Doctors talk about new methods of treating glaucoma

Therefore, at the initiative of the Russian Glaucoma Society (RGO), events are regularly held where leading experts easily convey the latest innovations in this field to Russian ophthalmologists. Recently, a special seminar of the group “Scientific avant-garde” (project of the Russian Geographical Society) was held, dedicated to novelties in the field of studying glaucoma and combined ophthalmopathology. Well-known specialists in Russian glaucomatology spoke about numerous fundamental studies carried out in 2022-2023 in the field of diagnostics and dynamic monitoring, as well as therapeutic, laser and surgical treatment of patients with glaucoma.

Says the head of the ophthalmological center, colonel of the medical service, doctor of medical sciences, professor of the department of ophthalmology. Academician A.P. Nesterov N.I. Pirogov” Ministry of Health of the Russian Federation Alexander Kuroyedov: “Our mission is to show events from the most truthful and reliable perspective in the field of everything related to glaucoma. The volume of information in this area is huge, it accumulates like a snowball – and it is not easy to get reliable data. Many studies are conflicting; the data of others lose relevance over time. Therefore, to be informed today is not just to read scientific articles, but also to analyze them, which will allow you to competently treat patients. For example, we have before us a scattering of drugs for the treatment of glaucoma, there are eight of them, and it seems like they are all the same, but which drug should be used? Some have side effects on the cardiovascular system or visual fields, others are less effective, but safer … And yet – not all news is relevant to us. It is important to understand what we really need to know, because the vast majority of news will never affect our lives.

Ophthalmologist, member of the expert council on glaucoma problems of the Russian Geographical Society, Ph.D. Oleg Nikolaevich Onufriychuk (St. Petersburg) analyzed all new studies on primary glaucoma over the past year and a half. During this time, scientists have investigated the role of genetics and risk factors in the development of the disease, and new studies have been conducted on the relationship of diabetes mellitus with glaucoma (scientists have found that the risk of glaucoma increases with a long history of diabetes and fasting glucose levels). It was studied whether alcohol consumption affects the level of intraocular pressure (IOP). It turned out that the habitual use of alcohol is associated with a higher level of IOP, and arterial hypertension, as scientists have established, still rather increases the risk of developing glaucoma. Scientists also substantiated the contraindication of the use of psychotropic drugs in angle-closure glaucoma (risks of complications increase).

Another interesting study showed the relationship between the level of air pollution and age-related eye diseases: for example, exceeding the permissible concentration of microparticles in the air increases the risk of developing glaucoma by 1.63 times. In addition, glaucoma increases the risk of dry eye syndrome by 1.77 times.

The presence of dyslipidemia (elevated levels of “bad” cholesterol) increases the risk of developing glaucoma by 1.25 times, but an increase in total cholesterol does not affect this risk in any way – only low-density cholesterol.

The ratio of neutrophils and leukocytes in the general blood test (it shows the relationship between cellular and adaptive immunity) changes with glaucoma, which indirectly proves the role of inflammation in the pathogenesis of glaucoma. And the chances of getting glaucoma are much higher in overweight people. With a lack of weight, however, too.

Alexander Kuroyedov told his colleagues about diagnosing and monitoring the condition of patients with glaucoma: “Every doctor saw a patient with glaucoma in his practice. But the causes of the disease are laid before the patient becomes the object of the doctor’s attention. Unfortunately, there is no demarcation between health and disease. Diagnosis is especially difficult on the verge of norm and pathology, when the disease has not yet developed. Nature does not tolerate jumps, and there are borderline conditions that glaucomatologists should pay attention to.

Kuroyedov spoke about the importance of using various diagnostic methods, not only new ones, but also some of the well-known ones, which are again becoming widespread today. During the pandemic, telemedicine began to actively develop, including the direction of teleglaucoma: a special smartphone program helps to remotely monitor the progression of the disease: “We also conduct such studies in our country, this is an effective method for examining low-mobility and bedridden patients,” said Kuroyedov .

