ESCRS SURVEY REPORT | JANUARY/FEBRUARY 2026
ESCRS Clinical Trends Series:
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ESCRS Clinical Trends Series: Glaucoma In this edition of the ESCRS Clinical Trends Series, ESCRS President Prof. Burkhard Dick examines key findings from the 2025 ESCRS Clinical Trends Survey, providing an in-depth analysis of how society members approach glaucoma management— from diagnosis to treatment—with a particular emphasis on minimally invasive glaucoma surgery (MIGS).
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EuroTimes Supplement January/February 2026 | ESCRS Clinical Trends Series: Glaucoma
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Prevalence of Glaucoma in Cataract Patients The 2025 ESCRS Clinical Trends Survey marks the tenth consecutive year of data collection, capturing insights from over 20,000 respondents to date. A longitudinal comparison revealed a steady decline in the proportion of cataract patients estimated to have glaucoma, from an average of 12% in 2018 to 9.6% in 2025 (Figure 1).
“Combined cataract surgery and MIGS is likely an important driver for the observed decline in glaucoma among cataract patients.”
Further Insights According to survey respondents:
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average number of patients seen per month considered as having glaucoma
What percentage of all your cataract patients would you estimate have glaucoma? 12.0% 11.5%
23%
10.9% 10.4%
2018
2019
2020
2021
10.1%
2022
9.7%
9.7%
9.6%
2023
2024
2025
of glaucoma patients prescribed more than two medications are not compliant
Figure 1. Percentage of estimated cataract patients with glaucoma from 2018 to 2025, showing steady decline over the years.
Several factors likely contribute to this trend: • Earlier cataract surgery—performed before glaucoma typically develops or progresses. • Combined procedures—mild glaucoma increasingly managed at the time of cataract surgery via MIGS. • Denominator effect—more patients without glaucoma undergoing cataract surgery lowers the overall proportion with coexisting glaucoma. Modern MIGS techniques (e.g., trabecular stent implantation or goniotomy) can be performed alongside phacoemulsification, effectively “treating” glaucoma in a single step. The European Glaucoma Society (EGS) explicitly notes that MIGS, while still evolving, can be combined with cataract surgery and is suitable for mild-to-moderate disease.* Consequently, fewer patients with advanced glaucoma (for example, those on multiple medications) now appear in the routine cataract list, as their disease is being addressed earlier. Viewed in this context, the decline in glaucoma prevalence among cataract patients likely reflects a positive shift in practice patterns rather than a true reduction in disease incidence. It highlights earlier cataract intervention, proactive glaucoma management, and integrated surgical approaches, ultimately helping to reduce the long-term burden of glaucoma.
15%
of cataract surgery patients on topical glaucoma therapy are MIGS candidates
58%
lack confidence in performing MIGS procedures on cataract surgery patients
*The latest EGS Guidelines can be found at : https://eugs.org/educational_materials/6
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Treating Glaucoma Medication remains the predominant first-line treatment for glaucoma (Figure 2). However, other modalities, particularly selective laser trabeculoplasty (SLT) and MIGS, are being notably utilized, especially following initial treatment.
What is your typical first-line therapy for newly diagnosed glaucoma? Bimatoprost intracameral implant 0.3%
Medications 77.6%
Surgery/MIGS 1.9% SLT 20.1%
Figure 2. Medication overwhelmingly remains the most common first-line therapy for newly diagnosed glaucoma.
“Poor adherence to multipledrop regimens is unfortunately very common.”
Medication and Patient Compliance
Survey respondents estimate that, on average, 23% of glaucoma patients prescribed more than two medications are non-compliant. This figure likely underestimates the true rate, as multiple studies report overall non-adherence in glaucoma patients ranging from 30% to 55%.1–4 Importantly, patients on multi-drop regimens exhibit higher non-adherence, with missed doses increasing over time. In my experience, any patient on three or more different drops is at particularly high risk. Managing multiple bottles, varying dosing schedules, and potential side effects can be challenging, especially for elderly patients. Common drivers of non-compliance include complex regimens, forgetfulness, medication costs, and adverse effects. Psychosocial factors, such as low health literacy or depression, also play a significant role. To improve adherence, I focus on simplifying and supporting the treatment regimen: • Simplify the regimen: Use fixed-combination drops when possible, reduce dosing frequency, and align drop schedules with the patient’s daily routines. • Educate your patient: Clearly explain the visionpreserving goals of therapy, confirm understanding, and encourage the use of reminders or smartphone apps. • Manage the ocular surface: Treat dry eye concurrently and switch to preservative-free formulations to reduce discomfort. • Offer laser/surgical options: SLT or MIGS can reduce or even eliminate the need for drops. In many cases, undergoing SLT or a simple trabeculotomy to remove one or two drops markedly improves adherence and IOP control. • Provide follow-up and support: Involve nurse educators, use phone reminders, and engage family members to reinforce consistent medication use.
