As ophthalmology looks to 2026, several emerging technologies have the potential to change how glaucoma is detected, monitored, and treated. From artificial intelligence (AI) to home monitoring and sustained-release drug delivery, these innovations could influence clinical practice, though their adoption will depend on factors such as workflow integration, cost, and patient acceptance.

The Eye Care Network spoke with Joel S. Schuman, MD, FACS, vice chair for research innovation and co-director of the glaucoma service at Wills Eye Hospital in Philadelphia, Pennsylvania, to discuss the developments likely to reach clinical practice in the near future, the challenges that may affect their implementation, and some of the experimental approaches that could influence glaucoma care over the next few years. This Q&A conversation provides a perspective on both the practical considerations and the emerging opportunities in the field.

Note: Transcript edited lightly for clarity and length. The thoughts and opinions expressed are those of Schuman and do not necessarily represent the opinions of this publication.

What emerging technologies do you believe are closest to transforming clinical practice, and what barriers might slow their adoption?

Joel S. Schuman, MD, FACS: No. 1 on everybody's mind is AI. The use of AI for imaging and also for risk prediction I think is probably the closest, and in some ways, already transforming practice.

Near term, we're looking at automated detection of glaucoma progression from optical coherence tomography (OCT) from the fundus photos, color fundus photos, from visual fields and from multimodal data. And that would include all of the things I just mentioned, as well as the electronic health record, and it's close, because we've already seen the adoption of AI for imaging in retinal disease, specifically in diabetic retinopathy, and so this was the first technology that was approved for use with AI by the FDA, and that technology is out there commercially, and it's being used heavily. I think that this has proven both the efficacy and safety of this sort of approach and the performance really rivals expert readers and the regulatory pathways are clear. Barriers in that area include the generalizability of the AI results, integration of the data into workflows, who bears the liability, and reimbursement.

The second item that I would bring up would be home or remote monitoring, and that includes home tonometry, virtual reality or home visual field and early handheld kiosk-type OCT, and these are close as well, because in the post-COVID era, we have more comfort with remote care, and the technology is maturing. Again, there are barriers: data reliability, patient adherence, data triage, burden, and also reimbursement.

I would add a third and a fourth technology. Third is the sustained release, or controlled release drug delivery, and here we have things like intracameral implants and next-gen depots for glaucoma, specifically at this point, for intraocular pressure lowering, but we're seeing studies of these sorts of devices for neuroenhancement or neuroprotection as well. These sorts of implants include the iDose or Durysta. Spyglass has an implant that is attached to an intraocular lens that's well long in studies. Perfused has an implant that's also well long in clinical studies showing neuro enhancement. There are some really interesting new technologies in this space that will transform the way that we do things. We have some already approved examples. The FDA has already approved Durysta and iDose, and I think that we're going to see more devices like that. The pipeline is maturing. On the barrier side, we have cost of these items versus generics, safety signals, patient acceptance, and workflow.

A new selective laser trabeculoplasty (SLT) device, the direct SLT, simplifies a procedure that is done and should be done by surgeons. It takes a procedure for which you need to have a fair amount of skill, you need to use a contact [gonioscopy] lens and visualize the trabecular meshwork and then treat the trabecular meshwork with a laser. And the new device, you simply point it at the eye. It finds the location that it's supposed to shoot at, and within a couple of seconds, it applies 100 spots translimbally, and so you don't need a contact [gonioscopy] lens in order to do it. It decreases the level of expertise that's necessary in order to perform the procedure. I would say that the barrier there is the "controversial" aspect of it in terms of who should be doing the procedure. It didn't succeed in the noninferiority studies, the GLAUrious study (NCT03750201)¹ that was published, and so you get about 2 millimeters less efficacy with that procedure.

What factors will determine whether an innovation would truly integrate into everyday practice, whether it be cost, training, workflow impact, or other factors as well?

Schuman: All of those things are important. Let's start off with 5 tests. First, I would say evidence. Is there good evidence? There’s a strong multicenter, real-world data that show outcomes that matter, and by that I mean things like progression, vision, and quality of life.

The second, you’ve already mentioned, workflow impact. It should simplify this. It’s not add clicks and screens.

Third, you also mentioned, I’ll call it economics. Is there a clear way of getting paid for doing the work, and what are the hidden costs? Are they either low hidden costs, or are there sizable hidden costs? And that includes training and staff time, but it also includes things like click fees, which we are seeing with direct SLT, that being another barrier to that particular technology.

Fourth, I would say, is interoperability. By that I mean that the technology has to work across devices with different types of electronic health records. There can’t be a vendor lock-in to a proprietary type of software where you can’t get the information out of the device. Also, I would add, we really should be able to interchange the information between devices that do the same thing. That’s a problem that we’re seeing now with OCT, for instance, where different manufacturers have great machines, but you can’t take the output of one machine and compare it with the output of another machine, even though both are stating that they’re measuring in microns. Apparently, a micron is not a micron when it comes to OCT, so it means something different on one machine manufacturer relative to another.

