As an ophthalmologist, glaucoma is one of the most common conditions that I treat. One of the major questions that the ophthalmologist or your eye doctor must decide on is when does the patient have glaucoma and when does it need to be treated. In order to decide this question, your doctor needs a lot of information. I think about several different items when making the decision about glaucoma treatment. 1)Does the patient have glaucoma? This is not as simple as determining the pressure. We learned from the ocular hypertension treatment study that a significant percentage of patients can have elevated intraocular pressure without developing any signs of damage. We need to examine multiple factors including the optic nerve appearance, corneal thickness, visual field, and ocular coherence tomography (OCT) to see if there is evidence of damage that is characteristic of glaucoma. In some cases, it may be desirable to monitor the eye and not provide any treatment. 2)What type of glaucoma does the patient have? The most common cause is primary open angle glaucoma. This type of glaucoma is not usually as aggressive as some other types of secondary causes of glaucoma such as pseudoexfoliation glaucoma or uveitic glaucoma. A more aggressive form would need to be treated at an earlier point. 3)How advanced is the glaucoma? This goes along with the first point. Some people with very mild glaucoma may actually only need monitoring whereas those with advanced glaucoma may need multiple medications or even surgery from the outset. 4)What is the patient's expected lifespan? This may seem strange, but it is crucial. I have seen so many patients that have been aggressively treated for glaucoma that by any metric would not have a loss of vision in their lifetime. This factor always needs to be evaluated in how advanced their glaucoma is. A person who is 95 with moderate glaucoma and pressures that are mid-twenties does not need the aggressive treatment that a 32 year old with advanced damage and pressure in the mid-twenties. The drops for glaucoma usually do not have major side effects, but they do have some. The cost of the drops can also add up, and anyone that has used eye drops knows that it is a pain in the neck to put in eye drops during the day. 5)Another major factor that we always take into account is patient preference. I always make these decisions with the patient. Some people have more of a risk tolerance than others, and some patients do not feel that they will be able to do the drops. These are just some of the factors that I take into account when managing glaucoma. I provide other options such as laser (laser peripheral iridotomy, slt, alt), and surgery such as cataract surgery, the istent, and glaucoma shunting procedures, but my first option is usually drops due to the high success rate, and low side effect profile. Please schedule an appointment if you think you may have glaucoma, you already have glaucoma, or feel that you may need a change in care.