As glaucoma care continues to advance, ophthalmologists are embracing innovative technologies and new approaches that are reshaping diagnosis and treatment. The Eye Care Network caught up with several leading members of the ophthalmology community for an in-depth discussion on key topics in glaucoma management—from integrating minimally invasive glaucoma surgery (MIGS) into treatment algorithms and addressing challenges in early detection of normal-tension glaucoma to the growing role of home monitoring and remote tonometry, and the emerging therapies and surgical techniques poised to transform care in the years ahead.

Joining in this discussion were the following:

• Thomas V. Johnson, MD, PhD, The Shelley and Allan Holt Rising Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
• Leonard K. Seibold, MD, Professor of Ophthalmology, Glaucoma Service Chief and Fellowship Director, University of Colorado School of Medicine, Aurora, CO
• Kateki Vinod, MD, Associate Professor of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York Eye and Ear Infirmary of Mount Sinai, New York, NY

The discussion began with a look at how MIGS fits into current treatment algorithms—and how each participant approaches patient selection and surgical decision-making in their practice.

How do you integrate MIGS into your treatment algorithm?

Johnson: MIGS is an integral part of the treatment repertoire that I offer to my patients. I feel that the majority of patients who have glaucoma and a visually significant cataract would benefit from a MIGS procedure at the time of surgery, either to help better control the IOP or to reduce the eyedrop burden. For patients with primary open-angle glaucoma (POAG), I tend to offer Hydrus (with or without canaloplasty) and for patients with primary angle-closure glaucoma (PACG), I typically offer canaloplasty with limited or 360-degree goniotomy.

I find that patients with progressing glaucoma also appreciate the option of a less invasive alternative to filtering surgery, though I typically recommend it when the target IOP is not below 15 since most MIGS have a difficult time achieving this level of absolute IOP reduction. A growing body of literature demonstrating the impact of MIGS on disease progression gives me confidence in these recommendations. For instance, we recently demonstrated that cataract surgery with Hydrus implantation reduces the rate of visual field loss in patients with POAG compared with their preoperative rate of progression.¹

Seibold: The easiest way to integrate MIGS into your practice is at the time of cataract surgery for any glaucoma or ocular hypertension (OHTN) patient in need of lower IOP, less medication dependence, or both. The shortcomings or topical glaucoma therapy are well known, so to be able to offer patients an avenue to reduce or eliminate their need for drops can be a huge patient satisfier. The need for cataract surgery presents a very low entry bar to integrate MIGS since you are already headed to the operating room. 

Vinod: Given its improved safety profile when compared with traditional glaucoma surgery (ie, trabs and tubes), MIGS allows us to intervene surgically much earlier in the disease course. I consider most patients with coexisting visually significant cataracts and mild-to-moderate open-angle glaucoma whose IOP goals are in the mid-to-high teens to be candidates for angle-based MIGS. When used as part of a combined procedure, trabecular MIGS offers the potential not only to provide additional IOP lowering beyond that produced by phacoemulsification cataract surgery alone, but also to reduce medication burden. This latter benefit is particularly important for patients with ocular surface disease (often resulting from chronic exposure to topical glaucoma medications and their preservatives) or suboptimal medication adherence. For patients with clear native lenses or those who are already pseudophakic, standalone MIGS is a valuable option to improve IOP control beyond what medications can achieve without the risks of traditional surgery. 

What challenges exist in early detection of normal-tension glaucoma?

Johnson: Diagnosing glaucoma in patients who have an IOP within the population normative range requires that clinicians have their antennae up to other important risk factors, like a suspicious looking optic disc or strong family history, to prompt a proper clinical assessment. Frequently, OCT is more informative than visual field testing for early detection, since most patients will manifest retinal nerve fiber layer defects or thinning, or macular ganglion cell complex thinning, prior to overt perimetric defects. The challenge lies in determining whether borderline defects on structural imaging are indicative of real disease, which typically involves following a patient over time and looking for progression. This is especially true in patients with myopia, who frequently demonstrate “red disease.” An important limitation of this approach, however, is that the patient and clinician are waiting for irreversible optic nerve damage to occur in order to confirm that the patient has glaucoma. For those with pre-perimetric disease, this may not have much impact on their visual function or quality of life, but novel methods to establish a confident diagnosis of glaucoma without having to wait for manifest disease progression would be a major advance for the field.

