Eight fast, usable lessons for clinics and ORs, from OCT literacy to OR ergonomics, built for real schedules and real patients.
On a humid Friday morning in Orlando, the Practical Tips in Glaucoma Management session moved at roller-coaster pace from imaging to incision. Practical, punchy and packed with pearls, the speakers wasted no time getting to the point. This glaucoma program tackled clinical and surgical efficiency from every angle.
The session moved from OCT interpretation and perimetry to drops, SLT, MIGS, modern trabs and efficiency on both clinic floors and surgical lists. It felt pure Orlando: practical, a little playful and focused on hitting “magical pressures” that actually hold up on Monday. The result was a toolkit of small adjustments with big yield, ready to plug into busy glaucoma workflows.
Seeing past the green
Dr. Swarup Swaminathan (USA) opened with a brisk primer on optical coherence tomography (OCT) literacy. Color alone misleads, he cautioned, since “green disease” can mask real damage when asymmetry is ignored or segmentation falters. New patients should be compared against a normative database and the fellow eye, and on follow-up, the priority is changed from baseline rather than a single snapshot.
He urged a return to anatomy by reviewing raw B-scans for true tissue morphology, not just sector maps. Common masqueraders include optic nerve head tilt, peripapillary atrophy, vitreous traction, ischemia and macular edema. Artifacts from media opacity and poor centration can also nudge thickness values into the false-normal range.
Progression analysis belongs in the center of the visit. Align scan protocols, check signal strength and verify segmentation before deciding that nerve fiber layer loss is real. “The green goblin is out to get you,” he joked, but the point landed: vigilance plus structure-function correlation keeps early or non-glaucomatous pathology from slipping by.
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Fields still matter
Perimetry is not relic tech, argued Dr. Rebecca Chen (USA), it is decision fuel. Use 24-2 for the wide map, 10-2 to interrogate central loss and size-5 stimuli when acuity is poor. SITA Fast and SITA Faster trim chair time while keeping clinical utility. “In spite of a lot of the technological advances…perimetry cannot be fully replaced by structural testing,” she said.
Everything starts with reliable fields. Among the indices, false positives do the most damage because an over-eager responder can disguise loss. After you have five reliable fields, move from event flags to trend analysis and measure slope. Test two to three times per year after diagnosis to catch rapid progressors, then confirm any apparent change with a repeat field.
Administrative pragmatics matter too. Be careful billing multiple fields on the same day, as reimbursement may not happen. OCT and fundus photography have clearer limits, so keep an eye on evolving payer policies as diagnostic use expands.
Drops with mercy
With a mantra of “know your target, start slow and be kind,” Dr. Prithvi Sankar (USA) delivered a brisk tour of practical glaucoma pharmacology. Landmark trials from OHTS (Ocular Hypertension Treatment Study) to CNTGS (Collaborative Normal-Tension Glaucoma Study) set the stakes: “reducing the intraocular pressure by about 20% decreased the incidence of glaucoma by 60% over five years.” Targets should reflect baseline risk and stage, then be revisited as life circumstances change. Start therapy thoughtfully rather than automatically low and intensify or de-escalate based on progression and tolerance.
Keep the ocular surface in the plan. Spare patients a “cactus garden” of toxicity by minimizing preservatives and drop burden, using combination agents where sensible and counseling on proper spacing. Cost and complexity derail adherence, so simplify regimens and educate with empathy.
Dr. Sankar’s vivid reminder about drop time hits home: for some, it can feel like “two hours. That is a movie a day, and there’s no song and dance in this. This is a total tragedy.” For image-conscious patients, especially those bothered by lash growth, iris darkening or fat atrophy, he often avoids prostaglandin analogs as first-line choices.
Lead with light
Dr. Eileen Bowden (USA) argued that selective laser trabeculoplasty (SLT) belongs at the front of the line. Drawing on LiGHT and COAST, she highlighted durable pressure control with standard-energy 360° treatment, fewer operations and safe repeatability.
In LiGHT, “there was a significantly lower rate of disease progression and reduced need for glaucoma and cataract surgery in the group initially treated with SLT,” she noted. The dose-response favors wider treatment angles; temper energy and expectations in pigment-heavy or inflammatory eyes.
The durability was impressive, too. “The median time to first SLT retreatment exceeded six years,” Dr. Bowden said, a horizon that rivals multi-drop regimens without the adherence tax. She acknowledged unresolved points like the role of post-laser anti-inflammatories and direct SLT without a gonio lens. In closing, she said that if SLT would be your choice for your own eye, it deserves to be your patient’s first option as well.
Angles and flow
Minimally invasive glaucoma surgery (MIGS) may be small on incision, but Dr. Constance Okeke (USA) treats it like a big strategy exercise. She walked through core pathways of goniotomy, canaloplasty, trabeculotomy, Schlemm’s scaffolding, supraciliary routes and subconjunctival shunts—then drilled into execution that starts with visualization.
