EGS 2026: Plenary highlights practical updates from the 6th edition glaucoma guidelines

The session reviewed key updates in the new European Glaucoma Society Guidelines, with a focus on surgical decision-making, laser treatment and the appropriate role of MIGS in contemporary glaucoma care

The EGS 2026 plenary session on the 6th edition of the European Glaucoma Society Guidelines¹ brought together leading glaucoma specialists to discuss how the updated recommendations can be applied in clinical practice. Chaired by Manuele Michelessi and Fotis Topouzis, the session moved from the broad principles of the new guidelines to practical discussions on bleb-forming procedures, laser treatment and minimally invasive glaucoma surgery.

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Opening the session, Ingeborg Stalmans introduced the major updates in the 6th edition, which builds on the previous guideline framework while placing greater emphasis on evidence-based recommendations, patient perspectives and practical decision-making. A notable development is the use of a pan-European survey of EGS members and an Experts by Experience patient panel to help prioritise clinically relevant questions. The new edition also includes expanded “Choosing Wisely” recommendations, updated flowcharts and dedicated sections on areas including artificial intelligence, cost-effectiveness, genetics, childhood glaucoma, angle closure and surgical management.

A central theme of the plenary was that glaucoma treatment should be individualised according to disease severity, target intraocular pressure, ocular anatomy, prior treatment and patient-specific factors. The guidelines continue to reinforce intraocular pressure lowering as the key modifiable treatment target, while recognising that the route to achieving this may differ substantially between patients.

Bleb-forming procedures remain central for patients needing substantial IOP reduction

In the session on how to do the best bleb-forming procedures, Panayiota Founti reviewed the continued importance of filtration surgery in glaucoma management. The 6th edition reaffirms that trabeculectomy remains the most effective glaucoma surgery for achieving low target intraocular pressures, particularly in patients with advanced open-angle glaucoma or those requiring very low long-term IOP.

For non-advanced open-angle glaucoma, the guidelines recognise a broader surgical landscape, but still distinguish clearly between procedures that provide modest IOP lowering and those with greater pressure-lowering potential. Bleb-forming techniques may offer greater IOP reduction than MIGS, although they also carry a higher burden of postoperative management and potential complications.

The updated guidance also addresses bleb-forming shunt devices, often referred to as minimally invasive bleb surgery. These procedures create a subconjunctival filtering bleb without a plate and may be considered in moderate to advanced glaucoma. However, the guidelines caution that they should not be treated as risk-free, because sight-threatening complications can still occur. Success depends on careful case selection, correct implant positioning and appropriate use of antimetabolites.

The panel discussion with Julian Garcia Feijoo, Gus Gazzard and Andrew J. Tatham reinforced the practical message that the choice of surgery should not be driven by procedure novelty alone. Instead, clinicians need to match the intervention to the patient’s target IOP, rate of progression and tolerance for postoperative follow-up.

Laser treatment has a strengthened first-line role

The session with Francesco Oddone was focused on how to do the best laser procedure focused on the strengthened role of selective laser trabeculoplasty in glaucoma care. In the 6th edition, SLT is recommended alongside prostaglandin analogues as a first-line option for primary open-angle glaucoma.

This reflects the increasing evidence base supporting SLT as an effective and cost-effective early intervention. The guidelines note that SLT offers clinical and economic advantages when used as a first-line treatment. For appropriate patients, reducing treatment burden may also support adherence and patient-centred care, particularly when daily topical therapy is difficult or poorly tolerated.

However, the guidelines do not position laser as a universal replacement for medical or surgical treatment. Rather, SLT should be considered as part of a personalised treatment pathway, taking into account baseline IOP, disease severity, target pressure and patient preference.

MIGS should be used selectively and with realistic expectations

The final themed presentation, delivered by Evgenia Konstantakopoulou, addressed how to do the best MIGS. The 6th edition guidelines recognise the value of MIGS in selected patients, particularly those with mild to moderate open-angle glaucoma or ocular hypertension, often in combination with cataract surgery.

MIGS procedures generally aim to improve trabecular or suprachoroidal outflow with less anatomical disruption than traditional filtration surgery. They may offer a favourable safety profile, quicker recovery and a reduction in medication burden. For patients with early or moderate open-angle glaucoma and visually significant cataract, the guidelines suggest that phacoemulsification alone or phacoemulsification combined with MIGS may be appropriate when IOP is at or near target.

However, the plenary also highlighted the limits of MIGS. The guidelines caution against overuse in rapidly progressing disease, noting that MIGS usually produces more modest IOP reduction and may not be sufficient for patients with advanced glaucoma or those requiring very low target pressures. In patients whose IOP remains significantly above target, a glaucoma intervention should be offered, and bleb-forming surgery with or without phacoemulsification may be more appropriate.

The closing panel discussion again emphasised proportionality: MIGS has an important role, but it should not be used as a default option when the clinical situation demands more substantial pressure lowering.

A more practical and patient-centred framework for glaucoma care

Across the plenary, the 6th edition guidelines were presented not simply as an update to terminology, but as a more practical framework for day-to-day glaucoma management. The inclusion of patient perspectives, clearer “do not” recommendations and updated treatment pathways reflects the complexity of modern glaucoma care, where evidence, safety, cost-effectiveness and patient burden all need to be balanced.

The guidelines also update angle-closure management, including a more selective approach to laser peripheral iridotomy in primary angle-closure suspects and support for clear-lens extraction in selected high-risk cases. These updates reinforce the broader theme of tailoring intervention to individual risk, rather than applying the same approach to all patients within a diagnostic category.

For ophthalmologists, the key clinical message is that glaucoma management is becoming more nuanced. SLT now sits firmly alongside prostaglandin analogues as a first-line treatment option, trabeculectomy remains the benchmark for achieving low target IOP in advanced disease, and MIGS should be reserved for appropriately selected patients with realistic expectations around pressure lowering.

The session reinforced that the goal of the 6th edition is not to promote a single treatment pathway, but to support better clinical judgement. By combining updated evidence, patient input and practical flowcharts, the new EGS Guidelines offer clinicians a structured approach to preserving vision while tailoring care to the needs and risks of each patient.

Guideline reference:

1. Pazos M, Traverso CE, Viswanathan A, Azuara-Blanco A, Abegão Pinto L, Stalmans I. Advancing glaucoma care: What’s new in the 6th edition of the European Glaucoma Society guidelines. European Journal of Ophthalmology. 2026;36(3):481-487. doi:10.1177/11206721261415983