Laser vs. Surgical Intervention
According to the Clinical Trends Survey, only 18% of respondents reported starting glaucoma treatment with a laser intervention, and just 3% initiated therapy with surgery (Figure 3). Following initial management with medications, clinicians become more inclined to adopt procedural options. Specifically, 24% introduced laser treatment after first-line medication and 20% after two medications. In contrast, only 11% proceeded to surgery after first-line therapy, while 23% did so after two medications. Notably, surgical intervention rose to 41% among patients already on three medications. Over 20% of respondents reported never using laser or surgery for glaucoma—an area with clear potential for advancement. Deciding between laser, such as SLT or direct SLT (DSLT), and surgery depends on disease severity, IOP target, and individual patient factors. In line with EGS recommendations, I consider DSLT early, even as a first-line or early second-line option, especially for patients with mild-to-moderate openangle glaucoma (OAG) or ocular hypertension. The EGS explicitly recommends offering SLT as an initial therapy in mild or moderate cases, supported by evidence from trials such as LiGHT.5 When the target IOP cannot be safely achieved with medications or laser—for example, when a reduction greater than 40% is needed in advanced disease—
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EuroTimes Supplement January/February 2026 | ESCRS Clinical Trends Series: Glaucoma
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When do you usually initiate laser/surgical intervention for your glaucoma patients? Laser
Surgery
41%
24%
20%
18%
23% 17%
21%
22%
11% 3% First line
After first line medication
After two medications
After three medications
I do not perform laser/surgical interventions
Figure 3. Laser therapy is typically used earlier in the glaucoma treatment process, whereas surgery is more often reserved for later stages—commonly after the use of three medications.
incisional surgery becomes indicated. Importantly, the EGS emphasizes that surgery “should not be left as a last resort,” but considered whenever drops or SLT are unlikely to preserve vision.
“For patients struggling with three or more medications, I move promptly toward interventions such as MIGS or trabecular bypass rather than maintain a heavy drop burden.”
Patient adherence and quality of life are central considerations. Achieving medication-free IOP control can substantially enhance quality of life by reducing costs and discomfort; benefits often seen following DSLT or surgical intervention. In my practice, I reserve traditional trabeculectomy or glaucoma drainage devices for patients requiring very low target pressures (e.g., advanced structural or functional damage) or those with failed prior surgery. MIGS procedures are my go-to approach for mild-to-moderate OAG, where moderate IOP reduction and medication minimization are the goals. In summary, I individualize treatment. I apply DSLT early when appropriate, particularly for mild-to-moderate OAG or patients with poor drop tolerability, and proceed to surgical intervention—typically MIGS or trabecular bypass—when medical or laser therapy alone cannot safely achieve the desired IOP control.
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MIGS Adoption Rates Non-Adopters and Barriers
Forty-five percent of respondents neither performed MIGS nor planned to within the next 12 months (Figure 4).
Of your surgical cataract patients with glaucoma, which of the following best describes your use of/ interest in MIGS? 45%
29%
15% 6%
Do not plan to offer MIGS in next 12 months
Plan to offer MIGS in next 12 months
Perform MIGS in 1–10% of my cataract patients
Perform MIGS in 11–25% of my cataract patients
2%
2%
Perform MIGS in 26–50% of my cataract patients
Perform MIGS in 51–100% of my cataract patients
Figure 4. MIGS adoption remains limited: 45% of respondents neither offer nor plan to offer it within 12 months, 29% plan to adopt it, and only 26% currently perform MIGS.
The reluctance to adopt MIGS is largely systemic and cultural. Many colleagues still view glaucoma primarily as a “medical” disease, defaulting to adding drops rather than pursuing surgical options. Cost and reimbursement challenges further limit adoption: in many hospitals and healthcare systems, MIGS lacks a dedicated billing code or adequate reimbursement, making it financially unattractive. In Italy, for example, surgeons often must code MIGS under other procedures, leading to underpayment and reluctance to invest time in learning new techniques. Other major barriers include cost, the learning curve, limited access, and lack of confidence with the surgical skills required (Figure 5). Clinics often lack the intraoperative gonioscopy skills or instruments required to perform MIGS, and without hands-on experience, surgeons remain hesitant. Overcoming these barriers requires a multipronged approach. • Education and training: hands-on workshops, wet-labs, proctoring, and sharing live cases or published outcomes (e.g., ESCRS MIGS Masterclasses) help demystify these procedures and build skill. I also recommend starting with simpler procedures such as ab interno trabeculotomies, goniotomies, or angle surgeries with implant combined with routine phacoemulsification. As colleagues see positive results, like reduced drop burden and satisfied patients, their comfort and confidence will grow.
