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The Future of Glaucoma

A clear vision for a better tomorrow: The Future of Glaucoma can be brighter

The new cornucopia of treatments for glaucoma

From new types of pharmaceuticals to novel surgical approaches, there are now many more treatments available for glaucoma, finds Michael Marshall

This article was commissioned and funded by Santen.

Edited by Nishani Amerasinghe & Wai Siene Ng

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The last decade has seen an explosion of new treatments for glaucoma. New drugs, new delivery systems for drugs and new surgeries have all proliferated at a dizzying rate.1,2 Coming after many years of minimal advances, the new treatments are exciting for patients and clinicians alike.3 Patients want to be told about the full range of available options, at the start of their glaucoma journey and throughout, so they can take ownership of their care.

The new treatments are also daunting. So many new approaches inevitably raise complex questions. Which ones are truly effective, and which are overhyped? How should the effective techniques be integrated into treatment plans? However, experienced ophthalmologists largely agree on which innovative treatments are the most promising, and how they can be combined to improve outcomes for patients.4

Patients who struggle to administer eye drops could finally have an alternative means of receiving medication into their eyes.

The evolving patient pathway

While the array of treatment options may seem more complex, they all aim to do one thing: preserve vision by preventing or minimizing further sight loss.5 This reality can disappoint patients who have already experienced vision loss and understandably seek restorative solutions. However, although vision restoration remains an exciting research frontier, clinical applications are still years away.6

It may provide some comfort that today’s treatment pathway – which targets intra-ocular pressure reduction through pharmacological management, before advancing to surgical interventions when necessary – has significantly improved.1,2 Innovations in drug delivery systems, novel pharmaceuticals, and advanced surgical techniques now offer patients more convenient and effective treatment options than ever before.1,2

Beyond drops

Eye drops are a cornerstone of glaucoma care, helping to reduce intra-ocular pressure and avert vision loss.4 As a delivery mechanism, their main advantage is that the drugs are delivered directly into the eye – unlike pills, the active components of which must pass through the gastrointestinal system and bloodstream. This means drops primarily have localised effects.

However, eye drops also have significant downsides. A common complaint is that they are difficult to administer, particularly for elderly or disabled people.7 As a result, patients can struggle to adhere to their treatment regimen despite their best efforts and lose vision.7

A range of alternative delivery systems have been developed in recent years. One of the most appealing systems are implants.8 These are surgically implanted into a patient’s eyes, after which they automatically and steadily release the drug. Instead of endless struggles with eye droppers, patients can simply allow the implant to do the work.

Multiple studies indicate that implants can reduce intra-ocular pressure. An early study published in 2017 found that an implant successfully reduced intra-ocular pressure for six months: 71% of patients did not require additional treatments during the study.9 A 2020 follow-up found that it was still effective for up to two years.10 Likewise, in a study published in February 2024, another implant performed as well as timolol eye drops at reducing intra-ocular pressure over 12 months.11,12

However, while these results are promising, ophthalmologists remain concerned about the durability of the implants.13 One of the biggest challenges for glaucoma care is the sheer volume of patients who must be cared for (see Sustainable Service Delivery). For this reason, implants are only viable if they can last a long time: ideally, more than a year. Otherwise, patients will need to come in every few months to have new implants injected into their eyes: this would place an impossible burden on both patients and clinicians.

If the implants can be shown to reliably last a long time, they will become extremely useful. Patients who struggle to administer eye drops will finally have an alternative means of receiving medication into their eyes.

A 2020 review of lasers in glaucoma highlighted several emerging laser treatments, including titanium–sapphire laser trabeculoplasty and pattern selective laser trabeculoplasty

New drugs

The last major advance in pharmaceuticals for glaucoma was the advent of prostaglandin analogues. When they were first approved around the turn of the century, they were revolutionary.14 A 2023 review noted that they are highly effective at reducing intra-ocular pressure, have limited side effects, and only need to be administered once a day.14

Alongside this, a range of wound healing and anti-scarring drugs has become available.15 These are used after surgeries like trabeculectomy to ensure long-term effectiveness.16 If the eye was left to its own devices after surgery, the body’s natural healing responses would form scars that would seal up the newly created drainage channels.16 The drugs modulate this response, so the channels remains open.16 Many promising new candidates are being developed.17

The most promising new pharmaceuticals are neuroprotective drugs.18,19 These target the neurons of the optic nerve, reducing the neuronal damage that leads to vision loss.18,19 This is a completely different mode of action to most existing glaucoma medications, which target intra-ocular pressure. Effective neuroprotectives would allow clinicians to “further protect the optic nerve,” says Andrew Tatham at Princess Alexandra Eye Pavilion, Edinburgh.

