Sustained-release procedural pharmaceuticals have introduced a new approach to glaucoma management by delivering intraocular pressure (IOP)-lowering medication directly to the eye while reducing or eliminating the need for daily topical therapy. Two FDA-approved options are currently available: the intracameral bimatoprost implant Durysta (AbbVie), administered in the office, and the travoprost intracameral implant iDose TR (Glaukos), implanted in the operating room as a standalone procedure or in conjunction with cataract surgery or minimally invasive glaucoma surgery (MIGS).
As clinical experience with these therapies continues to grow, surgeons are refining how they incorporate sustained drug delivery into the treatment paradigm, whether as an alternative to topical medications, an adjunct to laser trabeculoplasty, or in combination with MIGS. Here, respected glaucoma specialists from across the United States share practical insights drawn from their own clinical experience. The following pearls are organized into 4 thematic areas:
- patient selection and counseling
- preoperative planning and implantation technique
- postoperative management, follow-up, and long-term expectations
- lessons learned from incorporating procedural pharmaceuticals into everyday practice.
Patient Selection and Counseling
Steven R. Sarkisian Jr., MD
Oklahoma Eye Surgeons
One of the biggest barriers to adopting procedural pharmaceuticals isn't learning the technique, it’s changing the way we think about glaucoma treatment. If your mindset is still, “Start a drop, add another drop, add another drop, then maybe laser, then surgery,” you’re probably not going to understand where these therapies fit.
I don’t think every patient should follow the same algorithm. The beauty of these technologies is that they allow us to individualize treatment. In my practice, selective laser trabeculoplasty (SLT) is first-line therapy for most patients with open-angle glaucoma. If SLT doesn’t achieve target pressure, then we have a conversation. We can add topical medication, with all of the challenges that come with chronic drop therapy, or we can consider a procedural pharmaceutical such as Durysta or iDose TR. I present the evidence, explain the options, and let the patient help decide. That’s a fundamentally different way of thinking about glaucoma care.
Christine Funke, MD
Barnet Dulaney Perkins Eye Center, Arizona
Most patients are unaware that nontopical pharmaceutical delivery exists, and when I offer procedural pharmaceuticals, many would prefer this form of therapy. I believe there is a misperception that patients would not value a year or more free of topical therapy. I ask patients on topical therapy, “Would you like to reduce or eliminate your eye drops?” This opens the door to a discussion around drug deliverable options.
Once a patient shows interest in nontopical options, it is nice to have a talk track about the available drug deliverables on the market. My discussion sounds something like this: “I have 2 options to reduce your medication burden. One option can be given in the office and lasts around a year, and the other option is given in the operating room and lasts around 3 years. The in-office option is an injection that you will not feel, and the intraoperative option is a similar experience to cataract surgery and can be paired with other minimally invasive glaucoma devices.” This simple discussion gives patients a clear view of their options and calms their fears around procedural therapy.
J. Morgan Micheletti, MD, FACS
Berkeley Eye Center, Houston
One of the most useful counseling lessons for me has been moving the conversation away from whether a patient is “compliant” and toward how much daily work the treatment plan requires by acknowledging the difficulty I myself would have with remembering drops. Most patients want to protect their vision, but glaucoma drops still ask them to remember every dose, manage refills and cost, deal with potential side effects, and do all of that for a disease they often cannot feel. I explain that iDose TR is an implant that delivers medication from inside the eye rather than relying on the patient to administer it daily. I also explain that the implant is one part of a long-term glaucoma plan with additional treatments potentially necessary in the future to continue managing the disease.
Jason Bacharach, MD
North Bay Eye Associates, California
How you frame the conversation matters. Early on, I would tell patients, “You could use drops, you could use laser, or now we have an option of implanting a pharmaceutical.” That wasn’t nearly as effective as simply saying, “Now we have a way to provide 24/7 pressure control without you having to take medicine every day. We implant a delivery system that is FDA approved, is covered by insurance in most cases, and provides durable IOP control.” That subtle shift changes the entire conversation.
I’ve also changed the order in which I discuss treatment options. I present sustained drug delivery and SLT first, because both have excellent evidence as first-line therapies. I explain that they may be used alone, together, or sequentially, depending on what the patient needs. Then I introduce topical medications as an excellent supplemental treatment if additional pressure lowering is needed or when those therapies lose effectiveness over time. I aim to be fair and balanced with patients, because no single treatment cures glaucoma and many patients will ultimately need a combination of therapies.
