Glaucoma specialists need to rethink how and when they intervene in a patient’s disease, placing greater emphasis on office-based therapies like selective laser trabeculoplasty (SLT) and sustained-release drug delivery to lower intraocular pressure (IOP), say Inder Paul Singh, MD, and Thomas Samuelson, MD. The doctors presented information on the effectiveness of office-based therapeutics during the 2025 annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS) April 25 in Los Angeles.
During their Glaucoma Subspecialty Day presentation, Ophthalmology Management reported, Drs. Singh and Samuelson guided the audience through cases illustrating how SLT and drug delivery can be deployed earlier to reduce reliance on IOP-lowering drops and, in some cases, delay or avoid surgical intervention.
“Office-based procedures fit the new interventional glaucoma mindset,” explained Dr. Singh, president of the Eye Centers of Racine and Kenosha in Wisconsin. “It’s about earlier intervention and decreasing the compliance issues that we face in glaucoma—we can’t wait for people to progress before we appreciate the impact of poor compliance.”
Under the traditional glaucoma treatment paradigm, patients often struggle with medication adherence due to a combination of uncomfortable side effects, cost, and forgetfulness. In addition, long-term use of drops preserved with benzalkonium chloride (BAK) is associated with ocular surface disease, which not only affects patients’ comfort and quality of life but may also compromise the success of surgical interventions. The long-term impact of drop therapy on surgical outcomes must be considered, said Dr. Singh, particularly when patients are taking 2 or more classes of medications.
“If you have someone on aqueous suppressants or prostaglandin analogs for 10 years, you’re decreasing flow through the trabecular meshwork and causing scarring,” he said. “Then you ask why your MIGS isn’t effective. Chronic drops, especially with BAK, could be part of the reason.”
In cases discussed during the presentation, patients received SLT in combination with drug-eluting implants to avoid the need to prescribe IOP-lowering drops. Durysta (AbbVie) and iDose TR (Glaukos) are the only sustained-release drug delivery systems currently approved for glaucoma by the US Food and Drug Administration (FDA), although several others are being evaluated in clinical trials, Dr. Singh noted. This approach allows for better disease control and preservation of long-term tissue health. “That’s the new paradigm shift in interventional glaucoma,” said Dr. Singh. “It’s not choosing between aggressive IOP control and quality of life. Now we can do both.”
Although SLT has been available for years, the presenters argued that it remains underutilized as a first-line therapy, despite 6-year data from the LiGHT trial supporting its safety and efficacy. “There’s still 50% of doctors out there who are not offering first-line SLT,” said Dr. Singh. “Maybe they’re giving too much of a choice to patients. But if the data are clear and the safety has been well documented, there’s no reason not to say, ‘This is how we treat.’”
Newer in-office technologies such as direct selective laser trabeculoplasty, or DSLT (Voyager; Alcon) have potential to improve clinic flow while also offering a noninvasive treatment option, the presenters noted. Voyager is an automated laser system that delivers treatment without requiring a gonio lens or manual aiming, streamlining the procedure and reducing the need for specialized training. Micropulse transscleral cyclophotocoagulation is another laser treatment option that targets the ciliary body to reduce aqueous humor production, and thus IOP.
Office-based therapies like SLT and drug delivery are not merely alternatives to drops—they are foundational steps in a broader interventional strategy, the presenters concluded. “None of these in-office therapies may be ‘forever’ treatment, but that’s OK,” said Dr. Singh. “The safety is so high, and the benefits are so great that even if the IOP-lowering effect doesn’t last forever, and the laser must be repeated, at least you’ve given your patient a period of time where they’re drop free. We have to change our mindset to say, ‘Look, drops are there as a bridge.’ They are there between our therapies and our surgical interventions.”
Source: Ophthalmology Management