Glaucoma Treatment Selection
Decision Logic, Side Effects & Taiwan Reality

1. Core principle: lifelong individualized management

Why isn't treatment just 'here's a bottle of drops'?

• Target IOP is individualized — AAO 2025 PPP suggests an initial 20-30% reduction below baseline, adjusted for severity, progression rate, life expectancy and side-effect tolerance; the more severe the disease, the lower the target. EGS 6th-edition reference values: about 18-20 mmHg with at least a 20% reduction in early glaucoma, about 15-17 mmHg with at least 30% in moderate glaucoma, and lower (e.g. 8-12 mmHg) in advanced disease, though EGS stresses that target IOP is an upper limit, that little evidence supports any particular algorithm, and that it must be estimated for each eye and reviewed over time
• IOP is only a surrogate — what matters is whether visual field and optic-nerve structure stop deteriorating. If IOP is 'at target' but OCT/fields still worsen, treatment must be intensified
• Treatment is lifelong — glaucoma is incurable, nerve damage is irreversible, and stopping treatment may allow further progression
• Adherence is the deciding factor — a systematic review found new users had drops available on only about 56% of days in their first year (Reardon 2011), which is why fixed-dose combinations, laser and durable surgical options matter so much

When the doctor says 'let's try another one' or 'let's add a bottle,' it isn't a verdict on prior treatment — it's optimization. With this mindset, the rest of the ladder makes sense.

2. First-line: SLT laser vs eye drops

① LiGHT trial: the evidence rewriting first-line

The LiGHT trial (Lancet 2019) is the key trial for SLT as first-line: 718 newly diagnosed OAG or OHT patients in the UK randomized to first-line SLT vs eye drops.

• 3-year: 74.2% of SLT patients were drop-free at target IOP; at-target visits were similar (93.0% vs 91.3%). No SLT patient needed glaucoma surgery (11 in the drops arm), cataract surgery was less frequent (13 vs 25), and SLT was more cost-effective
• 6-year extension (Ophthalmology 2023): 69.8% of SLT-arm eyes stayed at or below target IOP without medical or surgical treatment; more drops-arm eyes progressed (26.8% vs 19.6%) and more often needed incisional glaucoma surgery and cataract surgery (a 2025 corrigendum exists, so per-group eye counts are not listed here)

② NICE 2022 rewrites the guideline

On the strength of LiGHT, NICE 2022 NG81 lists 360° SLT as first-line for newly diagnosed, non-advanced COAG and for OHT with IOP ≥ 24 mmHg at risk of lifetime visual impairment, instead of drops (excluding pigment dispersion syndrome). The AAO PPP 2025 accepts laser trabeculoplasty as initial therapy while noting drops remain the most common start; the EGS 6th edition (2025) lists laser trabeculoplasty as a first-line option alongside monotherapy.

③ Why do most Taiwanese ophthalmologists still start with drops?

This isn't a deviation from guidelines but practical individualization:

• NHI coverage differs: most drops are covered, and the NHI fee schedule includes laser trabeculoplasty (60007C, not distinguishing SLT from ALT), but not every hospital has an SLT laser
• Primary-care access: drops are dispensed at any clinic; SLT is mostly available at mid-to-large hospitals
• Patient preference: many patients are wary of 'laser' and prefer trying drops first
• SLT not suitable for some: pigment dispersion syndrome, advanced glaucoma (NICE favours surgery), patients unable to position at the slit lamp
• SLT isn't universal: in LiGHT, about a quarter of SLT patients still needed drops at 3 years

3. The five PGA drops: a complete comparison

Prostaglandin analogues (PGAs) are the most potent single-agent IOP-lowering drops, with the fewest systemic side effects and only once-daily dosing — making them the first-line drug class in most international guidelines. Taiwanese clinics see five main PGAs: latanoprost, bimatoprost, travoprost, tafluprost, and the newer dual-mechanism (uveoscleral + NO-mediated trabecular outflow) latanoprostene bunod (Vyzulta) — marketed in Taiwan. Under NHI, PGAs (including Vyzulta) are restricted to patients for whom β-blockers are ineffective or unsuitable (section 14.1.1), and Vyzulta has its own quantity cap (1 bottle per 8 weeks for one eye); discuss details with your doctor.

