January is Glaucoma Awareness Month, drawing our attention to what I am reminded of every single day in my practice: We are living in a public health moment when the population is aging,1 glaucoma prevalence is rising,2 and far too many patients with glaucoma remain undiagnosed, untreated, or undertreated without their knowledge. Yet the more sobering truth is this: The increased incidence of glaucoma isn’t just a function of an aging population. It reflects current gaps in access to care, disease awareness, and timely intervention.
For those of us who manage patients with glaucoma, we must rise to the challenges of not only detecting disease early enough to change the trajectory but also intervening early enough to protect our patients’ vision over decades rather than months or years. Surmounting evidence, especially a recent interventional glaucoma consensus treatment protocol, supports how interventional glaucoma may reshape our philosophy of glaucoma care.3
Early Detection Is Essential
Glaucoma is a silent thief of sight for several reasons. First, it is asymptomatic in early and even moderate disease before symptoms such as functional vision loss are noticed. Second, most patients do not undergo a routine comprehensive eye exam unless they perceive worsening vision or difficulty with glasses affecting their quality of life. Meanwhile, chronic optic nerve damage progresses.
Many patients arrive in my exam lane shocked to learn they have a condition capable of irreversible vision loss. The disconnect is not their fault. It comes from longstanding misconceptions about vision and aging, socioeconomic barriers to specialty care,4 and health-literacy challenges that make chronic disease difficult to conceptualize. In underserved communities, cultural norms and language barriers add another layer of complexity.
The burden falls on us. We must strive to detect glaucoma in patients whose eyes feel perfectly fine and then help them understand why they should care enough to act immediately with an interventional mindset.
Screening, Outreach, and Early Detection Strategies
Early detection is only as good as the pathways that lead patients into our offices. Although age and elevated IOP remain the strongest demographic risk factors for glaucoma onset and progression,5-9 a recent consensus statement I contributed to concluded that family history and genetic predisposition also play a significant role in early stage glaucoma.4 Among the most underdiagnosed for early stage glaucoma included minority populations in part due to a larger socioeconomic issue of low access to care and follow-up in populations with a high risk of progressive vision loss.4 Our expert consensus group also indicated young patients with a family history of glaucoma and those with normal tension glaucoma may also be at an increased risk for underdiagnosis.
In addition to evidence-based screening, local efforts that make screening accessible are also important. Community outreach has become more creative and better integrated into primary care, including the following:
- Mobile screening units in neighborhoods with low access to eye care;
- Partnerships with primary care physicians, endocrinologists, and family medicine clinics;
- Screenings at pharmacies, senior centers, and health fairs; and
- Targeted outreach to high-risk groups.
Even when screening is effective, referral pathways are a historical pain point. For decades, a limited glaucoma procedural and/or surgical toolbox led some optometrists and comprehensive ophthalmologists to retain glaucoma patients for longer than ideal and hesitate to recommend procedural intervention. It was not, however, because they lacked insight but rather because the next step was an invasive and often risky procedure.
The past decade has moved the needle significantly. Safer, effective, evidence-based interventional options including selective laser trabeculoplasty (SLT), procedural sustained-release pharmaceuticals,and MIGS have opened the door for earlier referral and collaboration.10-15 Today, our partners in the community are more motivated to refer patients knowing intervention is less invasive than ever before, and comprehensive-minded colleagues are more willing to increase their procedural knowledge to offer many of these interventions themselves. This shift has been one of the most exciting transformations in glaucoma care.
Treatment Recommendations and Patient Education
Some patients with early stage glaucoma hesitate to initiate therapy for reasons including cost, fear, and doubt about their disease severity.4,16-18 Our early stage glaucoma expert consensus group indicated a lack of perceived disease severity as the biggest barrier to treatment adherence, followed by treatment side effects.4 Additionally, up to 90% of glaucoma patients do not refill their prescriptions regularly.19
An IRIS Registry study of more than 149,000 patients with primary open-angle glaucoma showed the rate of incident monocular blindness was 4.2%. Patients who went a year or more without an encounter had a higher risk of incident blindness over the following 6 years.20 Patients with a 1- to 2-year lapse had an adjusted relative risk of 1.19 (95% CI: 1.05-1.35) for monocular blindness, increasing to 2.17 (95% CI: 1.66-2.78) for those with a 3- to 4-year lapse. Closing the gap between diagnosis and intervention means ensuring patients transition from detection to engagement to continuity of care as smoothly as possible.