Seibold: The challenges of early detection of normal tension glaucoma (NTG) center around the subtle nature of signs and symptoms with this disease. Optic nerve cupping in NTG can be more focal on exam and easily missed. Similarly, disc hemorrhages, which are more common in NTG, can be easily mistaken for blood vessels on exam. Retinal nerve fiber layer (RNFL) thinning on OCT can be so focal, the global and quadrant analyses may fail to detect an abnormality. Visual field deficits in NTG often occur more focally and in a paracentral location where they may be missed with 30-2 or 24-2 strategies or falsely assumed to be from macular pathologies. Elevated IOP is one of the most common risk factors identified and the absence of this may lull clinicians into a false sense of security on the possibility of glaucoma during routine exams.

Vinod: A high degree of vigilance is required to detect NTG early in the disease course to avoid a delayed diagnosis. In the setting of IOP measurements in the “normal” range, subtle abnormalities in the OCT RNFL suggestive of early glaucoma can easily be overlooked, especially during busy clinic sessions. We call this “green disease” when, for example, a wedge defect is present on the RNFL thickness and deviation maps on an OCT RNFL but is not flagged by color-coding as being abnormal on the average RNFL thickness and/or sectoral analysis. In the same vein, a subtle paracentral defect observed on standard Humphrey visual field (HVF) 24-2 testing may erroneously be interpreted as a “nonspecific” finding during a cursory review, when in reality a follow-up HVF 10-2 might reveal a more marked defect consistent with NTG. High myopes in particular present unique diagnostic challenges in identifying early NTG. While their optic nerves may be especially vulnerable to the effects of IOP within the “normal” range due to decreased scleral rigidity and poor structural support for retinal nerve fibers, myopia itself can introduce artifact in the OCT RNFL and cause nonprogressive visual field defects unrelated to glaucoma. Consideration of corneal biomechanics is also important when assessing a normal-tension glaucoma suspect, as IOP readings may appear deceivingly “normal” in the setting of a thinner central corneal thickness or low corneal hysteresis.

How has home monitoring or remote tonometry influenced patient management?

Johnson: Our practice has dramatically increased its use of remote tonometry in recent years and found that it has had a profound impact on our care of patients with glaucoma. For patients with clear visual field progression, it has helped refine our recommendations for advancing therapy. For instance, some of our patients lose visual field despite an in-clinic IOP consistently in the 10-13 mm Hg range. In those patients, home tonometry typically shows one of two things: either an IOP consistently in the low teens or occult IOP fluctuations, most commonly in the early morning before clinic opens. For the former patients, I typically recommend a trabeculectomy shooting for a target of 8-10 mmHg. For the latter group, I feel comfortable offering less aggressive surgical intervention based on the idea that I may only need to blunt intermittent IOP spikes rather achieve a very low target IOP consistently.

Home tonometry has also helped us increase our workflow efficiency by enabling us to monitor IOP changes after therapy adjustments without as many clinic visits. For instance, we will often ask a patient to perform home tonometry before and after addition of an eye drop or SLT to judge efficacy, which saves the patient a trip to the clinic and frees up our appointment slots for more urgent issues. In addition, examining a range of IOP measurements over several days pre- and post-intervention provides significantly greater confidence in our judgement of the treatment impact.

Finally, we have found remote tonometry useful in monitoring high-risk postoperative patients. For instance, some of my patients perform home tonometry after trabeculectomy, which alerts me to the need for laser suture lysis in real-time, something that is beneficial since establishing flow in a bleb promptly is critical to prevent scarring and surgical failure. I believe that remote tonometry is going to become an integral part of glaucoma patient care very soon. Indeed, other fields of medicine learned the importance of properly monitoring highly dynamic physiological parameters decades ago – physicians don’t generally prescribe systemic anti-hypertensives based on isolated in-clinic blood pressure measurements or titrate insulin dosages based on a single spot-checks of blood glucose. Why should we as ophthalmologists be making treatment recommendations based on isolated in-clinic IOP measurements?

Seibold: Home monitoring has been a real game changer in my practice. With home tonometry, we have been better able to assess an individual patients present level of IOP more completely, and also identify treatment responses more accurately after an intervention such as medication or laser treatment. We have also been able to identify IOP spikes after hours or at times we failed to detect these during clinic visits. Conversely, we have also determined when a patient is NOT spiking after hours and are reassured in their level of IOP control by performing home tonometry. Thus, home monitoring has enabled us to make more informed and confident treatment decisions for patients. 