Once you develop a comfortable way to have that conversation, it becomes surprisingly efficient. It doesn’t take much additional time, and it gives patients the opportunity to make a more informed decision about their care.
Shivani S. Kamat, MD
University of Texas Southwestern Medical Center
I will often perform SLT and implant Durysta in close succession, rather than using a stepwise approach, particularly when I suspect SLT alone is unlikely to achieve the patient’s target IOP. I perform gonioscopy on every patient and would not consider these procedures in someone with a narrow angle.
Arkadiy Yadgarov, MD
Omni Eye Services, Georgia
An important lesson for surgeons is to think of iDose TR primarily as a replacement for a single topical medication. In my practice, I reserve iDose TR for patients in whom replacing one medication with sustained drug delivery is the primary goal. For patients with more refractory glaucoma requiring greater pressure reduction, I combine iDose TR with a standalone MIGS procedure to achieve additional IOP lowering while simultaneously reducing medication burden.
Robert F. Melendez, MD, MBA
The Juliette Eye Institute, New Mexico
One thing I’ve learned after more than 3 years using Durysta is that patient selection really matters. The ideal patient is already controlled on a single glaucoma medication but wants to get off drops because of cost, ocular surface irritation, or simply the challenge of remembering to take them. Those are probably the 3 biggest reasons patients are interested in the implant.
In my experience, about 90% of patients respond very well. The package insert says the implant lasts about 6 months, but we’ve seen pressure control last a year or even longer. The other advantage is eliminating the burden of daily drops. Patients don’t have to remember them, purchase them, or deal with the side effects associated with topical medications, and they really appreciate that.
Like any therapy, it doesn’t work for everyone. I’d estimate that roughly 10% of patients don’t respond adequately, and those patients simply go back on topical therapy. Fortunately, that’s been the exception rather than the rule.
Syril K. Dorairaj, MBBS, MD
Mayo Clinic Jacksonville, Florida
Pranav Vasu, MPH
Creighton University School of Medicine, Nebraska
It helps to draw a clear line between who is eligible for sustained release implantables and who is a good fit. On paper, the label is incredibly broad. But just because a patient qualifies doesn't mean they’re the ideal candidate.
This approach has been especially valuable for patients with Alzheimer or Parkinson disease. In these cases, poor compliance isn't a lack of willpower. It’s a direct result of pathologic cognitive decline, tremors, or dexterity issues that make aiming a drop bottle quite difficult. A sustained-release implant takes that daily struggle completely off the table.
Of course, anatomy is still the ultimate deciding factor. A thorough slit-lamp exam is essential before moving forward. If we see narrow iridocorneal angles, peripheral anterior synechiae, or any abnormality that could compromise a clean implantation, we may look at other options.
Finally, setting expectations with families and caregivers is vital. Everyone needs to understand that while this is a massive win for compliance and dramatically lifts the daily treatment burden, it’s a tool for ongoing glaucoma management rather than a permanent cure.
Savak “Sev” Teymoorian, MD, MBA
Harvard Eye Associates, California
I like to tell people that every glaucoma patient comes with a cost. I’m not talking about financial cost. I’m talking about the physician’s time, the staff’s time, and the patient's effort. You can either pay that cost upfront, or you can pay it later—with interest. The “interest” is the phone calls about prior authorizations, the complaints about medication costs, the ocular surface irritation, the missed doses, and ultimately the progression of disease that requires more invasive treatment. We all know this cycle because we deal with it every day.
Procedural pharmaceuticals give us an opportunity to interrupt that cycle. By delivering medication directly, we eliminate many of the barriers that make topical therapy difficult. Patients aren't worrying about remembering drops, paying for monthly refills, or dealing with chronic ocular surface toxicity. Instead of repeatedly solving the same problems, we can focus on controlling the disease.
Surgical Planning and Technique
J. Morgan Micheletti, MD, FACS
Evaluating the angle anatomy is imperative. I confirm that I can clearly visualize an open angle and the intended superonasal implantation site in clinic. I often consider pairing implantation with another procedure targeting another part of the outflow system, such as a canaloplasty or iStent infinite (Glaukos), when indicated. Given the guidance on retreatment for patients who benefited from their first iDose TR, I have begun to consider collecting baseline endothelial cell counts on these patients as well.
