Glaucoma treatment options: an overview

Reflecting on glaucoma management in the UK, consultant ophthalmologist, Richard Stead, describes the 2022 National Institute for Health and Care Excellence (NICE) guidance as a “paradigm shift.”

The Newmedica glaucoma service lead highlighted that before this guidance was published, the first-line treatment for glaucoma was eyedrops to lower intraocular pressure.

“We would try different types of eyedrops before we progressed on to Selective Laser Trabeculoplasty (SLT) and then surgery,” Stead shared.

“But the NICE guidance changed our treatment paradigm so that now we offer SLT as a first-line treatment,” he said.

Richard Stead

Richard Stead, consultant ophthalmologist and glaucoma service lead at Newmedica

Stead added that while SLT is now the first treatment that is offered to patients, a range of topical medications in the form of eyedrops still play an important role in glaucoma management.

Turning to surgery, Stead highlighted that in the past a trabeculectomy was the most common surgical option.

“Since around 2015, there has been an explosion in minimally invasive glaucoma surgery (MIGS). These are devices that we can implant, often at the same time as cataract surgery, to help tap into the physiological outflow and control the pressure in the eye,” he explained.

Stead observed that for more advanced cases of disease there is filtration surgery – with trabeculectomy still the gold-standard for this form of surgery.

“There are also some new kids on the block – Xen and Preserflo, which both involve putting a tiny tube in the eye,” he said.

“On the final rung of the ladder, if you can’t have surgery or if we have already tried surgery, then we can consider cyclodiode laser – where we target the inflow system and the ciliary body,” Stead explained.

The NICE guidance changed our treatment paradigm so that now we offer SLT as a first-line treatment

Looking ahead

Stead, who is also a qualified optometrist, highlighted that researchers are currently investigating whether a form of vitamin B3, nicotinamide, could play a therapeutic role.

“In animal models, and in a very limited human trial, nicotinamide was shown to be potentially protective against glaucoma,” he said.

“The beauty of nicotinamide is that it is cheap, and it is available over the counter,” he added.

Stead shared that this development could open up another therapeutic pathway for glaucoma beyond the traditional approach of lowering intraocular pressure.

“We know that that’s not the only disease driver in glaucoma. There are other factors at play,” he said.

Stead highlighted that while the research is still at an early stage, the field of neuroprotection could be a “game changer” within glaucoma care.

“It would offer another avenue to prevent progression beyond drugs and surgery,” he said.

Jagdeep Singh

Jagdeep Singh, head of clinical proposition at Newmedica

Specialist optometrist at Royal Shrewsbury Hospital and head of clinical proposition at Newmedica, Jagdeep Singh, told OT that he has recently been involved in the implementation of a new minimally invasive glaucoma surgery technique at Newmedica Berkshire.

“ELIOS uses an excimer laser to create microscopic channels in the trabecular meshwork to restore or enhance the eye’s natural aqueous outflow,” he explained.

“Compared to conventional MIGS techniques, it’s implant‑free, meaning no permanent stents, valves or shunts are left in the eye,” Singh said.

He added that ELIOS can be combined with cataract surgery.

“Our initial outcomes have been extremely positive, helping to reduce the need for glaucoma drops, improving the quality of life for patients as well as having a low complication profile,” Singh shared.