Interventional glaucoma and other modern evolutions were on trial during an AAO 2025 Day 2 symposium on overtreatment of mild glaucoma and undertreatment of advanced cases.
Is modern glaucoma care leading us astray?
A provocative Saturday afternoon symposium at the American Academy of Ophthalmology Annual Meeting 2025 (AAO 2025) took a long, hard look at glaucoma care in the United States and around the world, and the impact of over- and underdiagnosis on patients and practice.
The merits of trabs and tubes were weighed against minimally-invasive glaucoma surgery (MIGS) and other modern treatments as speakers argued that the specialty has fallen into overtreating patients with minimal disease while neglecting those at greatest risk of blindness.
The overtreatment problem
Dr. James Brandt (USA) opened with an assessment of how glaucoma care has drifted away from patient-centric care. And it all starts with patient knowledge.
He noted that most glaucoma patients don’t even know they had the disease, yet “[many] were receiving topical treatment, and a quarter of them had actually undergone incisional glaucoma surgery.”
“We might tell a patient that they only have mild glaucoma, but just uttering the ‘g’ word initiates a fear of blindness and depression in a significant portion of our patients,” Dr. Brandt said. He presented OATS data showing that even among patients with little to no visual field loss, “receiving a diagnosis had a real and measurable impact on their well-being.”
Dr. Brandt closed with a simple plea for balancing awareness with fear. “Overdiagnosis is important following glaucoma, especially as our treatments for ocular hypertension and mild disease are not entirely benign,” he said, firing an opening salvo against modern interventions that would continue through the session.
“When our patients hear the word ‘glaucoma,’ they often hear the word blindness, and even among patients unlikely to be impacted in their life, the ‘g’ word has real and measurable impact,” he noted.
Physicians, according to Dr. Brandt, should be wary of both the good implications of a diagnosis—and the bad ones an overdiagnosis could bring.
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Is advanced disease a crisis in reverse?
Dr. Kuldev Singh (USA) presented a similar picture from the opposite end of the spectrum. “There’s only one major consequence of undertreatment of patients with advanced disease, and that’s blindness,” he said bluntly. “I can really stop right here, but I have another six minutes.”
Dr. Singh presented Medicare data showing a precipitous decline in trabeculectomy procedures in the United States. He attributed this partly to financial incentives distorting clinical decision-making, citing data that found an increase in goniotomy procedures and a drop in stent procedures following Centers for Medicare & Medicaid Service (CMS) reimbursement changes.
“In the United States, medical practice has become transactional in a fee for service environment,” Dr. Singh lamented before taking aim at modern interventional glaucoma.
Dr. Singh quoted a prominent MIGS surgeon who wrote about struggling “to determine who the best patients are for a given treatment.”. The logic behind this, Dr. Singh noted, has far reaching implications. “For several centuries, the way to practice medicine was to find the best treatment for a patient. But nowadays, people are trying to find the best patients for a treatment.”
Tubes and trabs, according to Dr. Singh, are the undeserved losers of this shift, and he pointed out alarming potential consequences for glaucoma patients. “Fellows are joining groups where they are told that they can’t do trabeculectomies and tube implants,” he said. “They just have to do phaco MIGS to optimize revenue for their practices.”
Disparities in treatment and outcomes
Dr. Leon Herndon, Jr. (USA) addressed a particularly resonant topic in today’s political climate: racial and ethnic disparities in glaucoma care. He noted that African Americans face “six to eight times higher risk of glaucoma-related blindness” yet show significantly worse surgical outcomes. Data from the University of California, Los Angeles (UCLA), revealed that in trabeculectomy outcomes, “there were significantly fewer patients of African descent who had success over this period of time” compared to European-derived patients.*
“To tackle the elevated burden of eye diseases facing marginalized communities, we need to promise and fulfill our commitment to increase racial and ethnic inclusion in clinical trials,” Dr. Herndon emphasized, noting that a meta-analysis of 105 glaucoma trials from 1994 to 2019 showed 71% white participants versus just 16.8% Black participants—despite glaucoma being seven times more likely to cause blindness in Black individuals.
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The patient perspective
Dr. Joshua Stein (USA) presented a peek into unpublished research using the National Eye Institute (NEI) Visual Function Questionnaire (VFQ)-9 questionnaire integrated into routine clinical practice at the University of Michigan, tracking over 90,000 patients. His findings revealed that rapidity of progression mattered more than baseline severity for quality of life.
“Rapid progressors of both eyes had on average a 14-point greater decrease in VFQ compared to those with stable visual fields,” Dr. Stein reported. For mild disease patients with rapid progression, the impact was even more dramatic: “a 22.5-point drop and this is just over a three- to six-year period.”
The Ghana perspective
The session concluded with the Robert N. Shaffer Lecture, delivered by Dr. Donald Budenz (USA), who shared his experience with thirty years of glaucoma clinical work and research in Ghana.
He compared Ghana’s lack of ophthalmologist availability (estimated to be two for every 1,000,000 people) with the rest of the world, citing a key statistic for perspective.
“It turns out that half of the world’s ophthalmologists live in China, the U.S., India, Russia, Japan or Brazil,” Dr. Budenz noted. “Places like Ghana have one ophthalmologist for every 500,000 people, whereas here in the U.S., there is one ophthalmologist for every 10,000 inhabitants.”
Working at the Tema Krishnan Eye Center—situated on the Greenwich Meridian and near the equator, making it “as close to the center of the earth as we can come to study glaucoma”—Dr. Budenz’s team conducted comprehensive population-based surveys and provided surgical care.
The star for Dr. Budenz in Ghana was trabeculectomy with mitomycin, as he explained its efficacy in African populations.
Some procedures, he noted, were still functioning twenty years later.
*Nguyen AH, Fatehi N, Romero P, et al. Observational outcomes of initial trabeculectomy with mitomycin C in patients of African descent vs patients of European descent: Five-year results. JAMA Ophthalmology. 2018;136(10):1106-1113.
Editor’s Note: The American Academy of Ophthalmology Annual Meeting 2025 (AAO 2025) is being held on 17-20 October 2025, in Orlando, Florida. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.