Reza Alizadeh, MD
Confirm angle anatomy and adequate anterior chamber depth before iDose TR; ensure clear view of the target quadrant. For Durysta, verify no prior severe cystoid macular edema or corneal endothelial compromise. I almost always get an endothelial cell count. Exclude the post–corneal transplant patients, even the most stable ones.
Lori Provencher, MD
I find it extremely valuable that I can (currently) combine iDose TR with other angle-based surgeries. I routinely use it with standalone trabecular stents, as I want to take full advantage of a trip to the operating room. I also think it’s helpful to combine iDose TR with cyclodialysis cleft creation, as concurrent PGA dosing may further optimize uveoscleral outflow and reduce IOP spikes.
Robert F. Melendez, MD, MBA
The injection itself is very straightforward and can be performed in the exam lane, a minor procedure room, or the operating room. We use an office-based surgery suite simply because it gives us access to a microscope, but the procedure doesn't require a formal operating room.
The eye is anesthetized, and we prep with povidone-iodine using the same concentration we use for cataract surgery. After placing a lid speculum, I stabilize the eye with a Weck-Cel sponge, aim toward the inferior angle, inject the implant, and withdraw the applicator. The actual injection takes only a couple of seconds.
Jai G. Parekh, MD, MBA, FAAO
EyeCare Consultants of NJ
Over the last few years now, iDose TR has been a game-changer for us in how we take care of our patients who need better IOP control in glaucoma. The bigger opportunity for our practice has been using it as a standalone procedure and most of the time along with the iStent infinite. We have achieved pressures well below 15 mmHg in these cases and often times eradicating the need for all drops beyond the PGA. Patients are happier and their ocular surface looks revamped.
Postprocedure Management and Long-Term Expectations
Reza Alizadeh, MD
Procedural pharmaceuticals aren’t “set it and forget it”—patients still need monitoring. Check IOP at 1 day, then 1 month, and watch for early spikes. Taper topical therapy gradually rather than stopping abruptly, and confirm device position at first follow-up.
Shivani S. Kamat, MD
My postoperative regimen depends on the procedure performed. For standalone iDose TR implantation, I often prescribe only a brief course of topical corticosteroids; in many cases, 1 week is sufficient. When iDose TR is combined with cataract surgery, I simply follow my routine postoperative cataract regimen without any additional management specific to the implant.
After Durysta implantation, I do not routinely prescribe postoperative drops and typically see patients within 1 month. Now that iDose TR is approved for readministration, Glaukos has indicated that routine specular microscopy is not necessary before repeat implantation; documenting corneal health is sufficient.
Manjool M. Shah, MD
Kellogg Eye Center, Michigan
We’re still learning how intracameral prostaglandin delivery differs from conventional topical therapy. If you look at the ARTEMIS studies with Durysta, the protocol isn’t how we practice today—patients received treatment every 4 months for 3 doses—but it taught us something important. If you think purely from a pharmacokinetic standpoint, once the drug is no longer being released, you’d expect IOP to return to baseline. That’s simply not what happened.
Even a year after the last implant, the majority of patients still hadn’t required rescue therapy. We saw hints of this as early as the phase 1 and phase 2 studies, where a single treatment continued to provide benefit in some patients for a year or even longer.
That suggests intracameral drug delivery may be doing something fundamentally different. Whether it’s the sustained kinetics, the higher local drug concentration, or another mechanism we’re still trying to understand, it appears we may be inducing structural or functional changes in the conventional outflow pathway that persist beyond the presence of the drug itself. That’s a fascinating area of investigation, and I think we'll learn much more about it over the next several years.
Robert F. Melendez, MD, MBA
I’ve rarely seen a wound leak, and I’ve never had an infection. The procedure is very safe, with minimal discomfort for the patient. Afterward, I recommend artificial tears for a day or two and prescribe ofloxacin 3 times daily for 5 days. If both eyes are being treated, I'll perform the second eye about a week later.
