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Look Beyond the Bottle in Glaucoma Care

Embracing interventional glaucoma will enhance future treatment and outcomes.

By: Christine Funke, MD
Ophthalmology Management September 14, 2026

Glaucoma is a consequential disease. A late or missed diagnosis may lead to a lifetime of complications defined by faster disease progression and severe vision loss.1,2 Although we now have access to myriad glaucoma treatments with proven safety and efficacy, the disease remains one of the most mismanaged in ophthalmology. This is partly due to how treatment is typically sequenced.

For decades, topical intraocular pressure (IOP)-lowering drop therapy has been the default first-line treatment for glaucoma. On its face, it is familiar, accessible, and straightforward—but it comes with a severe downside. Despite their best intentions, 90% of patients do not adhere to their prescribed drop schedule, and 50% completely stop using their drops within 6 months,3-5 leading to greater disease severity and a decline in quality of life.

A growing community of glaucoma specialists, including myself, believes defaulting to drops sets many patients up to fail. In addition to the high likelihood of progression due to poor adherence, they also may experience increased anxiety and guilt from their noncompliance.6 On the other hand, intervening earlier in the disease state takes the treatment burden out of patients’ hands and improves their quality of life while promoting IOP stabilization and delaying or preventing disease progression.5 This interventional glaucoma (IG) approach has led to a significant paradigm shift in glaucoma care, one driven by safety advances, robust clinical data, and an honest reckoning with the realities of long-term topical therapy.

Drop Therapy’s Promise and Problem

By the time many patients arrive in my chair, they have already lost meaningful visual field that cannot be recovered. My goal is to slow the progression of their disease and preserve as much function as possible for as long as possible, and this fundamentally informs my treatment approach for each individual patient.

IRIS Registry:
Loss to Follow-up

  • 50% of patients with primary open-angle glaucoma (POAG) were lost to follow-up, and approximately two-thirds of those patients never returned after their lapse in care.
  • 4.7% of patients with POAG developed blindness over a 6-year period.
  • Patients lost to follow-up for 2 years had a 1.43× higher risk of blindness, while those lost for 3 years had a 2.17× higher risk, compared with patients with no lapse in follow-up.
  • Race and ethnicity significantly modified the association between lapses in care and blindness risk (P=.02), with Black patients experiencing the highest risk of incident blindness after loss to follow-up.

Source: 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;8(6):544-552. doi:10.1016/j.ogla.2025.05.001.

There is no question that topical medications effectively lower IOP, and they still have a meaningful role in my practice. However, I use them primarily as a bridge therapy because the human factor is real. Ask yourself honestly: How many of your patients correctly administer their drops every day—and continue doing so consistently for years? The answer, according to the literature, is sobering. Studies show that within 6 months of initiating topical therapy, approximately half of patients no longer use their medication as prescribed, and by year 3, only 37% continue refilling the initial medication.7 Another study showed up to 90% do not refill their prescriptions continuously.8

These are not fringe findings. Other studies have shown up to 60% of patients are nonadherent to topical prostaglandin analog therapy for reasons including side effects, difficulty of drop instillation and regimen complexity, forgetfulness, lack of motivation, and cost.9-11 Drop therapy also carries its own side effects, including ocular surface disease, hyperemia, and periorbital changes that can meaningfully affect quality of life and adherence alike.12-14

There is also an issue of diurnal IOP fluctuation. Even in patients who are compliant, topical drops create a waxing and waning effect on IOP. We see a brief snapshot of our patients in clinic, but what is their pressure doing when they are stressed, when they miss a dose, or when they travel? We have no good way to capture 24-hour pressure data on every patient, and that gap in monitoring is a clinical vulnerability.

Beyond pressure control, data from the IRIS (Intelligent Research in Sight) Registry showed patients who go 3 or more years without follow-up have an increased likelihood of losing vision in at least one eye.15 In the same study, half of patients with primary open-angle glaucoma went more than 1 year between appointments at least once. Of those, 67% never returned for care.

When you step back and consider the cumulative effect of missed doses, inconsistent IOP control, and irregular monitoring, the long-term prognosis for patients managed primarily with drops becomes significantly less favorable than our clinical intuitions might suggest. We are prescribing a lifelong therapy for a lifelong disease and expecting patients to maintain a near-perfect daily routine, indefinitely, for an asymptomatic condition they cannot feel getting worse. When I frame it that way, the compliance crisis we face is entirely predictable. Yet, for too long we have responded to noncompliance by threatening patients with surgery rather than reconsidering our treatment algorithm.

A Procedure-First Approach

Historically, reluctance to move toward earlier surgical intervention was rooted in legitimate safety concerns. Traditional incisional glaucoma surgery, namely trabeculectomy and tube-shunt procedures, carried meaningful risks of complications, vision loss, and failure. In that landscape, surgery was a last resort reserved for end-stage or emergency cases.

