For decades, glaucoma management has centered around eye drops as the first line of defense. Despite therapeutic advances and procedures becoming less invasive and evidence mounting that early intervention is beneficial, many ophthalmologists remain hesitant to recommend surgery early in the disease state. Although it is often assumed patients are reluctant to undergo a procedure, research and clinical experience show that patients generally trust their doctor’s recommendations.¹ Now is the time to reconsider our own hesitations as providers: Are patients wary of surgical intervention, or are we using drops as a crutch?

The Limits of Eye Drops

Topical drops are traditionally the first choice for managing primary open-angle glaucoma and high intraocular pressure (IOP). Despite their popularity, these regimens are disliked by both patients and doctors due to poor adherence. Studies indicate that 20% to 70% of glaucoma patients fail to follow their prescribed drop regimen, resulting in unstable IOP, uncontrolled diurnal fluctuations, accelerated disease progression, and vision loss.^2-4 Insurance and reimbursement issues add to the challenges, making drops a suboptimal long-term treatment strategy. Delaying surgical  intervention until glaucoma worsens can restrict treatment options and complicate surgical results. Early surgery, in contrast, improves visual outcomes and minimizes risks compared to delayed treatment.^5,6 Additionally, extensive use of antiglaucoma medications can cause ocular surface disease, accelerate trabecular meshwork damage, and lead to other adverse effects, reducing the effectiveness of later procedural interventions.⁷

In addition to these clinical drawbacks, long-term drop therapy also creates significant operational burden for both patients and practices. Drops require ongoing prescription management, repeated follow-up visits, and time-consuming patient education and monitoring. These strain clinic resources and increase administrative workload.

Overcoming Surgeon Hesitance

Given the limitations of drops as glaucoma therapy, there is a growing case for minimally invasive procedural intervention to become the new first-line defense for stabilizing IOP, helping to prevent disease progression, and reducing the patient’s treatment burden.

Despite the clear benefits of minimally invasive glaucoma surgery (MIGS), many providers remain reluctant to perform these interventions as standalone procedures, often reserving them for combined cataract cases. However, modern MIGS techniques—such as stenting, canaloplasty, and procedural pharmaceuticals—have demonstrated low-risk profiles and consistent efficacy, making them safe and effective options for IOP control even when performed independently of cataract surgery.⁸

Mounting evidence supports selective laser trabeculoplasty (SLT) as a safe and effective primary treatment with outcomes similar to other MIGS procedures.⁹ SLT directly addresses the pathology in the trabecular meshwork, and it has shown similar IOP-lowering benefits to drops without uncomfortable side effects and compliance issues.^10,11 SLT reduces the mean IOP and IOP variation which is strongly associated with slowing glaucoma progression.^12,13

The growing utilization of procedural pharmaceuticals further underscores the momentum toward interventional approaches. These minimally invasive treatments deliver targeted, sustained IOP control through localized drug delivery, reducing or eliminating the need for daily drops. Procedural pharmaceuticals broaden the therapeutic landscape, offering clinicians greater flexibility in tailoring safe, effective, and durable glaucoma management strategies.

The field is shifting from delaying surgery until the disease worsens to one where early intervention can help to prevent disease progression and vision loss more effectively while reducing both clinical and operational burden. The paradigm shift, however, is slow. If we continue using drops instead of procedural intervention as first-line therapy, we not only risk disease progression but also miss opportunities to offer patients better outcomes.

Are Patients Really Afraid of Surgery

There is a common assumption that patients are inherently afraid of surgery. In our experience, when patients are well informed about their options, many are open to advanced procedures. The key is to help patients make the best clinical decision for them by recommending the best procedure for not only their disease state but also their lifestyle. By shifting the narrative and building confidence around surgical interventions, providers can align patient perceptions with clinical goals. Patients are often more receptive to procedural intervention when they understand it offers more stable disease control compared to drops.

Reframing the Conversation Toward Procedures

Interventional glaucoma (IG) care represents a shift in mindset—one that prioritizes procedural intervention and frames it as a proactive approach rather than a last resort. To be interventional is to adopt a procedure-first mentality, using topical therapy as a bridge or supplemental therapy. It is essential for patients to understand that glaucoma is a progressive disease, and procedures may provide a more reliable way to manage IOP over time and have the potential to remodel diseased tissue.

Equally important is educating patients about the real risks associated with chronic drop use. Beyond common side effects and adherence challenges, improper or inconsistent use of drops can lead to ongoing disease progression and even irreversible vision loss.¹⁴ Yet, because drops are often presented as benign or low risk, patients may not appreciate these limitations. Providers should therefore discuss topical therapy with the same transparency regarding success rates and risks that they use when describing procedural options.

Providers should emphasize to patients that modern IG procedures are safe and effective, often with short recovery times and improved visual outcomes.^5,6 Reassuring language, such as “less invasive” or “minimally invasive,” can also alleviate patient concerns and bridge the gap between perceptions and clinical goals.

Building Confidence in Surgical Interventions

Patients can pick up on the confidence level of the surgeon. If we present a procedural option with conviction, patients tend to be more receptive and less fearful. Developing confidence in surgical interventions requires practice and consistency. The more frequently procedural pharmaceuticals are used, the more familiar surgeons become with their benefits, making it easier to recommend them as primary treatments. Additionally, educating and involving the entire care team ensures that consistent messages about the benefits of procedures are emphasized with patients at every point of care.

Clear decision pathways, based on a thoughtful review of evidence, can also reduce hesitation to suggest procedural intervention. Establishing guidelines that outline when to recommend procedures based on patient risk factors and disease progression provide a structured framework for clinicians, making it easier to introduce procedures earlier in the disease state. Focusing on what is best for the patient from an efficient and effective disease management standpoint will facilitate the shift to an IG approach.

Conclusion

Relying on topical drops as the primary treatment option may limit the potential for better patient outcomes. It is time for a paradigm shift in glaucoma care, and it is time for surgeons to set aside their hesitation to consider procedural intervention as primary therapy. We must stop using perceived patient fear of the OR as an excuse and start embracing modern procedural techniques that offer a more effective, sustainable way to control IOP and reduce patient and practice burden. The future of glaucoma management does not lie in drops alone, but in embracing an interventional approach that aligns patient trust with clinical best practices. GP

Inder Paul Singh, MD, is a glaucoma surgeon and the president of The Eye Centers of Racine and Kenosha in Wisconsin. He reports financial relationships with AbbVie, Alcon, Bausch + Lomb, Ellex, Glaukos, iStar Medical, Ivantis, Kala Pharmaceuticals, New World Medical, and Sight Sciences. Reach him at inderspeak@gmail.com.

Savak “Sev” Teymoorian, MD, MBA, is a cataract and glaucoma surgery specialist at Harvard Eye Associates in Laguna Hills, California. He reports consulting, speaking, and research fees from AbbVie and Glaukos. Reach him at sevakteymoorian@hotmail.com.

Christine Funke, MD, is with the Barnet Dulaney Perkins Eye Center in Scottsdale, Arizona. She reports financial relationships with AbbVie, Alcon, Dompé, Elios, Glaukos, New World Medical, Nova Eye Medical, Sight Sciences, and Théa. Reach her at cfunke525@gmail.com.

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