Open-angle glaucoma when IOP-lowering medications and laser trabeculoplasty have not achieved target IOP
When IOP-lowering medications — whether as monotherapy or combination regimens — together with laser trabeculoplasty have been unable to maintain intraocular pressure at or below the individualised target, and optic nerve or visual field stability cannot be preserved, further escalation is indicated.
Previous treatment — goals not achieved
Prior therapy: IOP-lowering medications across multiple drug classes (monotherapy or combination regimens), with or without laser trabeculoplasty.
Goals that were not met: IOP at or below the individualised target; stable optic nerve and circumpapillary RNFL status; stable visual fields.
Next step — treatment approach
At this stage, the protocol addresses incisional glaucoma surgery as the primary intervention category. Which procedures are considered, and on what basis, is detailed in the full protocol.
Clinical goals at this stage
- IOP maintained at or below the individualised target level
- Stable optic nerve and circumpapillary RNFL status
- Stable visual fields
References
DOI: 10.1016/j.ophtha.2025.12.029
- Trabeculectomy remains the most effective surgical procedure to lower IOP; it is generally indicated when medications and appropriate laser surgery are insufficient to control disease and can be considered in selected cases as initial therapy.
- A 2005 Cochrane Systematic Review concluded that antifibrotic agents may be used intraoperatively and postoperatively to reduce the subconjunctival scarring after trabeculectomy that can result in failure of the operation, and therefore intraoperative MMC should be used.
- Aqueous shunts have traditionally been used to manage medically uncontrolled glaucoma when trabeculectomy has failed to control IOP or is deemed unlikely to succeed.
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