Glaucoma care has long depended on a fragile premise: that patients will remember, tolerate, and correctly administer topical therapy indefinitely. Drops are familiar, easy to prescribe, and somewhat effective, but they also place long-term disease control in the hands of daily patient behavior.

That reality is prompting a reassessment of the drop-first default. Interventional glaucoma reframes procedures such as SLT, procedural pharmaceuticals, and MIGS not as late-stage escalation, but as primary therapy options that may reduce reliance and adherence and better match the realities of lifelong care. The question is not whether drops still have value, but whether they should remain the default when more durable approaches are available.

"Most patients do intend to use their drops correctly," says Morgan Micheletti, MD,* partner, director of research, and fellowship director at Berkeley Eye Center, Houston, TX. "But life is busy. I often tell patients that I would struggle too if I had to use eye drops every day, indefinitely."

For Dr. Micheletti, missed drops expose the limits of a model that asks patients to manage a mostly asymptomatic disease with near-perfect consistency. With multiple medications, cost issues, refill delays, irritation, and everyday disruption, nonadherence is not surprising; it is predictable..

"It’s not anyone's fault," he says. "It's just the reality of asking someone to manage a disease they often can't feel yet."

Ryan Smith, MD,* a multi-specialty ophthalmologist at Pacific Eye Institute, Upland, CA, sees the same challenge. He has learned that asking patients directly whether they use their drops rarely shows the full picture. "If you ask, 'Are you taking your drops?' most people say yes because they want to please us. So I ask, 'How many times a week do you miss your eyedrops?' That usually gets a more honest answer."

He also watches refill timing. With prostaglandin analogs, adherent patients often complain the bottle does not last long enough – so if it is lasting well beyond a month, something is off, he says. Instead of “shaming” patients, Dr. Smith asks about the difficulties they're having – cost, dexterity, forgetfulness – “and that opens the conversation about alternatives.” He tells them, “I can't be with you every day to make sure you use your drops, but I can do a procedure that reduces your dependence on them.”

For Dr. Smith, that is the practical appeal of intervention: it reduces the extent to which treatment success depends on perfect daily execution by the patient."I have an interventional glaucoma mindset," Dr. Smith says. "Patients primarily treated with drops are lost to follow-up (12M or more) at a rate of 65% - that's 2 out of 3 of our patients. Conversely, patients treated procedurally lapse at a rate of only 25% ⁽¹⁾. On top of that, the LiGHT trial, showed strong outcomes with SLT compared with relying solely on drops ⁽²⁾."

For newly diagnosed patients, notes Dr. Smith, it is more straightforward to present procedural intervention as the preferred approach. The harder conversations are with long-standing patients managed on drops for years. In those cases, Dr. Smith frames the discussion around evolving evidence. "I explain that new evidence has changed how I practice and that we should reconsider the treatment plan based on what we now know."

The language problem

One of the biggest obstacles is language. Drops are described as non-invasive; procedures are thought of as a more aggressive step. A drop sounds familiar and benign; a laser sounds immediate and intimidating.

"Drops may be non-invasive in the sense that they aren't a procedure, but that's a pretty narrow way to define it," Dr. Micheletti says. "Over years, patients deal with redness, burning, tearing, ocular surface disease, fluctuating vision, medication allergies, cost issues, refill problems, and the stress of trying to stay consistent."

Dr. Smith explains, "Drops are certainly less invasive than a tube shunt or trabeculectomy, but they are not without long-term risks and side effects, some of which are irreversible." Prostaglandin analogues may cause iris or periocular pigmentation, and periorbital fat atrophy. In some cases, the signs are visible before the slit lamp exam begins. "You can often identify glaucoma patients in the waiting room because of the appearance of their eyelids and face – irritation, skin changes, orbital hollowing."

The point is not to dismiss topical therapy, but to describe the full trade-off. "By the time I explain all of that, many patients become much more open to procedural intervention," says Dr. Smith.

Patient acceptance still varies. Some long-term patients are attached to their drops, especially when they feel stable. In these cases, Dr. Smith “revisits risks, answers questions, and sometimes encourages patients to compare older photographs with recent ones to notice periocular changes.” For progressing patients, however, the balance shifts. Adding more drops often means more side effects, higher costs, and diminishing returns.

