AOA 2026: What to know about patient care in secondary glaucoma cases

Justin Schweitzer, OD, FAAO, discussed key themes from his lecture, “The Secondary Silent Thieves: Understanding Secondary Glaucomas,” presented at the AOA Optometry’s Meeting 2026 in Phoenix, Arizona. The session focused on secondary glaucomas, which he emphasizes can be more challenging and often more aggressive than primary open-angle glaucoma, leading to faster and more severe vision loss if not recognized and managed appropriately.

Schweitzer outlined several major forms of secondary glaucoma: pigmentary glaucoma, pseudoexfoliative (exfoliative) glaucoma, steroid-induced glaucoma, uveitic glaucoma, and both acute and chronic angle-closure glaucoma. Each subtype requires a tailored diagnostic and therapeutic approach. He noted that effective care begins with timely and accurate diagnosis, followed by an informed selection of treatment modalities, including topical medications, selective laser trabeculoplasty (SLT), and various surgical options.

Schweitzer also highlighted commonly missed clinical signs that should raise suspicion for secondary rather than primary glaucoma. For pigmentary glaucoma, he stressed the importance of carefully examining the corneal endothelium for pigment deposition and a Krukenberg spindle, performing gonioscopy to identify a heavily pigmented trabecular meshwork, and using retroillumination to detect iris transillumination defects. For pseudoexfoliative glaucoma, he underscored the need for a deliberate, close inspection of the lens to identify pseudoexfoliative material that may be subtle and easily overlooked without a high index of suspicion.

Therapeutically, Schweitzer explained that in pseudoexfoliative glaucoma, early cataract extraction can be pivotal because removing the lens may slow disease progression; this is often combined with minimally invasive glaucoma surgery (MIGS) or other surgical interventions. In pigmentary glaucoma, he reviewed the role of SLT in lowering intraocular pressure, while cautioning about the risk of IOP spikes in these heavily pigmented angles. As a result, he brings these patients back sooner—within 1–2 weeks rather than the more typical six weeks—for post-laser monitoring.

Finally, he emphasized that successful comanagement of complex secondary glaucoma hinges on robust, bidirectional communication between optometrists and surgeons. Optometrists should partner with like-minded surgeons who perform cataract and MIGS procedures, clearly delineate roles in care, and thoroughly educate patients about what to expect at the surgical center. From the surgical side, detailed feedback regarding the procedure performed, rationale, and target intraocular pressure is essential. Schweitzer concluded that when communication breaks down, patient experience suffers first, followed by deterioration of the professional relationship—ultimately compromising outcomes for those who need care the most.