Open-Angle Glaucoma Treatment
A stepwise, individualized approach that starts with the least invasive effective option and escalates only as needed to protect your vision.
A Stepwise, Individualized Approach
Open-angle glaucoma is a chronic, lifelong condition, and treatment is built in steps — starting with the option that offers the best balance of effectiveness and low risk for your specific situation, and escalating only when needed. Below is the general order we consider, though your specific plan is always individualized to your pressure, optic nerve health, and preferences.
Step 1: Eye Drops or SLT Laser
Either a once-daily eye drop (typically a prostaglandin analog) or selective laser trabeculoplasty (SLT) is a reasonable first-line treatment. The landmark LiGHT trial found that starting with SLT led to better disease control and fewer patients needing eye drops at all over several years, without added risk.1 We discuss both options and let your preferences help guide the choice. See our Eye Drops & Oral Medications and SLT Laser pages for full detail.
Step 2: Additional or Combination Drops
If target pressure isn't reached with a single drop or SLT, additional drop classes (or combination drops) are added, or SLT is performed if it wasn't already tried, before considering surgery.
Step 3: MIGS Surgery
For patients not at target pressure despite drops and/or SLT, minimally invasive glaucoma surgery (MIGS) — iStent, ab-interno canaloplasty, Hydrus, or Xen — offers a lower-risk surgical option, especially convenient when combined with cataract surgery if a cataract is also present. See our MIGS Surgery page.
Step 4: Trabeculectomy or Tube Shunt Surgery
For more advanced disease, or when MIGS doesn't achieve the needed pressure reduction, traditional filtering surgery (trabeculectomy) or a glaucoma drainage device (tube shunt) can achieve a larger, more durable pressure reduction. See our Trabeculectomy and Tube Shunt Surgery pages for how we choose between them.
Lifestyle & Medication Review
At every stage, we also review your broader medical history, medications, and lifestyle, since several common medications and habits can influence eye pressure and disease course. See our Lifestyle, Diet & Medication Risk Review page.
Learn more about the condition itself on our Open-Angle Glaucoma page.
References
- Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393(10180):1505-1516.
Frequently Asked Questions
What's usually the first treatment?
Either a prostaglandin eye drop or SLT laser, based on the LiGHT trial evidence that both are reasonable first-line choices — the decision often comes down to patient preference between a daily drop and a quick in-office laser.
Will I need surgery eventually?
Not necessarily. Many patients are well controlled for life with drops and/or SLT alone. Surgery (MIGS or traditional) is reserved for patients whose pressure or disease progression isn't adequately controlled by less invasive options.
How is my target pressure determined?
Target pressure is individualized based on your current eye pressure, degree of optic nerve damage, rate of progression, and other risk factors, then reassessed over time as we track your optic nerve and visual field.
Can treatments be combined?
Yes, routinely. Many patients use a combination of an eye drop plus SLT, or a MIGS device plus a drop, to reach target pressure with the least overall treatment burden.
See a glaucoma specialist. Dr. Robert Gunzenhauser is Harvard-educated and UCLA fellowship-trained in glaucoma, providing expert diagnosis and treatment for Open-Angle Glaucoma Treatment at Inland Glaucoma Center in Upland, CA.