RESEARCH

Those with glaucoma or a family history should be reassured that medical research is advancing with exponential speed. It is now quite conceivable that within the next ten years several breakthroughs will be made in the areas of genetics, detection of the disease, medical therapy, neuroprotection and even neuro-regeneration.

The geneticists are rapidly closing in on the human genome, identifying the blueprints for what makes our cells function, and therefore what goes wrong in disease. In glaucoma at least fifteen different genes have now been identified that are associated with different sub-types of glaucoma. At the present time they are able to offer a DNA test (which uses a simple smear of cells from the inner lining of the mouth) for the TIGR gene. Unfortunately, this gene only represents a few percent of all glaucoma types, but soon it may be possible to screen for many more varieties as they are discovered. This will lead to earlier detection and treatment of the disease, particularly in families with a known history.

The other advances that will come from genetic research will be related to the mechanisms of the disease process, and once these are understood it will be possible to engineer more specific treatments and possibly even the ultimate goal of a cure. Work is already being done with viral vectors, to get viruses to act as our helpers and deliver genetic repair material into altered or damaged cells. The genetics will also help understanding of neural development. It might be even possible to clone an eye!

In detection of glaucoma, we are looking towards diagnostic tests that may be able to detect damage prior to the usual visual field tests that we currently rely on. There are already several commercial alternatives to the standard field test which look at different visual functions. These include the Frequency Doubled Perimeter (FDT), blue on yellow
perimetry and flicker perimetry. It is claimed that in some cases these tests show changes earlier, but like all subjective tests, some patients will find them difficult to perform.

The difficulties with field tests though have led to the search for objective methods of detecting damage, that do not force the subject to make a decision about whether or not they see a barely visible image. These include scanning the optic nerve head to measure its thickness (e.g. Scanning Laser Polarimeter, Heidelberg Scanning Laser Ophthalmoscope) or measuring the tiny electrical signals that the eye sends to the brain (multifocal VEP perimetry). As these tests become more accurate they will help to identify damage at earlier stages of the disease.

In medical therapy we have had the addition of several new drops in the last few years (Trusopt, Xalatan, Alphagan) providing us with more choices to suit individual patients. However, there is a multitude of studies being done to improve upon these and to search for more specific drugs with fewer side effects. Drugs that improve blood flow to the eye are being investigated. There is also a major push to design drugs that will actually strengthen the resistance of the optic nerve cells (ganglion cells) to stop them from dying off if they are subjected to high pressures, a poor blood supply or a lack of nerve growth factors. This field of research is called "neuroprotection" and while still in its infancy it has made major advances in understanding how the ganglion cells die.

One innovative idea has been an attempt to develop a pressure sensor that is incorporated into an intraocular lens, implanted at the time of cataract surgery. This could transmit accurate data about what is really going on throughout a 24-hour period.

Overall I believe the prospects in glaucoma are very good, and that our children will certainly not have to worry about the possible burdens of glaucoma-related visual loss. For those that already have the disease we need to be vigilant to keep the condition under control, and hold out for these new breakthroughs.

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