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Top-Ten From 2001 Subspecialty Day - Glaucoma 2001: Evolution and Revolution

Robert Fechtner

• 1. Are we there yet? - Automated Detection of Progressive Structural Injury.
  
  David S. Greenfield
  Methods for change detection exist but are untested in large populations. New strategies need to be validated against accepted measures of structural and functional change. Hardware and software are rapidly evolving.

• 2. Maximal therapy: when is enough, enough?
  
  Kuldev Singh
  Most glaucoma patients should be treated with the 1 or 2 agents that best lower IOP. The individual therapeutic trial remains crucial to guide therapy. If you are thinking of adding a third agent, consider laser trabeculoplasty. Four drugs are usually too much of a good thing.

• 3. Are generic equivalents equivalent?

  Yes. Louis B. Cantor
  FDA considers topical products as equivalent if they are pharmaceutically equivalent. Despite the lack of therapeutic equivalency requirements, there is a lack of reported failures or complications related to generic glaucoma medications. Cost savings may be considerable.

  No. Ronald L. Gross
  The advantage is cost savings, but there is a lack of data confirming therapeutic equivalence and safety equivalence. Differences in inactive components may affect efficacy and tolerability. With numerous generics it may be difficult to know what the patient is using. There is inadequate data to confirm or reject concerns.

• 4. Is diurnal IOP more important than we thought?
  
  Robert N. Weinreb
  Fluctuations of IOP in individuals can be important for the diagnosis and treatment of glaucoma. A large diurnal fluctuation may be an independent risk factor for the progression of glaucoma. A few measurements of IOP in a glaucoma patient during the daytime period are insufficient for optimal glaucoma management. It is important to evaluate the effectiveness of anti-glaucoma medications in lowering IOP throughout the day and night.

• 5. Target IOP: how low?
  
  Paul F. Palmberg
  As much as 95% of glaucoma damage may be pressure dependent. This may represent both elevated IOP and abnormal sensitivity to pressure. The AGIS results suggest that in patients with moderate to severe glaucomatous damage, one should strive to achieve pressure in the low normal range. Thus getting to about 10 mm Hg may give the maximum benefit for POAG patients. However, the risk of surgery must be weighed against the risk of progress

• 6. Herbs, potions, and incantations: alternative therapy and glaucoma.
  
  Robert Ritch
  Treatment  could theoretically be aimed at the origin or mechanisms of various disorders that lead to glaucoma or to IOP and non-IOP dependent factors. Alternative therapy can lower IOP (cannabis, exercise), improve circulation or have neuroprotective properties (cannabis, ginkgo biloba extract). These and other traditional medicines will require further investigation.

• 7. Does glaucoma affect the brain?
  
  Yeni H. Yucel
  Glaucoma is traditionally viewed as a disease of the retinal ganglion cells or the optic nerve. However, recent investigations in the experimental monkey model of glaucoma show extension of glaucomatous injury beyond retinal ganglion cells to the central nervous system.

• 8. What damages the nerve in glaucoma?
  
  Joseph Caprioli
  Pressure dependent and pressure independent mechanisms have been proposed. A debate about mechanical versus ischemic has gotten us nowhere. We must consider cellular and molecular pathways. Combinations of mechanisms may be operative to different extents in a single individual, but little is currently know about the actual mechanisms of glaucomatous optic nerve damage. Molecular tools will allow basic discoveries relevant to the process.

• 9. Clinical use of SWAP and FDT
  
  Christopher A. Girkin
  SWAP is valuable for the detection of high-risk suspects, best in younger patients with clear media. But test variability limits widespread use. FDT is useful in population screening for glaucoma and may detect defects earlier than SAP. But it has limited test locations (17-19) and no longitudinal data are available.

• 10. Should treatment of glaucoma in blacks differ?
  
  M. Roy Wilson
  Differences in POAG between blacks and whites appear to be limited to prevalence and severity and not to fundamental differences in cause. Different treatment of disease based on race is justified if differential response is explainable on biological grounds. Such explanations are lacking for glaucoma.