← Back to Patient Education EPSAZ — The R's Framework

Your glaucoma treatment, explained from the start

Every treatment decision at EPSAZ follows a single principle: start where nature intended, and only move forward when clinically necessary. This is the R's Framework.

1. The Philosophy Behind Your Treatment

Your eye has a beautifully designed fluid system. It produces a clear fluid that nourishes your lens and cornea as it circulates throughout your eye. It provides the nourishment needed in place of blood which serves a similar function in the body as it circulates through your body . However blood not being clear would block vision if used in the eye. This fluid the Aqueous Humor drains it out through natural microchannels. When these channel get clogged or sluggish, pressure builds up and damages the optic nerve which connects your eye to your brain. This can cause iGlaucoma, a disorder than causes progressive lloss of peripheral vision and can lead to blindness

At EPSAZ, we treat glaucoma by working with your eye's design — not around it. Our approach is organized around a simple principle:

We start with the approach most in harmony with how your eye was designed to work. Each procedure in our framework is chosen to address the problem at the most natural level first. We only move to a more complex approach when the gentler option is not enough. We never skip steps unnecessarily. We chose therapy with the best chance to be effective with the least risk,

This protects you in two ways. First, it means you receive the gentlest effective treatment first. Second, it preserves every future option — no door is closed before it needs to be. A patient who starts with SLT laser or light therapy can still have ABiC, XEN, or Trabeculectomy later if needed. A patient who jumps straight to trabeculectomy has fewer options left. However we would recommend this if the other less invasive options will only delay what is needed to preserve vision

Why this matters for a lifetime of care. Glaucoma is a lifelong condition. The average patient diagnosed at age 60 will manage it for 25–30 years. Some patients start earlier and if caught early can benefit by early intervention to avoid procedures with more risk later on in life. The decisions made early in that journey shape what is available later. We think carefully about that long horizon every time we recommend a procedure.

2. Procedural Pharmaceutical (iDose or Durysta). Phamraceuticals that can be delivered into the eye directly for up to 3 years. This provides continuous 24 hour of the medication directly to the tissues that help lower the eye pressure.These treatments prevent any missed doses, avoid the risk of forgetting your drops at home, and significantly improve ocular surface health - which all directly translate to improved vision quality, preservation and quality of life. These treatments can be offered anywhere along the treatment pathway and can be layered along with all the treatments available at EPSAZ and discussed in the R’s frameworkbelow. We offer the Durysta implant in our clinic (90 day duration) and the iDose for more durable effect at 3 years in the surgery center.

2. The R's — your treatment ladder

We call our framework "the R's" because every step starts with that letter. Here is the full ladder — from the most natural step to the most interventional. Most patients will only ever need the first few rungs.

R1 · Reactivation — SLT Laser

Gentle laser stimulates your eye's own drainage cells. Nothing is cut, removed, or implanted. Repeatable. The most physiologically gentle.

(Natural drainage cells awakened)

R2 · Rejuvenation — ABiC / iTrack

A hair-thin catheter travels 360° around your drainage canal and gently opens it. Restores all three parts of your natural system. No implant.

(Natural drainage restored)

R3 · Reinforcement — iStent

A tiny titanium microstent helps fluid bypass the clogged drainage angle. Usually placed with cataract surgery. Permanent, invisible, undetectable.

(Natural canal with reinforcement)

R4 · Removal — GATT / KDB

The clogged filter is removed rather than restored. This option is chosen when structural removal is deemed better than gentle opening in your case. Pressure reduction similar to ABiC.

(Natural canal, filter removed)

Redirection — four levels, from least to most complex:

R5a · Internal Redirection — AlloFlo

Creates a new drainage compartment inside the eye. No bleb. Fluid stays within the eye — the least disruptive redirection option.

(New internal pathway)

R5b · Small Bleb — XEN Gel Stent

A tiny soft straw stent guides fluid through the eye wall into a small controlled bleb under the conjunctiva. Safest external filtration.

(Exits eye, small controlled bleb)

R5c · Full filtration — Trabeculectomy

A guarded opening in the eye wall drains fluid into a bleb under the eyelid. Gold standard for lowest pressures. Requires intensive follow-up.

(Full bypass, larger bleb)

R5d · Aqueous Shunt — Molteno / Ahmed/Ahmed/Baervaldt/ Others

A silicone tube routes fluid to a small reservoir on the eye surface. For complex, failed, or refractory glaucomas. Highest pressure reduction.

