Eye drops dethroned: New glaucoma consensus puts procedures first

For decades, eye drops have been the go-to first line of defense against glaucoma — but a new expert consensus is challenging that norm. The Interventional Glaucoma Working Group has unanimously agreed on a new treatment framework that repositions drops as bridge or supplemental therapy, not the primary approach. Instead, the protocol calls for starting with procedural options: sustained-release drug implants, selective laser trabeculoplasty (SLT), and minimally invasive glaucoma surgery (MIGS), progressing to more involved interventions only as needed.

The shift is backed by solid evidence. The LiGHT trial showed SLT was more cost-effective than drops and achieved similar IOP control — and longer follow-up revealed that patients who started with laser had better visual field preservation over time, even when IOP levels were comparable between groups. Sustained-release implants (like iDose TR and Durysta) also sidestep the compliance and ocular surface issues that plague traditional topical therapy.

Key Takeaways:

• Eye drops are not eliminated — they're repositioned as supplemental or last-resort therapy before filtering surgery
• Procedural-first approaches reduce reliance on patient compliance, a known weak point with topical therapy
• The protocol applies to newly diagnosed, otherwise healthy patients; real-world cases with prior treatment history require individualized judgment

Why it matters: Drops may seem like the conservative choice, but poor adherence and ocular surface damage can quietly drive disease progression. This consensus signals a meaningful paradigm shift toward more proactive, procedure-based glaucoma care.