It is hard if not impossible to find a patient with glaucoma who is 100% compliant with their medication regimen. That's not cynicism; it's the nature of treating a chronic disease that requires lifelong therapy. The moment we assume a patient is doing fine on drops is the moment we stop looking closely enough, allowing glaucoma to progress quietly under our noses.
The Growing Burden of Glaucoma
Glaucoma is the leading cause of irreversible blindness worldwide,1 but nearly 50% of people with glaucoma are undiagnosed.2 How can they manage their intraocular pressure (IOP), the only proven modifiable risk factor for glaucoma,3 if they don’t even know they have it?
In my practice, I see specific patterns among patients who fall through the cracks. Patients with mildly elevated IOP in the upper teens to low twenties mmHg often miss follow-up visits because they don’t realize the damage being done by the disease. When they finally return, it’s commonly with a significant spike in IOP or visual field loss and nerve damage that weren’t there before.
I see a similar blind spot with normal-tension glaucoma. These patients tend to be labeled as glaucoma suspects because their IOP isn’t elevated and the cupping or visual field findings may appear borderline. It’s not enough to watch and wait for obvious progression of optic nerve or visual field damage because glaucoma is already present at a lower starting pressure and damage is occurring.
Approximately 60% to 70% of the patients I see either have glaucoma or are silently developing it. It is my responsibility as their doctor to catch the disease as early as possible and keep them engaged in their care once they are diagnosed. Drops work but are not necessarily the best answer. Research shows that 65% of patients are lost to follow-up when managed with topical drops, and nearly two-thirds (62%) of those who lapse from care don’t return within 3 years.4
Reframing the Patient Discussion
I’ve come to believe that my first visit with a patient is an investment in their trust. The more time I spend educating patients at the initial visit—explaining how glaucoma continues to worsen without treatment and setting honest expectations—the more likely they are to stay engaged and adherent over the long run. I tell patients directly, “Even if you have no symptoms today, this will get worse over time if we don't monitor and treat it.” I also tell them they'll likely need regular follow-up visits and multiple treatments over the course of their journey with the disease and that everyone's anatomy and disease course is different. I urge patients to have their IOP checked typically 3 to 4 times per year, along with an annual optical coherence tomography scan and visual field analysis at minimum.
I’m careful not to overdo follow-up. Too many visits can wear patients down to the point that they don’t want to come back. The goal is enough follow-up to catch changes without adding disruption that pushes people away from care. Drops also play into this equation. Patients on drops are 2.6 times more likely to be lost to follow-up compared to those managed with a procedure.4
Reframing the conversation also means reframing the order of options. Rather than starting with drops, selective laser trabeculoplasty (SLT) is my preferred first-line therapy for most patients with early stage glaucoma. If they qualify for SLT, I present it as the primary option and mention drops only as a backup if SLT doesn't achieve the target IOP. I also try to make the procedure less intimidating by using the phrase “a beam of light” rather than “laser” and explaining how it stimulates the eye to release natural enzymes that rejuvenate its own drainage system. If patients ask whether SLT is performed with a laser, I draw a parallel with a laser pointer that doesn’t destroy tissue.
Challenges With Current Treatment Patterns
A large real-world analysis found that more than 96% of patients receive topical drops as first-line therapy.5 However, up to 60% of patients are nonadherent to topical prostaglandin therapy for reasons ranging from adverse effects and cost to difficulty with drop instillation.6-8 Further, studies show that up to 50% of patients fail to receive the intended benefit of their treatment, and as many as 90% don't refill their prescriptions continuously.9,10
I'll admit, I can easily put a drop in someone else’s eye but struggle to instill a drop in my own. If a physician has trouble, imagine an older patient with arthritic hands or reduced dexterity or somebody with no one at home to help. Even with video instruction on proper technique, roughly 80% of patients still don't instill their drops correctly.11 They touch the lid, miss the eye and hit the cheek, or contaminate the tip. Proper instillation is a serious gap in how the disease is managed and one I think we chronically underestimate.