I. Paul Singh, MD
The Eye Centers of Racine and Kenosha, Wisconsin
One thing I’ve learned is not to rush to restart glaucoma drops just because the pressure is a little higher after Durysta or iDose TR implantation. If the patient is still within the target range, I’m comfortable watching because you’re avoiding the peaks and troughs created by intermittent topical dosing. It’s not just about driving pressure lower; it’s about maintaining stable pressure. Compared with topical drops, procedural pharmaceuticals tend to flatten the IOP curve throughout the day and night, so I have more confidence that the patient’s pressure isn’t fluctuating nearly as much. As long as the IOP remains within a range I’m comfortable with, I don’t mind if it’s a point or two higher. That’s one of the nuances of sustained drug delivery, and it’s something you become more comfortable with over time.
Lessons Learned and Dispelling Myths
Huda Sheheitli, MD
University of Minnesota Medical School
Adherence remains one of the most persistent barriers to successful glaucoma management. We cannot assume patients are consistently using their drops. In my practice, these are the 2 patient populations I offer sustained-release options to most often: younger, busy patients who simply forget, and older patients who struggle with the mechanics of instilling drops themselves. Younger patients are often juggling work, travel, and irregular schedules, and drops are easy to deprioritize when someone feels asymptomatic, which most glaucoma patients do. Older patients face a different set of obstacles: arthritis, tremor, poor aim, and difficulty tilting the head back or judging whether a drop actually landed on the eye, all of which can lead to underdosing even in a highly motivated patient. For both groups, the issue isn’t willingness, it’s practicality.
Reena A. Garg, MD
Visionary Eye Doctors, Maryland
One misconception is that sustained-release procedural pharmaceuticals and angle-based MIGS should be viewed as competing treatment options. In my experience, they are highly complementary because they target different mechanisms of aqueous humor outflow. Canal-based procedures improve conventional outflow, while iDose TR provides continuous prostaglandin therapy to enhance uveoscleral outflow without relying on daily patient adherence. By addressing both pathways, these therapies can work synergistically to achieve greater IOP reduction, increase the likelihood of medication reduction or drop independence, and provide more consistent diurnal IOP control. Equally important, combining these modalities allows us to tailor treatment to the individual patient rather than applying a one-size-fits-all approach.
Savak “Sev” Teymoorian, MD, MBA
For physicians who haven’t yet incorporated procedural pharmaceuticals into their practice, my advice is simple: Try them before deciding they're not for you. Pick a few appropriate patients and give yourself an opportunity to see the results firsthand. Then listen to your patients. Ask what it's like not having to remember drops every day. Ask whether their eyes feel better. Ask whether they're relieved not to deal with pharmacy issues or medication costs. Those conversations are often more convincing than any lecture or clinical trial presentation.
When patients return with good pressure control and tell you they’re happy to be off drops, that’s powerful feedback—not just for them, but for you as the physician. Once you’ve seen that experience a few times, you’ll probably recognize many more patients who could benefit from this approach. I think the key is giving the technology an honest evaluation before deciding where it fits in your practice.
Manjool M. Shah, MD
One misconception is that these therapies should be judged solely by how long they release drug. I think that's looking at the problem the wrong way. Glaucoma is progressive. The disease continues to evolve over time, so a treatment that controls pressure today may eventually become insufficient because the disease has advanced—not because the therapy failed. We shouldn’t overlook a therapy simply because it’s time limited.
The other point is that getting the drug inside the eye may have effects that outlast the drug release itself. That’s certainly what we’ve observed with Durysta, and I think it’s something we’ll continue to evaluate with newer sustained-delivery platforms such as iDose. My expectation—and admittedly it’s based on early clinical experience—is that even after the reservoir is essentially empty, we’ll continue to see some durability of effect because we’re changing the outflow system in a more meaningful way than we do with topical therapy. That’s why I think this is an area worth watching very closely.
Zarmeena Vendal, MD
Westlake Eye Specialists, Texas
One of the biggest myths, I think, is that patients are the rate-limiting step in accepting this kind of technology—that they’re somehow fearful or skeptical. In fact, that isn’t the case at all. Patients value innovation even more in glaucoma than in cataract because they’re not dealing with an elective procedure. They’re dealing with a chronic disease, and they’re afraid of losing their sight. They value innovation and appreciate the recommendations of their physicians.
It's actually surgeons who are the rate-limiting step. If they embrace the interventional glaucoma mindset and make a strong recommendation, patients are often quite enthusiastic about procedural pharmaceuticals. GP