Our job is to transform patient uncertainty into shared decision-making. I practice in a referral-based model, and the first step toward patient engagement happens before they meet me. When optometric partners explain the benefits of procedural intervention therapies, patients arrive curious rather than frightened.
When I meet a patient for the first time, I begin with a simple sentiment: Glaucoma is a lifelong journey, and we will partner together to find the best solution for them. I let them know my job is to make the process as easy as possible for them while protecting their vision for the rest of their life. This phrasing sets expectations and builds empowerment rather than fear. I also rely on visual tools like optic nerve and OCT imaging to help patients see what they cannot feel and emphasize that glaucoma management today is not what it was 20 years ago.
Why Interventional Glaucoma Resonates
Patients usually understand the practical benefits of therapies like SLT, procedural pharmaceuticals, and MIGS options. They tell me about their busy schedules, dry eye, arthritis, contact lens wear, night-shift jobs, or memory challenges—all of which make adherence to drops difficult. In those conversations, interventional glaucoma becomes an obvious choice. It fits their lifestyle and relieves the burden of daily medication while maintaining proven efficacy. In my practice, we gravitate toward SLT, procedural pharmaceuticals, and MIGS for early stage glaucoma.
The LiGHT Trial demonstrated what many of us now see daily: SLT reduces the need for incisional surgery more effectively than drops and offers sustained IOP control with repeatability.10,11 Equally important is how patients respond. When I confidently recommend SLT as first-line treatment, they perceive its value. I’ve seen essentially no resistance when a patient understands the evidence and their optometrist has set the stage.
The next step in my approach is often a sustained-release procedural pharmaceutical therapy, helping patients maintain consistent pressure control without worrying about adherence to topical drops.12-14,21-23 For patients who need longer and more robust control, procedural pharmaceuticals such as the travoprost intracameral implant 75 mcg (iDose TR; Glaukos) offer consistent therapy for up to 3 years.
MIGS options like the iStent (Glaukos) and other trabecular meshwork bypass stents as well as goniotomy with a device like the OMNI Surgical System (Sight Sciences), canaloplasty, and trabeculotomy devices target the conventional outflow pathway to achieve an IOP-lowering effect. Additionally, studies have shown that MIGS effectively decreases the risk of permanent visual field damage.24
SLT, procedural pharmaceuticals, and MIGS are complementary tools in the early stage glaucoma treatment algorithm. Patients are reassured when they hear there are many treatments we can consider. If one doesn’t achieve the desired effect, we simply try the next option.
Conclusion
Glaucoma Awareness Month is a reminder that early detection and early intervention must become community priorities. As eyecare professionals, we must champion this year-round by strengthening our referral networks, investing in patient-friendly education, collaborating with optometrists and primary-care providers, and embracing the evidence-based tools of interventional glaucoma that make early action easier than ever.
When we detect glaucoma early and act early using evidence-based procedural interventions such as SLT, procedural pharmaceuticals, and MIGS, we give patients the best chance to maintain vision throughout their lives. In my experience, patients are more ready for a procedural option than we think. Our job now is to close the gap between diagnosis and intervention. GP
References
1. Pascariu MD, Canudas-Romo V, Vaupel JW. The double-gap life expectancy forecasting model. Insurance Math Econom. 2018;78:339-350.
2. Allison K, Patel D, Alabi O. Epidemiology of glaucoma: the past, present, and predictions for the future. Cureus. 2020;12(11):e11686.
3. Funke C, Ristvedt D, Yadgarov A, Micheletti JM. Interventional glaucoma consensus treatment protocol. Ex Rev Ophthalmol. 2025;20(2):79-87.
