Top 10 Modern Glaucoma Treatments

Glaucoma, affecting over 3 million people in the US, is a leading cause of vision loss, often with few early symptoms. This eye condition increases pressure on the optic nerve and can lead to irreversible damage if not managed effectively.

Traditional methods for treating glaucoma typically involve lowering intraocular pressure. This is done through medication, laser therapy, or surgery. However, these methods can have potential risks and require long recovery times. This highlights the importance of modern glaucoma treatments.

These newer methods, including advanced medications and minimally invasive surgeries, offer a safer, more effective approach with quicker recovery, revolutionizing how we manage this challenging condition.

This article will explore the top 10 modern glaucoma treatments, examining their efficacy, safety, and patient-specific considerations. We will also discuss the challenges in evaluating these interventions and the importance of considering factors like patient preferences and treatment selection costs.

Understanding Glaucoma

Glaucoma causes slow loss of peripheral vision and can eventually lead to loss of central vision.

Glaucoma predominantly affects about 3% of the population over 50 years old, standing as a leading cause of irreversible visual impairment in older individuals. The disease often remains undetected in its initial stages due to its asymptomatic nature, leading to substantial vision loss before diagnosis.

Risk factors such as age, ethnicity, family history, genetic factors, and physical eye conditions cause this silent progression.

Glaucoma develops slowly, and initial symptoms are not noticeable, so a comprehensive dilated eye exam and measuring intraocular pressures are required for diagnosis.

Now that we know more about glaucoma, let’s look into its types.

Types of Glaucoma

Glaucoma is classified into open-angle and angle-closure glaucoma, each with distinct characteristics and implications for eye health.

1. Open-angle glaucoma is the more common form that develops gradually, which impairs the eye's ability to drain fluid effectively. This leads to increased eye pressure and subsequent optic nerve damage.
2. Angle-closure glaucoma, also known as closed-angle or narrow-angle glaucoma, develops when the iris is too close to the eye's drainage angle, potentially leading to blockage.

Both types of glaucoma highlight the need for regular eye examinations to prevent irreversible vision loss due to these often asymptomatic conditions in their early stages​​.

Top 10 Modern Glaucoma Treatments

In this section, we’ll explore the top 10 modern glaucoma treatments, carefully selected based on crucial criteria such as:

• Efficacy
• Active ingredient
• Side effects
• Cost considerations

We provided this list to provide an informed perspective on each treatment option, not for self-prescribing purposes. Now, let's examine these treatments in detail.

Treatment Using Prescribed Medication

The first line of treating glaucoma is using prescription medication to help lower intraocular pressure. Here are the top medications in this category.

Iyuzeh is a unique and preservative-free latanoprost ophthalmic solution that can lower intraocular pressure by 3 to 8 mmHg compared with 4 – 8 mmHg by Pfizer’s Xalatan. Its formulation minimizes potential irritations often associated with preservatives in ophthalmic solutions.

This medication is a prostaglandin F2α analogue specifically designed to reduce elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Iyuzeh works by increasing the outflow of aqueous humor, which results in lowered intraocular pressure​.

It comes in a single-day use vial, with a recommended dosage of one drop in the affected eye(s) once daily in the evening​. A pack of 30 0.2 ml single-dose eye drops of Iyuzeh costs approximately $372, and is available in 0.005% concentration.

Pros

• First preservative-free latanoprost solution, ideal for sensitive patients.
• Effectively reduces elevated intraocular pressure in glaucoma and ocular hypertension.
• Simplified once-daily dosing regimen.
• Compatible with other topical ophthalmic drugs for IOP reduction.

Cons

• Common side effects include eye redness, irritation, and blurred vision.
• Potential for long-term changes in eye pigmentation and eyelash growth.
• Risk of exacerbated inflammation in patients with a history of intraocular inflammation or herpetic keratitis​.

Xalatan contains latanoprost, which is an effective ophthalmic glaucoma agent. It's a prostaglandin analog, enhancing fluid drainage efficacy. It lowers eye pressure by increasing the fluid drainage from the eye, effectively treating glaucoma and intraocular hypertension​.

