Eyeworld

FALL 2026 | EYEWORLD | 75 G factors besides IOP, including visual field and OCT progression vs. stability, other treatments the patient has already had before, prior intol- erances, attitudes toward procedures, tolerance for risk, age, etc. He noted that patients with poor medication adherence, presentation with advanced disease, very high starting IOP, poten- tial for limited follow-up, and specific causative genetic mutations may benefit from a combined approach. Dr. Lin has experience using a wide variety of glaucoma procedures and devices to help his patients and said his approach to combin- ing therapies continues to change with more experience and as more data is available. "I think most ophthalmologists are now comfort- able offering SLT much earlier in the treatment algorithm," he said. "I have not been an early adopter of sustained release drug delivery devices, but if concerns such as cost and corneal endothelial cell health were not considerations, I could see them playing bigger roles in care. I do offer standalone MIGS and phaco/MIGS slightly earlier than I did previously, especially when it is clear that adherence is an issue or it is clear that maximum tolerated medical thera- py is not sufficient, but the patient and I are not quite ready to proceed with something such as a trabeculectomy or tube shunt." When determining if medication alone is no longer effective, Dr. Funke said it's important to ask yourself what the definition of controlled glaucoma is. "Is a patient controlled if they come to clinic with a low IOP? Unfortunately, the current diagnostic testing for glaucoma does not easily delineate which patients are well con- trolled," she said. "Therefore, we must assume what glaucoma studies continue to show us; most patients are not compliant with topical medications, and the diurnal curve is not blunt- ed with topical therapy during sleeping hours. I think most patients are not controlled with topical therapy alone, and a combined approach to therapy must be utilized." Dr. Funke said that in a patient who has had an interventional procedure in the past and is actively treated on topical therapy, she watches the visual fields and OCT readings. "If there is progression on diagnostics, I need to change my treatment strategy. This can mean a might want to decrease the medication burden. "Some people are much more conservative, and they want to work their way up from least in- vasive to most invasive, in a stepwise approach. Others want to proceed with a more aggressive intervention immediately because they hate the idea of being on several medications," she said. "But I do counsel patients that sometimes the surgeries won't be as effective as we want, and they still might require additional surgery or continued topical medications after surgery. I think expectation setting is crucial." Dr. Funke stressed that while topical drops are an effective method of treating glaucoma, they are not a great long-term solution. Dr. Funke has several goals as a provider treating glaucoma. The first, she said, is to ensure that some form of an interventional procedure has been performed (e.g., laser, drug-eluting device, MIGS). "I think these procedures are an import- ant component of treatment, as they assist in depressing diurnal IOP variation and circumvent the issues around topical treatment." Dr. Funke said she has seen large numbers of patients return to care after months or years of non-compliance to follow up in her last de- cade of practice. "I have seen a distinct pattern where those who had some form of laser/surgi- cal care lose less visual field than those who had topical therapy alone," she said. Her second goal as a provider is to limit the amount of topical medication used. Though topical therapy is effective, Dr. Funke noted that most patients find it challenging to use daily. "While I would love to see all patients con- trolled without the burden of topical therapy, limiting a patient to a maximum of two topical medications is my real-world goal." Her third and final goal is to ensure patients know the alternative treatments available, both topical and procedural. When determining if it's time to move on from a medication-alone approach, Dr. Lin looks at it from the perspective that this option is "not effective enough." If used regularly, most com- mon medications don't exhibit tachyphylaxis, he said, where the response to medication decreas- es over time, but he noted that it may be more accurate to describe outflow obstruction as worsening, and therefore, the current medica- tion is not sufficient. There are numerous other continued on page 76

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