1. Summary of programme area and objectives

1.1 A programme of clinical research will be undertaken focusing on the different stages of development, management and progression of the glaucomas.

1.2 Prevention and surveillance

· identification of the relative importance of raised intraocular pressure and non-pressure risk factors
· community access to optometrists and eye health care

1.3 Symptoms, presentation and referral

· define the natural history of glaucoma and
· identify risk factors for progression

1.4 Phenotyping, information and communication

· determine the relationship between the phenotype, genotype and environmental influences
· describe associations of particular ocular features with disease progression and responsiveness to treatment

1.5 Diagnosis, investigations and pathology

· develop more accurate and reproducible measurement techniques

1.6 Interventions -surgery, medical, radiological

· efficacy and safety of new surgical techniques, (wound healing -
see programme 9), and new medical treatments

1.7 Follow-up

· develop information management tools to generate clinical risk profiles for development or progression

1.8 Nursing, community care, rehabilitation

· patient's perspective of disease, visual impairment and quality of life

  2. Programme plan

Clinical research

2.1 The natural history of POAG (and risk factors for progression), and to some extent the other glaucomas, has yet to be defined. Accurate measurement of disease progression is becoming possible with the advent of more reproducible measurement of ONH structure and visual function. Improved clinical definitions (phenotyping) of the glaucomas will aid the process. Identification of the relative importance of raised intraocular pressure and non-pressure risk factors will enable better risk profiling of individual patients.

2.2 Accurate phenotyping (description of the observable physical or biochemical characteristics) of the glaucomas is essential to determine the relationship of disease state to genotype and environmental influences. The development of robust phenotyping techniques is needed. This will permit the association of particular ocular features with patterns of disease and/or responsiveness to treatment.

2.3 Continuing research is required into more accurate and reproducible techniques to define structural (retina/ONH) and functional (psychophysical / electrophysiological) changes in glaucoma. These techniques will provide greater insight into the pathophysiology of retinal and optic nerve damage in glaucoma. The relationship of structural to functional measurements remains poorly defined. More accurate estimation of disease progression will result from improved measurement techniques and this will, in turn, permit better-defined outcomes of therapeutic interventions. The role of new measurement technologies in clinical practice needs to be investigated.

2.4 Little is known about the burden of the disease on the individual. The relationship between the degree of visual field loss and quality of life needs to be determined. The impact on the individual of the diagnosis and treatment interventions also needs to be elucidated.

2.5 Continued research into the effect of therapeutic interventions is required, as the therapeutic options available are continually changing. These need to be large studies with sufficient statistical power to answer the questions asked. Historically, the intraocular pressure has been the main measured outcome of treatment. Other outcome measures, such as ONH/retina structural and functional measurements, may be more appropriate. The efficacy and safety of new surgical techniques and methods of modulating wound healing need to be compared. New classes of medicine, with different side-effect profiles, need to be compared to existing standards. Gene and cell therapies will become available once the mechanisms of glaucoma have been elucidated.

2.6 Information technology is an instrument that can be used to improve data management and should result in improved care of individual patients. New software tools need to be developed to synthesise and display the results of diagnostic techniques used to detect and characterise the disease, with an aim to generate clinical risk profiles for individual patients, either for the development or progression of disease.

  3. Future development work in the programme during 2002/3

The priority focus for research in this programme is as follows:

3.1 Epidemiological and Service Issues
· Optimal treatment strategies to arrest disease progression

3.2 Clinical and laboratory Issues
· Mechanisms for raised intraocular pressure
· Cellular mechanisms of optic nerve damage