Eyeworld

76 | EYEWORLD | FALL 2026 G UCOMA she said. "These have the advantage of the effi- cacy of topical pharmaceuticals and don't carry the burden of patient compliance." Dr. Funke also said that her approach continues to evolve. "As the interventional glaucoma options become more abundant and effective, I continue to be more confident in the success I will achieve from laser and surgi- cal treatment. Thus, I am more likely to use interventional glaucoma methods to remove the burden of multi-drop therapy for patients." There may be other factors to consider as well—including access, pricing/reimbursement, and more. "Unfortunately, the reality of practic- ing medicine involves understanding what pro- cedures and topical medications are covered by insurance companies," Dr. Funke said. "Patients may be unable to afford brand-name medica- tions and certain procedural options. Knowing how to navigate within this quagmire of differ- ent coverage policies can be burdensome for providers and patients. Depending on policies, a patient may have limited access to care." She added that each case is approached differently. "For some patients, I stay within the boundaries of what is covered by their policy. For other patients, I will petition for a cover- age review," she said. "I also try to be involved in studies, which allows patients options that would otherwise not be available." Dr. Goldburg agreed that access and insur- ance coverage may play a role when choosing an appropriate treatment plan. Drop prices can be expensive, depending on insurance, she said, adding that SLT will often be covered. "I think that's just another reason to offer patients SLT early," she said. Dr. Lin noted that the landscape for provid- ing care will likely continue to change. "There are so many MIGS and other devices in develop- ment, and perhaps some will have more favor- able efficacy versus safety profiles than others for specific patients," he said. "While it would be nice to make glaucoma surgery outcomes as predictable as cataract surgery, there is too much variability in patient healing responses and underlying mechanisms of disease for us to have a single go-to procedure that we do for every single patient with glaucoma. We will need to continue to evaluate where each new approach fits in our toolbox for each patient." Dr. Goldburg is particularly excited to see how drug-eluting technologies evolve. She mentioned SpyGlass Pharma's investigational medication change or an additional procedure," she said. "In this scenario, I also like to have a conversation around compliance of topical ther- apy. Normalizing poor compliance is important (as opposed to shaming patients when they are inconsistent with topical treatment). Getting to the root of progression will help further define what next steps are best for each patient." In addition to IOP, Dr. Funke said there are other factors to consider. A high IOP in clinic can aid in understanding a lack of control, but a low IOP isn't as clinically relevant. "Because a single IOP measurement is only one small snapshot in time, I prefer looking for worsening disease via HVF and OCT," she said, adding that a weeklong home diurnal test can give a better understanding of waking hour diurnal variation. Recently, Dr. Funke has begun to use home visual field monitoring by Peripherex. "This system uses eye tracking technology to capture a visual field on a com- puter or laptop," she said. "While these fields are different from a Humphrey visual field, they can be done more frequently and can be used to capture field changes faster." Other factors to consider are the patient's ability and willingness to take topical therapy. Dr. Funke said she finds that patients who require treatment beyond initial SLT will often benefit from a combination of procedures and topical therapy. "When combining treatment modalities, I try and think of the mechanism of action provided by each treatment," she said. "If I use canaloplasty to work on the convention- al drainage structure, the patient may benefit more from a prostaglandin analog that works on the unconventional drainage system. Histor- ically, we have used different pharmaceutical compounds to a similar end, but now we can in- corporate interventional glaucoma procedures, which carry the added benefit of bypassing the issue of patient compliance." Dr. Funke said that SLT is one of her favor- ite ways to treat early glaucoma. "The LiGHT Trial helped pave the way toward using this as first-line therapy," she said. "However, MIGS in combination with cataract surgery or as stand- alone procedures are a fantastic way to slow progression of glaucoma loss." She added that the HORIZON Trial highlighted the positive long-term effects of Hydrus (Alcon), and she expects similar long-term results from all MIGS modalities. "In my practice, I have also seen a large growth in the use of drug-eluting devices," continued from page 75

• Cover