Another challenge with drops is the administrative cost. Every topical regimen generates prior authorizations, refill calls, and questions about whether a patient is taking a generic or brand-name drop. When a patient progresses, we're often left guessing whether it's due to nonadherence, a generic substitution that isn’t absorbed the same way, or something else entirely. That uncertainty erodes confidence in how well the disease is controlled.
It's time more of us start pushing back on a "wait and see" mentality. Gone are the days when it is appropriate to wait for obvious optic nerve or visual field progression in a patient with suspected normal-tension glaucoma or to continue topical therapy while hoping adherence improves. Patients progress under our noses far more often than we'd like to admit, and the earlier we intervene, the easier it generally is to achieve target IOP.
A Modern Treatment Approach
September is Interventional Glaucoma (IG) Month. It’s a good reminder of the benefits of moving beyond drop dependence to a more proactive approach to glaucoma care. A stepwise approach to early stage glaucoma treatment is well-established.12 In an algorithm developed by the Interventional Glaucoma Working Group, the use of a procedural pharmaceutical is positioned as a first-line treatment option alongside SLT and, for severe glaucoma, is even considered a first-line treatment. Although drops may be used as bridge and supplemental therapy, tissue-sparing (eg, trabecular bypass and canaloplasty) and non–tissue-sparing minimally invasive glaucoma surgery (MIGS) procedures are preferred over maximum tolerated medical therapy. Traditional filtering surgery remains a last resort, considered when substantial IOP reduction is imperative to prevent irreversible optic nerve damage or when the drop burden is significant.
I follow the same approach. If SLT doesn’t get a patient to the IOP target, I educate them about the benefits of a procedural pharmaceutical, including the continuous delivery of IOP-lowering medication to targeted tissue with a sustained duration, which may buy them time before starting drops. I also recommend procedural pharmaceuticals early in the disease course. In some instances, I reach for a procedural pharmaceutical before SLT, especially when there might be a high risk for a post-SLT IOP spike, such as in a patient with pigmentary glaucoma or pseudoexfoliation. If the starting IOP is high, I might elect to use the procedural pharmaceutical first and, once the IOP decreases, proceed with SLT. Also, if a patient is scheduled for cataract surgery, I would likely add a procedural pharmaceutical to the cataract procedure, with or without a MIGS procedure.
In pivotal trials of the intracameral travoprost implant (iDose TR; Glaukos), 81% of patients—23% of whom were on 2 or more medications at baseline—were completely free of topical IOP-lowering medication at 12 months.13 At 24 months, the concentration of travoprost free acid in the aqueous humor was ample enough to elicit a maximal IOP-lowering effect, demonstrating efficacious drug delivery beyond 2 years.14 And at 36 months, the IOP-lowering effect after a single administration of either a fast-eluting or slow-eluting travoprost implant compared with twice-daily timolol was both clinically and statistically significant.15 Mean IOP reduction ranged from 7.6 mmHg to 8.8 mmHg and 7.3 mmHg to 8.0 mmHg for the fast-eluting and slow-eluting implant groups, respectively.
Positive outcomes were also seen with the bimatoprost intracameral implant (Durysta; AbbVie). Through 15 weeks, there was a mean IOP reduction of 5 mmHg to 8 mmHg. Data at 18 months showed that 77% of patients maintained their target IOP after a single administration.16-18 My real-world results track closely with these trials.
When I lead with SLT or procedural pharmaceuticals and reserve drops as a bridge or supplemental therapy rather than a first-line treatment, the benefits extend well beyond the exam chair. Patients spend less time managing prescriptions and less money on chronic medications. They also experience less frustration with adverse effects associated with years of preserved medication use. For my practice, it means fewer prior authorization requests, fewer refill calls, and less uncertainty when a patient's IOP isn’t where I want it.
Conclusion
A stepwise approach to glaucoma care doesn’t mean abandoning topical therapy entirely. It means considering it as a bridge and supplement therapy when procedures alone aren’t enough. When you believe in the treatment you recommend, communicate that confidence clearly, and intervene earlier with effective procedural treatments rather than waiting for disease progression, you can improve IOP control while building the kind of trust that keeps patients showing up year after year. GP
References
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