Small, persistent steps will bring clinical adoption to new glaucoma therapies

San Francisco-"If you wanted to be at the start of a major change in how we do things in glaucoma, you’re there," said Richard A. Lewis, MD, who spoke during the Stephen A. Obstbaum, MD, Honored Lecture at Glaucoma Day. Dr. Lewis is a cataract surgeon and glaucoma specialist, Grutzmacher & Lewis Surgical Eye Specialists, Sacramento, CA.

Although there is no lack of good ideas for new glaucoma therapies, he said, the therapies themselves have been slow to develop and become adopted clinically.

Future therapies may include microincisional or non-penetrating procedures, controlled fistula with or without devices, canal- or suprachoroidal-based procedures, medicated device implants, and, ultimately, gene therapy, Dr. Lewis added.

Six steps to get from where we are, with trabeculectomy considered the gold standard, to advanced therapies that remain tantalizingly just out of reach, according to Dr. Lewis, include:

Good ideas, financial backing, and advocates.

Detailed, randomized, prospective clinical trials.

FDA approval.

Endorsement by the American Glaucoma Society and the American Medical Association.

Approval of CPT codes.

Clinical adoption.

These steps often are multifaceted and more daunting than they may appear on the surface, however.

"The first . . . steps are good ideas and financial backing," he said. "The ideas are there but from a venture capital standpoint, glaucoma is primarily a pharmaceutical market. Surgical technologies and advances remain a small fraction of the market. In addition, there is often a lack of receptiveness to the glaucoma specialist. We have not taken the lead."

Though daunting, the steps to "get from here to there" certainly are not insurmountable, he continued.

"There are many positives," Dr. Lewis said. "New procedures . . . have the attention of big pharmaceutical companies, venture capitalists, FDA, and specialty societies.

"We just need to hope that the current economic environment doesn’t deter the progress that’s being made," he concluded. "Whatever the future holds, one thing is certain: a value-based approach to glaucoma therapy will be essential."