① Why are PGAs dosed in the evening?

IOP follows a diurnal rhythm — many people have higher IOP at night while lying down asleep; the timing and size of the peak vary with age, posture and disease. PGAs are dosed once daily and last ~24 hours, and labels advise evening dosing. If a dose is missed, simply continue with the next dose — don't make it up or double it; labels note that dosing more than once daily may reduce the IOP-lowering effect.

② Five-PGA comparison table

* Latanoprost, travoprost and bimatoprost show trough-to-peak values from the van der Valk 2005 meta-analysis; the others show the AAO PPP 2025 class range (25-33%); individual variation is large. NHI coverage: all PGAs are restricted to patients for whom β-blockers are ineffective or unsuitable (Taiwan NHI drug reimbursement rules (updated 2026-10-22), section 14.1.1); discuss details with your doctor.

③ PGA-specific side effects in detail

* Overall, bimatoprost has the highest side-effect frequency and tafluprost the lowest. PAP is significant enough to warrant the dedicated callout below.

④ Which PGA for whom?

Choose latanoprost: most adults without contraindications — many generics, lowest cost, NHI-covered (like other PGAs, restricted to patients for whom β-blockers are ineffective or unsuitable), relatively mild side effects. Start broad, escalate if needed.

Choose bimatoprost: latanoprost insufficient and stronger drop needed; patient unbothered by cosmetic side effects (lashes, PAP).

Choose tafluprost (especially preservative-free):

• Significant dry eye, ocular surface disease, contact-lens wearers
• BAK preservative allergy
• Patients heading toward glaucoma surgery — the AAO PPP notes preoperative BAK-preserved drops may be a risk factor for trabeculectomy failure, and EGS warns long-term BAK may lower filtering-surgery success

Avoid bimatoprost:

• Young women (cosmetic asymmetry from unilateral use)
• Pre-existing ptosis or lid laxity
• Appearance-sensitive professions

Caution with any PGA: active uveitis; CME history or recent cataract surgery; HSV keratitis history.

4. Other drug classes — side effects in detail

When PGA monotherapy is insufficient or contraindicated, other classes are added or substituted. Each has a distinctive side-effect profile, and the doctor evaluates systemic status (asthma, heart disease, diabetes, sulfa allergy, age) before prescribing. Below: a comparison table first, then per-class deep dives.

① Five-class quick-reference table

② β-blocker — the systemic-side-effect concern

The most common second-line add-on to a PGA. But topical β-blockers are absorbed systemically, and labels warn that the adverse reactions of oral β-blockers may also occur with eye drops — a frequently underestimated clinic risk.

Other effects to monitor: fatigue, reduced exercise tolerance, depression (especially in elderly), sexual dysfunction. Betaxolol (no longer marketed in Taiwan) is β1-selective with less airway impact (relative — not absolute — contraindication for asthma) but also weaker IOP reduction.

③ α2 agonist — high allergy rate

Brimonidine is the most common α2 in Taiwan, typically third-line on top of PGA + β-blocker; apraclonidine (not marketed in Taiwan) is used abroad short-term around SLT to prevent IOP spikes.

Hallmark feature: high rate of allergic conjunctivitis — labels report allergic conjunctivitis, hyperemia or itching in about 10-20% of patients, a common reason to stop. Other points:

• Strict contraindication in infants — toxicity case reports of respiratory depression, somnolence, hypotension
• Elderly drowsiness, dizziness — avoid before driving; consider evening dosing if necessary
• Reasonable β-blocker alternative for asthmatics

④ Carbonic anhydrase inhibitors — topical mild, oral potent but short-term

Topical (Brinzolamide, Dorzolamide) lowers IOP 15-20% with mostly ocular side effects: metallic taste (drainage to mouth), stinging, transient blur. Systemic effects are minimal, but patients with marginal corneal endothelium (Fuchs etc.) face decompensation risk and warrant careful evaluation.