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“The low rate of MIGS adoption does not surprise me; despite considerable data on safety, many surgeons remain hesitant.”
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What are the main barriers to doing more/any MIGS procedures? 36%
Cost to patient or clinic 13%
The learning curve of the procedure or lack of training
11%
Lack of access to necessary technology I am not comfortable with the surgical skills required for MIGS procedures Patients in my practice are not good MIGS candidates
6%
32%
17%
15%
6% 6% 10% 14%
Does not improve patient outcomes enough beyond medication or laser therapy Insufficient evidence or clinical guidelines regarding the effectiveness of MIGS
5% 8%
Additional time to manage these patients both postoperatively and during surgery
8% 9%
Other (please specify)
50%
Perform MIGS Do not perform MIGS
6% 7%
Figure 5. Non-clinical factors are the biggest barriers to performing MIGS procedures, both among those who currently perform MIGS and those who do not.
• Economic measures: Hospitals and health systems should negotiate better pricing for MIGS devices and establish dedicated billing codes. Demonstrating long-term cost-effectiveness through reduced medication use, fewer follow-ups, and lower complication rates, can justify the initial investment. In some settings, adoption has improved when MIGS is offered as part of bundled or inpatient payments (e.g., during cataract surgery). • Technology access: Device manufacturers can support early adopters by providing demonstration units. Some clinics have addressed access issues by sharing equipment or organizing “MIGS days”, during which multiple procedures are performed efficiently in a single session. • Mentorship and awareness: early adopters can guide colleagues through proctoring programs. Including MIGS in national guidelines (e.g., EGS) and sharing patient success stories, especially medication-free outcomes, can drive wider acceptance. In summary, the current low adoption of MIGS reflects primarily non-clinical barriers, including reimbursement, culture, training, and access. Addressing these through coordinated efforts in education, mentorship, and economic advocacy, supported by real-world outcomes, can increase surgeons’ confidence and demonstrate the long-term value of MIGS. As hospitals recognize the cost and follow-up benefits and surgeons gain experience, adoption is likely to grow.
“Many clinics still lack the intraoperative gonioscopic skills or equipment required to perform MIGS.”
Systemic progress in both health economics and hands-on training will be essential to overcome these non-clinical barriers and expand access to MIGS.
Adopters and Emerging Momentum
Encouragingly, 26% of ESCRS survey respondents already perform MIGS, and an additional 29% plan to adopt it soon—a combined adoption rate of 55% that reflects clear momentum and growing interest (Figure 4). Many surgeons prefer to “wait and see” before changing their practice. I expect adoption to rise as more long-term data emerges and newer MIGS devices gain regulatory approval. Globally, MIGS remains relatively new. FDA approval occurred only about a decade ago. So gradual adoption is expected rather than immediate widespread use.
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Factors Impacting MIGS Candidacy The survey found that, on average, respondents believe only 15% of cataract surgery patients on topical glaucoma therapy are MIGS candidates, though this figure seems conservative. Part of this discrepancy may stem from differing definitions of what constitutes a good versus poor candidate. A good MIGS candidate typically has mild-to-moderate OAG, a moderate target IOP in the mid-teens, and challenges with drops, such as poor adherence or intolerance. EGS and other guidelines emphasize MIGS for mild-to-moderate glaucoma, including primary OAG, pseudoexfoliation, and pigmentary glaucoma, particularly when patients are noncompliant or experience side effects. In practice, I look for: • Open angles on gonioscopy—no synechiae or angle closure. • Early to moderate optic nerve damage, where a modest IOP reduction is sufficient. • Medication burden, especially patients on multiple drops or reporting side effects. • Lens status, as combining MIGS with cataract surgery is a logical and efficient choice. Conversely, poor candidates include patients with advanced glaucoma requiring very low IOP (e.g., single-digit targets) or those with angle-closure, neovascular glaucoma, or scarred angles. Patients unable to adhere to post-operative follow-up may also be suboptimal candidates, as some MIGS procedures require monitoring or bleb management. Essentially, when the disease is too severe or the angle anatomy is unfavorable, I opt for a traditional filtering procedure.
