When to escalate glaucoma treatment: Key lessons from three complex cases

As glaucoma management evolves toward earlier intervention, the question of when and how to escalate treatment remains central to clinical practice. Deborah Ristvedt, DO, who is in practice with Vance Thompson Vision in Alexandria, Minnesota, moderated an Ophthalmology Times Case-Based Roundtable® at the 2026 American Society of Cataract and Refractive Surgery Annual Meeting in Washington, DC, and focused on interventional approaches in glaucoma management. The discussion emphasized a paradigm shift toward earlier, proactive strategies to reduce medication burden, improve IOP stability, and preserve visual function across mild-to-severe disease.

The roundtable participants discussed several complex cases that demonstrated a shift toward earlier and more proactive interventional glaucoma management. Clinicians are increasingly prioritizing reduced medication burden, improved IOP stability, and timely escalation based on disease severity. A flexible, patient-centered approach encompassing laser, sustained drug delivery, minimally invasive glaucoma surgery (MIGS), and filtering surgery is considered essential for optimizing long-term outcomes.

Cases demonstrating varying disease severity and management approaches

Case 1. Advanced age is not a contraindication. A 98-year-old woman presented with mild primary open-angle glaucoma (POAG) and an elevated IOP of 31 mm Hg in the right eye despite 4 topical antiglaucoma agents. She reported significant adverse effects, including ocular surface irritation—fluctuating vision, redness, and irritation—as well as systemic symptoms of dizziness and lightheadedness, raising fall risk concerns. Despite her advanced age, the patient was otherwise healthy with good visual acuity of 20/25 in the right eye and 20/20 in the left eye. Slit-lamp examination showed decreased tear film, trace staining, and bilateral IOLs.

Selective laser trabeculoplasty (SLT) was used to reduce IOP, achieving a decrease to 20 mm Hg on 1 prostaglandin analog. Given questions about nighttime IOP, intracameral bimatoprost (Durysta; Allergan) was subsequently administered. The patient is currently off all topical medications, with IOP of 15 mm Hg in the right eye and 14 mm Hg in the left eye, Ristvedt reported.

Case 2. Severe glaucoma requires rapid escalation. A 64-year-old pseudophakic man with severe POAG presented with an IOP of 38 mm Hg in the right eye despite maximal medical therapy (4 medications) and previous SLT, and 13 mm Hg in the left eye. He demonstrated advanced optic nerve damage (0.95 cupping) and significant visual field loss.

The clinical considerations included high IOP with advanced structural and functional damage, failed SLT, and the need to preserve remaining vision in the right eye. Given the severity of the glaucoma despite maximal tolerated medical therapy, a subconjunctival filtering procedure using a device (Xen Gel Stent; Allergan) was selected. Two years postoperatively, IOP was controlled at 15 mm Hg following needling with 5-fluorouracil.

Case 3. Stepwise escalation in pseudoexfoliative glaucoma. A 76-year-old pseudophakic man with pseudoexfoliative glaucoma presented with an elevated IOP of 31 mm Hg in the right eye on 3 medications and early structural and functional changes. Left eye IOP was 17 mm Hg. The right angle was open with 0.75 cupping; left eye cupping was 0.65. Optical coherence tomography showed inferior retinal nerve fiber layer loss in the right eye.

With uncontrolled IOP on multiple medications and the presence of pseudoexfoliative material, a goniotomy (OMNI 360/180; Sight Sciences) targeting the trabecular meshwork was performed. The procedure was initially successful, but IOP rebounded to 32 mm Hg at 6 months, managed with a combination medication.

An implantable device (iStent infinite; Glaukos Corporation) was subsequently implanted in the angle with the remaining trabecular meshwork, achieving control for approximately 1 year. IOP then increased again to 38 mm Hg, and the patient’s IOL dislocated, requiring Yamane fixation, leaving IOP uncontrolled. Another device (Xen Gel Stent) was ultimately selected as definitive treatment for refractory disease after 2 angle-based procedures.

Case takeaways

Case 1. Age alone should not preclude interventional treatment. Reducing medication burden in older patients may improve both ocular surface health and systemic safety. Sustained-release therapies and SLT can be effective tools for achieving this goal.

Case 2. In cases of severe glaucoma, especially with rapid progression or advanced field loss, clinicians should move quickly to more definitive surgical options rather than pursuing incremental interventions. Angle-based procedures may be insufficient in this context.

Case 3. Pseudoexfoliative glaucoma often demonstrates fluctuating and progressive behavior, requiring iterative escalation. Although MIGS can delay more invasive surgery, clinicians should recognize when to transition to subconjunctival filtration for sustained control.

The approach to interventional glaucoma

Ristvedt commented that the interventional glaucoma consensus protocol gives clinicians a starting point for thinking about earlier glaucoma management. With early intervention, clinicians can be proactive rather than reactive in achieving 24-hour IOP stability and preventing visual field loss.

Selecting the appropriate intervention depends on disease stage, prior treatments, and patient-specific factors. “The consensus protocol has given us a guideline that we don’t have to follow to a T. However, in a number of different scenarios, we work on a case-by-case basis and look at the severity as well as the algorithm for the treatment of glaucoma,” Ristvedt said.