Defining interventional and controlled glaucoma

Inder Paul Singh, MD, a glaucoma and anterior segment surgeon and president of the Eye Centers of Racine & Kenosha in southeastern Wisconsin, spoke at EnVision Summit in Puerto Rico about the evolving concept of interventional glaucoma. Singh framed interventional glaucoma not as a single procedure or a rush to surgery, but as a proactive, longitudinal approach to managing glaucoma with a focus on both early intraocular pressure (IOP) reduction and quality of life.

Singh emphasized that patient compliance is a real and significant challenge in glaucoma care. Because non-adherence to eye drop regimens can lead to disease progression, he argued for earlier and more aggressive intervention using procedures rather than relying solely on topical medications. The foundation of this strategy, in his view, is primary selective laser trabeculoplasty (SLT). He described SLT as the most physiologic approach, directly treating the trabecular meshwork, a key site of outflow resistance. SLT is presented as a baseline procedure that can be repeated and built upon over time.

Singh outlined a stepwise “patient journey”: starting with SLT, repeating it if needed, then considering sustained drug delivery options if SLT alone is insufficient. When cataract surgery becomes relevant, he advocated combining it with MIGS (minimally invasive glaucoma surgery) procedures targeting the conventional outflow pathway, potentially followed by additional drug delivery or other MIGS approaches (such as those in the suprachoroidal or subconjunctival spaces) if pressures remain suboptimal or effects wane.

A key philosophical point is expectation setting: patients should understand that glaucoma management is a journey involving multiple possible interventions over time, not a single, permanent fix. This mindset also reduces pressure on surgeons to have one “perfect” surgery.

Finally, Singh calls for a redefinition of “controlled glaucoma.” He argued that control should not be judged solely by IOP numbers and visual field/OCT stability while on multiple drops. Instead, drop burden, side effects, cost, forgetfulness, and other barriers to adherence must be factored in. He noted data suggesting that patients off medications, with equivalent IOP reduction achieved via procedures, often experience less progression, fewer secondary surgeries, and better long-term outcomes. Therefore, even patients seemingly stable on multiple drops may warrant interventional treatment if their burden of therapy is high, even in the absence of overt complaints.