At the 2025 ASCRS annual meeting in Los Angeles, Iqbal Ike K. Ahmed, MD, FRCSC, and Arsham Sheybani, MD, hosted the first-ever live episode of MIGS Unplugged with guests Brian Shafer, MD, and Christine Funke, MD. Also in attendance was an audience of more than 40 experts in interventional glaucoma, invited to offer differing perspectives and help fuel discussion.

This interactive program explored the use of interventional glaucoma therapies, including selective laser trabeculoplasty (SLT), MIGS procedures, and sustained drug delivery. The panel debated the rationale for earlier intervention, the challenges of encouraging patients and colleagues to consider procedural versus pharmaceutical options, and the need for more clinical data to guide treatment approaches (Figure 1).

Interventional Glaucoma Guidance to Date

The discussion began by Dr. Ahmed posing an introspective question to the panel: “Have we done a good job as leaders in interventional glaucoma to adequately provide the right evidence or guidance for the community to move?”

Dr. Funke answered that, while more could be done in this area, she thinks the field has provided a solid explanation of the benefits of interventional glaucoma. The challenge, she noted, is explaining how to apply interventional glaucoma in practice. Dr. Sheybani added that another challenge is the emphasis on disease severity versus on the patient’s full picture, including their history, age, life expectancy, etc. “[This way] I think [ophthalmologists] … start missing a lot and then lose confidence in angle procedures as a standalone option,” he said.

From the audience, Nathan Radcliffe, MD, commented that he believes many practitioners feel more comfortable discussing laser iridotomy than SLT with patients, despite recent data favoring the latter approach (Figure 2). Dr. Radcliffe noted that, if the physician’s confidence lies with a procedure, patients are more inclined to consider that alternative to drops. “[Often, patients] are not here to get options. They came to an expert to get an opinion, and that opinion should be decisive,” he said.

Positioning Interventions Along the Patient Journey

Dr. Sheybani posed a question of where along the patient’s treatment journey each panelist introduces drug delivery. Dr. Shafer said that the treatment algorithm has certainly changed and is following a similar progression to what occurred in the retina space about 20 years ago with the introduction of anti-VEGF injections. He stated that he considers the use of sustained drug delivery to be a reasonable first-line approach. Dr. Funke agreed, noting that she may recommend SLT followed by a sustained drug delivery option 2 to 3 weeks later, depending on the individual patient.

The panel turned again to audience participation as Manjool Shah, MD, asked, “Do we not already have enough evidence that interventional modalities compared to their controls are better [in regard to] SLT versus [drops]?¹ Do we not have enough evidence that a [canal-based] procedure at the time of cataract surgery [is better than] cataract surgery alone? I think we do.” Dr. Shah therefore questioned why the focus is on whether to intervene. “How far are we from a place where not intervening is a violation of standard of care?” he asked.

Dr. Ahmed responded that the rationale for intervention seems to be more widely accepted. However, the penetration of combination phacoemulsification and MIGS and first-line SLT, for example, is around 50% and 40%, respectively. Gaps in real-world practice exist.

Dr. Ahmed then posed a question to Dr. Shafer regarding canaloplasty and the growth of standalone stenting, and if his procedural process has changed.

“I have been a fan of canaloplasty because, if the goal is to rejuvenate [the natural drainage system] and we want to have … longevity with this patient, in theory, if you [perform] a canaloplasty, you could potentially let that ride for a couple of years [and] … go back [and perform] another canaloplasty,” Dr. Shafer explained. Dr. Shafer continued to explain how he may combine sustained drug delivery with canaloplasty.

Barriers to Being Truly Interventional

The program ended with a comment from Joshua Frenkel, MD, MPH, who noted, “It seems to me that the hardest conversation … is just convincing that patient who is on maybe two drops … that it is worthwhile to go back to the OR. That’s the biggest hurdle to standalone procedures.”

In response, Dr. Ahmed stated that one of the most important aspects of these conversations is for the practitioner to be confident that performing a procedure versus adding yet another drop is the most beneficial option (Figure 3). Part of this, however, entails better identification of disease progression.

“I think glaucoma needs [more frequent] follow-ups than just once or twice a year,” Dr. Ahmed said. “If [the patient] is already on two meds, I think [they] should have at least three tests a year and visual fields, considering the variability.”

Dr. Ahmed acknowledged the logistics behind this are difficult, especially from a payer perspective, but continued to ask, “How well can [we] follow [glaucomatous progression] if [we are] using an outdated visual field machine that can't properly assess progression or looking at an OCT that doesn't have a strong, robust statistical analysis?” Dr. Sheybani agreed, stating that, to be truly interventional, practitioners must have diagnostic confidence.

“Clearly, there is room for all these procedures. I think we need to thank industry for that,” Dr. Ahmed concluded. “[In response to] my first question, ‘Are we doing [a good] enough job to not only take care of our own patients but [also] to move our field forward?’ I think that's a calling we all should pick up … and everybody has an ability to do that.”

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): A multicentre randomised controlled trial. The Lancet. 2019;393(10180):1505-1516. doi:10.1016/s0140-6736(18)32213-x