Finally, trust. The clinicians need interpretable outputs with predictable safety, and those things are important in integrating a technology into your practice. The winners don’t have to be the flashiest tools in 2026. They’ll be the ones that make a busy clinic run better.

How can clinicians or practices prepare now to take advantage of the most promising 2026 innovations once they reach maturity?

Schuman: That's a great question. There are several things that practices could be doing now to prepare. One is cleaning up their data. Standardize the OCT and visual field protocols; ensure high-quality analyzable data; prepare the IT systems for exporting and interpreting new data streams; and build digital readiness, so identify an internal innovation level and train staff so that they can understand and work with AI and remote monitoring technology so that they're literate in those areas.

Start small and measure what the impact is. You want to pilot the new tools in defined patient groups with clear metrics so that you know that you're receiving output of value and then scale only if there's a measurable benefit.

Finally, prepare patients and payers. Educate the patients on the coming shifts to continuous monitoring of intraocular pressure, for instance, and controlled-release therapies and engage payers and institutions early about workflows and reimbursement.

Are there any, for lack of a better word, "wild card" innovations or maybe experimental approaches in 2026 that could unexpectedly disrupt the field?

Schuman: Yeah, I think there are a few. Let's start with neuroprotection and metabolic therapy. For instance, nicotinamide or nicotinamide and pyruvate is nicotinamide vitamin B3. It's been shown now in a few studies that it may have a neuro-protective or neuroenhancing effect, but it's still in clinical trials. It's widely available. You don't need a prescription to get it. On the other hand, you can have some serious side effects, deleterious side effects from it, specifically liver inflammation related to the supplement. That's where the clinician needs to educate the patient about both the risks and benefits of potentially using this and we as clinicians are pretty used to and adept at providing that information and educating the patient appropriately. But this is one you can't just kind of throw into the mix. You need to really discuss it with your patient. It is not something that, for instance, the American Academy of Ophthalmology and the American Glaucoma Society are recommending that we prescribe or recommend to our patients, and certainly not without educating them about what the risks are.

Neurotrophin mitochondrial support—we're seeing phase 1/2 studies. If phase 2 and 3 results are strong, that could shift glaucoma care from being completely IOP-centric to including biologically modifiable targets.

Second, I would mention gene therapy and regenerative strategies. The resilience of the retinal ganglion cells may be something that we can enhance. People are working very hard on optic nerve regeneration. We're very much not there yet, but it is an area of intense scientific interest and of clinical importance. Stem cell approaches for optic nerve regeneration and support are also in studies. Finally, I would mention one area that consortium and I are working on in terms of stem cell therapy for trabecular meshwork regeneration in order to restore normal pressure control in people with glaucoma by introducing stem cells to the trabecular meshwork and outflow system. The early clinical signals there would reshape the long-term expectations.

Two more things. One is identification of new biomarkers and continuous monitoring, so perfusion metrics, tier and aqueous biomarkers or reliable real-time intraocular pressure measurements could change the way that we diagnose and treat and what the thresholds are for those treatments. Artificial intelligence for treatment planning, so individualization of therapy in glaucoma that would identify the trajectory of a given individual and allow you to treat based on the likelihood that that person is going to get worse and how quickly they're likely to get worse. It could optimize the timing of surgery. For instance, if you have somebody who's unlikely to get worse over a long period of time, maybe that's somebody that you would follow with laser or laser in medicine, whereas if you have somebody who's likely to get worse quickly, that's somebody who you might go directly to surgery, or you might have a very low threshold for moving to surgery in that patient.

There's one more thing that I would mention, which is genetics and the use of polygenic risk scores. That is available now, and it is something that can help to predict who is likely to develop glaucoma. If you look at people who have the lowest polygenic risk scores versus those that have the highest. It's not just a test that you can send off and say, "Okay, well, you're going to get glaucoma or you're not." It will give you a likelihood, but if the patient falls into those very high risk or very low risk groups, it can give you some confidence in planning that patient's follow up and treatment.

Anything else to add or that you feel is important for our audience to know?

Schuman: We've talked about a number of things. Hopefully, that is helpful for clinicians in our community, and there's plenty for researchers, scientists to work on. We still have a long way to go in enhancing the way that we deliver glaucoma care and what we can deliver, but I think that we're seeing progress. I'm excited about the new things that are becoming available and that people are working on now.

Joel S. Schuman, MD, FACS
E: [email protected]
Schuman is vice chair for research innovation and co-director of the glaucoma service at Wills Eye Hospital in Philadelphia, Pennsylvania.

Reference

1. Gazzard G, Congdon N, Azuara-Blanco A, et al. Randomized noninferiority trial of direct selective laser trabeculoplasty in open-angle glaucoma and ocular hypertension: GLAUrious Study. Ophthalmology. 2025;132(10):1091-1104. doi:10.1016/j.ophtha.2025.05.004