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By these criteria, 25-30% of my cataract patients with glaucoma are good MIGS candidates, considerably higher than the 15% reported by survey respondents.
“I caution against promising drug-free status after any MIGS procedure.”
Advantages of MIGS According to survey respondents, the main advantages of MIGS are the ability to be performed in conjunction with cataract surgery, reduction or elimination of medication burden, lower risk of complications, and preservation of the conjunctiva (Figure 6). These benefits largely hold true: • Combination with cataract surgery: MIGS is often performed through the same clear corneal incision used for phacoemulsification, adding only a few minutes to the overall surgery. This combined approach efficiently addresses both lens opacity and IOP at once, an important convenience for both patient and surgeon. • Reduced medication burden: Reduction in topical therapy is a major benefit and discussed earlier in Medication and Patient Compliance. Complete medication freedom
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What do you believe are the main advantages of a MIGS procedures over other treatments for early-to-moderate stage glaucoma patients? It can be performed in conjunction with cataract surgery
67%
Reduces/eliminates medication burden
57%
Lower risk of complications
52%
It preserves the conjunctiva
43%
Less pain and discomfort
35%
It is the most effective option reducing IOP in these patients It does not have any advantages over other treatments for glaucoma Other (please specify)
12% 4% 1%
Figure 6. The ability of MIGS to be performed in conjunction with cataract surgery was the top perceived advantage, cited by 67% of respondents. In contrast, only 4% of respondents felt MIGS offered no advantages.
can be achieved in some cases, but not in every MIGS patient. Many patients will still need at least one drop postoperatively. Thus, setting realistic expectations is essential. • Lower risk of complications: MIGS procedures have a remarkable safety profile compared to traditional glaucoma surgeries. They cause minimal collateral tissue damage with no external bleb (except bleb-forming procedures) and a very low risk of choroidal detachment, flat anterior chamber, or hypotony. The result is faster recovery, less postoperative discomfort, and a markedly reduced risk of serious complications such as hemorrhage or effusion. • Preservation of conjunctiva: A frequently overlooked but important advantage is conjunctival preservation. MIGS leaves the external ocular anatomy essentially intact (except for bleb-forming procedures). This preserves the option of traditional filtering surgery in the future if glaucoma progresses, offering a valuable safety net for long-term disease management. Some expectations surrounding MIGS require careful calibration. For example, while some may hope MIGS can achieve IOP reductions comparable to trabeculectomy, this is generally overstated. MIGS is most appropriate for mild-to-moderate glaucoma, where a modest IOP reduction (often into the midteens) is sufficient. It is not a substitute for advanced glaucoma requiring very low target pressures. These benefits make MIGS particularly appealing for early glaucoma. None are myths; each is supported by evidence. The critical factor is matching the procedure to the patient’s disease stage and target IOP. When done appropriately, MIGS provides a gentler, patient-friendly step up from topical
therapy without exposing patients to the risks associated with full-filtering surgery.
MIGS Procedures Preferences There are currently several different MIGS procedures available. Among survey respondents, angle surgery with an implant (62%) and angle surgery without an implant (43%) were the most commonly reported (Figure 7). In contrast, subconjunctival and suprachoroidal procedures were less frequently performed (29%). This pattern aligns my own practice, as I primarily perform angle-based procedures, with or without implants, at the time of phacoemulsification - a combination many surgeons find straightforward.
Angle-based MIGS
Angle surgeries with an implant were among the first approved MIGS procedures, providing modest IOP reduction while reliably reducing medication burden, and were notably utilized by 62% of survey respondents (Figure 7). Angle procedures without implants are performed by 43% of MIGS surgeons (Figure 7). These “bleb-less” techniques are appealing because they are low-cost, have a safety profile comparable to implants, and can be performed during cataract surgery. They work by excising or opening the trabecular meshwork, yielding IOP reductions similar to a single stent, and avoiding risks associated with implant displacement or clogging.
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Subconjunctival MIGS
Subconjunctival MIGS, performed by 29% of surgeons (Figure 7), creates a permanent outflow pathway under the conjunctiva, achieving IOP reductions closer to those of trabeculectomy. While effective, they can produce blebs that may require postoperative needling, which makes some surgeons approach them with caution.
Which MIGS procedure do you perform?