⑤ Rho kinase inhibitors — newer, weaker, unique mechanism

Netarsudil (Rhopressa) and Ripasudil are newer agents that directly relax the trabecular meshwork to enhance outflow — a mechanism distinct from existing drugs. In Taiwan, netarsudil is available only as Rocklatan (with latanoprost, licensed 2026); neither netarsudil alone nor ripasudil (used mainly in Japan) is licensed.

Weaker IOP lowering (10-20%) with mainly ocular side effects: about half (53% on the label) develop hyperemia, and about one in five subconjunctival hemorrhage (painless redness) or corneal verticillata (slit-lamp visible but vision-sparing). Use case: add-on after multiple agents fail, or alternative for patients with PGA / β-blocker contraindications.

⑥ Pilocarpine — relegated to special indications

Largely reduced role today; almost exclusively used for:

• Acute angle-closure: miotic to pull open the angle (caution: at very high IOP the ischemic pupil does not respond to miotics, so it usually works only after other agents have lowered IOP)
• Pre-LPI miosis
• Rare special indications (juvenile glaucoma, post-op IOP spikes, etc.)

Why is it less used? Miosis causes poor night vision; sustained ciliary contraction induces myopia; headache and brow ache are common. Most importantly: pilocarpine can precipitate retinal tears or detachment (labels note higher risk in susceptible people and those with retinal disease, and advise a retinal exam first) — one reason it is rarely used long term.

⑦ Preservative BAK — the hidden long-term toll

Most drops contain BAK preservative; chronic exposure across multiple bottles causes ocular surface epithelial damage, chronic conjunctivitis, dry-eye worsening, and allergic reactions. Also worth noting: preoperative use of BAK-preserved drops may be a risk factor for later trabeculectomy failure (AAO PPP).

5. Fixed-dose combination drops (Taiwan-available list)

When monotherapy is insufficient and two classes are needed, the choice is between two separate bottles or a single combination bottle. Reasons to combine:

NHI rule: fixed combinations are covered only as second-line (or later) therapy for patients whose IOP remains poorly controlled after a single IOP-lowering drug (Taiwan NHI drug reimbursement rules (updated 2026-10-22), section 14.1.2); starting a combination at diagnosis does not meet this condition. The per-product coverage column in the tables below is not part of the rule text — discuss details with your doctor.

① Why use a combination?

1. Better adherence: drops per day cut from 4 to 2, with measurably better compliance
2. Less BAK exposure: two bottles each contain BAK; one combination halves the load
3. Reduces washout: two separate bottles spaced too closely (< 5 min) wash each other out
4. Simpler prescription

② When NOT to combine?

• Want to adjust each agent independently (combos can't be down-titrated)
• Hard to attribute side effects (which component caused it?)
• Need different timing (PGA at night, others in morning)

③ Taiwan-available combination drops

PGA + β-blocker (Timolol) — once daily

Profile: strongest, most popular, once daily. Contraindicated in asthma/heart disease (β-blocker limit).

CAI + β-blocker — twice daily

Profile: suitable as the 'third weapon' on top of PGA, or as primary therapy in PGA-intolerant patients. Asthma/heart disease still contraindicated.

α2 + β-blocker — twice daily

Profile: β-blocker + α2 combination, but causes drowsiness in elderly; contraindicated in infants.

CAI + α2 (no β-blocker) — usable in asthma/heart disease

Profile: β-blocker-free — key option when asthmatic or arrhythmic patients need two-class therapy.