One promising neuroprotective drug is nicotinamide, a form of vitamin B3.19 Initial studies in mice suggested that nicotinamide could reduce glaucomatous degeneration, apparently by preventing metabolic disruption and mitochondrial dysfunction.20,21 By 2021, a phase 2 clinical trial had shown that a combination of nicotinamide and pyruvate improved visual function in open-angle glaucoma.22 A review published in July 2024 concluded that there was significant “preclinical evidence” that nicotinamide protects retinal ganglion cells and preserves the optic nerve – and, as a bonus, lowers intra-ocular pressure.19 Clinical trials are underway: for instance, University College London and Moorfields Eye Hospital launched a four-year study of nicotinamide for glaucoma in 2022.23

While nicotinamide is heavily studied, neurotrophic factors are also being explored for their potential neuroprotective effects. As early as 2011, researchers were aware that low levels of neurotrophic factors could contribute to the onset of glaucoma.24 However, even as the evidence for benefits of neurotrophic factors has accumulated, it has proved challenging to deliver the chemicals to the eye effectively and safely.25,26

One promising approach is gene therapy, which would enable the patient’s body to produce its own neurotrophic factors.27 However, a recent review found that such work was “still in the early stages of research” and that there was “a lack of human clinical trials”.28 Gene therapy to enhance production of neurotrophic factors is therefore still some years away.

Overall, neuroprotective drugs for glaucoma are promising but proven therapies will take a few more years to come through.29 A key challenge has been that human clinical trials often don’t show benefits, despite the promising evidence from animal trials.29 A review published in March 2024 highlighted this problem and called for researchers to focus on combination therapies, which may be more effective.29

New surgeries

Finally, a host of new forms of surgery for glaucoma have been developed in recent years.2 The cornucopia of methods can be dizzying, and there has been some confusion over terminology: however, the European Glaucoma Society’s Terminology and Guidelines for Glaucoma clarifies most of the ambiguities.4 The guidelines help healthcare professionals navigate decision-making by offering a clear framework for treatment selection, based on disease severity, patient-specific factors, and risk-benefit considerations.4 They help define when to consider medications or laser procedures and when newer surgical options, such as minimally invasive glaucoma surgery (MIGS), may be appropriate.4

Lasers are a major category of glaucoma surgery and have evolved significantly with newer, more targeted techniques emerging in recent years.4 While laser trabeculoplasty has been used for decades to reduce intra-ocular pressure and is a well-established treatment option, newer techniques have emerged.30,31 Diode laser cycloablation has been found to be effective for refractory glaucoma, and in recent years less aggressive methods that include rest intervals have also proved useful.32,33 A 2020 review of lasers in glaucoma highlighted several emerging laser treatments, including titanium– sapphire laser trabeculoplasty and pattern selective laser trabeculoplasty.34

There has also been a lot of hype about the various forms of micro invasive glaucoma surgery (MIGS), such as trabecular meshwork bypass.35 The idea has been to develop forms of surgery that, because they are less invasive, have fewer side effects and allow for faster recovery.36 MIGS can be suitable for patients with mild or moderate disease who cannot tolerate eye drops, or for whatever reason do not take them.36,37 For Imran Masood at the Birmingham and Midland Eye Centre, the most promising forms of MIGS are those that increase aqueous outflow – and thus lower intra-ocular pressure – by modifying Schlemm’s canal or inserting implants into the suprachoroidal space.37,38,39

These additional surgery options offer several benefits. They can be tailored to specific types of glaucoma and to patients’ needs, improving personalised care – something patients are eager to experience.4 In future, genomic and biomarker data could also be used to help guide the choice of procedure, further personalising the experience (see genomics and biomarkers). “That’s something I could see within the next five years, a genetic test that guides what surgical treatment you’d have,” says Anthony Khawaja at Moorfields Eye Hospital in London.
“You should only have one, maximum two, eye operations in your lifetime, particularly if you’ve got glaucoma,” says Sancy Low at St Thomas’ Hospital in London. So, it’s crucial to only perform surgeries that will have significant and lasting effects.

