Eyeworld

74 | EYEWORLD | FALL 2026 G UCOMA REWIND. REFRESH. REFINE. by Ellen Stodola Editorial Co-Director About the physicians Christine Funke, MD Barnet Dulaney Perkins Eye Center Phoenix, Arizona Samantha Goldburg, MD Cole Eye Institute Cleveland Clinic Cleveland, Ohio Michael Lin, MD Associate Director Glaucoma Service Massachusetts Eye and Ear Assistant Professor of Ophthalmology Harvard Medical School Boston, Massachusetts best choice. "That said, the majority of patients in my clinic are still taking drops of some sort; perhaps they were started on them by another doctor, I started them after they reached the point of SLT exhaustion, my surgery didn't quite achieve sufficient glaucoma control and we're not ready for another one yet, etc.," he said. As first-line treatment, Dr. Goldburg said she prefers SLT, when possible, ever since the LiGHT (Laser in Glaucoma and Ocular Hyper- tension) Trial data showed that SLT first is very effective. "A lot of patients prefer to not be on a drop," she said. "Some physicians worry that recommending a laser procedure may sound intimidating to patients. I frame it by empha- sizing that SLT is supported by robust clinical evidence, has an excellent safety profile, and it is the first-line treatment I would choose if I were in their shoes." Dr. Goldburg also offers SLT to patients who initially present already using drops, as a way to decrease medication burden. Drops are not "harmless," Dr. Goldburg said, and she carefully discusses this with her patients. Many patients who have already experienced the effects of chronic topical therapy are enthusiastic about the opportunity to reduce their medication bur- den, even just by a single drop. Dr. Goldburg will add a topical medication if IOP remains above target after SLT. She's also recently started using Durysta (bimatoprost intracameral implant, AbbVie). Though she was initially skeptical because of the limited dura- tion, Dr. Goldburg finds this beneficial because it can help patients remain off drops longer if performed as the next step following SLT. She offers this as an option, and patients typically like it, but she is careful to add that patients will likely need to use drops later. While Dr. Goldburg prefers to start with SLT instead of drops, she likes to maximize medical therapy before proceeding with surgery, when possible. This can help determine if the patient can be controlled on medication alone, and if the answer is no, because they have very severe disease and are still progressing even on maximum medications, it's an easy decision to move to the OR. If they can be controlled on maximum medications, great, she said. Some patients may want to continue with this because it's a less invasive approach. Others, however, F inding the most effective way to ap- proach a patient with glaucoma can be a challenge, and it may take time to find the best treatment or combination of treatments. Christine Funke, MD, Samantha Goldburg, MD, and Michael Lin, MD, discussed where they start for these patients, how they are combining medications with pro- cedural intervention, and the future of treat- ments in the glaucoma field. Dr. Funke finds it beneficial to begin ther- apy immediately when a patient is diagnosed with glaucoma. This is when topical therapy is appropriately utilized, she said. "I will start a patient on topical therapy the day of initial consult with the understanding that the topical therapy is only the first step of treatment and will be used as a bridge until further treatment is implemented," she said. "My goal of using topical therapy as a bridge is based on the statis- tics around poor long-term compliance rates of drop therapy. Within 6–12 months, the majority of patients will no longer be using their topical medications." Proper medication use continues to decrease as more topical agents are added. SLT or DSLT is often the next step in the therapeutic journey for a patient. "Using laser is essential, as it depresses diurnal fluctuation in addition to lowering IOP," she said. "For most patients, I will stop the topical therapy follow- ing SLT to observe the level of control the laser procedure has achieved." When deciding which treatment to start with for his glaucoma patients, Dr. Lin said there are a number of factors to take into ac- count, including angle anatomy, disease mech- anism and severity, untreated IOP, likelihood to adhere to drops, family history, age, etc. "I do not always start with drops," he said. "If the angle is open and untreated IOP is in the 20s or even low 30s, I think many ophthalmologists will offer primary SLT, as we are doing in the COAST [Clarifying the Optimal Application of SLT Therapy] Trial. For patients who have NTG with lower starting IOP, drops may be more effective at lowering IOP." He added that there will always be pa- tients who are "squeamish" about the idea of laser or surgery, but it's possible to help many of them accept the option of proceeding with this treatment if you clearly explain why it's the It takes two: combining medications with procedural intervention in glaucoma

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