PGA + Rho kinase

④ Combination drop strategy

1. Failure on 3 classes (including PGA) → adding a combination bottle outperforms adding a monotherapy (if the new class is novel)
2. Both bottles needed long-term → switch to an equivalent combo to reduce drops and BAK
3. Combo at initial diagnosis? Most guidelines still recommend starting with PGA monotherapy and adding as needed; combo first-line only for very high initial IOP requiring rapid lowering

6. Add-on vs switch — the decision logic

When PGA monotherapy is insufficient, there are two paths: add-on or switch. How to decide?

① When to add

• Partially effective: IOP dropped but not at target (e.g., baseline 24 → 19 on PGA, target 17) → add second class
• Patient can manage multiple bottles (adherence, schedule allows)
• Side effects tolerable

② When to switch

• No effect: barely any IOP change on PGA → try another PGA (inter-individual variability exists) or switch class
• Intolerable side effects: severe redness, marked PAP → switch to latanoprost/tafluprost or non-PGA
• Allergy: switch to PF or different class

③ Monocular drug trial

Some clinicians have treated one eye with the new drug while using the other as a control, then compared IOP. However, the AAO PPP 2025 notes that studies show monocular trials do not reliably predict long-term efficacy (the eyes may respond differently, IOP fluctuates asymmetrically, and drops can affect the fellow eye), and prefers comparison with multiple pre-treatment readings in the same eye; the EGS 6th edition considers uniocular trials potentially useful in some cases.

④ Washout considerations

• PGA → another PGA: no gap needed, swap directly
• PGA → non-PGA: the previous drug's effect may linger while the new one takes time to work; the AAO PPP 2025 suggests a follow-up 2-8 weeks after a change to confirm the response
• Combo → mono: similar to above

7. The role of SLT and repeat treatment

The detailed SLT indications, mechanism and procedure are in Chapter 2. Here we focus on two common clinic questions:

① Does repeat SLT still work?

Yes. Unlike old ALT, SLT doesn't destroy trabecular tissue and is repeatable. Studies show:

• The effect of a first SLT wanes over time; how long it lasts varies widely (EGS)
• When effect wanes, repeat SLT achieves comparable response
• Evidence for third or later SLT is lacking (EGS); if 2-3 rounds are not enough, escalate to other options

② Do I still need drops after SLT?

Three outcome categories:

• Complete success (IOP at target and stable): can suspend drops, monitor; reintroduce drops only when SLT effect fades
• Partial success: SLT + fewer drops (e.g., from three to one)
• Failure (no meaningful drop): return to drops, consider other options

③ When SLT is not suitable

• Pigment dispersion syndrome (NICE does not recommend SLT first-line; heavily pigmented meshwork is more prone to IOP spikes, although EGS lists pigmentary glaucoma as an SLT indication)
• Advanced glaucoma needing large IOP drops → SLT usually insufficient
• Uveitis (an EGS contraindication)
• Corneal opacity preventing clear meshwork visualization
• Inability to position at the slit lamp (severe cervical spine issues, tremor)

8. MIGS — a complete brand guide

MIGS (Minimally Invasive Glaucoma Surgery) is a fast-evolving field since 2010. Common features: small wound, conjunctiva-sparing, safer, faster recovery, moderate IOP lowering (less than trab). The most common application is combined with cataract surgery — leveraging the cataract incision to add a glaucoma intervention.

① Six-MIGS comparison table

② Per-device key points

iStent inject W (Glaukos) — trabecular-bypass MIGS. The original iStent was the first FDA-approved trabecular-bypass MIGS (2012); iStent inject was approved in 2018 and the W model is a 2020 design update, with a tiny implant (< 0.4 mm). In the pivotal trial, 75.8% of combined eyes vs 61.9% with cataract surgery alone achieved ≥20% unmedicated IOP reduction at 2 years (about 1.6 mmHg more). Conjunctiva fully spared, preserving future trab success.

Hydrus Microstent (Alcon) — 8 mm nitinol scaffold that dilates Schlemm canal over ~90° (combining bypass and channel expansion). HORIZON 5-year data show better IOP control than cataract surgery alone and fewer later incisional glaucoma surgeries (2.4% vs 6.2%).

