma surgery (MIGS) procedure such as a trabecular microbypass or an angle-based device.

I tailor the procedure to each patient’s IOP target, anatomy, and disease stage. Glaucoma is not a cookie-cutter disease, and 2 patients with the same diagnosis, visual field loss, and IOP may have entirely different journeys based on their age, access to care, tolerance for office visits, insurance status, and, frankly, their psychological relationship with the disease. The value of having multiple tools, including SLT, procedural pharmaceuticals, MIGS, and topical drops as a bridge or adjunct, is that I can meet each patient exactly where they are.

Monitoring disease progression is essential not only for clinical decision-making but also for patient engagement. Therefore, visual fields are completed at every appropriate visit. Patients who see their own data and understand what we’re tracking and why become partners in their care rather than passive recipients of treatment.

Rethinking Success

A glaucoma encounter used to be defined by IOP. Now with IG, we can influence behavior change. Rather than asking patients to remember their drops daily and come back for monitoring when their eyes “feel fine,” we can remove barriers to compliance with earlier procedural intervention.

When we ask patients better questions, acknowledge compliance is hard, and offer solutions that don’t depend on adherence, patient satisfaction increases. Happy glaucoma patients are not a trivial outcome. They come back, they follow up, and they refer others.

Savak Teymoorian, MD, MBA, is a cataract and interventional glaucoma surgeon at Harvard Eye Associates in Laguna Hills, San Clemente, and Orange County, California. Dr. Teymoorian is a speaker, researcher, and consultant for Glaukos and AbbVie. He can be reached at [email protected].

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