CLINICAL: Glaucoma

‘Isn’t One Drop Enough?’

The answer often depends on the specific patient

An active, 68-year-old female presented with progressing early open-angle glaucoma, despite reporting “good” ad-herence with her topical prostaglandin analogue monotherapy. Specifically, her IOPs were in the low 20s, but not at the target mid/high-teens IOP range. Pachymetry showed average thickness measurements, gonioscopy revealed a visible ciliary body in all four quadrants with 2+ trabecular meshwork pigment, and her clinical exam showed pseudophakia OU and otherwise normal ocular health OU. After discussing the need for further IOP reduction, I offered the pa-tient additional topical therapy or selective laser trabeculoplasty (SLT) as adjunctive therapy. After thoughtful consideration, the patient profoundly asked, “Isn’t one drop enough?”

Here, I explain how we should answer this often-asked question, the treatment approach I took with this specific patient and why.


Although the patient’s age and the stage of the disease helps direct our treatment decisions, we must also remember that we are treating a patient who may have very real challenges, such as medication side effects, cumulative cost barriers and, as is the case with the patient above, possible variable adherence to the prescribed medication.

Thus, if the goal is to treat the patient who has the elevated IOP, vs. the patient’s IOP itself, then maximum tolerated medical therapy, also known as MTMT, should be individualized. In such a personalized approach, we seek to find the best treatment that is medically effective and overcomes the challenge(s) relative to the patient.


Based on the fact that the patient mentioned above reported “good,” but not “great” medication adherence to her monotherapy, I felt there was no point in pursuing the maximum medical therapy route — something potentially relatively unlimited, due to the several topical therapy options and combinations available. Instead, I educated her on SLT, which usually goes something like this:

“Another way to lower your eye pressure is to use a lens like this (referring to the gonio lens) with a laser on a machine like this (referring to slit lamp) to improve the normal drainage pathway in your eyes. The procedure takes a few minutes, you don’t have to have your eyes dilated, there are no restrictions following the procedure, and it doesn’t affect your vision. The treatment usually lasts, on average, three to five years and then it can be repeated, if necessary, with somewhat similar results. You will still need regular glaucoma testing and evaluations, though, as the disease process can still change during this time. If this is the case, you may still need another drop to help lower your eye pressure more.”


In seeing so many glaucoma patients throughout our day, it’s easy to solely focus on the disease process vs. both the disease process and the patient who has the disease. In my mind, the best way to find this balance and personify the treatment is to put ourselves in the patient’s shoes and ask, “What is the best treatment approach for me?” In this patient’s case, SLT made the most sense. For information on SLT as a first-line treatment, visit . OM