In 2002, a couple of my favorite glaucoma specialists, Robert Fechtner, MD, and Tony Realini, MD, wrote one of my favorite articles, “56,000 Ways to Treat Glaucoma.”¹ The article describes the myriad medical options for lowering IOP in glaucoma patients (the number doubles every time you consider dosing options, ie, timolol 0.5% vs 0.25%). Fifty-six thousand options is a lot, so we would do well to be thoughtful about how to start, what to use, and in what sequence to use it. I often say, you could take a lifetime trying what’s available, so cut to the chase to get your patient’s IOP under control before they lose vision. To me, the article demonstrated that we have an embarrassment of riches when it comes to treating IOP in glaucoma. The authors focused on medical therapy, so we have many more options when we consider laser, MIGS, and incisional surgery.

Let us consider that Drs. Fechtner and Realini wrote that article 19 years ago, when I was just a little tyke. Many new options for glaucoma have arrived since. Medically, we have seen a few preservative-free drugs (tafluprost, latanoprost, dorzolamide-timolol), at least 1 fixed combination (brimonidine timolol), a modified latanoprost with new nitric-oxide donation (latanoprostene bunod), and a new class of medications, the rho kinase inhibitors, including our first PGA-containing fixed combination. I am not a math wizard, but when we take 56,000 and double it 7 times, we top 7 million options and the numbers start getting philosophical. Factor in our laser options, laser trabeculoplasty (selective and micropulse), diode (standard, endocyclophotocoagulation, and micropulse) and we get to something like 60 million options.

MIGS also arrived since 2002, with a few ways to do goniotomy, 2 trabecular microbypass stents, canaloplasty, and a few other variations on the scene. We are at just under a billion options before we consider the image on the cover of Glaucoma Physician, Allergan’s Xen 45 gel micro stent.

And then sustained delivery arrived. We have 1 FDA-approved option today in Durysta from Allergan, and Glaukos recently released encouraging phase 2b data on the iDose TR. So, here we are in 2021 with near-infinite ways to treat glaucoma. We have the tools; it is on us to educate ourselves on all of the options, and it is on us to get to know our patients well enough to know how we can best care for them. We have innumerable opportunities to help people, and a lot of work ahead to learn the best way to treat this challenging disease. GP

Dr. Radcliffe is a clinical associate professor of ophthalmology at the New York Eye and Ear Infirmary of Mount Sinai and a surgeon at the New York Eye Surgery Center.

Reference

1. Realini T, Fechtner RD. 56,000 ways to treat glaucoma. Ophthalmology. 2002;109(11):1955-1956. doi:10.1016/s0161-6420(02)01437-9