However, the biggest benefit of having additional procedures available is that it makes it easier to delay or even avoid full trabeculectomy. While trabeculectomy can be effective, it comes with significant side effects and risks, so it should be reserved for patients whose glaucoma is severe or progressing rapidly.4 For those with milder cases, less interventionist procedures like MIGS and drugs may well be enough to prevent vision loss.4

Artificial intelligence could perhaps be used to support decision-making, as could genomics and biomarkers

Conclusion

Today, one of the biggest challenges in glaucoma care is the sheer diversity of treatments for glaucoma, some of which are better evidenced than others. While it is good to have options, it is also difficult to choose the optimal pathway for individual patients. Artificial intelligence could perhaps be used to support decision-making, as could genomics and biomarkers. However, in the near term there is a need for standardised practices such as decision trees: this would help clinicians to navigate the complexity and provide patients with holistic care. It is also important to tell patients about the full range of options, using appropriate language, so they can take ownership of their own care. While restoring lost vision remains out of reach, it is possible to significantly reduce rates of vision loss by making good use of the many available pharmaceuticals and surgeries.4

Nishani Amerasinghe is a Consultant Ophthalmic Surgeon at University Hospital Southampton.

Wai Siene Ng is a Consultant Ophthalmic Surgeon at the University Hospital of Wales in Cardiff.

What matters to patients

Consistent themes around ‘knowing my options’ and having a clearer understanding of when different treatment options should be considered came through from the patient research.40 Having an idea of what might need to be done in the future and the fact there is a treatment ‘toolkit’ offers reassurance for patients, even at the time of diagnosis when there is a lot of information to process. Visibility of options has the potential to drive engagement and adherence, according to the patients we spoke to.40

We were told that covering potential options provides reassurance and reduces anxiety, but that this does not always happen. For example, being introduced to the possibility of surgery being needed as a standard part of care reduces the fear when it becomes necessary, and being presented the future options for their glaucoma is reassuring.40

When it comes to surgery, early information on potential surgical interventions would help prepare patients and drive engagement. However, for patients further along their glaucoma journey, caution is needed when it comes to discussing surgical options.40 Health professionals should not assume that it has already been raised: often it can come as a surprise. When surgery is discussed, giving it a name helps patients to do their own research and feel more engaged in the treatment decision.40