Vinod: Remote monitoring is revolutionizing the delivery of glaucoma care. By expanding glaucoma diagnostics beyond our offices into our patients’ homes with home tonometry and perimetry, we are able to obtain a more complete clinical picture and thereby optimize our management decisions. Importantly, home monitoring empowers patients to take a more active role in their glaucoma care. Home tonometry enables identification of IOP fluctuations and peaks (especially late at night and early in the morning) that would otherwise be missed during brief, infrequent office visits.

I routinely use this invaluable technology to evaluate patients whose visual fields appear to be progressing despite seemingly well-controlled IOPs measured in the office. Home tonometry results influence my determination of whether surgery is indicated and what surgery to perform and subsequently assists in assessing the postoperative IOP response. Home perimetry using virtual reality (VR) visual fields is a welcome alternative to standard automated perimetry (SAP) for many patients. SAP is long, arduous, and patient- and operator-dependent. Home monitoring with VR perimetry reduces bottlenecks in the office by freeing up both the SAP device and technician staff. VR perimetry may also help identify visual field progression earlier. However, at the present time, not all VR perimeters are equal in their ability to detect disease progression. Given such limitations, VR perimetry in its current state is perhaps best used as a supplement to, rather than a replacement for, SAP.

Which emerging therapeutics or surgical techniques may transform glaucoma care in the next 5 years?

Johnson: While subconjunctival stents have added a less invasive option for patients who require low IOP, they remain prone to fibrosis and failure, and clinical research has demonstrated their inferiority to trabeculectomy. I am excited for novel subconjunctival devices that might finally offer a safer yet equally (or more) efficacious alternative to traditional filtering surgery. I am also very excited for the advent of neuroprotective medical therapy for glaucoma. I am aware of a handful of companies which have new treatments in or nearing clinical trial, and after decades of hype, I am cautiously optimistic that we may finally have neuroprotective therapies at our disposal in the near future.

Seibold: Extended medication release modalities are likely to transform glaucoma care over the next 5 years. We already have seen two implants come to the clinic, but additional technologies are coming with the potential for even longer, more stable medication release as well as the potential for additional medications to be delivered. Surgical techniques and devices continue to be developed and modified to allow for faster, safer, and more effective filtering options for glaucoma patients as well. These include smaller diameter tube shunts, larger diameter stents, and titratable implants to better regulate flow.

Vinod: New glaucoma lasers are likely to become game changers in glaucoma management within the next few years. We learned from the LIGHT trial that SLT is an effective first-line therapy for newly diagnosed ocular hypertension and early open-angle glaucoma, stabilizing disease better than initial medical therapy and reducing the need for both cataract and incisional glaucoma surgery. As glaucoma laser technologies become safer and more efficient, their wider adoption not only by glaucoma specialists but also by comprehensive ophthalmologists will facilitate earlier intervention and hopefully decrease the overall disease burden in our growing and aging population.

Among these new options is direct SLT (DSLT). Already approved in the US, DSLT is performed via a translimbal approach without the need for gonioscopy. Additional laser technologies in the pipeline which are not yet FDA-approved include femtosecond laser image-guided high-precision trabeculotomy (FLightT; ViaLase), which is noninvasive, and excimer laser trabeculostomy (ELIOS; ELIOS Vision), which can be combined with phacoemulsification cataract surgery to improve aqueous outflow.

Thomas V. Johnson, MD, PhD
E: [email protected]
Johnson is The Shelley and Allan Holt Rising Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland. Johnson is a consultant for AbbVie, Qlaris Bio, and Thea Pharma, and receives research support from Alcon, BrightFocus Foundation, Firecyte, ICare USA, Injectsense, Maryland Stem Cell Research Fund, National Institutes of Health, Perfuse Therapeutics, Research to Prevent Blindness, The Glaucoma Foundation, US ARPA-H, and US Department of Defense.

Leonard K. Seibold, MD
E: [email protected]
Seibold is Professor of Ophthalmology, Glaucoma Service Chief and Fellowship Director, University of Colorado School of Medicine. Seibold consults for AbbVie, New World Medical, and Thea.

Kateki Vinod, MD
E: [email protected]
Vinod is Associate Professor of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York Eye and Ear Infirmary of Mount Sinai. Vinod has no financial disclosures.

REFERENCE

1. Hamilton NR, Akhlaq A, Nnoromele PO, et al. Clinical outcomes of Hydrus microstent implantation for open-angle glaucoma: results from a large academic center. Ophthalmol Glaucoma. doi:10.1016/j.ogla.2025.08.011