Glaucoma specialists are increasingly turning to interventional strategies—laser, MIGS, and sustained-release pharmaceuticals—as first-line options for managing early stage disease. In February, a group of 10 experienced surgeons published an Interventional Glaucoma Consensus Treatment Protocol, which offers a structured, stage-specific treatment framework grounded in this proactive approach. By prioritizing procedures over topical drops, the protocol reflects a growing commitment to durable IOP control and long-term visual preservation through earlier intervention.

Two of the protocol’s authors are Christine Funke, MD, of the Barnet Dulaney Perkins Eye Center in Scottsdale, Arizona, and Deborah Ristvedt, DO, of Vance Thompson Vision in Alexandria, Minnesota. They recently spoke with Glaucoma Physician about interventional glaucoma (IG). In our conversation, which has been edited for length and clarity, they discuss how the IG protocol was developed, suggested strategies for implementation in clinics and surgical centers, and reflected on what IG will mean for glaucoma management moving forward.

GP: How did the Interventional Glaucoma Consensus Group come together? 

Dr. Funke: This started with a group of physicians who were looking at their individual practices to share ideas about glaucoma management, and specifically interventional glaucoma (IG). That group was selected through Glaukos.

We had a day-long meeting to discuss how we each dealt with glaucoma. When they said they wanted to see if we could come to a consensus on IG, I think everyone laughed. But as we discussed what things were important and not important and how we like to treat people, that helped us see that consensus wasn’t going to be as complicated as we thought coming in. Within a few hours, we were able to agree on how most primary open-angle glaucoma (POAG) patients should be treated in an ideal scenario. For the most part, it was a pretty simple algorithm. That’s how that was born. It was a fun group to be part of, to say the least.

Dr. Ristvedt: This has been the best journey of my career, honestly. I started in 2011 as a third-generation ophthalmologist, and at that time, I strongly felt that we needed to do better. Over time, by really investing in and learning the surgical approach to glaucoma, I found ways that I believed in to treat patients. It was great to collaborate with like-minded individuals on the IG protocol. Members of this group can see where we need to go with treatment. Everyone is passionate about educating others because we know it is the right thing for patient care.

GP: In your view, what has slowed adoption of interventional care, and how can this protocol change that?

Dr. Funke: Change takes time, and I think physicians are a little slower than the average person when it comes to adopting change. Interventional glaucoma is a large shift, so the idea of asking everyone to shift their entire dogmatic style of glaucoma treatment is a big task. As more data become available, more people will become comfortable with IG.

We’ve never had consensus in glaucoma on how we want to treat disease. One of the reasons we need a protocol is so people can feel like they’re going with what the majority has decided is a good approach.

GP: How can a proactive approach help preserve vision before significant damage occurs?

Dr. Ristvedt: We understand the pathophysiology at the level of the trabecular meshwork, and know that most of our resistance lies there. What we’re seeing in interventional glaucoma is that the earlier you intervene, the more likely we are to restore and revitalize that natural outflow pathway. 

Drops cause long-term effects, like periorbital atrophy and ocular surface disease. These side effects can lead to poor quality of life because patients aren’t seeing as well due to fluctuating vision. It’s not that drops don’t work; it’s just that when we look at how they’re being used, compliance is down because not everyone remembers 100% of the time to take their medication or drops. Also, half of our patients stop drops because they don’t understand the impact of glaucoma down the road. They don’t have visual field loss now, but if they don’t stay controlled, it could lead to blindness. That’s what’s so sad—when you see patients come in with extreme visual field loss because they just stopped taking their medication.

GP: What key messages should glaucoma specialists be communicating to patients when recommending treatment early in the disease course? 

Dr. Funke: When I see patients—or even when I’m talking to colleagues—I stress that glaucoma, if managed early with interventional procedures, offers a real opportunity to preserve healthy tissue, especially the trabecular meshwork and angle-based structures. These tissues still have potential to heal. That’s why selective laser trabeculoplasty (SLT) works so well, and why MIGS work so well—particularly in patients with mild or early disease, like ocular hypertensives or those who haven’t yet started medications. If we manage glaucoma early, we’re much more likely to preserve visual field and avoid big, traditional filtering surgeries down the line.

