At this year’s glaucoma subspecialty day at the American Academy of Ophthalmology (AAO) meeting, David S. Friedman, MD, PhD, MPH, outlined a vision for “truly personalized glaucoma care,” emphasizing how genetics, patient-reported outcomes, and emerging technologies can help clinicians tailor management to each patient’s unique risk profile, lifestyle, and visual needs.
Dr. Friedman is the Edith Ives Cogan Professor of Ophthalmology at Harvard Medical School and serves as the director of the glaucoma service and the medical director of clinical research at Massachusetts Eye and Ear. Dr. Friedman has published more than 450 peer-reviewed articles and has been instrumental in landmark studies on angle-closure glaucoma, including the EAGLE trial and the Zhongshan Angle Closure Prevention (ZAP) study as well as carrying out clinical trials to improve patient adherence to therapy and several large epidemiologic studies.
During our conversation, which has been edited for length and clarity, Dr. Friedman discussed what personalized care means in practice, the role of patient needs and genetics in shaping management, and how innovations in monitoring and treatment are poised to transform how glaucoma patients are identified, treated, and followed.
Glaucoma Physician: The American Glaucoma Society Subspecialty Day Lecture during AAO is one of the most prestigious in ophthalmology. What does receiving this honor mean to you personally and professionally?
Dr. Friedman: I was very happy to learn that I had been selected. It's an honor, a once-in-a-lifetime opportunity. The wonderful thing about this lecture is that it’s a chance to think about what I want a large group of people to take away from my talk, to bring back to their patients and to their clinics. That’s how I’ve been reflecting on the selection.
GP: Your lecture topic this year is “truly personalized glaucoma care.” Could you explain what that means to you?
Dr. Friedman: We’re at a crossroads in glaucoma care. Over the past 20 or 30 years, we’ve learned so much that’s changed what we’re capable of doing for patients, and now we can deliver care that’s genuinely individualized. The way I think about our role as glaucoma specialists is simple: to make sure every person with glaucoma gets the care they need—and the best care possible.
One major systemic failure is the fact that around half the people with glaucoma remain undiagnosed in the US and many more in less developed countries. Advances in artificial intelligence, imaging, and risk assessment can help us close that gap.
Personalized care will involve deploying our understanding of glaucoma genetics to improve the care we provide. We’re finally reaching the point where the enormous investment in glaucoma genetics can be applied directly to patient care—whether it’s gene therapy for rare, early-onset glaucomas or using genetic profiles to understand risk, predict progression, and tailor treatment in more typical cases. For the first time, we’re close to moving beyond the “one-size-fits-all” approach that has defined glaucoma management for decades.
GP: What role do patient lifestyle and socioeconomic factors play in tailoring glaucoma management plans?
Dr. Friedman: A big part of personalized care is understanding the person across the chair from us—what it means for them to live with glaucoma. We often focus on preventing blindness, but for most people, glaucoma is disabling long before that point. It affects their mobility, their emotional well-being, their confidence, and their ability to work. We need to do a better job of recognizing and measuring those impacts through patient-reported outcomes.
There’s also the reality that many patients struggle with taking their drops regularly. That’s been well documented in research, including some of my own work. Given we know this is a problem, we should be providing treatments that do not rely on adherence when possible. We should do more selective laser trabeculoplasty, which was shown to be better than drops as a first-line therapy in the LIGHT Trial. And when drops are needed, we can support adherence with better communication, reminders, and education. Ultimately, we must tailor management to each patient’s daily life and resources—not just prescribe the same plan for everyone.
GP: Are there emerging tools or technologies that you expect will transform personalized glaucoma care in the next decade?
Dr. Friedman: Yes, and it’s an exciting time. One area I’m very interested in is how we can use technology to identify and monitor patients more effectively. For example, there’s a study led by Felipe Medeiros showing that if you intensively test the visual field over a short period—say, a month—and then repeat it 6 months later, you can quickly identify patients with rapidly worsening glaucoma. Those patients are the ones we really need to focus on.
Looking ahead, new tools like virtual reality–based or home visual field testing, and centralized or hybrid care models, could help us monitor patients more frequently and more efficiently. That means we could see those who need us most more often, while maintaining oversight of others remotely. It’s going to change the way we practice, but in a good way. We’ll have better data, better monitoring, and ultimately a more tailored approach to every patient’s needs.
GP: You mentioned the growing role of genetics in glaucoma care. How do you see genetic testing and risk profiling changing the way we diagnose and manage glaucoma in the coming years?
Our group, led by Jenny Wiggs at Mass Eye and Ear, is working closely with colleagues Nazlee Zabardast and Louis Pasquale on an NIH-funded study exploring exactly that question. We’ve invited individuals with high and low genetic risk scores for glaucoma to participate, and the results have been striking. Those with high genetic risk show a much higher prevalence of glaucoma—close to 20%—with half being undiagnosed. So, if we everyone knew her risk score today, we could start identifying many undiagnosed patients.
Genetics also has powerful implications for families. For example, if a young patient presents with glaucoma, we can now determine which specific gene is responsible and then screen their siblings to identify who truly needs close monitoring. That’s a practical, near-term win for genetics in everyday care.
Looking ahead, we’re starting to see how certain genes influence how glaucoma manifests and progresses. Work by my colleague, Inas Aboobakar, has found that some genetic profiles appear to be associated with defects near fixation or with mitochondrial dysfunction. That’s where we can start tailoring therapy—one size may not fit all. There are already randomized trials testing nicotinamide, which targets mitochondrial pathways. Patients with certain genetic profiles may respond far better to that approach. As more people undergo genetic testing and we collect more longitudinal data, we’ll be able to group patients by genetic subtype and treatment response. That’s where glaucoma genetics is heading—toward a truly individualized model of care over the next 5 to 10 years.
GP: What is a key insight or practical step you hope glaucoma specialists will take away from your lecture to bring personalized care into their daily practice?
Dr. Friedman: Practically speaking, the first thing I would recommend is that we all do more laser trabeculoplasty as initial therapy for individuals with glaucoma and ocular hypertension. I also think we should be more aware of the disabilities our patients face, ask them about those challenges, and refer them to services if needed. And finally, I hope some of the evidence supporting intensive monitoring helps us find ways to conduct more tests, enabling us to identify patients who are worsening more rapidly. Overall, these are some specifics, but the general theme is: Let’s do what patients really need and figure out how to treat them the best we can. I hope the doctors in the audience leave asking themselves what else they can do to provide even better care for the patients sitting across from them right now.
Dr. Friedman: Getting to the point where I can give this talk relies heavily on mentorship and collaboration. None of the research or clinical work I’ve described is done by one person; it’s really a team effort. I’m very thankful for all the guidance and support I’ve had over the years. GP