“Tilting the patient’s head away 30 to 45° and then tilting the operating microscope towards you ~30° will allow you to set up for success and get the right angle,” she said. Access follows anatomy, so use OMNI (Sight Sciences; California, USA) to feel for points of resistance in Schlemm’s canal and respect collector system variability.
For XEN (Allergan; Dublin, Ireland), air bubbles can create antifibrotic pockets that keep the bleb breathing. When the canal tightens, she advised controlled patience: “If there is any area of resistance, use viscodilation with purpose…pause for a couple seconds and you can sometimes go further.”
Adjuncts like ALLOFLO (Iantrek; New York, USA) and DEXTENZA (Ocular Therapeutix; Massachusetts, USA) can aid healing and inflammation control. As techniques advance, surgeons must evolve too, staying sharp and prepared to customize their approach for each patient, each canal and each cleft.
Trabs, tuned and precise
While MIGS gets the buzz, Dr. Anup Khatana (USA) made the case that trabeculectomy isn’t going anywhere. From pre-op strategies like axial length tracking and pre-treatment with fluorometholone to intraoperative flap geometry that reduces astigmatism, Dr. Khatana mapped out a modern, precision-based approach to an old-school procedure.
Tips like posterior Tenon’s advancement, aqueous “bleb rolling” and laser-smoothing VICRYL™ sutures added new polish to trabs. Even mitomycin use is evolving, with post-op injections sidestepping ischemic blebs. With careful control of flow, sutures and postoperative inflammation, surgeons can get both pressure and optics right. “Refractive glaucoma surgery” may sound like a contradiction, but with evolving expectations, Dr. Khatana argued, it’s time we all learn to walk that tightrope.
A final question from the audience gave Dr. Khatana a chance to clarify his position on 5-fluorouracil (5-FU) versus mitomycin C (MMC). He admitted a strong preference for highly diluted MMC (sometimes as low as 0.05 mg/mL) because of persistent keratopathy issues he encounters with 5-FU, despite using careful self-sealing injection techniques. However, he acknowledged that access to MMC can be a challenge in private practice settings. “We’re lucky to have an in-house compounding pharmacy,” he said, highlighting a resource advantage many practices lack and confirming that 5-FU remains a practical option for many surgeons.
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High volume, high touch
Efficiency isn’t about rushing, said Dr. Angela Turalba (USA). “Having an efficient clinic isn’t just about seeing more patients…We also need to make the most use of the limited time we have with each patient.”
She mapped out practical moves that add up: scheduling templates that front-load testing, pre-charting with smart phrases and slit lamps prepped with lenses and labeled toolkits so rooms are grab-and-go. Physical cues and preference lists lighten cognitive load, while EMR messaging huddles keep teams aligned without hallway detours.
Space does work too. Stagger technician and provider flow, cluster similar visits and design exam lanes that minimize backtracking. Documentation can be right-sized with AI scribe tools that capture the story while clinicians keep eye contact.
The horizon is hybrid with home monitoring devices, eConsults and telemedicine that “can help address our increasing demand for glaucoma care,” she noted. Efficiency isn’t a unicorn, it’s a team sport. With some planning, communication and the right tech, glaucoma care can be both high-volume and high-touch.
Prep, posture, precision
Dr. Manjool Shah (USA) delivered a masterclass in OR efficiency that was peppered with humor, humility and hard truths. Plan the day with pre-op huddles and a visible whiteboard so roles, timings and contingencies are clear. Standardize trays, confirm meds and walk the team through the first three steps. “Go slow to go fast,” he said. “Every complex case is a series of small simple steps.”
Ergonomics is the key: microscope tilt, chair height, foot pedal placement and arm support preserve accuracy and the surgeon’s spine. The risk is real: “Forty percent of us will suffer chronic neck or back issues. Ten percent will stop operating because of chronic neck and back issues.” Build micro-pauses into the flow to reset posture and vision. Close the loop with concise op notes and templated orders so turnovers stay smooth.
Dr. Shah’s bottom line was sustainability. Efficiency protects time, outcomes and careers when preparation, communication and ergonomics work in concert.
Flow over frenzy
Efficiency in glaucoma care is not about moving faster. It is about structure that holds, communication that lands and systems you can repeat without losing the patient in front of you. The gains often live in the details: a pre-charted visit, a verified segmentation, a head tilt for gonio, a preloaded suture, a microscope set to spare the surgeon’s neck.
Across clinic and OR, today’s playbook reclaimed minutes and trimmed risk so attention returns to decisions that change vision. Efficiency becomes a clinical outcome when habits harden into culture. Keep the small wins, share them and let them compound. That is how busy services stay humane and how “magical pressures” turn into durable ones.
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.