Framing and education

Many patient decisions are shaped less by clinical risk than by how choices are presented. "A lot of it comes down to education and framing," says Dr. Micheletti. "If drops are presented as the simple first step and procedures are described as something we save for later, most patients are naturally going to choose drops."

To broaden that frame, Dr. Micheletti uses a simple analogy: both horses and cars can move someone from one place to another, but once cars became available, most people chose the option requiring less daily upkeep. "In glaucoma, drops still have a role. But we now have options like SLT, procedural pharmaceuticals, and MIGS that can reduce the reliance on daily patient behavior, especially early in the disease."

When the discussion centers on preserving vision long-term rather than avoiding a procedure today, the decision can look very different. "Procedures feel immediate and tangible, while glaucoma vision loss can feel distant and abstract, especially when the patient feels fine," Dr. Micheletti says. "That makes fear of a procedure very understandable. The challenge is helping patients understand that in glaucoma, the goal is to prevent vision loss before they notice it, because once that vision is gone, we can't bring it back."

"We have a lot of responsibility here, and the words we use matter," Dr. Micheletti continues. "Drops are the way we used to manage glaucoma by default, because historically that's what we had. Now options like SLT, procedural pharmaceuticals, and MIGS can be discussed much earlier, and for many patients they may be a very reasonable first-line approach."

When patient burden becomes practice burden

The burden of chronic topical therapy does not stop with the patient. When patients struggle with access, cost, tolerability, dosing, or adherence, those difficulties often flow directly back into the clinic.

Dr. Micheletti sees that connection every day. "Patients call about refills, pharmacy substitutions, prior authorizations, formulary changes, cost, irritation, confusion about dosing, missed doses, and whether they should stop or continue drops around surgery. Staff and physicians spend a lot of time managing those issues, but much of that work is not formally tracked."

Each of those calls reflects a problem the patient is trying to solve, but it also requires action from the practice. A prescription may take seconds to send, yet sustaining topical therapy over years can involve repeated conversations about adherence and side effects, resolving insurance or pharmacy problems, navigating substitutions and shortages, and helping patients understand changes to their regimen.

"There's chair time spent discussing compliance and side effects, but there are also prior authorizations, insurance denials, pharmacy substitutions, shortages, and confused patients calling the office because their medication changed," Dr. Smith says. While those issues are being resolved, patients may experience interruptions in treatment, while staff and physician time is redirected toward keeping the medication pathway functioning.

For Dr. Smith, this is one reason the apparent simplicity of prescribing a drop can be misleading. The workload associated with topical therapy is distributed across the patient, pharmacy, insurer, and practice – and much of it remains invisible unless something goes wrong.

"I think it would be incredibly valuable for practices to track the time and resources devoted to refill requests, prior authorizations, compliance issues, and pharmacy problems," he says. "Many practices probably don't realize how much operational burden is tied to chronic drop management."

Seen in that context, reducing the burden on the patient may also reduce the burden that ultimately returns to the practice. Problems with access, adherence, tolerability, and complexity are not separate operational issues; they are different points along the same treatment pathway.

Bridge therapy, not default therapy

The issue extends beyond ophthalmology. Optometrists are often the first clinicians to identify glaucoma or ocular hypertension, and it is natural to begin treatment with medication. Dr. Smith encourages a different approach. "When I speak to optometrists, I tell them starting a drop is reasonable – but frame it as ‘bridge therapy’. Tell the patient: 'I'm starting you on this medication temporarily while referring you for evaluation of a more durable long-term option.'" That language preserves the value of topical therapy while preventing it from becoming the unexamined default.

Dr. Smith's perspective is also shaped by his work as a cornea specialist. "One of the advantages of MIGS and similar procedures,” he explains, “is that reducing or removing medication burden can improve comfort and ocular surface health. We now have good evidence supporting that."

The emerging interventional model does not require clinicians to abandon drops. It asks them to reposition drops more thoughtfully – as bridge and supplemental therapy, or a strategic part of a broader plan rather than the automatic foundation of care.

In a lifelong disease, the least invasive option is not always the one easiest to prescribe. It may be the one that asks the least of the patient every day, while doing the most to protect vision for the years ahead.

* Dr. Morgan Micheletti and Dr. Ryan Smith were compensated by Glaukos for their involvement this article.

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