Interventional glaucoma: Redefining the optometrist’s role in modern glaucoma management

Glaucoma, a leading cause of irreversible blindness globally, has traditionally been managed through a combination of topical medications, laser procedures and incisional surgeries.The advent of interventional glaucoma, a treatment paradigm emphasizing earlier, proactive and often minimally invasive procedures, has transformed how clinicians approach this chronic disease. This article explores the principles of interventional glaucoma and emphasizes the critical and evolving role optometrists play within this model. From early diagnosis and patient education to collaborative care for lasers and minimally invasive procedures, optometrists are uniquely positioned to lead this proactive approach to glaucoma care.

Glaucoma is often described as the silent thief of sight due to its insidious progression and asymptomatic early stages.¹ Historically, treatment followed a conservative approach, starting with pharmacological therapy and escalating to laser or surgical interventions only when medications failed.² However, the limitations of this reactive strategy, particularly in patient adherence and delayed surgical referrals, have prompted a re-evaluation of treatment protocols.

Enter interventional glaucoma, a modern proactive treatment paradigm that seeks to intervene earlier in the disease course with procedures that are effective yet less invasive than filtration surgeries.³ This shift not only improves disease control but also reduces the burden of long-term medication use.³ In this context, optometrists are increasingly becoming pivotal figures, both as primary eye care providers and as integral partners in multidisciplinary glaucoma care teams.

The evolution of glaucoma treatment

In traditional glaucoma management, treatment focused on lowering IOP using a stepwise model:

• Topical medications, often starting with prostaglandin analogues²
• Laser trabeculoplasty (typically selective laser trabeculoplasty [SLT]) introduced after medication failure²
• Filtration surgeries (e.g., trabeculectomy or tube shunts), reserved for advanced or refractory cases²

Although this model is effective for some patients, it has several shortcomings. These include poor adherence and financial obligations to lifelong eye drops, delayed escalation of therapy, increased disease progression, significant adverse effects from medications and invasive surgeries and a reactive (rather than preventative) clinical approach. The interventional glaucoma paradigm re-evaluates this progression, advocating for earlier use of laser, minimally invasive glaucoma surgeries (MIGS) and sustained-release procedural pharmaceuticals.³ The goal is to intervene sooner, preserve optic nerve function and minimise long-term medication dependence.

Defining interventional glaucoma

Interventional glaucoma is not defined by a specific procedure but rather by its proactive treatment philosophy. Key features include the following:

• Individualised care that balances IOP control, patient lifestyle and long-term prognosis⁴
• Early diagnosis using advanced imaging, such as optical coherence tomography (OCT), pachymetry and visual field analysis⁵
• Lower thresholds for initiating laser therapy, such as first-line SLT
• Timely referral or collaborative care for MIGS procedures
• Rather than waiting for disease progression or medication failure, this model empowers clinicians to offer safe, minimally invasive procedures earlier, when they are most effective.³

The expanding role of optometrists

As front-line providers in eye care, optometrists are ideally positioned to drive the interventional glaucoma model. Their role has evolved beyond screening and referral. Today, professionals are active participants in the diagnosis, treatment, collaborative care and ongoing monitoring of glaucoma.

• Early detection and risk stratification. Routine eye exams present a prime opportunity for early detection. With access to advanced diagnostic tools such as OCT, visual field testing, gonioscopy, pachymetry and corneal hysteresis, optometrists can identify glaucoma suspects and initiate risk stratification early.⁵ By closely monitoring ocular hypertension and subtle nerve fiber layer changes, optometrists play a vital role in determining when to escalate care.⁵
• Initiation of treatment. Recent studies, such as the LiGHT trial (ISRCTN32038223), have shown that SLT is a more effective first-line therapy than medications, with a superior adverse effect profile and improved adherence.⁶ As of now, optometrists in 14 US states are authorised to perform SLT, and that number continues to grow yearly.⁷ Additionally, optometrists manage pharmacological therapy by tailoring medication regimens, educating patients on administration, and mitigating adverse effects. As early intervention becomes standard, optometrists will increasingly be responsible for initiating or recommending nonpharmacologic therapies.
• Collaborative care for laser and surgical procedures. With the rise of MIGS (e.g., iStent [Glaukos] and OMNI Surgical System [Sight Sciences]) and sustained-release procedural pharmaceuticals (eg, bimatoprost intracameral implant [Durysta; AbbVie Inc.] and iDose [Glaukos Corp.]),³ optometrists have embraced a critical collaborative care role. They are involved in preoperative counselling and selection of procedural candidates; post-procedure follow-ups to monitor wound healing, IOP trends and complications; and adjusting therapy in response to procedural outcomes. This collaborative framework enhances continuity of care and allows glaucoma specialists to focus on surgical cases.
• Patient education and adherence support. Optometrists are uniquely trusted providers who often have long-standing relationships with their patients. This continuity fosters better communication around disease progression and treatment options, improves adherence to prescribed regimens and reinforces the benefits of early interventional approaches. As interventional glaucoma emphasises preventative action, the optometrist’s ability to counsel and motivate patients becomes increasingly valuable.

Barriers and opportunities

Despite the advantages of interventional glaucoma, challenges remain, including the following:

• Patients and clinicians may be hesitant to adopt new treatment modalities or unaware of the evidence supporting them.
• Access to equipment like SLT lasers or OCT imaging can be a barrier in smaller practices.
• Interprofessional collaboration still needs improvement to ensure smooth referral and collaborative care communication.

However, these challenges also present opportunities, such as the following:

Optometrists can play a central role in educating patients and clinicians about the robust evidence supporting interventional glaucoma therapies.

Collaborative care models can improve patient access and reduce specialist wait times.

Continuing education and certification programmes can enhance optometric proficiency in glaucoma care.

Conclusion

Interventional glaucoma represents a transformative shift in the treatment of a historically undertreated disease. By embracing early, minimally invasive therapies, this model seeks to prevent irreversible vision loss before it occurs. In this new paradigm, optometrists are not only gatekeepers but leaders orchestrating early detection, initiating evidence-based treatment, co-managing procedural cases and providing lifelong support to patients.

As technology advances and collaborative care models evolve, the role of optometrists in glaucoma management will only continue to grow. Positioned at the intersection of access, expertise and continuity of care, optometrists are indispensable allies in the fight against glaucoma-related blindness.

Khanh Hoang, OD

E: [email protected]

Hoang grew up in Toronto, Canada, and earned a bachelor of science degree in honors science from the University of Waterloo. He went on to receive his doctor of optometry degree from the Illinois College of Optometry, graduating cum laude. During his time there, he was inducted into Beta Sigma Kappa and Tomb and Key, both honor societies in the field of optometry. In July 2024, Hoang completed a postgraduate residency in ocular disease at Omni Eye Services. Following his residency, he joined Omni Eye Services full time as a consultative optometrist, with a clinical focus on glaucoma. That same year, he was honored with the Optometry Times 2024 Visionary in Eye Care Resident Recognition Award for Best in Optometry. He currently serves as a consultant for Glaukos.

References

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5. Medeiros FA, Zangwill LM, Alencar LM, et al. Detection of glaucoma progression with Stratus OCT retinal nerve fiber layer, optic nerve head, and macular thickness measurements. Invest Ophthalmol Vis Sci. 2009;50(12):5741-5748. doi:10.1167/iovs.09-3715

6. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393(10180):1505-1516. doi:10.1016/S0140-6736(18)32213-X

7. Major victory for West Virginia patients, optometrists. American Optometric Association. Accessed August 15, 2025. https://www.aoa.org/news/advocacy/state-advocacy/major-victory-for-west-virginia-patients-optometrists