New Glaucoma Treatments: Netarsudil, Sustained-Release Implants and MIGS
Last updated: October 2026
Glaucoma treatment has expanded in three directions at once: new drop mechanisms, implants that deliver drug inside the eye for months, and minimally invasive glaucoma surgery (MIGS). This post maps what is new, how each works, and the exam-favourite pitfalls.
Newer topical drugs
| Drug | Class and mechanism | Points to remember |
|---|---|---|
| Netarsudil 0.02% (FDA 2017; fixed combination with latanoprost from 2019) | Rho-kinase (ROCK) inhibitor. Increases trabecular outflow and lowers episcleral venous pressure. | Conjunctival hyperaemia is very common. Also corneal verticillata, subconjunctival haemorrhages, and reticular epithelial corneal oedema. |
| Latanoprostene bunod 0.024% (FDA 2017) | A prostaglandin analogue that also donates nitric oxide, which relaxes the trabecular meshwork. It adds conventional outflow to uveoscleral outflow. | Usual prostaglandin side effects: hyperaemia, lash growth, iris pigmentation. |
| Omidenepag isopropyl 0.002% (Japan 2018; FDA 2022) | Selective EP2 receptor agonist; not a prostaglandin F2α analogue. | No prostaglandin-associated periorbitopathy, so useful in cosmetically concerned patients. Macular oedema reported in pseudophakic and aphakic eyes. Avoid combining with tafluprost. |
Sustained-release implants
Adherence to drops is poor in every population studied. Intracameral implants deliver drug for months without relying on the patient.
| Bimatoprost implant (Durysta) | Travoprost implant (iDose TR) | |
|---|---|---|
| Design | 10 µg biodegradable rod injected into the anterior chamber, resting in the inferior angle | Titanium implant containing 75 µg travoprost, anchored through the trabecular meshwork into the sclera. Drug elutes continuously. |
| FDA approval | March 2020 | December 2023. A January 2026 label update allows re-administration if corneal endothelial cell density criteria are met. |
| Evidence | ARTEMIS 1 and 2: IOP lowering non-inferior to timolol over the primary period | At 36 months, about 70% remained controlled on the same or fewer medications, vs 58% with timolol |
| Key cautions | Labelled for a single implant per eye, with no re-administration. Corneal endothelial cell loss. Contraindicated in corneal endothelial dystrophy (such as Fuchs) and after corneal or endothelial transplant. Take care where the posterior capsule is absent or ruptured (the implant can migrate). | Endothelial cell density guides repeat treatment. It is a procedure, not an injection. |
MIGS: a resident's map
| Route | Examples | What to know |
|---|---|---|
| Trabecular bypass (Schlemm's canal stents) | iStent, iStent inject W, Hydrus | Usually combined with phaco in mild to moderate open-angle glaucoma. In the HORIZON trial, Hydrus with phaco needed less later incisional surgery than phaco alone at 5 years. |
| Trabecular excision or incision | Kahook Dual Blade goniotomy, GATT (gonioscopy-assisted transluminal trabeculotomy), Trabectome, OMNI | Removes or opens the inner wall of the canal. Transient hyphema is common. GATT is useful in juvenile and steroid-induced glaucoma. |
| Suprachoroidal | CyPass (withdrawn 2018) | Exam favourite: withdrawn after 5-year COMPASS-XT data showed progressive endothelial cell loss, especially with proud stent position. |
| Subconjunctival (bleb-forming, "MIBS") | XEN gel stent, PreserFlo MicroShunt | Used with mitomycin C. Lower IOP than canal-based MIGS, but with bleb-related risks such as needling, hypotony and bleb infection. |
- Canal-based MIGS are limited by episcleral venous pressure (about 8–10 mmHg), so they rarely achieve very low targets.
- Trabeculectomy (with antimetabolite) and tubes remain the procedures for low target pressures and advanced disease.
Viva pearls
- Netarsudil is the drug that lowers episcleral venous pressure.
- Omidenepag is an EP2 agonist and avoids prostaglandin-associated periorbitopathy.
- CyPass was withdrawn for endothelial cell loss. A good answer to "a MIGS device withdrawn from the market".
- Know the MIGS by location: Schlemm's canal, suprachoroidal space, subconjunctival space.
Related: SLT as first-line treatment, ocular pharmacology, bleb grading and hypotony and AAO colour codes for eye drops.
Key sources
- FDA approves iDose TR re-administration labeling (January 2026)
- Medeiros FA et al. ARTEMIS 1 (bimatoprost SR). Ophthalmology 2020
- Ahmed IIK et al. HORIZON 5-year results (Hydrus). Ophthalmology 2022
- COMPASS-XT 5-year endothelial cell data, which led to the voluntary market withdrawal of CyPass in August 2018
- US prescribing information for Rhopressa, Vyzulta and Omlonti
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