I started my glaucoma practice in the fall of 1983. Ronald Reagan was president, Indiana Jones and The Temple of Doom was playing on movie screens across the country, and the Celtics beat the Lakers to win the 1983/1984 NBA championship.
The diagnosis and treatment of glaucoma were advancing. Beta-blockers (ie, Timoptic [Merck & Co., Inc., Whitehouse Station, NJ]) were first-line therapy followed by pilocarpine then epinephrine. Drug delivery was a popular topic at meetings, and the highlight was the Pilosert. Resembling a contact lens, the device was placed in the upper cul-de-sac under the upper eyelid and could deliver pilocarpine in two concentrations for a full week of dosing. The Humphrey Visual Field Analyzer (Carl Zeiss Meditec, Inc., Dublin, CA) was replacing Goldmann kinetic perimetry. Laser iridotomy and trabeculoplasty were gaining in popularity. My first publication in the Archives of Ophthalmology was a prospective comparison of trabeculectomy with 5-year follow-up.1 The use of antimetabolites after filtering surgery was becoming the standard of care to reduce conjunctival fibrosis and enhance IOP lowering.
As I look back, 25 years seem to have come and gone in the blink of an eye. In the field of glaucoma, there has been definite progress. The plethora of NEI-funded studies have helped to define whom to treat and how to follow patients with glaucoma. Optic nerve imaging and progression analysis of visual fields help clinicians manage the disease. The prostaglandin analogs are far superior in regard to safety and efficacy than prior therapies, and researchers are unraveling the genetic cause of glaucoma.
Even so, deep down, I am disappointed that we have not accomplished more. To some extent, anyone who sees patients with glaucoma must feel similarly. I judge the following six areas as showing the least progress during the last 25 years:
- The classification and diagnosis of glaucoma. Why are we still limited to the gonioscopic diagnosis of primary open-angle glaucoma for the majority of our patients? Clearly, improved therapy depends on a more precise understanding of the cause of the disease.
- Drug delivery. If you have not heard Alan Robin, MD, speak on patients' use of eye drops for glaucoma, I strongly recommend you catch his presentation in the future. Poor drug delivery has implications for current treatment modalities as well as the value of clinical drug research.
- Low- or normal-tension glaucoma. We have gained little or no understanding of why some patients have glaucomatous cupping and visual loss in the absence of elevated IOP.
- Surgical options for glaucoma. Trabeculectomy remains the primary surgical approach to advanced glaucoma despite the long list of complications mentioned in my 1984 study1 and reiterated in the Tube Versus Trabeculectomy Study.2 Thankfully, some exciting procedures and devices are in development that may obviate the need for filtering surgery.
- Help for the visually impaired. With the exception of large print and computerized vocal aids, there are few new aids for patients who have lost vision due to glaucoma.
- Screening methods. We still need more effective, sophisticated screening tools to detect early disease in high-risk populations.
My guess is that improved understanding of the genetics underlying glaucoma will bring forth a more specific approach to the disease's diagnosis and treatment. I hope that I am still in practice when that change comes and that it takes less than 25 years!