XEN Gel Stent (AbbVie) — most trab-like mechanism: gelatin tube drains aqueous from anterior chamber to subconjunctival space, forming a small bleb. Done under local anesthesia in the operating room with fewer complications than trab; some need post-op 5-FU. Caveat: conjunctiva is breached, potentially reducing future trab success.

PreserFlo MicroShunt (Santen) — approved in the EU, Canada and Australia but not yet FDA-approved (a US pivotal study was still under way in 2026); subconjunctival drainage similar to XEN but made from SIBS biocompatible polymer; stiffer and more positionally stable, with lumen/length engineered to avoid hypotony. Conjunctiva-involving, with the same future-trab consideration.

Kahook Dual Blade (New World Medical) — pure excisional, no implant: a dual-bladed instrument excises a strip of trabecular meshwork. No foreign-body reaction, lower cost, also useful for pigmentary glaucoma. Slightly weaker IOP lowering than other MIGS but fully spares conjunctiva.

OMNI 360 Surgical System (Sight Sciences) — full 360° treatment (trabeculotomy + canalplasty) rather than focal; theoretically broader effect. No Taiwan device licence found.

③ Why was CyPass withdrawn? A cautionary case

CyPass Micro-Stent (Alcon), FDA-approved 2016, was a suprachoroidal MIGS device. But the COMPASS-XT 5-year extension found significant corneal endothelial cell loss, prompting voluntary global withdrawal in 2018.

Lesson: 'minimally invasive' doesn't equal long-term safety. Newer MIGS aren't necessarily better than those with 5-10 years of data.

④ MIGS practical principles

1. Mild-moderate OAG only, not advanced: advanced disease needs aggressive lowering — MIGS usually insufficient
2. Combined with cataract = ideal timing: gain a MIGS without an extra incision
3. Conjunctiva preservation matters: future trab fares better with virgin conjunctiva (a key consideration with subconjunctival-drainage MIGS like XEN/PreserFlo)
4. Cost & NHI: the MIGS devices licensed in Taiwan include the iStent series, XEN and PreserFlo; these devices are not on the NHIA special-material coverage list (updated ROC 115.11.05) and are not in any self-pay-difference category, so they are usually self-pay; please confirm the price with the operating hospital
5. Not a panacea: failed MIGS may still require trab or tube shunt

9. Traditional surgery ladder

① Trabeculectomy — still the gold standard for advanced disease

• Oldest (since 1968), strongest IOP-lowering: can reach < 10 mmHg; some patients off all drops
• Mechanism: a guarded scleral flap allows aqueous to drain into a subconjunctival bleb
• NICE 2022 recommends glaucoma surgery with MMC augmentation as first choice for advanced COAG
• PTVT (Ophthalmology 2020) 3-year data: as primary surgery, trab with MMC achieved lower IOP with fewer drops than tube; failure rates did not differ significantly (33% tube vs 28% trab)
• Complications: early bleb leak, hypotony, infection (blebitis, endophthalmitis); late encapsulation failure, accelerated cataract, vision loss
• Close early follow-up, then longer intervals; the surgeon sets the actual schedule according to recovery
• Long-term bleb infection risk (large Japanese prospective study: 5-year cumulative bleb-related infection about 2.2% after MMC trabeculectomy, 7.9% after a bleb leak)

② Tube shunt (Ahmed / Baerveldt)

• For: failed trab, complex cases (uveitic, neovascular, post-corneal-transplant, post-trauma), pediatric glaucoma
• Two main brands:
• PTVT 5-year: failure rates did not differ significantly (tube 42% vs trab 35%); inadequate IOP reduction was the most common reason in both groups, reoperation failures were more frequent with tubes, and failures from persistent hypotony occurred only with trabeculectomy
• Complications: tube migration, endothelial loss, diplopia (compression on extraocular muscles)

③ Cyclophotocoagulation

• Mechanism: laser destruction of ciliary epithelium reduces aqueous production rather than enhancing outflow
• Three modalities:
• Not first-line surgery; reserved for failed prior surgeries or eyes with poor visual prognosis

④ When to escalate from drops/laser to traditional surgery?

