Evolving glaucoma management through the decades: insights from Thomas W. Samuelson, MD

As part of the celebration of Ophthalmology Times’ 50th Anniversary, Thomas W. Samuelson, MD, reflects on the evolution of glaucoma treatment over recent decades, highlighting a shift from a traditional stepwise approach of eye drops, laser, and surgery toward a more individualized, interventional strategy that prioritizes patient quality of life and long-term disease management.

The current paradigm often involves managing glaucoma with laser or drops until cataract surgery, at which point a MIGS procedure is incorporated based on disease severity. Samuelson, who is attending surgeon and a founding partner of Minnesota Eye Consultants in Minneapolis, emphasizes that "one of the most important points in the lifetime of a glaucoma patient is when cataract surgery is planned," as it presents an opportunity for simultaneous glaucoma intervention.

Samuelson highlights the increasing focus on reducing the treatment burden for patients. "We're trying to take the burden of treatment off of patients. We're trying to lessen their load," he explains, noting the role of selective laser trabeculoplasty or direct selective laser trabeculoplasty, depot drug delivery, minimally invasive angle surgeries (MIGS), and goniotomy procedures. These safer interventions help mitigate the risks of medication toxicity, a common issue for long-term glaucoma patients.

Although topical therapy remains an essential component of care, Samuelson views it as increasingly adjunctive: "I'm not one that thinks we can get rid of drops. We're always going to have drops, but drops have become more of an adjunct and supplemental therapy." Many patients can now transition from initial treatment to cataract surgery with a MIGS procedure without reaching the multi-drug regimens that were once standard.

For severe glaucoma, traditional procedures like trabeculectomy and tube shunts remain necessary. However, Samuelson underscores the benefit of reserving these high-risk surgeries for the patients who truly need them. "What used to happen is we'd have to offer people with mild to moderate glaucoma a very aggressive operation, because that's all we had." Now, safer, staged interventions provide a more tailored and patient-friendly approach.