Debate Non-IOP Lowering Therapies Will be the Future of Glaucoma Management: Con

INTRODUCTION: Point-Counterpoint: IOP lowering therapies will always play a role in the future of glaucoma management. Lowering of intraocular pressure (IOP) either with medications or surgical interventions has been the mainstay of glaucoma therapy for well over 100 years and remains the only proven method to retard or prevent the development or progression of the disease. However, despite the fact that IOP lowering therapy is available, patients still may progress despite lowering of IOP. In addition, patients can develop glaucoma even at a low IOP. These findings have stimulated the development of alternate hypotheses regarding the pathogenesis of glaucomatous through non-IOP related mechanisms. There is clear evidence that vascular changes that alter perfusion to the optic nerve, changes in the supportive tissues of the lamina cribrosa, immunologic and excitotoxic/neurodegenerative changes all play an important role in the development of glaucoma. However I will argue in this debate that despite these insults, that IOP lowering therapy will always remain a valid and important treatment for glaucoma. This is because IOP load is integrally related to changes in the vasculature and the supportive cellular and connective tissue components of the lamina cribrosa and thus play a key role in the axogenic injury to the optic nerve that is critical to the development of glaucoma.