Someday, there will be a neuroregenerative treatment. There will be neuroprotection. There will be a genetic (DNA) therapy, perhaps with stem cells or other progenitor cells, for patients with glaucoma. Their vision will not be maintained but restored. When this great day arrives, will the treatment(s) to lower IOP that we have used for the last century be of value? I suspect not.
Until these dreams become reality, the therapy for glaucoma remains the same: control the IOP. Defining the level of control and the optimal way to achieve it remains problematic. For the most part, IOP is controlled with topical medications. The fact that patients cannot remember to use their daily drops and, when they do, often cannot instill them is frequently discussed and well understood, even as we continue to prescribe eye drops. Only a small percentage of patients undergo glaucoma surgery, which is generally reserved for individuals with more advanced disease. It is interesting that, despite various multicenter studies demonstrating that surgery results in lower IOP and less visual field loss, we continue to favor topical medication.
Someday, drug delivery devices will facilitate the treatment of glaucoma. They will deliver drugs for weeks, probably months, at a time. The device may be placed like a contact lens (eg, Ocusert), or it may be inserted like a punctal plug (eg, devices under investigation by QLT Inc. [Vancouver, British Columbia, Canada] and Vistakon Pharmaceuticals, LLC [Jacksonville, FL]). Alternatively, it may be placed in the vitreous like the Retisert (Bausch + Lomb, Rochester, NY) or Posurdex (Allergan, Inc., Irvine, CA). Drug delivery devices may become a bridge to more localized treatment in the back of the eye. Alcon Laboratories, Inc. (Fort Worth, TX), a company with no prior interest in the glaucoma surgical market, is expected to complete its acquisition of Optonol Ltd. by the end of the first quarter of 2010. What prompted this move by a company that has focused on pharmaceuticals, at least in the field of glaucoma? Perhaps Alcon sees an opportunity in surgical devices. That would be a promising development.
Someday, we will have a better treatment for glaucoma, and we will shake our heads when we consider how we managed patients' glaucoma during the first decade of this century. I hope someday comes soon.