• 3 classes (including PGA) + SLT, IOP still not at target
• Visual field continues to progress (new or worsening defects confirmed by repeat testing with the same strategy)
• OCT shows RNFL thinning beyond normal aging rate
• Uncontrolled IOP after acute angle-closure
• Severe drug side effects preventing continued use

10. The special pathway for angle-closure glaucoma

PACG management differs from OAG because the mechanism is angle closure, not trabecular dysfunction.

① Laser peripheral iridotomy (LPI) — prophylactic or therapeutic?

• Mechanism: a small hole in the peripheral iris allows aqueous to bypass the pupil, relieving pupillary block
• Therapeutic LPI (post-attack or chronic angle-closure): standard care
• Prophylactic LPI (suspect narrow angle, no prior attack): controversial.
  • ZAP trial (Zhongshan Angle Closure Prevention, 2019) showed that while prophylactic LPI reduces acute attacks, absolute risk is low — routine prophylaxis isn't clearly superior to observation
  • AAO PPP 2025: for primary angle-closure suspects (PACS), LPI should be considered, with observation as an alternative; LPI is favoured with angle closure in the fellow eye or a family history of PACG, medications that may provoke pupillary block, symptoms of intermittent angle closure, poor access to care or follow-up, or frequent dilated exams

② EAGLE trial: cataract surgery as treatment for PACG

EAGLE trial (Lancet 2016) reshaped angle-closure management: 419 patients aged 50+ without cataract, with newly diagnosed primary angle closure (IOP ≥ 30 mmHg) or PACG, randomized to LPI + medical therapy vs clear-lens extraction with IOL.

• 3-year: the lens extraction arm had better quality of life, lower IOP and better cost-effectiveness, and was much more likely to control IOP without drops
• Conclusion: the AAO PPP 2025 says that for PAC with raised IOP and PACG, early lens extraction can be considered as an initial option even when the lens is still clear (no need to wait for vision to drop); EGS advises against clear-lens extraction in low-risk patients under 50

③ Practical PACG management in Taiwan

1. Acute attack: medical IOP control (oral acetazolamide, α2, β-blocker) → pilocarpine (after IOP drops) → LPI as soon as feasible (paracentesis or similar if the cornea is too hazy) → consider lens extraction; LPI for the fellow eye promptly
2. Chronic / progressive after LPI: evaluate lens extraction + possible combined goniosynechialysis depending on angle status
3. PACS (narrow angle, normal IOP, no PAS): consider prophylactic LPI with the risk factors above; observation otherwise

11. Taiwan-specific considerations

① Disproportionately high NTG share

Local studies (including the Shihpai Eye Study) consistently show most Taiwanese glaucoma patients have IOP within the 'normal' range. Implications:

• The 'IOP > 21' cutoff misses many patients
• Optic nerve (fundus / OCT) and visual fields matter more than IOP alone
• Targets need stronger individualization (CNTGS proved 30% reduction helps NTG too)

② Higher PACG share than Western populations

Taiwanese and East/Southeast Asian populations have shorter axial lengths and shallower anterior chambers; PACG is considerably more prevalent than in Western populations. Practical implications:

• Gonioscopy at initial visit is critical
• Lens extraction has elevated role in PACG (EAGLE-supported)
• Cataract evaluation in elderly should include angle-closure risk assessment

③ Taiwan NHI coverage (three tiers)