Interventional glaucoma is really about proactive care—trying to heal what’s been damaged but not yet destroyed. If we wait too long, fibrotic scar tissue forms, and you can’t reverse that. This is consistent across the studies—IOP reduction is more successful in earlier disease, especially when we’re targeting the angle.

Dr. Ristvedt: I’ve found that educating our optometric referral network is crucial because that’s often where these patients are starting. It’s been fun to work together in a collaborative effort to prevent blindness from glaucoma. I take pride in building those relationships. Now, when patients are referred to our practice, they usually arrive saying, “My optometrist said I have glaucoma, and that you have a procedure that can help me. I’m excited!” The optometrist plants that seed.

As a physician, you never want to tell a patient, “This is what you have to do.” You need to find the right language that eases their fears. When you use the word “laser,” it can sound like you’re burning tissue, so I don’t use the word “laser.” I call it “light therapy,” and explain that it opens channels in the outflow pathway to lower IOP and limit the progression of their disease. When I explain it that way, patients feel confident and at ease. 

GP: What’s your advice for communicating IG with optometrist colleagues? 

Dr. Ristvedt: I advise other surgeons to develop relationships with those optometrists who are sending you their patients and to build trust. That trust can create a wonderful collaborative effort where the optometrists understand they’re going to get their patients back. Comanagement can provide a connection that enables you to put a good plan in place if the patient needs further treatment. Patients love it! Just the other day, a patient said how cared for they felt because of that communication. So, it’s all about building relationships and trust.

GP: What are some practical strategies for implementing this protocol across a surgical practice, particularly in group or multispecialty ASC settings? 

Dr. Funke: One of the most impactful things I did was write out my own glaucoma treatment protocol. I challenge others to do the same. You’ll probably end up with something very similar to what we came up with as a consensus group. But more importantly, once you write it out, you’re holding yourself accountable. 

It’s easy in a busy clinic to hand over an eye drop and move on, or to check pressure and say, “You’re good to go.” But if you take the time to really ask patients how they’re doing—how their dry eye is, how compliant they are—you start to see things differently. You realize that, as a surgeon, you’re not doing your best by sticking to topical therapy when you have so many low-risk options with better long-term outcomes.

So the first big shift for me was holding myself to that higher standard. Then, I started talking to others around me—my support staff, the optometrists I work with, other MDs, and of course, the patients themselves. Everyone needs to buy in, because this is a big shift from how glaucoma has traditionally been managed.

When you’re comfortable sharing the IG approach with your community, that’s when things get exciting. Others see your passion, they see how happy your patients are, and they see the outcomes. It’s rare to have patients come out of a glaucoma clinic happy—but that’s happening, because they’re getting off meds and being offered real options. 

Dr. Ristvedt: Communication is key. If there is a multispecialty setting that you are operating in, talk to your colleagues. Develop a consensus with your colleagues to implement these strategies, just as we did when bringing this new protocol to life.

When your colleagues are on board, it’s going to be better for patient care. It will increase confidence and decrease confusion among the team members who are working for you. That’s what’s so exciting.

What I’ve found is that now our team is so invested in IG that they question why we’re not intervening if the patient has glaucoma. When your team is keeping you on track it’s a beautiful thing. That’s what happens when you communicate and build a consensus together.

GP: What final thoughts do you have about IG and this protocol?

Dr. Ristvedt: We’ve gotten an excellent response to the protocol. The protocol is really just a visual guide to what we’re doing as IG specialists in our practices when patients present for the first time with moderate, mild, and severe glaucoma. It’s always going to be a “choose your own adventure” scenario, based on what you think is right for your patient. We can always go down rabbit holes, and we will have to change things once in a while. But if surgeons stick to this framework, they’ll find that this strategy makes sense.

Dr. Funke: Glaucoma used to be about waiting until end-stage disease before considering surgery. Surgery meant high risk. But now, we’re talking about very low-risk procedures—it’s a different way of thinking about the same disease. 

We all went into medicine to help people, and this is a tangible way to make a big difference. It’s been a game-changer in my group practice. I’ve seen a clear shift: fewer patients on multiple meds, fewer progressing to tubes and trabs. So to anyone considering this approach, I say go for it. It’s a win for everyone involved. It takes time, but it’s worth it. GP