It's been proven to be well-tolerated and an effective medication in managing glaucoma. A study recommends it for effectively managing intraocular pressure (IOP) with fewer side effects and lowering the costs associated with potential eye surgeries. Potential side effects of this drug may include eye swelling, redness, sensitivity to light, vision changes, and discomfort. The price for a 2.5ml bottle of Xalatan in 0.005% concentration is around $275.

Pros

• Effectively treats high eye pressure.
• Administered only once a day.
• Causes less eye irritation compared to many alternatives.
• Available as a cheaper generic form.
• Good at preventing vision loss.

Cons

• Can permanently change eye color.
• May trigger herpes infections in the eye.
• Potential for allergic reactions.
• Can have side effects like eye discomfort and vision changes.

Lumigan, containing bimatoprost, is an eyedrop medication used to lower pressure in the eye by increasing fluid drainage. It treats various types of glaucoma and other conditions causing high eye pressure. It starts to work within 4 hours and lasts for 12 hours.

Lumigan is suitable for use by individuals 16 years of age and older. It also simplifies the treatment regimen with a single daily application. A 2.5 ml bottle of 0.03% Lumigan costs approximately $245. The 0.03% strength is available as a lower-cost generic, while the 0.01% strength is brand-only.

Pros

• Effectively reduces high eye pressure.
• Only needs to be used once a day.
• Begins working within 4 hours and effects last from 8 to 12 hours.
• Generic option available for lower cost.

Cons

• Can permanently darken eye color.
• Requires the removal of soft contact lenses before use.
• Common side effects include itchy and irritated eyes.

Rhopressa contains netarsudil, which is a first-in-class medication. It's approved for treating elevated intraocular pressure in individuals with open-angle glaucoma or ocular hypertension. According to a study, Netarsudil effectively lowers eye pressure and is a good alternative to laser or surgery, especially for those with a baseline eye pressure under 20 mmHg.

It is a rho kinase inhibitor that blocks rho kinase, a protein in the eye. Its mechanism increases fluid outflow from the eye and reduces pressure in the episcleral layer veins, thus lowering eye pressure.

Rhopressa stands out for its mechanism of enhancing trabecular meshwork outflow, unlike other classes that primarily increase uveoscleral outflow or decrease aqueous production. This unique action allows for potential synergistic effects when combined with other glaucoma medications, making it a favorable adjunctive therapy.

The cost for a 2.5 milliliters supply of Rhopressa, 0.02% solution, is around $373, varying based on the pharmacy.

Pros

• Can be used with other glaucoma medications.
• Does not darken the eye color.
• Requires only once-daily use.
• No systemic side effects.

Cons

• Higher cost as a brand medication.
• Common side effects of red eyes.
• Potential risk for eye irritation and bacterial infection.

Vyzulta, with its active ingredient latanoprostene bunod, is a once-daily eye drop formulated to reduce intraocular pressure by in patients with open-angle glaucoma or ocular hypertension at a concentration of 0.024%, according to a study of Japanese subjects who used this drug for a year. As a newer medication in the field of ophthalmology, it stands out for its efficacy and unique mechanism of action.

Upon application, it is metabolized in the eye into latanoprost acid, a prostaglandin analog, and butanediol mononitrate, helping to lower eye pressure by increasing the outflow of aqueous humor. It's safe for systemic use and beneficial for patients on multiple medications. A 2.5ml bottle of Vyzulta, 0.024% solution, costs around $295. Some of its side effects include changing the eye color, red eyes, eye irritation, pain, and risk of bacterial keratitis.

Pros

• Unique dual mechanism for effective intraocular pressure reduction.
• Demonstrates superior efficacy in lowering eye pressure.
• Safe for systemic use, suitable for patients on other medications.
• Convenient once-daily dosing regimen.
• Familiarity and established safety profile of its latanoprost component.

Cons

• May cause permanent changes in eye color.
• May cause red eyes and eye irritation.
• Not recommended for use in children under 16 due to unknown long-term effects.

Combigan is a new glaucoma treatment combining brimonidine and timolol. Taken twice daily, it effectively lowers intraocular pressure by suppressing aqueous production through different pathways. In studies, Combigan outperformed individual agents, showing superior mean IOP reductions over three and twelve months. Adverse effects were minimal, with a 3.6% discontinuation rate.

