Much of the recent focus in glaucoma treatment has been on interventional options, such as laser, MIGS, and procedural pharmaceuticals, rather than topical therapy. But medications have not been displaced entirely. Drops should remain part of the treatment framework, but they must be used strategically, said Jason Bacharach, MD, during a Glaucoma subspecialty day presentation at the American Society of Cataract and Refractive Surgeons (ASCRS) meeting in Washington, DC.

“Today, it almost feels like you’re a villain if you talk about medications,” Dr. Bacharach, the founder of North Bay Eye Associates in California, noted. But despite that perception, topical drops remain a common first-line treatment, he reminded the audience, with a 2024 survey of ASCRS members showing nearly 74% of respondents used drops as initial therapy, rather than laser.¹

In his presentation “What Role Do Meds Play in the IG Era?,” Dr. Bacharach proposed reconsidering their role through use of a minimal instillation drop strategy (MIDS), which emphasizes limiting medications while using them in a targeted way. “The days of loading patients on multiple medications before you do something are largely over,” he explained. “Today, medications are better viewed as supplements or bridge therapies.”

In the MIDS framework, drops can be used to support procedural interventions—either to augment intraocular pressure (IOP) lowering after surgery or to maintain control when procedural effects diminish. The goal, he said, is to identify combinations where the interaction between a medication and a procedure produces a greater effect than either would alone.

To guide decision-making, Dr. Bacharach outlined an approach focusing on tolerability, efficacy, adherence, and mechanism of action (TEAM). Each component, he said, should be considered in the context of the individual patient and the procedural plan.

Tolerability remains a central concern, particularly because nearly two-thirds of patients with severe ocular surface disease (OSD) have glaucoma. Dr. Bacharach emphasized the role of preservatives like benzalkonium chloride (BAK) in contributing to OSD.

“Although preservatives help prevent contamination, cumulative exposure can negatively affect the ocular surface,” he said. “Overall, higher preservative load is associated with reduced quality of life and may negatively affect surgical outcomes.” He noted that many medications are now available in preservative-free formulations.

Efficacy includes not only the inherent potency of a medication but also how it is delivered. Fixed combinations can improve effectiveness and simplify regimens. Dr. Bacharach observed that a few agents have demonstrated greater IOP reduction than latanoprost, including fixed combinations such as netarsudil/latanoprost (Rocklatan; Alcon) and nitric oxide–donating therapies such as latanoprostene bunod (Vyzulta; Bausch+Lomb).

Adherence remains a persistent challenge. Citing the Collaborative Initial Glaucoma Treatment Study, Dr. Bacharach noted that missed doses were associated with worse visual outcomes.²

“There was a direct correlation between people missing drops and people losing vision,” he said. Simplifying regimens and minimizing drop burden should help to improve adherence, he added.

The final component of the TEAM approach, mechanism of action, extends beyond pharmacology to include procedural compatibility. Over the past decade, most therapies have targeted the trabecular meshwork. The next step, Dr. Bacharach suggested, is understanding how these approaches interact. “We need to find out what drops work well with certain procedures,” he said. “We do have some early studies that show that netarsudil works well with SLT and goniotomy. There’s going to be another study presented at this meeting that shows the same thing. I think that’s where we’re going to head, to really use drops in a smart fashion.”

Future advances may help refine this strategy. Large datasets, such as those from the IRIS Registry, and artificial intelligence–aided analytic tools could provide insight into which combinations of medications and procedures are most effective. But for now, Dr. Bacharach said, medications remain relevant in the interventional glaucoma era—but only when used with a clear plan. “If you prescribe drops using a thoughtful, evidence-based approach, you can absolutely be a hero,” he concluded. GP

References

1. Rhee DJ, Sancheti H, Rothman AL, et al. Primary practice patterns for the initial management of open angle glaucoma. J Glaucoma. 2024;33(9):671-678. doi:10.1097/IJG.0000000000002453

2. Newman-Casey PA, Niziol LM, Gillespie BW, Janz NK, Lichter PR, Musch DC. The association between medication adherence and visual field progression in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2020;127(4):477-483. doi:10.1016/j.ophtha.2019.10.022