4. Provencher LM, Schehlein EM, Shah M, Singh IP, Swaminathan SS, Vendal Z. Consensus statement: evolving strategies in early stage glaucoma management. Glaucoma Today. 2025;4:S1-S12.
5. Chauhan BC, Mikelberg FS, Balaszi AG, et al. Canadian Glaucoma Study: risk factors for the progression of open-angle glaucoma. Arch Ophthalmol. 2008;126(8):1030-1036.
6. Le A, Mukesh BN, McCarty CA, Taylor HR. Risk factors associated with the incidence of open-angle glaucoma: the Visual Impairment Project. Invest Ophthalmol Vis Sci. 2003;44(9):3783-3789.
7. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):714-720.
8. Kapetanakis VV, Chan MPY, Foster PJ, et al. Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): a systematic review and meta-analysis. Br J Ophthalmol. 2016;100(1):86-93.
9. Rao HL, Kumar AU, Babu JG, Senthil S, Garudadri CS. Relationship between severity of visual field loss at presentation and rate of visual field progression in glaucoma. Ophthalmology. 2011;118(2):249-253.
10. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393(10180):1505-1516.
11. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151.
12. Medeiros FA, Walters TR, Kolko M, et al; ARTEMIS 1 Study Group. Phase 3, randomized, 20-month study of bimatoprost implant in open-angle glaucoma and ocular hypertension (ARTEMIS 1). Ophthalmology. 2020;127(12):1627-1641.
13. Bacharach J, Tatham A, Ferguson G, et al; ARTEMIS 2 Study Group. Phase 3, randomized, 20-month study of the efficacy and safety of bimatoprost implant in patients with open-angle glaucoma and ocular hypertension (ARTEMIS 2). Drugs. 2021;81(17):2017-2033.
14. Weinreb RN, Christie WC, Mederios FA, et al. Single administration of bimatoprost implant: effects on 24-hour intraocular pressure and 1-year outcomes. Ophthalmol Glaucoma. 2023;6(6):599-608.
15. Balas M, Mathew DJ. Minimally invasive glaucoma surgery: a review of the literature. Vision (Basel). 2023;7(3):54.
16. Reardon G, Kotak S, Schwartz GF. Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review. Patient Prefer Adherence. 2011;5:441-463.
17. Gupta D, Ehrlich JR, Newman-Casey PA, Stagg B. Cost-related medication nonadherence in a nationally representative US population with self-reported glaucoma. Ophthalmol Glaucoma. 2021;4(2):126-130.
18. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol. 2008;53(suppl1):S57-68.
19. Friedman DS, Quigley HA, Gelb L. Using pharmacy claims data to study adherence to glaucoma medications: methodology and findings of the Glaucoma Adherence and Persistency Study (GAPS). Invest Ophthalmol Vis Sci. 2007;48(11):5052-5057.
20. Williams AM, Liang HW, Lin HHS. Loss to follow-up and risk of incident blindness among patients with glaucoma in the IRIS registry. Ophthalmol Glaucoma. 2025:S25898-4196(25)00104-8.
21. Sarkisian SR, Ang RE, Lee AM, et al, for the GC-010 Travoprost Intraocular Implant Investigators. Phase 3 randomized clinical trial of the safety and efficacy of travoprost intraocular implant in patients with open-angle glaucoma or hypertension. Ophthalmology. 2024;131(9):1021-1032.
22. Szekely G, Voskanyan LA, Stephens KG, et al. Aqueous humor concentrations of travoprost free acid and residual drug in explanted implants from patients administered a travoprost intracameral implant. Ophthalmol Ther. 2025;14(5):989-1003.
23. Berdahl JP, Sarkisian SR, Ang RE. Efficacy and safety of the travoprost intraocular implant in reducing topical IOP-lowering medication burden in patients with open-angle glaucoma or ocular hypertension. Drugs. 2023;84(1):83-97.
24. Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual field outcomes of the HORIZON trial. Am J Ophthalmol. 2023;251:143-155.