Procedures Over Prescriptions: An Interventional Framework for Glaucoma Management

Sometimes, meaningful shifts in medicine start with small decisions. A stent placed during cataract surgery. A referral for SLT instead of starting a topical drop. A clinician wondering if there’s a better way to manage pressure over the next 20 years, not just until the next visit. Over time, those choices add up. And together, they signal a turning point.

Minimally invasive glaucoma surgery (MIGS) was once viewed as an adjunct, a specialized option reserved for certain surgeons and specific cases. But by 2025, it has become something else entirely—a foundational part of glaucoma care and a key entry point into what is now recognized as interventional glaucoma.¹

This article explores that shift and how MIGS has moved from optional to essential, how the interventional glaucoma framework offers a structured approach to care by disease stage, and what every ophthalmologist should know to incorporate MIGS confidently and effectively into their practice today.

While this expands our clinical toolkit, more importantly, it reflects a change in timing, intention, and strategy that better aligns with the nature of a chronic, progressive disease and the long-term needs of the patients we serve.

As interventional glaucoma gains traction, many ophthalmologists are looking for clearer guidance on how to apply its principles in practice. The “Interventional Glaucoma Consensus Treatment Protocol,” published in Expert Review of Ophthalmology, offers one such framework.²

Developed by a working group of glaucoma specialists, the protocol outlines a stepwise approach to treatment based on disease stage, from ocular hypertension (OHT) to severe glaucoma. It organizes available procedures not just by mechanism or anatomy, but by practical, patient-centered considerations, such as procedural burden, tissue impact, and how each choice shapes future options.¹

The result is a clear, stage-based structure that reflects how many clinicians are already thinking about glaucoma care. For those newer to MIGS or procedural decision-making, it offers a way to navigate treatment selection with more confidence, grounded in clinical logic and shaped by the practical realities of glaucoma care.¹

In the context of interventional glaucoma, MIGS represents two of five procedural treatment categories that can be tailored to disease severity and patient characteristics.

Both laser procedures and procedural pharmaceuticals are positioned as first-line options, with selection based on the patient’s needs, clinical presentation, and provider discretion:

Includes selective laser trabeculoplasty (SLT), micropulse laser trabeculoplasty (MLT), and direct SLT (dSLT). SLT is often considered early in the disease course due to safety, repeatability, and ability to delay or reduce reliance on topical medications. The LiGHT trial was significant in confirming that SLT can be done as first-line therapy.³

With compliance at the forefront of conversation, we can even make a strong statement that SLT provides 100% compliance. The 6-year extension of the LiGHT trial showed a significant difference in disease progression between those treated with SLT as first line compared to the drops-first arm.⁴

As a result, the cumulative trabeculectomy rate was much greater in the drops-first arm. This indicates that early treatment in the disease course may affect the rate of disease progression in the TM.

Sustained-release intracameral drug delivery systems such as iDose TR and Durysta are also positioned as first-line options within the protocol. These are used as standalone or adjunctive options to provide consistent intraocular pressure (IOP) control without daily compliance and adherence challenges.

Durysta is performed in the clinic, with 66% of patients achieving IOP lowering for 6 months, and 35% of patients achieving IOP lowering for 12 months.⁵ It can be nicely paired pre- or post-SLT and MIGS for patients who need additional treatment, or an option for those who have difficulty with their drops.

In clinical trials, iDose TR maintained IOP control in the majority of patients at 12 months, with 81% remaining drop-free at 36 months.⁶ Additionally, 69% remained controlled on the same or fewer drops compared to 45% of patients treated with topical timolol.

iDose TR can be used across the spectrum, from OHT to Severe POAG. There is so much promise with drug delivery, as we are seeing the power of 24-hour duration to promote less fluctuation, stability beyond its intended endpoint in many patients, and fewer side effects over time.

Techniques such as trabecular micro-bypass and canaloplasty that preserve trabecular meshwork integrity help maintain eligibility for future procedures. I have found canaloplasty to be very useful in patients who have ocular hypertension and mild POAG, as early intervention can optimize the outflow.

iSTENT inject W and Hydrus have been approved for mild to moderate POAG, combined with cataract surgery. These devices bypass the trabecular meshwork, which is the area where we get the most resistance.