Minimally invasive glaucoma surgery (MIGS) has matured over the past decade. Now, it includes a range of trabecular, suprachoroidal, and subconjunctival procedures that lower IOP with a dramatically improved safety profile compared to traditional surgery.16 Procedures such as selective laser trabeculoplasty (SLT), implantation of a sustained-release drug delivery device, and trabecular micro-bypass stents provide effective tools that may be deployed earlier and with greater confidence.

Interventional Glaucoma Data

  • More than 90% of patients are noncompliant with glaucoma medication use, and 50% discontinue medication within 6 months.
  • Of approximately 12 million diagnosed and treated eyes, an estimated 11.5 million are likely treated with drops; only about 320,000 are treated with selective laser trabeculoplasty (SLT) and 400,000 with MIGS plus procedural pharmaceuticals.
  • In Newton Registry data, 81% of encounters involved ocular hypertension or mild-to-moderate glaucoma, compared with 19% involving severe glaucoma.
  • Only 17% of patients received a procedural intervention, while approximately 99% of observed procedural recommendations were accepted when delivered with conviction.
  • 65% of topically managed patients were lost to follow-up for more than 12 months, compared with 25% of procedurally managed patients; patients on drops were 2.6× more likely to be lost to follow-up.
  • 40% of patients received no visual field testing during the studied period, and less than 10% received testing in accordance with AAO recommendations.

Source: Market Scope. Q1 2024 Interventional Glaucoma Survey. 2024. Licensed to Glaukos Corporation.

The LiGHT trial provided compelling evidence that early SLT can deliver excellent IOP control with less vision field loss over time compared to topical therapy. Nearly 75% of patients were medication-free and surgery-free at 3 years while maintaining their target IOP,17 and 3 years later, 69.8% remained medication-free and surgery-free.18

Alongside SLT, the emergence of procedural pharmaceuticals has opened a new frontier in IG. These implants allow us to deliver proven IOP-lowering medications directly to the eye in a controlled, sustained fashion, eliminating the human factor that makes drop therapy unreliable. Constant, steady medication elution provides more consistent IOP control around the clock, and the placement is performed by us and is not dependent on the patient. Evidence suggests most patients are completely free of IOP-lowering topical medication 12 months after receiving a travoprost intracameral implant 75 mcg (iDose TR; Glaukos).4 Additionally, both clinically and statistically relevant IOP-lowering treatment effects have been shown through 36 months after a single administration of slow-eluting travoprost implant compared with BID timolol.19 As of January, travoprost intracameral implant 75 mcg is now approved for retreatment using a repeat protocol, reflecting the safety and tolerability of the implant for repeat use.20 For patients who have failed topical therapy or who are likely to struggle with adherence (which, honestly, is most patients), sustained-release therapy represents a powerful next step.

Treatment Sequencing

I now think of the IG paradigm in roughly the following sequence: For newly diagnosed patients with mild to moderate disease, SLT is often my first conversation. Laser therapy is noninvasive and well supported by evidence.17,18 When patients ask why I am not starting them on drops like their neighbor uses or their previous doctor prescribed, I walk them through the data. If there is a wait for the laser suite, I may bridge with a topical agent. I explicitly explain that drops are a temporary solution, not a long-term plan.

If SLT does not achieve adequate control, my next move is typically a procedural pharmaceutical. Sustained-release platforms have become one of my go-to tools precisely because they address the fundamental limitation of drop therapy without requiring a patient to change their behavior. I think of them as a close second to laser. It’s still minimally invasive, but it offers something laser alone cannot: medication on board, all the time. For patients with more advanced disease at presentation or those in whom I anticipate needing a more significant pressure reduction, I think seriously about MIGS. Often, it is offered in conjunction with a procedural pharmaceutical. The goal at every stage is to do something that changes the physiology of the eye rather than something that depends on patient behavior to sustain its effect.

I want to be clear: Treatment sequencing is not about performing more procedures for the sake of it. It is about honest alignment between the nature of the disease and the nature of the therapy. Glaucoma is a lifelong and progressive disease that demands a reliable, durable treatment strategy—one that is not wholly dependent on perfect patient execution every single day.

When I counsel patients who confess they have not been using their drops, I do not lecture them. I normalize it. I tell them most people given topical medications struggle to maintain them long-term. Then, I tell them that there are better options. Framing adherence in this way changes the entire tenor of the conversation and, in my experience, leads to better patient engagement and acceptance of procedural therapy.

The Benefits of an Interventional Glaucoma Approach

Shifting earlier to procedural therapy is a more sustainable practice model for physicians, staff, and a practice’s long-term health. Consider the administrative burden that drop-dependent care generates. Every patient on topical therapy is a potential source of prior authorization requests, pharmacy callbacks, insurance appeals, formulary substitutions, copay complaints, and patient calls with questions about cost, side effects, and their regimen. This recurring friction may be eliminated with a sustained-release implant or successful SLT treatment for months or years at a time. Multiply that across hundreds of patients, and the downstream effect on staff bandwidth is significant. Additionally, reducing such administrative noise frees your team to focus on higher-value patient interactions.