References

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  3. Ophthalmology Times. Envision Summit 2025. Accessed September 2025. Available at: https://www.ophthalmologytimes.com/view/envision-summit-2025- new-developments-in-glaucoma-treatment-and-tailoring-them-to-the-patient
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  10. Craven ER, Walters T, Christie WC, et al. 24-Month Phase I/II clinical trial of bimatoprost sustained-release implant (Bimatoprost SR) in glaucoma patients. Drugs. 2020;80:167–179. doi: 10.1007/s40265-019-01248-0
  11. Sarkisian SR, Ang RE, Lee AM, et al. Travoprost intracameral implant for open-angle glaucoma or ocular hypertension: 12-month results of a randomized, double-masked trial. Ophthalmol Ther. 2024;13(4):995–1014. doi: 10.1007/ s40123-024-00898-y
  12. ClinicalTrials.gov. Randomized study comparing two models of a travoprost intraocular implant to timolol maleate ophthalmic solution, 0.5%. Accessed September 2025. Available at: https://clinicaltrials.gov/study/NCT03519386
  13. Lee CK, Ma KT, Hong YJ, Kim CY. Long-term clinical outcomes of Ahmed valve implantation in patients with refractory glaucoma. PLoS One. 2017;12(11):e0187533. doi: 10.1371/journal.pone.0187533
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  16. Collotta D, Colletta S, Carlucci V, et al. Pharmacological approaches to modulate the scarring process after glaucoma surgery. Pharmaceuticals. 2023;16(6):898. doi: 10.3390/ph16060898
  17. Dave B, Patel M, Suresh S, et al. Wound modulations in glaucoma surgery: A systematic review. Bioengineering. 2024;11(5):446. doi: 10.3390/ bioengineering11050446
  18. Wang J, Wang H, Dang Y. Rho-kinase inhibitors as emerging targets for glaucoma therapy. Ophthalmol Ther. 2023;12:2943–2957. doi: 10.1007/s40123-023- 00820-y
  19. Babighian S, Gattazzo I, Zanella MS, et al. Nicotinamide: Bright potential in glaucoma management. Biomedicines. 2024;12(8):1655. doi: 10.3390/ biomedicines12081655
  20. Williams PA, Harder JM, John SWM. Glaucoma as a metabolic optic neuropathy: Making the case for nicotinamide treatment in glaucoma. J Glaucoma. 2017;26(12):1161–1168. doi: 10.1097/IJG.0000000000000767
  21. Tribble JR, Otmani A, Sun S, et al. Nicotinamide provides neuroprotection in glaucoma by protecting against mitochondrial and metabolic dysfunction. Redox Biol. 2021;43:101988. doi: 10.1016/j.redox.2021.101988
  22. De Moraes CG, John SWM, Williams PA, et al. Nicotinamide and pyruvate for neuroenhancement in open-angle glaucoma: A Phase 2 randomized clinical trial. JAMA Ophthalmol. 2022;140(1):11–18. doi: 10.1001/jamaophthalmol.2021.4576
  23. UCL News. Vitamin B3 trialled as glaucoma treatment. Accessed September 2025. Available at: https://www.ucl.ac.uk/news/2022/feb/vitamin-b3-trialled-glaucoma-treatment
  24. Johnson TV, Bull ND, Martin KR. Neurotrophic factor delivery as a protective treatment for glaucoma. Exp Eye Res. 2011;93(2):196–203. doi: 10.1016/j. exer.2010.05.016
  25. Lambuk L, Mohd Lazaldin MA, Ahmad S, et al. Brain-derived neurotrophic factor-mediated neuroprotection in glaucoma: a review of current state of the art. Front Pharmacol. 2022;13:875662. doi: 10.3389/fphar.2022.875662
  26. Nafissi N, Foldvari M. Neuroprotective therapies in glaucoma: I. Neurotrophic factor delivery. Wiley Interdiscip Rev Nanomed Nanobiotechnol. 2016;8(2):240–254. doi: 10.1002/ wnan.1361
  27. Harada C, Guo X, Harada T. Monogenic gene therapy for glaucoma and optic nerve injury. Neural Regen Res 2025;20(3):815–816. doi: 10.4103/NRR. NRR-D-24-00133
  28. Sulak R, Liu X, Smedowski A. The concept of gene therapy for glaucoma: the dream that has not come true yet. Neural Regen Res 2024;19(1):92–99. doi: 10.4103/1673-5374.375319
  29. Bou Ghanem GO, Wareham LK, Calkins DJ. Addressing neurodegeneration in glaucoma: mechanisms, challenges, and treatments. Prog Retin Eye Res. 2024;100:101261. doi: 10.1016/j.preteyeres.2024.101261
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  31. Manchester Royal Eye Hospital. Selective laser trabeculoplasty (SLT Laser): information for patients. 2019. REH 174 TIG 80/10. Accessed September 2025. Available at: https://mft.nhs.uk/app/uploads/sites/2/2018/04/REH-174-Selective- Laser-Trabeculoplasty.pdf
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Read The Articles Here

Article 1: Introduction

A clear look at a better future for glaucoma care. Glaucoma is one of the most common causes of vision loss and blindness. More than 3% of people over 40 have glaucoma, and perhaps 10% of over-75s.

Read more >

Article 2: Setting the Scene

A shared vision of the future of glaucoma care. Glaucoma patients and healthcare professionals have different perspectives on glaucoma care, but they share many of the same priorities.

Read more >

Article 3: Artificial Intellegence

AI could help the highest-risk patients get glaucoma care . While artificial intelligence has many possible uses in glaucoma, its greatest potential is in identifying those at greatest risk.

Read more >

Article 4: Sustainable Service Delivery

Ensuring the right patient is seen by the right person at the right time. How can the healthcare system ensure that every glaucoma patient is seen, while also maintaining empathic health professional - patient relationships.

Read more >

Article 5: Innovative Treatments

The new cornucopia of  treatments for glaucoma. From new types of pharmaceuticals to novel surgical approaches, there are now many more treatments available for glaucoma.

Read more >

Article 6: Health Equality

Ensuring access to glaucoma care is truly equitable. Poor people and members of ethnic minorities often receive worse glaucoma care. Fixing these inequities requires a tailored approach.

Read more >

Article 7: Patient Education and Engagement

People with glaucoma need clarity about their condition. Patients with glaucoma who are educated about their diagnosis are more likely to actively engage in their care and often have better outcomes.

Read more >

Article 8: Conclusions and Recommendations

What if we 
got it right? The Future of Glaucoma Care in the UK. Shaping the future of glaucoma care at every level
will not only improve patients’ lives but deliver lasting benefits for society.

Read more >

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Job code: NP-GLAU-UKIE-0167 | Date of Prep: October 2025

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