Glaucoma management continues to evolve beyond simply lowering intraocular pressure (IOP). During the continuing education course “Tackling Tough Glaucoma” at Optometry’s Meeting 2026, hosted by the American Optometric Association, presenters Justin Schweitzer, OD, FAAO, and Jessica Steen, OD, FAAO, explored emerging technologies, treatment strategies, and clinical considerations that can help eyecare professionals (ECPs) identify disease earlier and better manage progression.

"Glaucoma is one of the more complex eye diseases that we treat. It presents in so many different ways, which creates challenges in treatment decision-making,” Dr. Schweitzer told Optometric Management. “New treatments have evolved and allow us to intervene earlier in the disease process. We are excited to share our clinical insights with our colleagues to help them prepare for the front lines of glaucoma management."

Here are some of the key takeaways from the course.

Don't Overlook Central Visual Field Loss

The presenters emphasized the value of incorporating 10-2 visual field testing into glaucoma management. Research shows that traditional 24-2 testing can miss central defects, even in patients with early disease, they said. Earlier detection of central visual field loss may help identify patients who are at greater risk for progression.

Consider 10-2 testing when:

• Central depressed points appear on a 24-2 or 30-2

• Paracentral defects are present on 24-2

• OCT reveals ganglion cell layer abnormalities

• Structural and functional findings don't align

SLT Continues to Move Earlier in Care

Long-term data continue to support selective laser trabeculoplasty (SLT) as an effective treatment option. Drs. Schweitzer and Steen highlighted evidence that shows many patients remain medication-free for years after SLT while experiencing lower rates of progression and fewer filtration surgeries compared to those treated initially with drops.

New automated, noncontact SLT technologies may also make treatment easier and more efficient to deliver. The presenters made the case for ECPs to consider SLT as a first-line option or in cases of adherence challenges or ocular surface disease.

Normal-Tension Glaucoma Requires a Broader Approach

Several cases in the presentation focused on normal-tension glaucoma (NTG) and reinforced that disease progression can occur despite seemingly acceptable IOP levels. Drs. Schweitzer and Steen discussed the following factors:

• Low ocular perfusion pressure

• Nocturnal hypotension

• Sleep apnea

• Migraine and Raynaud's phenomenon

• Thin corneas and low corneal hysteresis

For progressing NTG patients, they said, evaluate systemic and vascular risk factors in addition to IOP.

Nighttime Pressure Matters

The course highlighted growing evidence that glaucoma patients may be especially vulnerable during overnight hours when IOP often rises and some topical glaucoma medications become less effective.

Drs. Schweitzer and Steen reviewed emerging technologies that are designed to address nocturnal pressure spikes, including a wearable device that lowers IOP during sleep through localized negative pressure. If progression occurs despite controlled office-hour pressures, they suggested considering the potential impact of nocturnal IOP fluctuations.

Sustained-Release Drug Delivery Is Expanding

Medication adherence remains a major challenge in glaucoma care. Drs. Schweitzer and Steen reviewed several sustained-release and alternative drug-delivery platforms, including intracameral implants, punctal plug systems, and drug-eluting technologies which aim to reduce reliance on daily eye drops while improving treatment consistency. The presenters encouraged ECPs to stay informed about emerging drug-delivery technologies that may improve adherence and reduce treatment burden.

MIGS Continues to Evolve

The course also explored the growing role of minimally invasive glaucoma surgery (MIGS). Beyond lowering IOP, Drs. Schweitzer and Steen said, MIGS procedures may also reduce medication dependence and side effects and improve quality of life. Long-term data from the Horizon trial showed slower visual field progression in patients receiving a Schlemm’s canal microstent compared with cataract surgery alone, they said.¹

Ocular Surface Disease Affects Outcomes

Chronic glaucoma medications can contribute to redness, irritation, and dry eye symptoms that negatively affect patient satisfaction and adherence. Drs. Schweitzer and Steen reviewed evidence that showed reducing medication burden through laser or surgical intervention may improve ocular surface health. They recommended that ECPs ask patients about drop tolerance and ocular comfort because these factors can influence long-term treatment success.

The Bottom Line

Successful glaucoma management requires a comprehensive, individualized approach. While IOP reduction remains the foundation of care, clinicians should also consider structural and functional testing, vascular risk factors, ocular surface health, treatment adherence, and emerging technologies when developing management strategies, Drs. Schweitzer and Steen concluded.OM

Reference

1. Montesano G, Ometto G, Ahmed IIK, et al.  Five-year visual field outcomes of the HORIZON trial. Am J Ophthalmol, 2023;251:143-155.  doi:10.1016/j.ajo.2023.02.008