There is also an argument for scheduling efficiency. Patients managed with procedural therapy tend to have more stable IOP and therefore predictable follow-up patterns with shorter visit times, creating greater capacity for new patient appointments and surgical cases. In a busy practice, that capacity directly translates to revenue and to the ability to serve more patients who need you.

On the revenue side, the economics of procedural care are straightforward. SLT, sustained-release implantation, and MIGS procedures generate professional fees that topical prescriptions do not. With adequate infrastructure and an efficient laser clinic workflow in place, volume grows quickly.

Comanagement is an underappreciated lever in an IG practice model. In my experience, optometrists in our community are eager for clear, reliable referral pathways. A defined comanagement protocol in which I see the patient for the procedure and initial postoperative care, then return them to their referring optometrist for ongoing monitoring, creates a partnership that benefits both practices. The optometrist retains the patient relationship and builds confidence in the referral, and you fill your procedure schedule with appropriate candidates.

Finally, there is the matter of professional satisfaction. Ask any glaucoma specialist what drew them to the specialty, and few will say they wanted to manage refill requests. Shifting toward an IG model means more time doing procedures and having meaningful conversations about disease trajectory and quality of life, and less time managing the downstream fallout of a treatment approach that does not work reliably. That shift, over the arc of a career, matters.

It is time to move beyond the bottle. The sooner we embrace IG as a community, the better our patients’ futures will be.

References

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  2. Liu H, Chen C, Chen Z, Li Q, Li Q, Liu W. Factors associated with delayed first ophthalmological consultation for primary glaucoma: a qualitative interview study. Front Med (Lausanne). 2023;10:1161980. doi:10.3389/fmed.2023.1161980

  3. Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606. doi:10.1016/j.ajo.2005.04.051

  4. Sarkisian SR Jr, Ang RE, Lee AM, et al; 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 ocular hypertension. Ophthalmology. 2024;131(9):1021-1032. doi:10.1016/j.ophtha.2024.02.022

  5. Sarkisian SR, Ang RE, Lee AM, et al. Travoprost intracameral implant for open-angle glaucoma or ocular hypertension: 12-month results of a randomized, double-masked trial. Ophthalmol Ther. 2024;13(4):995-1014. doi:10.1007/s40123-024-00898-y

  6. Religioni U, Barrios-Ridríguez R, Requena P, Borowska M, Ostrowski J. Enhancing therapy adherence: impact on clinical outcomes, healthcare costs, and patient quality of life. Medicina (Kaunas). 2025;61(1):153. doi:10.3390/medicina61010153

  7. Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606. doi:10.1016/j.ajo.2005.04.051

  8. Friedman DS, Quigley HA, Gelb L, et al. 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. doi:10.1167/iovs.07-0290

  9. 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. doi:10.2147/PPA.S23780

  10. 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. doi:10.1016/j.ogla.2020.08.010

  11. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol. 2008;53(suppl1):S57-68. doi:10.1016/j.survophthal.2008.08.002

  12. Zhang X, Vadoothker S, Munir WM, Saeedi O. Ocular surface disease and glaucoma medications: a clinical approach. Eye Contact Lens. 2019;45(1):11-18. doi:10.1097/ICL.0000000000000544

  13. Ruiz-Lozano RE, Azar NS, Mousa HM, et al. Ocular surface disease: a known yet overlooked side effect of topical glaucoma therapy. Front Toxicol. 2023;5:1067942. doi:10.3389/ftox.2023.1067942

  14. Kim HW, Choi YJ, Lee KY, Lee MJ. Periorbital changes associated with prostaglandin analogs in Korean patients. BMC Ophthalmol. 2017;17(1):126. doi: 10.1186/s12886-017-0521-4

  15. 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;8(6):544-552. doi:10.1016/j.ogla.2025.05.001

  16. Balas M, Mathew DJ. Minimally invasive glaucoma surgery: a review of the literature. Vision (Basel). 2023;7(3):54. doi:10.3390/vision7030054

  17. 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. doi:10.1016/S0140-6736(18)32213-X

  18. 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. doi:10.1016/j.ophtha.2022.09.009

  19. Berdahl JP, Sarkisian SR, Ang RE, et al; Travoprost Intraocular Implant Study Group. 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. doi:10.1007/s40265-023-01973-7

  20. Glaukos. Glaukos announces US FDA approval of NDA supplement allowing for re-administration of iDose TR. January 28, 2026. Accessed May 5, 2026. https://investors.glaukos.com/news/news-details/2026/Glaukos-Announces-US-FDA-Approval-of-NDA-Supplement-Allowing-for-Re-Administration-of-iDose-TR/default.aspx

Christine Funke, MD

Christine Funke, MD, is a glaucoma specialist in private practice. She is a recognized educator and speaker in interventional glaucoma and MIGS. She is a speaker and consultant to Glaukos. Reach her at christine.funke@bdpec.com.