If you look at the evolving treatment landscape in glaucoma from 30,000 feet, a few things seem obvious. The first is that selective laser trabeculoplasty (SLT) is moving into the position of primary therapy, standing on the shoulders of the prospective multicenter LiGHT trial.¹ Even this relatively straightforward change will result in dramatic adaptations from ophthalmologists a well as optometrists. To this, I would say, let the chips fall where they may, and let’s all make an effort to move toward laser first for the benefit of our patients. 

But then what are we to do if a supplemental therapy is needed after laser? To me this comes to a fundamental question. Was the LiGHT trial a study that showed how wonderful laser is? Did it show us the potential pitfalls of topical therapy? Or did it say something more profound about the value of doctor-administered interventions over self-administered drop therapy? To be clear, we don’t have all of the necessary data to answer this question, although we do know that eye-drop compliance is suboptimal in the best of hands. That said, the field of interventional glaucoma is in full blossom with no end of novel treatments in sight. Multiple new laser approaches are in clinical study or awaiting approval. We have a growing number of trabecular meshwork procedures and stents that can be used as standalone procedures, separately from cataract surgery. Options for stenting the supraciliary space have returned and are growing. And we currently have 2 FDA-approved sustained drug-delivery therapies.

It is now entirely conceivable to take a patient from initial treatment decades into the glaucoma treatment paradigm without consistently using topical therapy. In such patients, topical therapy could indeed become a “bridge therapy” that is used for short-term pressure control between interventions, an idea suggested by Dr. Ike Ahmed. 

Is the collective community of eye doctors and their patients ready for this radical paradigm shift? Almost certainly we are not, but I think we can begin making the shift. We can pay attention to compliance and preservatives and ocular surface disease and recognize when therapies other than drops could improve the patient’s quality of life and stabilize their glaucoma. I do believe that putting more effort into the use of preservative-free topical therapies will help us along this pathway. And finally, it is unlikely we would take advantage of all the wonderful interventions available to us in coming years if we are not fully taking advantage of SLT today. This is where we need to start.

As you read this issue of Glaucoma Physician and learn about some of the wonderful things coming to us in the future or arriving today, take a moment and visualize how your own algorithm will evolve in light of these advancements. 

Nathan M. Radcliffe, MD, is a clinical associate professor of ophthalmology at the New York Eye and Ear Infirmary of Mount Sinai and a surgeon at the New York Eye Surgery Center.

Reference

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial [published correction appears in Lancet. 2019;394(10192):e1]. Lancet. 2019;393(10180):1505-1516. doi:10.1016/S0140-6736(18)32213-X