~Doctor, I Have a Question. What are some of the greatest advances in glaucoma treatment?
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As physicians, our goal is to preserve vision and quality of life for all our patients. Our populations are ageing and life expectancy is increasing, which means that there will be more people with glaucoma and they will have the disease for a longer period of time.
Fortunately, we live in a world of rapidly changing paradigms in science. New advances in biotechnology and biological science occur every day. Our technology is rapidly improving. We have novel medical interventions, new surgical devices, and the future use of AI (artificial intelligence) in glaucoma management will allow us to detect glaucoma earlier.
What’s new in medicine and lasers?
For the majority of patients, the current trend is to try to use as few eye drops as possible and expand use of laser trabeculoplasty much earlier in the course of the disease. Instead of eyedrops first, many doctors will offer laser surgery first. The goal is to try and minimize the medication burden – that’s a new treatment paradigm in our daily practice – and has been hugely advanced in the last 10 years.
Patients may still be taking drops, but fewer times during the day. There are now three medications that are taken only once a day, and there are four combination drops on the market, This means that maximal eye drop therapy can be limited to just two times during the day for most patients.
A new and important future option will be sustained drug delivery systems.
Right now, only one device, Durysta, has been approved for use in the US. After placement inside the eye, the small implant releases medication very slowly over 4 to 6 months. To date, it has only been approved for a single, not repeated use, for an individual patient. Other ways to do this are in the pipeline – second generation implants, punctal plugs and injections to the back of the eye among them.
In the realm of surgery, before the recent development of MIGS (minimally invasive glaucoma surgeries) there were only two main types of surgery for glaucoma – trabeculectomy and drainage device implantation. Today it’s a complex field, with many different MIGS using different anatomic pathways to allow IOP to be lowered. Some of these less invasive procedures are done with cataract surgery; others alone. It is estimated that in 2022 five percent of all glaucoma patients will have some kind of glaucoma procedure.
What about the future?
Neuroprotection refers to the ability to protect optic nerve cells directly. If we could strengthen the nerve cells from dying, that would be the holy grail of glaucoma therapy. It is a field of active ongoing research. Glaucoma, like Alzheimer’s and Parkinson’s, is a neuro degenerative disease and glaucoma will benefit from all the research into these other diseases as well.
The future also looks bright for the field of precision medicine and precision ophthalmology, which uses genetics to transform the diagnosis and treatment of disease. There’s a worldwide effort to use the power or genetics to help us diagnose the disease and to develop new treatments and care for our patients. Applied genetics uses this information to provide each patient with a genetic diagnosis of their ophthalmic condition so we can pinpoint the diseases with great accuracy. In 2017, in a “first” for the U.S., the FDA approved a gene therapy to treat patients with a rare form of inherited vision loss in children that can lead to blindness.
Dr. Liebmann is Shirlee and Bernard Brown Professor of Ophthalmology, Vice-Chair, Department of Ophthalmology, and Director of the Glaucoma Division at Columbia University Irving Medical Center in New York City. In November, Dr. Liebmann, a member of the Foundation Board, presented a Zoom webinar on “New Horizons in Glaucoma Treatment.” This “Doctor, I Have a Question” column incorporates some highlights from that presentation. The entire webinar can be viewed on TGF’s website.