A patient with primary open-angle glaucoma (POAG) is on maximum tolerated medical therapy (timolol + latanoprost + dorzolamide) with IOP of 21 mmHg, but shows progressive visual field loss. The NEXT most appropriate step is:

• A Add a 4th topical agent (brimonidine)
• B Trabeculectomy with mitomycin C ✓
• C Selective laser trabeculoplasty (SLT)
• D Cyclodestructive procedure (cyclodiode laser)

Explanation

When maximum tolerated medical therapy fails to control IOP and the disease continues to progress, surgical intervention is required. Trabeculectomy with mitomycin C (an antimetabolite to prevent bleb scarring) is the gold-standard filtration surgery that provides consistent IOP lowering. Adding a 4th agent to maximum tolerated therapy has limited additional efficacy and adds to side effect burden. SLT is appropriate as adjunct or when surgery is not yet indicated but not after maximum medical therapy is failing. Cyclodestructive procedures are reserved for refractory glaucoma with poor visual prognosis.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.