Pros

• Effective IOP Reduction: Combigan delivers superior IOP reduction compared to individual agents, ensuring better disease management.
• Proven Efficacy: Backed by international success, Combigan offers a reliable solution for glaucoma treatment.
• Twice-Daily Convenience: With a straightforward dosing schedule, Combigan simplifies the therapeutic process for enhanced patient adherence.

Cons

• Adverse Effects: While generally well-tolerated, the fixed combination may lead to higher treatment-related adverse events compared to some monotherapies, necessitating careful monitoring.
• Limited Individualization: Fixed combinations like Combigan, while convenient, may limit individualized dosing for patients with unique needs, potentially impacting treatment customization.

Durysta is the first implant to be approved for reducing eye pressure. It’s a tiny, dissolvable implant that releases bimatoprost medication to reduce eye pressure. The implant, inserted directly into the eye, releases medicine over several months, helping to lower the internal eye pressure​​​​​​.

A single Durysta implant can reduce eye pressure for up to several months. It continuously releases medication, removing the necessity to remember daily dosages. It also ensures direct and consistent drug delivery to the target tissue, providing more sustained intraocular pressure control than eye drop formulations.

Priced at approximately $2,297, it's ideal for patients who haven't responded well to other treatments or have allergies to other medications.

Pros

• Long-lasting effect, reducing eye pressure for several months.
• Eliminates the need for daily eye drop administration.
• Provides direct, consistent drug delivery to the eye.
• Offers stable intraocular pressure control.

Cons

• Common side effects include eye redness, irritation, and increased eye pressure.
• Potential temporary color changes in the iris.
• Can only be used once per eye.

Surgery and Laser Treatments

Other treatment options for glaucoma involve laser and surgical procedures to help lower the intraocular pressure in the eyes. Here are the options available in detail to help manage glaucoma.

SLT is designed to lower eye pressure effectively, providing an alternative to conventional glaucoma treatments. SLT reduces IOP by about 20% to 30% and is effective in about 80% of patients, with results visible within three months.

The procedure's effects can last up to five years, with the option for repeat treatments. It involves applying laser energy to the eye's drainage tissue (trabecular meshwork), which is the natural fluid drain. This process stimulates a chemical and biological change in the tissue, enhancing fluid drainage and subsequently lowering IOP.

This cold laser technique results in less scar tissue formation and minimal pain. However, the full effect of the treatment might take one to three months to manifest. The estimated cost of this procedure is around $2000.

Pros

• Results are typically visible within three months.
• Effects can last up to five years, with options for repeat treatments.
• Cold laser technique results in minimal scar tissue and pain.

Cons

• Full effect may take one to three months to manifest.
• High cost might be a consideration for some patients.

Femto Laser-Assisted Trabeculotomy, commonly referred to as FLIGHT is a non-invasive procedure. It enhances aqueous humor outflow in glaucoma patients by creating a precise channel connecting the anterior chamber to Schlemm's canal.

This is achieved using ViaLase® Laser technology, which delivers femtosecond laser pulses through the cornea and into the iridocorneal angle.

FLIGHT has shown promising results in reducing intraocular pressure (IOP). In a study, the mean IOP was reduced by 34.6% from 22.3mm Hg to 14.5mm Hg over 24 months. Additionally, 82.3% of eyes in the study achieved a 20% or greater reduction in IOP.

The procedure's safety profile is favorable, with no serious device-related adverse events reported after two years​. Further research is necessary to fully understand its application across different patient profiles, particularly in cases of narrow-angle glaucoma.

Pros

• Non-invasive and does not require opening the eye.
• Showed significant reduction in intraocular pressure over 24 months.
• High safety profile with no serious adverse events reported in studies.
• Treats a small portion of the angle, reducing potential harm.

Cons

• Effectiveness in narrow-angle glaucoma cases requires further research.
• Challenges in visualizing the trabecular meshwork in certain eyes.
• Risk of iris incarceration following channel creation in some cases.

MIGS techniques reduce intraocular pressure (IOP) by enhancing the eye's natural aqueous outflow. The procedures include bypassing the trabecular meshwork with stents, dilating Schlemm's canal, augmenting uveoscleral outflow with microstents, or decreasing aqueous production through ciliary body ablation.