62% 43% 29%
Suprachoroidal MIGS
Suprachoroidal MIGS leverages the physiological uveoscleral outflow route, a concept first explored with cyclodialysis clefts. Classic cyclodialysis was effective in lowering IOP but often caused hypotony, bleeding, and eventual cleft closure. Modern suprachoroidal MIGS use micro-stents or spacers to create controlled aqueous outflow without permanent clefts. Current devices in use or development include ab-interno or ab-externo stents that shunt fluid from the anterior chamber into the suprachoroidal space. While promising, suprachoroidal MIGS remains rarely used in clinical practice. The popularity of MIGS procedures is largely driven by safety, familiarity, and awareness. Angle-with-implant MIGS were first to market and feel familiar to many surgeons. Angle-without-implant procedures are simple and inexpensive. Subconjunctival MIGS attracts those seeking greater IOP reduction but require bleb management. Overall, these preferences reflect a balance between efficacy, safety, and practical considerations, consistent with the survey findings.
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Angle surgery with an implant
Angle surgery without an implant
Subconjunctival and/or suprachoroidal
Figure 7. Angle surgery, with or without an implant, was the most commonly performed MIGS procedure.
Conclusion The 2025 ESCRS Clinical Trends Survey highlights a clear shift toward earlier, more individualized glaucoma care, with growing momentum behind SLT and MIGS. Although adoption remains uneven due to reimbursement and training barriers, continued investment in education and system-level support will be essential to translate this progress into broader, routine clinical practice across Europe and beyond.
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About the Survey
The 2025 ESCRS Clinical Trends Survey was conducted during the 43rd Congress of the ESCRS in Copenhagen, Denmark, with members and congress attendees also able to participate online through the ESCRS website. The survey addressed several areas of clinical practice, including general cataract surgery, astigmatism and toric IOLs, presbyopia correction, glaucoma and MIGS, and corneal refractive surgery. More than 2,300 ophthalmologists responded to the 120 questions, which were developed and reviewed in collaboration with ESCRS leadership and substantiated by a data scientist. To better understand the educational needs of its members, ESCRS leadership continually references these annual surveys and the feedback they elicit. The insights collected inform and enhance educational opportunities featured at the Annual Congress of the ESCRS, the ESCRS Winter Meeting, as well as the ongoing ESCRS Clinical Trends Series.
About the Expert
Dr. Burkhard Dick is Professor and Medical Director at Ruhr University Eye Hospital Knappschaft Kliniken, Bochum, Germany, where he leads one of Europe’s most technologically advanced centers for cataract, glaucoma, vitreoretinal and refractive surgery. His clinical and research interests span cataract, presbyopia, simultaneous vision IOL technology, and laser-assisted surgical techniques, with a particular focus on optimizing visual outcomes and advancing precision in anterior segment surgery. He is the current President of the ESCRS and has long played a leading role in the organization’s educational and scientific activities. In addition to his work with the ESCRS, he serves as the General Secretary of the German Society of Cataract and Refractive Surgery (GSCRS, DGII), promoting scientific excellence and global collaboration in the field. Professor Dick has published over 300 peer-reviewed papers in international journals and has published several books and also contributed to several major textbooks and surgical reference works. He is widely regarded as a pioneer in femtosecond laser-assisted cataract surgery and digital operating room integration, innovations that have shaped modern ophthalmic practice. His contributions have earned him multiple international honors and listings among the world’s most influential ophthalmologists, recognizing his lasting impact on cataract and refractive surgery worldwide. REFERENCES: 1. Novella A, Quaranta L, Pasina L, et al. Drug Utilization, Adherence and Predictors of Drug-Changes and Discontinuation of Glaucoma Drug Therapies. Adv Ther. 2025;42(8):37433761. doi:10.1007/S12325-025-03247-Y 2. Negese Kebede B, Mohammed Seid S, Kefyalew B, Gesese E. Glaucoma medication non-adherence rate and associated barriers among glaucoma patients in Hawassa, Ethiopia. BMC Ophthalmol. 2024;24(1). doi:10.1186/S12886-024-03750-W 3. Moore SG, Richter G, Modjtahedi BS. Factors Affecting Glaucoma Medication Adherence and Interventions to Improve Adherence: A Narrative Review. Ophthalmol Ther. 2023;12(6):2863-2880. doi:10.1007/S40123-023-00797-8 4. Oltramari L, Mansberger SL, Souza JMP, de Souza LB, de Azevedo SFM, Abe RY. The association between glaucoma treatment adherence with disease progression and loss to follow-up. Sci Rep. 2024;14(1). doi:10.1038/S41598-024-52800-2 5. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009 6. Ahmed IIK, De Francesco T, Rhee D, et al. Long-term Outcomes from the HORIZON Randomized Trial for a Schlemm’s Canal Microstent in Combination Cataract and Glaucoma Surgery. Ophthalmology. 2022;129(7):742-751. doi:10.1016/j.ophtha.2022.02.021
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