For patients with an unaltered visual field, a long-known but little-used test called “microperimetry” may be useful. In addition, devices for home optical coherence tomography have appeared – they allow patients to conduct self-testing. “Home self-tonometry is also promising, with its help the doctor can make remote decisions about changing the therapy regimen. New generation smart soft contact lenses enable continuous 24-hour monitoring of glaucoma progression or treatment efficacy. Diagnostic surgery is also developing. There are devices that combine several techniques (coherence tomography, perimetry, etc.). And, of course, one cannot but mention the possibilities of artificial intelligence in glaucoma — the future belongs to multimodal algorithms,” says Alexander Kuroyedov.

The fact that the time has come for changes in the treatment of glaucoma, said Associate Professor of the Department of Ophthalmology of the North-Western State Medical University. Mechnikova, ophthalmologist, Ph.D. Victoria Korelina. She noted that new drugs for the treatment of this disease appear infrequently in the world, but now we are at the epicenter of events: new drugs with a new mechanism of action are being developed before our eyes, as well as new combination therapy regimens and new drug delivery systems that offer new hopes. patients: “There is a shift in focus towards neuroprotection, which is associated with a change in the idea of ​​glaucoma: it has come to be understood that the basis of the disease is not only a violation of hydrodynamics and an increase in intraocular pressure, but also disorders in the parts of the cerebral cortex.”

Another important trend is that ophthalmologists are gradually abandoning beta-blockers: these drugs have been used in medicine for 65 years, and 45 in ophthalmology (the first publication was published in 1977 and was called Timolol). For a long time they were the main treatment for glaucoma, but today doctors are forced to admit that some have stopped working, while others have severe side effects. “It’s time for them to take a well-deserved rest. Moreover, with prolonged use, patients begin to get used to it. The hypotensive effect disappears within a year in half of the patients, and according to recent studies, addiction is formed within six months of treatment, and if the drugs are used for two years, they will remain effective for only 3%. It is necessary to switch to drugs with new mechanisms of action, primarily the group of Rho-kinase inhibitors. They have been used in Japan for 10 years, and in the USA since 2017. Unfortunately, they are not yet available in Russia. Another group of new drugs is modified prostaglandin analogues. In Russia, they are also not yet available. But in our country in 2022, a modern (and the only one in the world!) Combination of prostaglandin analogues and local carbonic anhydrase inhibitors was registered, and this is a very promising treatment,” says Korelina.

Laser treatment options for patients are also developing, as Aleksey Seleznev (Ivanovo), Associate Professor, Ophthalmologist of FSBEI HE IvGMA, told. According to him, two years ago, lasers were considered a weak link, but everything turned out to be not quite so. American scientists have found that in many cases the method has advantages, including after it patients recover faster. A 2022 Cochrane Library review found that laser treatment is more effective in slowing glaucoma at a lower cost and has almost no side effects. “Of course, glaucoma treatment starts with medication. But many patients do not use the drops for their intended purpose, they bury them in the wrong place. Sometimes they bury everything at once before a visit to the doctor, which does not bring any benefit. And up to a third stop using them altogether during the first year of therapy, including due to side effects. By the way, about 10% of patients do not respond to any dosage forms. All this determines the inevitable prospects for surgical treatment, and its invasiveness and risks must be taken into account, ”said Alexei Seleznev and mentioned the most promising laser treatment methods today, including selective trabeloplasty and micropulse cyclophotocoagulation. These methods have a high safety profile and long-term efficacy, the expert concluded.

And yet, many patients require surgical treatment. Associate Professor of the Department of Ophthalmology, KSMU, Ph.D. Andrey Brezhnev (Kursk) noted that today in glaucoma surgery in the country there has been a trend towards an increase in minimally invasive interventions, as in Europe and the USA, although in absolute terms, “anemic” operations in our country still make up no more than 2% of all surgical interventions. Now we have a growing number of combined interventions (when, for example, glaucoma is operated simultaneously with cataract), attempts are being made to introduce surgery into pediatric practice. In recent years, new glaucoma implants have appeared, and yet operations are often postponed for later: many drugs work, and the patient always chooses a less invasive method of treatment. The expert added that the effectiveness of surgical intervention strongly depends even on whether the patient smokes or not (for smokers, the efficiency is three times lower!), and urged all glaucoma patients to stop smoking immediately.

Experts noted that surgery, unfortunately, does not return vision to patients, as well as other methods of treatment. But there is hope that drugs will be developed in the world that can prevent the death of the retina – and then the problem of glaucoma will be largely solved.