The iSTENT inject has long-term data showing the power of two stents when it comes to IOP reduction and medication reduction. Hydrus, in my hands, is used for patients who have mild to moderate POAG, many times, on multiple glaucoma drops.²

We know from the HORIZON data that there is less visual field progression after the Hydrus implant. Five-year survival analysis showed an increased probability of visual field worsening by 5.5 dB (P = .0170), indicating a greater proportion of fast progressors in patients who have cataract surgery alone.⁷

Lastly, iSTENT infinite, for those who have failed prior procedures or uncontrolled on maximal tolerated medical therapy (MTMT), can be performed in conjunction with cataract surgery or standalone. iSTENT infinite has three microstents that are placed 2 to 3 clock hours apart for increased multidirectional outflow.

Studies have proven that in many patients who have failed bleb-forming procedures, you can still think about going back to the angle for improved outflow and IOP control.^8,9

Procedures like goniotomy create permanent structural changes to the trabecular meshwork by removing the tissue. In the consensus protocol, this is a procedure I like to reserve for after stenting or canaloplasty alone, if possible.

As it can be combined with canaloplasty in devices such as the OMNI and iTrack device, or through removal by many options, such as Kahook Dual Blade, SION, and MST trabectome, it affords us surgeons the opportunity to be more versatile.

Goniotomy can be performed as a standalone procedure or in conjunction with cataract surgery. A few clock hours to 360-degree trabeculotomy, like GATT, gives us more options with the disease state.

In addition, I like to combine endoscopic cyclophotocoagulation (ECP) with canaloplasty and trabeculotomy, which works on the inflow and outflow pathway, in cases where patients need maximum pressure reduction prior to filtering surgery, or those on MTMT to lessen the burden of drops.

When the angle is not an option, we have the opportunity to think about MIBS, which includes the utilization of the XEN gel stent. This is a great opportunity to lessen drops and decrease IOP, with less risk for trab-like risks.¹⁰

It is still very important to manage the outflow through the XEN Gel Stent, watching for fibrosis, inflammation, and failure. I have found it useful to manage fibrosis early by needling and placing 5-fluorouracil (5-FU) or mitomycin. The key is maintaining healthy, non-inflamed conjunctival tissue and following these patients closely.

While prescription eye drops remain an option, they are increasingly positioned later in the treatment sequence and continue to fit as bridge therapy in between early intervention, particularly for patients who require more pressure lowering than the procedural interventions alone are able to achieve.

Each of these categories plays a role in stage-based glaucoma management, helping clinicians balance efficacy, safety, and long-term planning.

One possible misstep is defaulting to topical therapy without considering procedural intervention as a first-line option. Another is “stacking” multiple medications over time—adding additional prescription drops when a procedure might provide more effective and lasting pressure control. In mild glaucoma, delaying procedural intervention can lead to preventable progression and increased structural damage.

Another issue is underestimating the cumulative impact of prescription eye drops over time. Beyond compliance and adherence issues, topical medications are associated with ocular surface disease, systemic side effects, and diminished quality of life.

In a 20-year longitudinal study conducted in Olmsted County, Minnesota, 13.5% of patients with glaucoma progressed to blindness in at least one eye despite treatment with topical medications.¹¹ Earlier intervention with laser, procedural pharmaceuticals, and MIGS can reduce IOP fluctuations, improve pressure control, and preserve future treatment options.

The interventional glaucoma framework supports this approach by matching treatment intensity to disease stage while accounting for patient-specific factors such as visual field status, comorbidities, and tolerance to prior therapy.

As the range of interventional options continues to grow, so does the need for thoughtful, stage-specific training for building procedural skills. Equally important is developing clinical judgment about when and how to intervene.

For those newer to procedural pharmaceuticals and MIGS, structured frameworks like the Interventional Glaucoma Consensus Protocol can support the learning process.^2,12 When used alongside clinical experience and mentorship, these tools can help clinicians gain confidence in treatment selection, preserve future options, and tailor care to the progression of disease.

The goal is not only technical proficiency but also a broader understanding of how and when to act within an evolving treatment landscape.

Procedural intervention continues to play a larger role in glaucoma management, particularly as data supports its use across all stages of disease. MIGS offers a way to lower intraocular pressure more consistently, reduce fluctuations, and minimize the burden of daily topical medications.

For patients in earlier stages of disease, procedural pharmaceuticals and many MIGS procedures also avoid conjunctival disruption, which can help preserve eligibility for future interventions.

When selected based on disease severity and patient characteristics—such as visual field status, prior treatment history, and tolerance to medications—MIGS can help stabilize progression and improve long-term outcomes. Earlier use of procedures like SLT, procedural pharmaceuticals, or tissue-sparing MIGS can prevent unnecessary delays in pressure control.

As the treatment landscape evolves, clinical decision-making continues to evolve as well. Leading with interventional strategies in routine practice supports better pressure control and helps preserve vision, independence, and quality of life over time.