What are the recent advances in glaucoma care worldwide?

Recent Advances in Glaucoma Care Worldwide

The landscape of glaucoma management has evolved significantly with the emergence of microinvasive glaucoma surgery (MIGS), combination pharmacotherapies, enhanced imaging technologies, and neuroprotective strategies that extend beyond traditional IOP-lowering approaches. 1

Pharmacological Advances

Novel Combination Therapies

• ROCKLATAN (netarsudil 0.02%/latanoprost 0.005%) represents a major advancement, demonstrating 1-3 mmHg greater IOP reduction compared to either monotherapy throughout 12 months of treatment in patients with open-angle glaucoma and ocular hypertension 2
• This fixed-dose combination addresses the adherence challenges inherent in multi-drop regimens while providing superior efficacy 2
• The availability of multiple medication classes has expanded significantly over the past decade, providing more options for individualized pressure control 1

Neuroprotection Paradigm Shift

• The therapeutic approach has fundamentally shifted from solely IOP-lowering to incorporating direct optic nerve protection, recognizing that pressure-independent mechanisms contribute to glaucomatous optic neuropathy 3, 4
• Alpha-adrenergic agonists like brimonidine demonstrate both IOP-lowering efficacy and neuroprotective benefits in preclinical studies, promoting retinal ganglion cell (RGC) survival 3
• Research focuses on maintaining RGC survival, protecting or rebuilding RGC connections in the retina and brain, and enhancing RGC function beyond pressure reduction alone 4

Surgical and Laser Innovations

Microinvasive Glaucoma Surgery (MIGS)

• MIGS procedures have emerged as a transformative class of interventions filling the gap between conservative medical management and traditional invasive surgery 1
• These procedures offer improved safety profiles with reduced complication rates compared to traditional filtration surgery 1
• The adoption of MIGS has contributed to a documented decrease in invasive incisional surgery over the past decade 1

Laser Trabeculoplasty Expansion

• Use of laser trabeculoplasty has increased substantially over the past decade, providing an effective intermediate option before proceeding to incisional surgery 1
• This trend reflects growing evidence supporting laser as an earlier intervention in the treatment algorithm 1

Advanced Diagnostic Technologies

Structural and Functional Imaging

• Optic disc imaging, retinal nerve fiber layer (RNFL) imaging, and macular imaging have become essential for baseline documentation and progression monitoring 5
• These technologies enable detection of definite optic disc, RNFL, or macular abnormalities consistent with glaucoma even before visual field changes manifest 5
• Standard automated perimetry (SAP) remains the gold standard for functional assessment, with severity classification based on hemifield involvement and proximity to fixation 5

Disease Staging Refinement

The 2021 guidelines establish clear severity classifications 5:

• Early: Definite structural abnormalities with normal visual fields
• Moderate: Structural abnormalities with visual field defects in one hemifield not within 5 degrees of fixation
• Severe: Structural abnormalities with bilateral hemifield defects and/or loss within 5 degrees of fixation

Emerging Biological Therapies

Regenerative Approaches

• Advanced-stage glaucoma research now explores electrical stimulation, stem cells, exosomes, extracellular vesicles, and growth factors as potential therapeutic modalities 6
• These approaches aim to address the irreversible nature of RGC loss that characterizes advanced disease 6
• Neuronal plasticity-based rehabilitation methods are under investigation to stimulate residual visual capacity in patients with established damage 6

Risk Factor Recognition and Screening

Established Risk Factors

The 2021 guidelines identify critical risk factors requiring heightened surveillance 5:

• Elevated IOP remains the primary modifiable risk factor
• Older age, with prevalence increasing substantially after age 40
• African American, Latino/Hispanic, and Asian American populations demonstrate 2-3 fold higher prevalence compared to non-Hispanic whites
• Family history of glaucoma
• Thin central cornea
• Myopia
• Type 2 diabetes mellitus
• Low ocular perfusion pressure
• Disc hemorrhage

Angle-Closure Disease Recognition

• Primary angle-closure glaucoma (PACG) disproportionately affects Asian populations, with 15.5 million of 20.2 million cases worldwide occurring in Asia 5
• In China alone, PACG causes bilateral blindness in 1.5 million individuals 5
• Highest prevalence rates occur in Inuit, Chinese, and other Asian populations 5

Treatment Algorithm Modernization

Target IOP Approach

• Clinical objectives now emphasize estimating a target IOP below which further optic nerve damage is unlikely, with adjustment to lower targets if deterioration occurs 5
• Gonioscopy documentation is mandatory for all patients to differentiate open-angle from angle-closure mechanisms 5
• Treatment selection balances efficacy with minimizing side effects and impact on quality of life 5

Angle-Closure Management

• Laser iridotomy remains first-line for relieving pupillary block, with iridoplasty reserved for persistent angle closure 5
• Lens extraction increasingly recognized as definitive treatment when laser and medical therapy fail to alleviate IOP elevation 5
• Prophylactic iridotomy indicated for fellow eyes with anatomically narrow angles 5

Global Disease Burden and Projections

Epidemiological Trends

• Global glaucoma prevalence projected to reach 112 million by 2040, up from 76 million in 2020, driven by population aging 5
• Open-angle glaucoma accounts for approximately 45 million cases, with angle-closure contributing 16 million 5
• The disease will disproportionately affect African and Asian countries as prevalence increases 5

Quality of Life Impact

• Patients with glaucoma are three times more likely to experience falls and six times more likely to be involved in motor vehicle collisions compared to controls 5
• Quality of life deterioration occurs even in early-stage disease, affecting reading, walking, and driving abilities 5
• Visual impairment from glaucoma warrants referral for vision rehabilitation and social services 5

Economic Considerations

Cost Stratification by Severity

• Annual direct medical costs escalate dramatically with disease progression: $623 for early glaucoma, $1,915 for advanced disease, and $2,511 for end-stage disease 5
• Early-stage costs predominantly reflect medication expenses, while advanced disease costs shift to home health care and rehabilitation 5
• Lifetime costs for glaucoma patients average $1,688 higher than patients without the condition 5
• Angle-closure glaucoma generates higher mean payments ($303) compared to open-angle glaucoma ($263), driven by increased laser surgery utilization 5

Clinical Practice Integration

Specialist Referral Criteria

• Consultation with glaucoma specialists indicated when diagnosis is uncertain, disease proves refractory to treatment, or advanced surgical intervention is required 5
• Appropriately trained personnel may perform diagnostic procedures (tonometry, perimetry, pachymetry, imaging), but interpretation and management require ophthalmologist expertise 5

Patient Education Emphasis

• Clinical objectives explicitly include educating and involving patients and family members/caregivers in disease management 5
• Patients with angle-closure disease should inform genetically related family members of their increased risk 5
• Vision rehabilitation resources available through professional organizations for patients with significant visual impairment 5