The following transcript has been edited for clarity:
Dr. Feulner: Welcome to AAO 2025 in Orlando. I'm Dr. Lisa Feulner, chief medical editor for Ophthalmology Management, and I have the honor and privilege of having Dr. Zarmeena Vendal join me today to talk about a very exciting topic in ophthalmology. Right now, we're going to talk about how we're taking care of our glaucoma patients in a better way, a more efficient way, a more effective way, and why interventional glaucoma is good for the patient, good for the doctor, and good for the practice. Dr. Vendal, can you tell me what you're doing differently in your practice for treating glaucoma than you've done before?
Dr. Vendal: You hit the nail on the head. What a great time to be practicing glaucoma. When I think about even just 15 years ago, the way we were thinking about glaucoma was very compartmentalized. You were either a young person with a job and a career, and you were looking into things like cataract refractive surgery, or you had this chronic condition called glaucoma, and we dealt with them so separately. And the beauty of what has happened in our space with this, what we call the interventional glaucoma revolution, is we can think of the patients as a whole now, and that's the best approach when it's a patient-centric approach. And so when the patient's in the center of that conversation, as you said, we as the clinician, the referring provider, whether that be an optometrist, another colleague or internal optometrist, we all start thinking the same way, which is how can we be more proactive? And so I would say I am more interventional today with the therapies that I offer my patients than I ever was, even just 5 to 10 years ago.
Dr. Feulner: What sort of interventional therapies are you doing, and how has your treatment paradigm changed?
Dr. Vendal: Great question. It was harder to be interventional when the treatments came with a lot of side effects, when the treatments came with surgeries like trabeculectomies and tubes. And we thought twice about doing that to a patient. And so now what we have in our toolbox, and it's a big toolbox for glaucoma, it's a journey for the rest of their lives. So we have in our toolbox or things that are way safer, may be equal in efficacy. And so here we're talking about laser like SLT and offering that earlier than ever before. Drug delivery, whether that's in the clinic or in the operating room. A great one is something like iDose (Glaukos) that we implanted the OR all the time. And then of course, minimally invasive glaucoma surgeries, the MIGS space with stenting, with canal and roofing procedures.
Our toolbox has gotten so sophisticated, but not just with things that work well, but things that address the other parts, the reality of glaucoma that's harder to deal with. Compliance issues like dry eye with chronic drops, patients who have trouble taking eye drops, cost of eye drops. So these things, these sorts of issues are what I think we're answering with these interventional techniques.
Dr. Feulner: And I also think that what we're doing for the patient, right, it's good for the patient, good for the doctor, good for the practice, is we're preventing diseases that these drops have created in these patients. Ocular surface disease, damage to the meibomian glands, damage to the mucin glands, changes in eye color, periorbital, fat atrophy.
Dr. Vendal: Direct toxicity to the trabecular meshwork from the chemicals themselves, all of it.
Dr. Feulner: Exactly. So we're able to now with interventional approaches, treat the patient in a more holistic way that gives them better control over their disease, stops us from creating new diseases for these patients. And what I've found in my practice, it reduces the anxiety that the patients feel about the progression of their disease, about forgetting to take their drop, worrying about did it get in their eye. And then of course, the expense associated with it.
Dr. Vendal: Right. Those studies that we know so well, the GAP study, for example. I mean, in their lifetime, our patients are going to have an 80% rate of noncompliance. And at any given point, 50% of them might discontinue their medication. So I feel like the writing's on the wall for those of us that practice in the glaucoma space, and it allows more of us to practice in the glaucoma space. It's not just a condition that glaucoma specialist treats anymore. And it shouldn't be because, gosh, 25% or a third of our patients are going to have the condition. So whether it's a comprehensive colleague, whether it's an optometric partner who's now going to send them in sooner, the patients are getting treated more proactively and we're being more preventative for sure.
Dr. Feulner: And what's really exciting is that we now have opportunities to treat them either in combination with cataract surgery or as a standalone, whether they're phakic or pseudophakic. So we can now customize their treatment with all the tools that we have in order to give them better control, better lifestyle. And in my practice, it's really changed my practice because I don't have as many short drop changing IOP checks. I don't have the phone calls from the patients or the pharmacies or the insurance companies where I have to change drops. So for me, it's really cut down on the number of extra visits per person and allowed me to open my schedule to see more patients that need to see me.
Dr. Vendal: And as a glaucoma doctor, my fear, just like all of the rest of us, is we are the rate-limiting step, the botttleneck. So the way I would say it's changed our practice is the patients are getting the treatment sooner. So our comprehensive ophthalmic surgeons are now doing interventional things like eye dose as well as myself. The optometrist in the community that refer to us are referring sooner because they are finding the thought of using something like drug delivery, for example, to be safe, that they can talk about it to the patient faster, sooner. And so the way our practice has changed is even just in the uptake of how much interventional surgery we're doing and benefiting the patient. And the third, which was a big surprise, was just the internal optometrists that work in the practice, how many of them were sending patients into my clinic to talk about these things. So it's just an amazing thing when it starts to snowball and in the direction that you want it to go, which is moving the needle, right? That interventional needle to be earlier before the visual field defect develops or before terrible chronic dry eye develops.
Dr. Feulner: You talked about snowball. So the snowball starts with treating the patient and then it snowballs into making more room for patients that need to see us. And the other part of this snowball that I didn't expect that kind of came out of this is that we had a full-time equivalent employee who sat answering the phone from patients, from insurance companies, prior authorizations, pharmacies. And now that I've moved away from drops, she's in the clinic 2 days a week doing visual fields and OCTs actually generating revenue for our practice. So the impact of interventional glaucoma has really affected every part of the practice, starting with the patient. And patients feel such joy to get off their drops.
Dr. Vendal: They sure do. And the other thing is patients value technology. That's a big piece I've learned in the last 20 years of owning my private practice. They want to hear about technology that controls their glaucoma better than what they had in the past, whether it's laser, whether it's drug delivery, in the case of something like drug delivery is 24-7 delivery of a medication instead of a topical situation. Patients value that innovation. I'll never forget, one of my patients that I did just recently pseudophakic on 3 medications for years failed three SLTs. And we talked about implanting iDose with just intracameral travoprost for her that she could actually have, even though she was pseudophakic because we can do it in a standalone fashion. And she was thrilled. In fact, her eye pressures were around 20 on 2 medicines. And after iDose, she was backed down to one medicine with pressure of 14 mmHg. And I asked her, why did you agree to do this therapy? And she said, there are 2 reasons: my kids and I looked it up, and it seemed like it was one of the newest and most innovative things available to me as a glaucoma patient. And she said, the second reason is because you, as my surgeon, made the recommendation.
Dr. Feulner: I think that is such a big key. I think our patients want to know what we think is best for them. So hopefully you enjoyed this discussion and Dr. Vendal and I encourage you to take in some courses this weekend at the academy, learn about interventional glaucoma, stop by some of the different booths that have products that you can use in your office. Learn more about it. It's really a life-changing experience for your patients, for your practice, for you as a physician, feeling like you're really treating a disease in an effective way and allowing you to see patients who need you. Thank you so much for taking time out of your schedule to join me today.
Dr. Vendal: It was a pleasure.