Doc - should I use drops or have surgery for my glaucoma? Which is best?
Early Surgery vs Staying on Drops in Glaucoma: What Happens Now, Next, and Later
When someone is diagnosed with primary open-angle glaucoma (POAG), one of the biggest decisions is how to start treatment. Should we begin with eye drops and try to control the intraocular pressure (IOP) medically? Or should we move to surgery early on and aim for long-term stability right away?
There’s no single correct answer. Both approaches can preserve vision — but they come with different experiences and long-term consequences. Let’s explore what tends to happen in the short, medium, and long term for patients who either stay on drops or go down the surgical route early, drawing on key clinical trials for context.
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Short-term outcomes: the first year
When treatment begins with eye drops, things usually start smoothly. Prostaglandin analogues, beta-blockers, and carbonic anhydrase inhibitors can all lower pressure effectively, and adjustments can be made quickly. For most patients, drops are safe, familiar, and easy to start. The big advantage is that they’re non-invasive and fully reversible. If something causes irritation or allergy, you can simply stop or switch.
In the first few months, side effects are often limited to red eyes, mild irritation, or changes in eyelash growth. The Early Manifest Glaucoma Trial (EMGT) showed that even modest reductions in IOP from early treatment significantly reduced the risk of disease progression compared with no treatment at all. So from the very beginning, it’s clear that lowering pressure matters.
But the Achilles heel of medical therapy is adherence. Missing doses blunts the treatment’s effect. In real life, many patients simply don’t manage every drop every day, and IOP control fluctuates.
Early surgery, on the other hand, delivers an immediate and often dramatic pressure reduction. Traditional trabeculectomy, tube shunts, or newer minimally invasive glaucoma surgery (MIGS) procedures can all achieve low IOP targets that drops alone might struggle to reach. This can be sight-saving for those with advanced or rapidly progressing disease.
However, surgery carries early risks. In the first few months, there’s a higher chance of complications like transient hypotony, inflammation, or bleb leaks. The postoperative period also demands frequent visits and close monitoring. The Collaborative Initial Glaucoma Treatment Study (CIGTS) found that patients treated surgically at the outset achieved lower average pressures than those treated with drops, but also experienced more early ocular discomfort and some short-term vision fluctuation.
So in the short term, the choice comes down to priorities. If you need a quick, deep pressure reduction because vision is at risk, surgery can deliver it. If you want to start conservatively and avoid surgical risk, drops remain an excellent and safe first step.
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Medium-term outcomes: one to five years
As months turn into years, what matters most is whether the optic nerve remains stable and visual fields stay steady. Over this timeframe, the big question is whether early surgery offers better visual outcomes than sticking with drops.
Interestingly, the CIGTS results showed no meaningful difference in visual field outcomes at five years between those who started with surgery and those who began with medical therapy — provided both groups maintained target pressures. In other words, it’s not the method that matters most; it’s how well the pressure is controlled.
That said, quality of life often diverges. Patients on multiple drops frequently report red eyes, irritation, and dryness from preservatives, and these symptoms can accumulate over time. Adherence also tends to decline as daily routines change or more medications are added. On the other hand, surgery patients who achieve good IOP control without drops often enjoy a sense of relief and freedom.
A landmark study that’s slightly different but still relevant here is the LiGHT trial, which compared first-line selective laser trabeculoplasty (SLT) with topical therapy. Patients who started with SLT — and therefore avoided long-term drops — reported better eye comfort and similar IOP control over several years. The takeaway was clear: reducing dependence on drops, by whatever means, can make life noticeably better for many people.
Somewhere between these two extremes sits the world of MIGS — minimally invasive glaucoma surgery. These small, elegant procedures, often done during cataract surgery, aim to lower IOP moderately while reducing medication use. The risk profile is much safer than trabeculectomy, and for mild-to-moderate glaucoma, the results are often very satisfying. Over three to five years, many patients remain on fewer or no drops, though MIGS typically doesn’t reach the ultra-low pressures that more advanced cases require.
So by the medium term, the picture becomes nuanced. If you’re able to stay adherent and your pressures are stable, medical therapy can be just as effective as early surgery. If you struggle with drops, intolerance, or adherence, or if you simply prefer fewer medications, earlier procedural options — from SLT to MIGS — can offer a good balance of control and convenience.
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Long-term outcomes: the decade view
Once we move beyond five years, the differences between medical and surgical pathways become more pronounced. Long-term data consistently show that trabeculectomy offers the most powerful and durable pressure reduction. Even after ten or fifteen years, many patients remain drop-free or require minimal medication to maintain low pressures.
However, surgery’s strength comes with strings attached. Filtration blebs can fail or leak, infections can occur years later, and some patients develop bleb-related discomfort or scarring that undermines success. So while the long-term pressure profile is excellent, the lifetime maintenance of a bleb requires commitment and regular specialist review.
For those on long-term drops, the story depends heavily on adherence. In well-motivated, consistent patients, medical therapy can preserve vision for decades. But as people age, other health issues and declining dexterity or memory can make strict adherence harder. Even small lapses can allow slow progression over the years. And of course, ocular surface disease from chronic preservative exposure becomes more common with age and cumulative treatment.
For patients with advanced or rapidly progressing glaucoma, early surgery often translates into better visual preservation over the long term. The greater and more consistent IOP reduction reduces the risk of further visual field loss. For mild or stable disease, though, drops and less invasive options remain perfectly safe and effective.
There’s also an economic and quality-of-life angle. Surgery involves higher upfront costs and an intense early recovery phase, but often saves years of medication and follow-up visits later. Drops, by contrast, spread the cost and the effort over a lifetime — and rely on daily discipline. Many patients prefer to avoid surgery until necessary, but for those struggling with adherence or side effects, earlier surgical intervention can be liberating.
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Who benefits from early surgery?
Some people are clear candidates for early surgical management: patients with advanced field loss at presentation, those progressing despite apparently good medical control, and those who can’t tolerate or adhere to multiple drops. Surgery is also a strong option for patients who need very low target pressures — for example, below 12 mmHg — that are hard to achieve with topical therapy alone.
For others, starting with drops or SLT makes perfect sense. If the disease is mild, pressures respond well, and adherence is reliable, conservative management remains the gold standard. Patients who are already facing cataract surgery might consider a MIGS procedure at the same time — a middle ground that can achieve lower pressures with minimal added risk.
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The bigger picture
Every major glaucoma trial reinforces one simple truth: controlling pressure matters more than the method used to control it. The EMGT, CIGTS, and LiGHT studies all agree on that point. The challenge is to choose the strategy that best fits the individual patient — not just their disease stage, but their lifestyle, preferences, and ability to maintain treatment over time.
For some, early surgery provides lasting security and independence from drops. For others, drops or laser keep the disease stable for years with minimal disruption. There’s no universal right answer, only a tailored one.
What’s crucial is staying engaged — monitoring pressures, visual fields, and optic nerve changes regularly, and being open to escalation if the disease advances. Glaucoma is slow, but relentless; our best results come from staying one step ahead.
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In summary
Patients who start with drops can expect a safe, gentle introduction to treatment, with good short-term control and minimal risk. Those who choose early surgery will experience a more dramatic initial drop in pressure and, if successful, less dependence on medications long-term — but with a higher early risk and the need for lifelong surgical follow-up.
Over decades, the best outcomes come from whatever keeps pressure low, vision stable, and life livable. Whether through bottles or blebs, the aim remains the same: to protect sight for the long run.