• Mostly covered: most PGAs (including Vyzulta), β-blockers, α2 agonists, CAIs as monotherapy and standard combinations (Cosopt, DuoTrav, Combigan, Xalacom, Azarga, Simbrinza; drugs must meet the section 14.1 conditions below); trabeculectomy; acute angle-closure laser treatment
• Hospital-dependent / partial: SLT (an NHI-listed laser trabeculoplasty procedure, but hospital equipment varies); some preservative-free formulations and newer combinations (the rules do cover preservative-free single-dose units within quantity caps, but product listing and hospital stocking vary)
• Mostly self-pay or restricted: MIGS devices (iStent, XEN, PreserFlo; no Taiwan licence found for Hydrus or Kahook), premium PF formulations, Rho kinase inhibitors (not among the classes listed in current rule 14.1.1)

* Actual coverage follows the latest National Health Insurance Administration announcement and hospital-specific rules; this article describes general tiers only.

④ Taiwan NHI coverage rules (updated 22 October 2026)

Section 14.1 'Anti-glaucoma drops' of the Taiwan NHI drug reimbursement rules (updated 22 October 2026, ROC 115-10-22) is summarized below. Confirm the latest version at the NHIA website and discuss details with your doctor.

Prescription rules — key points:

• Chronic prescriptions limited to ophthalmologists (since June 2025), with IOP value documented at the visit
• Non-ophthalmologists can prescribe at most 1 month at a time, must instruct the patient to have IOP measured, refer to ophthalmology for IOP measurement within 3 months at most, and arrange regular optic-nerve and visual-field follow-up
• No co-administration within same class (e.g., can't use two PGAs or two β-blockers simultaneously)
• NHI-designated under-served areas and mountain/offshore-island areas: under the NHI Telemedicine Coverage Plan, after a joint video consultation with an ophthalmologist and with IOP data attached, the local doctor may also issue chronic refills

What this means for patients in practice:

• NHI prefers β-blockers as first-line — clinically PGAs are often preferred (better efficacy, once-daily convenience), but NHI requires prior β-blocker failure/contraindication/intolerance documented. The physician judges based on individual context
• Fixed combinations require failed monotherapy first under NHI — patients wanting fewer drops need prior monotherapy on record; direct combination = self-pay
• Preservative-free single-dose units are gentler for long-term use, ocular surface sensitivity, or coexisting DED; NHI covers — discuss with your ophthalmologist
• SLT laser, MIGS, traditional glaucoma surgery are not in drug coverage; some are NHI-covered (procedure fee + standard supplies), some are self-pay (specialty devices like iStent, XEN gel stent). Discuss specifics with your ophthalmologist

* Source: Taiwan NHI drug reimbursement rules, updated 22 October 2026 (ROC 115-10-22), section 14.1 Anti-glaucoma drops (14.1.1 monotherapy, 14.1.2 combinations). Surgical procedures are covered under separate medical-payment regulations, not in the drug regulations referenced here.

⑤ Considerations for remote-area patients

Taiwanese patients in mountainous regions, outer islands and rural areas face:

• Difficulty with monthly clinic visits → poor adherence
• Limited access to perimetry equipment
• SLT or early lens extraction + MIGS particularly suited here → reduces long-term drop dependence
• Also consider 3-month prescriptions and PF formulations (preserve ocular surface)

12. 8 common decision-making Q&As

Closing

Glaucoma treatment is a marathon, not a sprint. From new diagnosis (SLT or PGA), to add-on or switch, to laser, MIGS, or trab — every decision isn't 'better' or 'worse', but an individualized integration of target IOP, side-effect profile, lifestyle, adherence, and NHI/economic burden.

After reading, hopefully you can have a deeper conversation with your doctor at the next visit:

• Ask why this drug (understanding boosts adherence)
• Ask how to monitor side effects (PAP, allergy, systemic effects)
• Ask what's next (if this isn't enough, what's the next step?)
• Ask about NHI vs self-pay differences (avoid unnecessary 'upgrades')

A doctor's job isn't just writing prescriptions — it's walking with you through this optic-nerve preservation campaign. Understanding the full treatment ladder is the best preparation a patient can do.