World Glaucoma Day: Modern approaches to care in demand

For World Glaucoma Day, ODs and MDs highlight modern approaches to glaucoma management, contrasting selective laser trabeculoplasty (SLT) and direct SLT (DSLT) while situating them within a broader interventional glaucoma philosophy that emphasizes early, proactive, and staged care.

First, Nathan Lighthizer, OD, FAAO, described SLT in terms of its efficacy and procedure characteristics. When used as a first-line treatment, SLT typically produces an IOP (intraocular pressure) reduction of about 20–35%, though the exact effect depends on treatment line, baseline pressure, and concurrent medications. The GLIOUS trial of DSLT demonstrated an IOP reduction of 18–27%, making its efficacy broadly comparable to SLT. Procedure time is a key differentiator: SLT generally requires 1.5 to 4 minutes per eye, influenced by the degrees treated and the operator’s experience, while dSLT delivers treatment in approximately 2.4–2.5 seconds, making it dramatically faster. Most patients feel little or nothing during SLT, whereas DSLT, delivered transsclerally with higher energy, tends to be felt more during the brief treatment window. However, that discomfort is limited to just a couple of seconds, versus several minutes for SLT.

Inder Paul Singh, MD, then placed these modalities within the framework of interventional glaucoma, which is less about favoring any single procedure and more about managing a lifelong disease through a sequence of interventions. He stresses that patient compliance issues and the need to prevent progression early demand an assertive, structured approach that still preserves quality of life. The journey often begins with primary SLT, targeting the trabecular meshwork as a physiologic first step. Over time, if SLT effect wanes or proves insufficient, clinicians may layer or sequence drug delivery systems, cataract surgery combined with MIGS, additional MIGS procedures in different outflow pathways, or topical drops. Singh emphasizes expectation-setting: patients should understand that multiple procedures over time are normal, and that the clinician’s goal is to prevent vision loss while maintaining the highest possible quality of life, rather than relying on a single “forever” surgery.

Finally, Pathik Amin, OD, FAAO highlighted a critical monitoring challenge: fast progressors in primary open-angle glaucoma (POAG), an estimated 15–20% subset who deteriorate more quickly than expected even with treatment. Identifying these patients requires frequent visual field and optical coherence tomography testing, but real-world practice falls short. A 2025 ophthalmology glaucoma study using nationwide claims data found that visual fields are performed only once every 1.6 years on average, well below recommended patterns. Amin pointed to strategies like cluster testing or front-loading visual fields—obtaining multiple tests in a compressed time frame—to build a robust dataset quickly, improve detection of rapid progression, and better tailor interventional strategies.

Overall, ECPs underscores a paradigm shift: glaucoma care as a proactive, iterative, and patient-expectation–driven journey, integrating laser options like SLT/dSLT with structured monitoring and a toolbox of interventional steps over the course of the disease.