These procedures are typically performed through a small incision in the cornea. MIGS stands out due to its high safety profile, minimal disruption of normal ocular anatomy, and effectiveness in lowering IOP. These surgeries are less invasive, carry a much lower risk of serious complications, and offer rapid recovery for patients.

MIGS, while safer, may offer less IOP reduction compared to traditional surgeries. Also, the effectiveness varies based on the specific technique and the patient's condition.

Pros

• High safety profile with lower risk of complications like hypotony or hemorrhages.
• Minimal alteration to normal ocular anatomy.
• Meaningful IOP reduction, potentially reducing the need for medications.
• Quick postoperative recovery.

Cons

• May provide less IOP reduction compared to traditional glaucoma surgeries.
• Effectiveness varies based on technique and patient condition.

The Future of Glaucoma Treatment

Advancements in glaucoma treatment are on the horizon, offering new hope for managing this condition. Three innovative areas stand out: nanotechnology, neuroprotection and regenerative medicine, and gene therapy.

• Nanotechnology: Nanomedicine introduces nano-delivery systems for glaucoma treatment, offering sustained medication release and improved bioavailability. This technology promises more effective drug delivery with lower dosages and the development of continuous IOP monitoring implants.
• Neuroprotection and Regenerative Medicine: This approach uses neuroprotective agents and stem cells to slow disease progression and potentially regenerate damaged optic nerves.
• Gene Therapy: Genetic research aims to identify glaucoma-linked genes to develop personalized therapies. Recent studies have successfully reversed glaucoma-induced vision loss in animal models by restoring youthful gene function in retina cells.
• NCX 470 (Nicox SA): In animal studies, this nitric oxide-donating prostaglandin analog has shown superiority over bimatoprost in lowering intraocular pressure (IOP). In Phase II trials, it demonstrated significant IOP reduction compared to latanoprost, potentially offering a stronger IOP-lowering effect with once-daily dosing​​.
• Cromakalim prodrug 1 (CKLP1): As an ATP-sensitive potassium channel opener, CKLP1 targets the reduction of episcleral venous pressure (EVP). This mechanism could allow for IOP reduction comparable to surgical interventions, potentially achieving lower IOP levels without the need for surgery. While still in the preclinical stage, it has shown promising results in animal studies​​.
• QLS-101 (Qlaris Bio): Another ATP-sensitive potassium channel modulator, QLS-101, is intended to reduce EVP-like CKLP1. Currently, in Phase II trials, it may offer an alternative noninvasive treatment to surgery and could spare patients from side effects commonly seen with prostaglandins.

Final Thoughts

The effective management of glaucoma is crucial for preserving vision and preventing blindness. Modern glaucoma treatments like Iyuezeh's preservative-free drops, Rhopressa's drainage-enhancing mechanism, and minimally invasive surgeries through small incisions like MIGS are revolutionizing care.

While safer and personalized, ongoing assessments through eye exams and field testing are vital to monitor progression and treatment efficacy while offering improved efficacy and safety profiles, it’s vital to have ongoing assessments to monitor disease progression and treatment effectiveness through comprehensive eye examinations and visual field testing.

Consulting eye care specialists is key to developing optimal plans for patient needs and preferences. With scientific advancements on the horizon, working closely with doctors can help navigate existing and emerging options to find the most suitable approach.

Can you get glaucoma in both eyes?

Yes, it is possible to develop glaucoma in the other eye if only one eye is affected initially. Some with closed-angle glaucoma in one eye can have a 40% to 80% chance of getting the same glaucoma. Each eye must be monitored and treated to prevent vision loss.

Can glaucoma be treated permanently?

No, glaucoma cannot be permanently cured. It requires ongoing management as there is currently no treatment for glaucoma that helps reverse damage or permanently eliminate risks that cause elevated eye pressure.

Is glaucoma treatment lifelong?

Yes, glaucoma treatment is a lifelong commitment in most cases. Patients need regular monitoring and adjustments to therapy over time to preserve vision and prevent progression.

Does laser treatment cure glaucoma?

Laser treatment for glaucoma works very well for most people but it doesn't work for everyone. Most people will still need to keep taking glaucoma medications even after laser treatment. One will need to wait 4 to 6 weeks after laser treatment to find out if it worked.