(Hardware to External reservoir)

Reduction — reduces fluid production directly:

R6a · Combined — ECP

Endoscopic laser treats shrinks the fluid-producing ciliary processes under direct camera view. Used with cataract surgery or standalone. Precise and targeted.

(Camera-guided, precise targeting)

R6b · Standalone — MCPC / GCPC

Diode laser through the sclera treats/ shrinks the fluid-producing ciliary processes .without incisions. MCPC first; GCPC for refractory, painful, or very high-pressure cases.

(Reduces Fluid Production

Where is Your Procedure On This Ladder? Your doctor has recommended a specific step based on your diagnosis, eye anatomy, pressure target, and treatment history. The procedure pages below explain exactly what that step involves and why it is right for you.

3. What our outcomes show — 6,476 patients

Every recommendation at EPSAZ is grounded in our own outcomes — not just published clinical trials. Here's what we see across our patient database, tracked through 5 years.

6,476Patients in our surgical database
8Procedures tracked through 60 months
60 monthsOur longest follow-up horizon
12-month outcomes by procedure
R StepProcedurePatientsIOP ReductionMeds SavedSafety
R1SLT1,442−3.0 mmHg−0.035/5
R2ABiC1,853−3.3 mmHg−0.495/5
R3iStent + cataract342−2.8 mmHg−0.464/5
R5bXEN394−6.3 mmHg−1.312/5
R5cTrabeculectomy298−6.4 mmHg−1.781/5
R5dTube shunt986−10.1 mmHg−1.161/5
R6bDiode laser1,114−8.8 mmHg−0.261/5

What "Safety" means here. Safety doesn't mean dangerous — all these procedures are performed safely every day. It reflects the level of post-operative management you need and the chance of needing additional interventions. A 1/5 safety rating means more monitoring and follow-up visits. A 5/5 means very simple recovery and almost no complications. Safety is one reason we follow the R's framework in order.

What medication savings mean for you. Each glaucoma medication costs roughly $1,166 per year. If your procedure eliminates 1.3 medications, you save about $1,500 yearly. Over a 30-year lifetime, that is nearly $45,000 — plus better quality of life, fewer side effects, and more consistent Treatment .

4. How the R's apply — Real Treatment Tourneys

Below are six typical patient journeys from our database. Your path may be one of these — or unique to your eye, your pressure, and your anatomy.

Early detection, mild glaucoma, normal anatomy

  1. SLT reactivation (IOP −3.0 mmHg).
  2. Patient remains controlled on SLT alone through 5+ years.

Result: Stable vision, minimal medications, no surgery.

Moderate glaucoma, needs more than laser, normal anatomy

  1. SLT reactivation (IOP −3.0 mmHg, not enough).
  2. ABiC rejuvenation (additional −3.3 mmHg).
  3. Combined pressure now at target, medications reduced.

Result: Durable control, preserved natural anatomy.

Cataract present at time of diagnosis

  1. Cataract removal + iStent reinforcement (same surgery).
  2. Addresses vision and pressure together.
  3. Simplifies follow-up, better vision, pressure improvement.

Result: Two problems solved in one procedure.

Advanced glaucoma at presentation

  1. ABiC rejuvenation attempted first (preserves anatomy).
  2. If insufficient, GATT removal follows (IOP −8–12 mmHg total).
  3. Avoids major surgery if possible; natural anatomy preserved longer.

Result: Staged approach gets best pressure on most conservative path.

Refractory glaucoma, multiple failed surgeries

  1. History: SLT, ABiC, XEN, all not adequately controlled.
  2. Aqueous Shunt (Molteno or Other) for sustained control.
  3. IOP −10.1 mmHg, medications minimized.

Result: Durable pressure control on most aggressive R step.

Very high pressure, painful eye, last-resort decision

  1. GCPC diode laser (aggressive cyclophotocoagulation).
  2. IOP −8.8 mmHg, pain resolved.
  3. Vision salvaged or maintained for comfort.

Result: Pain relief and pressure control when vision potential is limited.

5. Explore Your Procedure

Click any procedure below to learn how it works, what to expect during surgery, your recovery timeline, and your follow-up schedule.

Questions about your procedure?

Call (623) 878-3939

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The material contained on this site is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider.

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