Eyeworld

74 | EYEWORLD | WINTER 2026 G UCOMA to the MOON and BACK Valerie Trubnik, MD, EyeWorld Glaucoma Editorial Board member, commented on new tools, techniques, and challenges in anterior segment surgery: "In the next decade, I'd like to see minimally invasive glaucoma surgery com- bine both therapeutic and diagnostic surgical treatments. It would be amazing to have something akin to a Dexcom continuous glucose monitoring system to measure intraocular pressure in real time and treat the pressure accordingly by releasing appropriate pharmaceuticals. If we combine that with a stent as well to target open collector channels, that would make it even more effective. Knowing where to place the stents is key; real-time OCT angiography that can attach to a scope while performing the stents would be key." by Manjool Shah, MD Glaucoma Editor T here is something inherently captivat- ing about looking up at the night sky. In ophthalmology—and in glaucoma specifically—our field has spent the last de- cade doing our own version of reaching for the cosmos. We are navigating an era where sustained release intracameral therapeutics, precision microinvasive filtering devices, and novel ab interno outflow proce- dures are no longer theoretical launchpads but real instruments in our operating rooms and clinics. We are charting a broader constellation of care than ever before, aiming to treat earlier, reduce chronic drop burdens, and preserve sight with unprecedented safety. Yet, as any astronomer or astronaut knows, charting distant stars is meaningless if you lose your footing on solid ground. In this issue of EyeWorld, the Glaucoma articles examine the tension between our expanding therapeutic galaxy and the earthly friction points that dictate whether patients actually benefit: the realities of care in resource-limited settings and the growing friction within reimbursement infrastructure. In our first article, Michael Giovingo, MD, and Oluwatosin Smith, MD, ground us in the fundamental mission of our specialty: delivering care where resources are scarce. Whether navigating underinsured populations in safety-net health systems domestically or training surgeons abroad, the challenges are universal. Compliance cannot simply be as- sumed when a patient stretches a single bottle of drops for months or faces structural barriers to clinic access. Both Dr. Giovingo and Dr. Smith emphasize how procedural interventions—an- chored by first-line laser trabeculoplasty (SLT), cost-effective angle surgery, and the promise of drop-free sustained drug delivery—are redefining how we protect patients vulnerable to follow-up lapses. Dr. Smith's reminder that surgical education must be sustainable, training local surgeons so that care multiplies long after a mission ends, underscores that global impact relies on thoughtful, reproducible strategies. In our second article, we confront an obsta- cle of a different sort: the bureaucratic gravity holding back innovation at home. I contributed alongside Nathan Radcliffe, MD, and Thomas Samuelson, MD, and we discuss how the rapid pace of glaucoma technology is colliding head- on with coding and reimbursement structures. The recent controversy surrounding cyclodialy- sis with scleral reinforcement and proposed LCD restrictions on sustained release implants serve as a sobering case in point. Coding systems and coverage policies are vital for stewardship, but they exist to enable patient care—not the other way around. When administrative inertia or coding mismatches leave surgeons unable to of- fer a clinically sound procedure while awaiting a new CPT code or coverage determination, our patients pay the price in irreversible field loss. Glaucoma does not pause while bureaucracy catches up. As we look forward and shoot for the stars, expanding our surgical and pharmacological horizons, our responsibility as clinicians and as a Society is twofold. We must continue to champion bold, elegant innovations that push our field into the future. But just as urgently, we must advocate to ensure that these break- throughs remain accessible, fighting policy barriers in our healthcare system and bridging resource divides across the globe. I hope you enjoy this issue and that it inspires you to look toward the horizon while staying steadfastly committed to the patients right in front of us. An expanding therapeutic galaxy in glaucoma

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