Interventional Glaucoma
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Introduction
One of the most significant and recent developments in the glaucoma field has been the advent of interventional glaucoma. Interventional glaucoma refers to the management of glaucoma by using procedures early to lower intraocular pressure (IOP).[1] This paradigm shift involves proactive rather than reactive intervention to address glaucoma earlier in the disease process, including in both standalone and combination-cataract settings. Conventionally, glaucoma treatment has followed a stepwise strategy beginning with medical therapy and progressing to surgery only when necessary.[2][3] However, this approach has shown several limitations, including patient adherence, ocular surface toxicity, and decreased quality of life.[4] In response to these challenges, surgical procedures that lower IOP, such as selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS), have emerged.[5] These procedures have allowed ophthalmologists to reduce both disease progression and dependence on chronic therapy.
By intervening earlier with minimally invasive surgical, laser, or drug-delivery treatments instead of prolonged topical medications, interventional glaucoma aims to take the burden of medication compliance off the patient. It also allows for standalone surgical interventions rather than letting cataract surgery dictate the glaucoma treatment plan. This article discusses the current and evolving landscape of interventional glaucoma and offers a structured framework for applying its principles in clinical practice.
Rationale for Early Procedural Intervention
Historical Basis for Conventional Glaucoma Management
Traditionally, incisional surgeries for glaucoma were strongly associated a high risk of postoperative complications, including endophthalmitis and conjunctival hemorrhage.[6] Furthermore, the capacity of trabeculectomy, tube shunt implants, and the EX-PRESS shunt in reducing IOP was found to decrease over time, resulting in re-operation rates of 15.1%, 14.0%, and 18.3%, respectively.[7][8][9] As a result, the management of glaucoma depended heavily on topical medications to control IOP. This approach was reinforced by the effectiveness of medications in lowering IOP and be administered in small increments over time.[10] Collectively, these factors contributed to a treatment paradigm in which medical therapy was prioritized and surgical intervention was reserved for later stages of disease.
Limitations of Glaucoma Management Associated with Medications
Adherence Challenges
Ocular Surface Toxicity
Delayed Escalation
Role of Procedures
LiGHT Trial
MIGS
Cataract Surgery
First-Line Treatment Options
Considerations That May Influence First-Line Treatment Option Choice
Severity of Disease and Target IOP
Patient Adherence With Topical Eyedrops
Ocular Surface Status
Deciding Between SLT and Topical Medications as the Initial Treatment
Escalation beyond Initial Therapy
Clinical Triggers for Escalation
Failure to Reach Target IOP
Documented Progression of Glaucoma
Intolerance That May Limit Adherence
Management Pathways
Repeat SLT
Additional Medications
MIGS
Additional Resources
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References
- ↑ De Francesco T, Bacharach J, Smith O, Shah M. Early diagnostics and interventional glaucoma. Ther Adv Ophthalmol. 2024;16:25158414241287431. doi:10.1177/25158414241287431
- ↑ Gillmann K, Baudouin C, Masood I, et al. A Systematic and Narrative Review of Safety and Complications in Minimally Invasive Glaucoma Surgery (MIGS) Between 2014–2024. Clin Ophthalmol. 2026;20:564425. doi:10.2147/OPTH.S564425
- ↑ Bedrood S, Berdahl J, Sheybani A, Singh IP. Alternatives to Topical Glaucoma Medication for Glaucoma Management. Clin Ophthalmol. 2023;17:3899-3913. doi:10.2147/OPTH.S439457
- ↑ 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. doi:10.1007/s40123-023-00831-9
- ↑ Richter GM, Coleman AL. Minimally invasive glaucoma surgery: current status and future prospects. Clin Ophthalmol. 2016;10:189-206. doi:10.2147/OPTH.S80490
- ↑ Wagner IV, Stewart MW, Dorairaj SK. Updates on the Diagnosis and Management of Glaucoma. Mayo Clin Proc Innov Qual Outcomes. 2022;6(6):618-635. doi:10.1016/j.mayocpiqo.2022.09.007
- ↑ Gedde SJ, Herndon LW, Brandt JD, et al. Postoperative complications in the Tube Versus Trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol. 2012;153(5):804-814.e1. doi:10.1016/j.ajo.2011.10.024
- ↑ Lee DA, Higginbotham EJ. Glaucoma and its treatment: a review. Am J Health Syst Pharm. 2005;62(7):691-699. doi:10.1093/ajhp/62.7.691
- ↑ Craven ER, Singh IP, Yu TM, Rhoten S, Sadruddin OR, Sheybani A. Reoperation Rates and Disease Costs for Primary Open-Angle Glaucoma Patients in the United States Treated with Incisional Glaucoma Surgery. Ophthalmol Glaucoma. 2022;5(3):297-305. doi:10.1016/j.ogla.2021.10.011
- ↑ Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701-713; discussion 829-830. doi:10.1001/archopht.120.6.701
